Despite Death Threats, Politician Fights Vaccine Exemptions

In the face of growing anti-vax sentiments, outbreaks have resurged. In response, Richard Pan, MD, California state senator and award-winning pediatrician, authored three bills that were approved by the state legislature: AB2109, to eliminate personal belief exemptions; SB277, to abolish nonmedical exemptions; and SB276, to create a review process to abolish inappropriate medical exemptions (MEs).

From being compared with brutal historical figures to enduring a physical assault and death threats, Pan experienced much opposition. He spoke with Medscape Medical News about why — despite all this — he keeps fighting for public health.

You started off in pediatrics. What drove you to politics?

I've always been active in medical associations, advocating for policies to help improve public health. When I was a faculty member at the University of California, Davis, I served on a county commission that funded programs for children aged 0 to 5. I also helped found a nonprofit to help low-income children get healthcare coverage. Then the 2008–2009 recession hit; things got worse for people here in Sacramento. I wasn't planning on running for public office but understood the role government plays in helping protect people's health. So, I ran for the State Assembly.

When I entered the legislature, California had very lax requirements for vaccination for school enrollment. Typically, parents just needed to sign a piece of paper at their school saying they didn't want their child to be vaccinated. Personal belief exemptions had risen. The California Legislature passed a law requiring pertussis vaccination for kids entering 7th grade after a pertussis outbreak in 2010, where 10 infants died and thousands were hospitalized.

Research showed that these outbreaks were in areas with high personal exemption rates. I authored the AB2109 bill, which says that people wanting a personal belief exemption need to talk to a licensed healthcare professional about the benefits of the vaccine and the risks of the diseases they prevent. It was modeled after a State of Washington bill, and implemented in 2014. That first year, the personal belief exemption rates dropped 20%. Then it rose again. AB2109 likely captured people who would have gotten their children vaccinated anyway but hadn't because it was inconvenient. It echoed the State of Washington experience.

Then, there was a measles outbreak that traced back to Disneyland in December 2014. It started spreading across California, the country, and beyond. We realized AB2109 wasn't enough to prevent outbreaks. That lead to SB277, which abolished nonmedical exemptions. It was supported by numerous parents and their legislators. We had families calling whose children had cancer or transplants, afraid to go out in public or to school where there were nonvaccinated kids. They wanted laws to protect them.

Parents pushed for this bill?

They formed Vaccinate California, a coalition including parents, child advocacy groups, businesses, local government, and educational groups. They all supported SB277. We passed it in June 2015. Of course, it still allows for actual MEs. We thought that if we abolished nonmedical exemptions, physicians would be held to a standard of care by the medical board.

A small number of physicians [still] sold MEs, wrote large numbers of them, and did a lot of damage. There were ads online, and lists of doctors selling exemptions were passed around by antivaccine parents in social media groups. Newspapers reported some schools had ME rates of 10% to 50%. Anything above 5% is implausible; there simply aren't that many people with true medical contraindications to vaccines.

A Pediatrics paper showed that numerous MEs in California did not seem appropriate or lacked necessary information.

One physician in the San Diego Unified School District had written a third of all the MEs, was advertising MEs, and certainly wasn't the regular doctor of all those patients. The second largest number were from a holistic physician already on probation by the medical board for other negligent acts. The third largest number were from a physician who did consulting for an antivaccine group. The fourth most MEs were written by Dr Bob Sears, who was on probation for writing inappropriate MEs.

The California Department of Public Health estimated that 40% of the MEs were inappropriate. We met with the medical board before authoring SB276 to see why they couldn't do something. But, they depend on patients complaining about doctors and allowing access to their medical records. When a patient's family refuses to provide access to records, the medical board can't investigate. They did get the records of one patient and found that the doctor had committed repeated negligent acts in granting that ME. Now he's under investigation for about four cases.

The medical board is trying to subpoena medical records from several physicians who wrote large numbers of MEs. But, in order to subpoena the records, especially against families' wills, they have to convince a judge to allow them access to the medical records for that doctor. Also, MEs go through the schools, and the schools can't release who got them. SB276 addresses several issues that had hindered the medical board in their efforts.

Why do some doctors write inappropriate MEs?

It's very profitable. They're charging $300, $500 each for them, and they're advertising. Some were in trouble with the medical board for negligent acts. These aren't doctors with high ethical standards.

It's hard to determine what someone's motivations are. Bob Sears founded an organization called Physicians for Informed Consent. The irony is, truly informed choice is what every doctor does when they talk to families about vaccines. Interestingly, Dr Sears promoted his book about vaccines and said there is no evidence behind his book or his recommended alternative schedule. He has talked about the fact that someone who is unvaccinated endangers the larger group and that his role is to cater to the anxieties of the parents. To me, that doesn't sound like a physician who doesn't know what the truth is. He was the lead witness in opposing SB276, yet he was sanctioned for inappropriate MEs.

Doctors writing medical exemptions all received medical training; they should know better. You can look at their behaviors and speculate on their reasons.

Tell us about some of the resistance you've faced.

The main pushback is from antivaccine extremists. The extremists won't listen to the science. They engage in bullying, intimidation, and threats. I get death threats on a regular basis. For SB276, they rallied outside the capitol around a poster of my face splattered with what appeared to be blood. Many of them wore t-shirts with that same image into the hearing room. Robert F. Kennedy Jr came to Sacramento for SB277 and called vaccines a Holocaust. He later apologized. Then he returned for SB276 and compared the antivaccine extremists as being like the Jews during World War II being put in [concentration camps]. I've been called Hitler and Dr Mengele.

I was struck on the back by an antivaccine leader who streamed it live on Facebook. He had been invited to speak in front of antivaccine groups and even attempted to run for office against me. Antivaccine groups had championed him in the past. He harassed me at other events, too.

After the bill got passed, a woman threw blood from the public gallery of the legislature onto the floor where the legislators were debating. One could argue that throwing a bodily fluid onto people is a bioterrorism attack.

How do you continue in the face of all this?

The main focus in my career has been social determinants of health. I'm proud of the work I've done in that area, helping underserved children. But when something as fundamental as vaccination is being eroded, we need to step up and provide that protection. Vaccination is one of the world's most important public health achievements, along with clean air and water and sanitation. There are so many children who could be disabled or killed by these diseases if we don't keep vaccination rates up.

Do you have any tips for doctors?

It's important to discuss vaccine safety and efficacy. Tell families that children need to be vaccinated for their protection unless they have a reason like cancer not to. Physicians need to speak with authority and confidence around the issue. Parents want to hear that the physicians who know their child and know the science are confident about the recommendations. You also want to listen to the parents. Have parents share the things they are hearing.

Pippa Wysong is a freelance medical and science writer with over 30 years of experience writing for both medical and popular audiences. She is a former staffer at the Medical Post and has written numerous projects for Medscape.

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