Dr. Jason V. Terk is on a mission to change that. "We're seeing outbreaks of diseases that are scary," warns Terk, a pediatrician and distinguished consultant with Cook Children's Physician Network. "People like me who are keeping an eye on public health - we're ringing the warning bell right now. Serious outbreaks of disease are likely to happen. People are going to get sick, and some people are going to die. And that's a preventable tragedy."
Bad things are already happening. A measles outbreak in the Pacific Northwest this year has sickened 68 people and counting, the vast majority of which have been unvaccinated children. Measles hit closer to home in 2018 with an outbreak in Ellis County that affected six. It's a worrisome trend. In 2000, measles was considered eradicated from the U.S. - but that was before the rise of the anti-vaxxer movement, social media and fake news. Today, measles cases have increased by more than 30 percent worldwide since 2016.
"This is a dangerous disease, and people die from it," continues Terk. "It is the most contagious thing that we would ever deal with. People are worried about Ebola being contagious? This is much more contagious than Ebola." Unlike cold and flu viruses, which spread on respiratory droplets, measles is a true airborne contagion. If someone with the disease enters a room, the air becomes filled with measles virus particles - and it can stay that way for up to two hours. Anyone who enters the space during that time who has not received the measles vaccine has a 90 percent chance of getting sick. "It is exceptionally contagious," he says, "It spreads very, very quickly."
Terk's passion for vaccine advocacy infuses every word that he speaks. The pediatrician began his practice around the same time that Dr. Andrew Wakefield published the infamous study that fraudulently linked immunization and autism with falsified data. The study has since been retracted and debunked numerous times. Wakefield lost his license after a tribunal found proof of 36 counts of dishonesty and the abuse of developmentally delayed children.
"It was really the beginning of the resurgence of anti-vaccine sentiment in this country," Terk says. "I began to get a sense that vaccines were something that we couldn't necessarily assume people were going to accept and understood also that we needed some advocacy to support what vaccines do for our patients, as well as society at large."
Terk is very active in Austin on vaccine issues and makes regular trips to speak with legislators. He serves on the Texas Medical Association (TMA) Council on Legislation and on the American Academy of Pediatrics Committee on Federal Government Affairs. He also works with TMA's Be Wise – Immunize program and is the former president of the Texas Pediatric Society.
"Vaccines are incredibly important," he affirms. "Second only to modern sanitation, they are the most important public health achievement that we've had happen in the last 100 years. They've saved so many lives and prevented so many serious illnesses from happening. If you don't have people standing up and advocating for vaccines, then more preventable illnesses and deaths occur. So, that's why I decided to become a vaccine advocate."
Long before Terk picked up the flag for vaccines, he took an interest in medicine while helping out with emergencies at his father's veterinary office. Later, at Jesuit College Preparatory School, the teenager was assigned to Parkland Hospital to complete the requirement for 100 hours of community service. "That's where I felt that pull toward wanting to do human medicine and take care of people. I felt like it was something that I could focus my idealism into. From that point going forward, I was pretty much set on becoming a physician."
Terk's path became clear during his pediatrics rotation in medical school at the University of Texas Medical Branch in Galveston. "I really connected with kids in that rotation, and I realized that taking care of children was what I wanted to do." He completed his residency at the prestigious Mayo Clinic in Minnesota and began practicing in Keller at Cook Children's Pediatrics.
The doctor has maintained his idealism and passion throughout his 23-year career. "I'm really blessed that every day I go to work, I get to do something that I love to do and that I know is meaningful not only to me, but to the people that I'm working with." Patients that were newborns when he launched his practice two decades ago are now beginning to graduate from it. "I've been able to witness them literally from birth to becoming an adult, and to have had a small part in that is really a privilege."
And the babies keep coming. Terk's practice welcomes two to five newborns every week. "It keeps me busy," he says. He also stays busy with his own family, which includes his wife of 24 years and two boys. His youngest is a junior at Keller High School, and his oldest is at Auburn University. Being a parent has enhanced his role as a pediatrician immensely.
"One of the challenges [of being a pediatrician] is understanding that depending on the age and developmental stage of your patient, you're going to have to approach that individual in a certain way that may be completely different from another child. You have to understand who your patient is and how to engage them in a way that me, the parent and the child get the most out of the visit." From infants and toddlers to tweens and teens, Terk must adapt his communication style to fit different age groups throughout the day. "I think if you've been a parent, you understand that how you interface with your child is going to evolve over time. I do that every day, depending on which door I'm walking into at the office."
Being a pediatrician has also helped Terk in his role as a father, but he still struggles with many of the same challenges that all parents face. "I might have a pretty good amount of medical knowledge and understanding about child development and parenting, but it doesn't mean that I don't have my own challenges as a parent … I like to joke to my parents in my practice that I probably have more power in their homes than my own," he laughs. "My wife reserves the right to listen to me or not."
For his adolescent patients, Terk is leading the charge to improve the adoption of a new vaccine that was introduced in 2006. It's a vaccine for an incurable viral infection that causes six different types of cancer - but only 33 percent of Texas teens are getting it.
Spread by kissing and sexual activity, human papillomavirus (HPV) is extremely common. Four out of five people will be infected at some point during their lifetime. Many will never show symptoms or realize that they have HPV. While most infections go away on their own within two years, some will mutate into cancers: cervical, vulvar, vaginal, anal, penile and oropharyngeal (middle throat) cancer. Cervical cancer kills 300,000 women per year worldwide, including more than 4,000 in the U.S. - and HPV is found in about 99 percent of cervical cancers, according to the National Cervical Cancer Coalition.
HPV's dramatic association with cervical cancer has positioned it as a concern for women's health. But the rates of oropharyngeal cancer in men have risen more than 300 percent in recent decades, and it's now the most common HPV-related cancer. "We are seeing an epidemic of cancers related to HPV infection, particularly males in their 30s and 40s," Terk says. "We've not seen the worst of it yet."
While Tarrant County's low immunization rates for childhood diseases like measles are headline news, the area's HPV vaccination rates are far lower. The vaccine works best when it's given to patients at age 11 or 12, before any kind of sexual activity occurs - even kissing. But most parents prefer to believe that their child will not touch anyone sexually until the night of their wedding, and HPV is seen as a sexually transmitted infection (STI).
"It's a mistake to think of HPV infection in the context of other STIs like syphilis and gonorrhea and chlamydia, which in the baseball analogy of sex, you have to hit a triple or a home run to get," Terk explains. "But first and second bases are covered with HPV. So, if you can imagine your child having some sort of making-out activity before they get married - which is much likely - then they're at risk for getting HPV infection. You cannot prevent it by virtue of your own good choices when 80 percent of our kids will become infected with the types of HPV that can cause cancer."
Pediatricians themselves bear some of the responsibility for low HPV vaccination rates. It's a stealthy virus that causes cancers 20 to 30 years after infection, long after pediatric patients have aged out. Pediatricians don't take care of the consequences of HPV, so they have no personal experience with the diseases that the vaccine would prevent. Moreover, talking about HPV with young patients and their parents is just … awkward.
"Some physicians who see adolescents may find it difficult to have frank conversations about sex. We like having positive relationships with the parents of our patients, and many in the past have avoided difficult conversations, perceiving that a parent may be hesitant about the HPV vaccine. So, it's been a little bit of an uphill battle," Terk says. "More research has come out that underscores how important an affirmative and unequivocal recommendation is for providing HPV vaccination. More physicians have come to understand that and have adjusted their approach so that more tweens and teens can get this important cancer-preventing vaccine. We've certainly done that at Cook Children's."
Terk has led the way. He spearheaded a quality improvement initiative in 2017 aimed at greater provision of the HPV vaccine across Cook Children's 27 primary care practices. Since then, they've seen significant progress, so much so that their recent HPV vaccination data was flagged by the state because it was so high. "They couldn't believe how well we were doing," Terk says.
"The bottom line for me is that I never want a patient of mine to get sick now, or later as an adult, from something we could have or should have prevented. That is the reason I decided to work on HPV vaccination. It's my worst nightmare as a pediatrician to imagine a former patient of mine developing a cancer that should have been prevented with the HPV vaccine. I really want to do everything that I can to give my patients what they need so they can be healthy and safe and well adults."
Vaccines engender healthy adults. But more and more parents are choosing not to immunize their children across the country and especially in Texas. State law was changed in 2003 to allow for personal-belief exemptions, which are also known as nonmedical exemptions or conscientious exemptions. Now, Texas is one of 18 states that let parents disregard the legal requirement for seven childhood vaccinations, including measles. Almost 60,000 public school students across Texas have opted out - and that number does not include private schools or home schools.
Fort Worth is one of the biggest offenders. It was singled out as one of the top 15 cities in America with the largest number of nonmedical exemptors in a 2018 study by PLOS Medicine. Plano, Austin and Houston also made the cut. In Tarrant County, 1.45 percent of students had conscientious exemptions in the 2017-2018 school year, a rate that has almost doubled in the past six years.
"We have our own unique culture here in Tarrant County," observes Terk. "This is where the West begins, and it's a fairly conservative area with a large population. We may have a larger number of people around here who object to mandates to vaccinate than in other places. When those like-minded people who may be less likely to vaccinate create communities within neighborhoods, schools and churches, then outbreaks of diseases like measles become more likely. Birds of a feather flock together."
In 1900, before the widespread adoption of vaccines, 16 out of every 100 children in America died from disease before the age of 5. It's a shocking statistic, but facts aren't enough to persuade groups like Texans for Vaccine Choice. Based in Terk's hometown of Keller, the anti-vaxx organization isn't just fighting for the freedom to skip childhood vaccines - but also to keep other parents from knowing that they did. The group opposes legislation like the Parents" Right to Know bill, an effort to provide campus-level data about the percentage of exemptors at every school.
"Parents of children who are immune-compromised or who have cancer need to know this information. Not because they want to "out" people, but because they need to understand the risks and make informed choices for their children," clarifies Terk. Children with compromised immune systems or cancer cannot be given vaccines. Neither can any infant less than 12 months old. Both groups are at far greater risk from fatal complications from diseases like measles. "The individual choice that someone might make when it comes to vaccines doesn't have just individual consequences - it has consequences for all of us. If people decide that they're going to do something that increases risk for the rest of us, then that's not right," Terk implores. "It's not an imaginary risk. It's a real one."
Personal-belief exemptions by definition rely on personal beliefs. All the scientific data in the world has no effect on belief-based objections to vaccines, which by their nature resist revision by factual evidence. That's why experts like Terk are learning to connect with anti-vaxxer parents not with more data, but by considering each person's unique moral foundation.
Morality is often seen in black or white, right or wrong. But morality takes on distinct nuances in different cultures. For example, Americans tend to value individualism highly while many Asian cultures place greater worth on community cohesion. The Moral Foundations Theory attempts to account for this variance. First proposed by social psychologists Johnathan Haidt and Jesse Graham, the theory was popularized in Haidt's 2012 bestseller, The Righteous Mind: Why Good People Are Divided by Politics and Religion.
The theory proposes that morality is based on six foundations: Care, Fairness, Loyalty, Authority, Sanctity and Liberty. Depending on which cultural group you belong to, each moral foundation will carry a different weight for you. The authors" research showed striking evidence of this difference in America's three main political ideologies: libertarians, liberals and conservatives.
It's pretty obvious that for libertarians, Liberty is by far the most important foundation. For liberals, Care and Fairness are dominant. Conservatives are equally sensitive to all six moral principles, which gives the impression (to liberals) that they don't place enough value on Care and Fairness. Meanwhile, conservatives see liberals as excessively concerned with Care and Fairness to the exclusion of equally important ideas like Loyalty and Liberty.
With differing moral foundations, each side perceives the other not only as having bad opinions - but of being morally wrong. That's why it's surprising that liberals and conservatives espouse anti-vaccine beliefs at similar rates. According to a 2015 study by the Pew Research Center, 10 percent of conservatives and 12 percent of liberals believe that childhood vaccines are unsafe. But the emotions behind those belief-based objections are very different.
"If you have someone with a libertarian-oriented worldview, then talking to them about the benefit of vaccinating themselves and their kid to protect the rest of society is not going to work," Terk explains. Instead, you must appeal to their sense of freedom: "Don't allow disease to infringe upon the liberty of living your life in a healthy way." Care-focused parents may respond to calls for compassion for disease victims" suffering, while Loyalty-focused parents react better when urged to protect their community and their country.
"This is about understanding where your patient is coming from or where your parent is coming from," adds Terk. "My job as a pediatrician is to make sure that my patient is properly protected from diseases that can kill or disable them. So, if I can appeal to someone in a way that resonates with them, then that makes me more effective in performing my mission as a pediatrician as I partner with the parent to guide the child into healthy adulthood."
Terk is hopeful that parents will make the right choices when it comes to vaccines - but he is not resting for a moment on his mission to keep kids healthy. "We're all in this together, even if we'd like to think that we are islands unto ourselves," he says. "When it comes to vaccines, we need to take care of ourselves. In doing that, we'll take care of the rest of us, too.
"Remember the sound of the bell that I am ringing right now."
photos by Olaf Growald
