Or I’m about to be, and my wife is getting a wee bit impatient, so I need to start packing, etc.  You know the drill.

Several weeks ago I argued that much of the the observed increase in autistic disorder over time can be explained by three phenomenon: (1) Diagnostic criteria have changed over some part of the period during which increases have been observed. The diagnostic criteria for autistic disorder were broadened over time. (2) The average age of diagnosis for autistic disorder became younger. (3) The efficiency of ascertainment (the probability that a true case is identified) has increased with greater awareness of the condition, introduction of new treatments and new resources, advocacy, broadening of diagnostic experience, and changes in diagnostic practices.

In another post in May I described a small study from England that “adds to arguments against the view that incidence of autism has increased over recent decades, and suggests that changes in diagnostic criteria are the most likely reason for the rise in the number of cases diagnosed.” I pointed out, however, that this small study was only a first step and we need more studies with larger sample sizes.

In the July 2008 issue of the the Journal of Autism and Developmental Disorders a much larger and more elegant study has been published. I would love to give you a detailed description, but I’m about to go on vacation. So quoting the abstract will have to suffice for now.

Trends in Autism Prevalence: Diagnostic Substitution Revisited

By Helen Coo and Hélène Ouellette-Kuntz of the Department of Community Health and Epidemiology, Queens University; Jennifer E. V. Lloyd of the Human Early Learning Partnership (HELP); and three other authors.

SUMMARY: The authors examined trends in assignment of special education codes to British Columbia (BC) school children who had an autism code in at least 1 year between 1996 and 2004, inclusive. The proportion of children with an autism code increased from 12.3/10,000 in 1996 to 43.1/10,000 in 2004; 51.9% of this increase was attributable to children switching from another special education classification to autism (16.0/10,000). Taking into account the reverse situation (children with an autism code switching to another special education category (5.9/10.000)), diagnostic substitution accounted for at least one-third of the increase in autism prevalence over the study period.

I’ve spent part of the last couple of days reading some of the arguments against the modern U.S. childhood vaccine schedule at places like the National Vaccine Information Center, SafeMinds, and in the medical investigative reporting of Robert F. Kennedy, Jr. One of the statements you run across quite often is that today’s children — going back to children born in early 1990’s — are less healthy and generally much sicker than children of earlier generations. Where does this idea come from? It turns out that one of the places that it comes from is a 2007 commentary published in the Journal of the American Medical Association (JAMA), entitled “The Increase of Childhood Chronic Conditions in the United States.” This commentary, by James Perrin, Sheila Bloom, and Steven Gortmaker — all of Harvard University — got an enormous amount of media attention, so it’s no wonder that it’s cited so often. Unfortunately, one of the most-cited statements from the commentary is an observations about time trends, in which the authors’ interpretations of the data are just downright wrong.

Bloomberg News Service started out their report on the JAMA commentary with the shocker, “The number of American children with chronic illnesses has quadrupled since the time when some of their parents were kids, portending more disability and higher health costs for a new generation of adults, a study estimates.” This is based on the following sentence from the JAMA commentary: “In 1960, only 1.8% of US children and adolescents were noted by their parents to have a limitation of activity due to a health condition of more than 3 months’ duration; in 2004, these rates had increased to more than 7% or more than 5 million children and youth.” This sentence is so loaded with problems that I need to devote a whole post to it, especially since it’s been quoted so often by the media.

If you’re a stickler for exactitude, you might be happy about two things, but not for long. Both the 1960 percentage of 1.8 and the 2004 percentage of 7 come from the same annual survey, The National Health Interview Survey (NHIS) carried out by the National Center for Health Statistics (NCHS). Both refer to the “percentage of children with limitation of activity resulting from one or more chronic health conditions.” Unfortunately, there have been several changes over time in the NHIS that render the two percentages incomparable, but the biggest problems are that:
(1) the definition of “children” in standard NHIS tabulations changed from 0-16 years old to 0-17 years old; and
(2) the NHIS question about activity limitation due to a chronic health condition changed completely between 1996 and 1997.

National Health Interview Survey Questionnaire Probes for Determining Presence of Activity Limitations, 1969-1996

Age under 1 year:
Is __ limited in any way because of his health?
Age 1-5 years:
Is __ able to take part at all in ordinary play with other children?
Is he limited in the kind of play he can do because of his health?
Is he limited in the amount of play because of his health?
Age 6-16 years:
In terms of health would __ be able to go to school?
Does (would) -_ have to go to a certain type of school because of
his health?
Is he (would he be) limited in school attendance because of his health?
Is he limited in the kind or amount of other activities because of his
health?
All ages responding NO to the above probes:
Is __ limited in ANY WAY because of a disability or health? (Added in 1969)
[Note: At one point, the interviewer explains that the health condition or disability must have a duration of three months or more.]

(Source: National Health Interview Survey questionnaire 1980.)

National Health Interview Survey Questionnaire Probes for Determining Presence of Activity Limitations, 1997-present

Age Under 5 years: Parent is asked:
“Is (child’s name) limited in the kind or amount of play activities [he/she] can do because of a physical, mental, or emotional problem?”
[Note: At one point, the interviewer explains that the physical, mental, or emotional problem must be a condition that once acquired is not cured or has a duration of three months or more.]

Age 0-18 years, Parent is asked
(1) “Does (child’s name) receive Special Education Services or Early Intervention Services?”
(2) “Is (child’s name) limited in any activities because of physical, mental, or emotional problems?”

Age 3-17: Parent is also asked:
(3) “Because of a physical, mental, or emotional problem, does (child’s name) need the help of other persons with personal care needs, such as eating, bathing, dressing, or getting around inside the home?“
(4) “Because of a health problem does (child’s name) have difficulty walking without using any special equipment?”
(5) “Is (child’s name) limited in any way because of difficulty remembering or because of periods of confusion?”

(Source: National Health Interview Survey 2006.)*

As I noted above, the JAMA Commentary said: “In 1960…only 1.8% of US children and adolescents were noted by their parents to have a limitation of activity due to a health condition of more than 3 months’ duration…” The actual source for this percentage of 1.8 is an excellent 1984 paper by Paul Newacheck and colleagues in the American Journal of Publlic Health. For the subject of today’s post, the paper by Newacheck et al. is useful for two reasons: First, it has a table (Table 1) showing the year-by-year trend in per cent of children (under 17 years of age) with limitation of activity between 1960 and 1981. During that period the reported percentage increased from 1.8 to 3.8. Second, the authors examine in detail “the hypothesis that increased prevalence of activity limitations can be explained by changes in survey procedures, changes in awareness of illness, and/or changes in the size of the institutional population.” For example:

1. Prior to 1967, only those respondents who had reported a chronic condition in response to probes earlier in the interview were asked about the presence of an activity limitation.
2. Beginning in 1967, questions pertaining to activity limitation were asked of all sample persons.
3. Also beginning in 1967, activity limitation categories were read to the respondent; previously, respondents had been asked to choose an appropriate activity limitation response from a printed card.
4. Beginning in 1969, when persons responded negatively to the usual probes on activity imitation an additional question was asked: “Is __ limited in ANY WAY because of a disability or health?” It was then left to the coder to determine whether the response would be classified as an activity limitation.

Since the Newacheck et al paper is a public access article, I’ll leave it to you to read their thoughts on changes in the awareness of illness during 1960-1981 (”…increased awareness has not been a major contributor to the upward trend.”) and changes in the institutionalized population during the period. I do agree with Newacheck et al. that between the early 1960’s and the early 1980’s there probably was a near doubling of the proportion of children with limitations of activity due to chronic illness.

But what I’d really like to show you is more recent time trends, especially trends in the 1990’s and early part of this decade. Most of the the following data comes from the report, America’s Children: Key National Indicators of Well-Being, which has been published annually by the Federal Interagency Forum on Child and Family Statistics since 1997. For some years, America’s Children did not publish data for 0-4 year old children. For those years, I got the data from Health, United States, an annual report on trends in health statistics published by NCHS.

It seems that the standard NCHS definition of “children” for NHIS tabulations from 1960 through the 1980’s was “under 17 years of age.” I’m not sure why they chose 1984, but the Federal Interagency Forum on Child and Family Statistics seems to have asked NCHS to go back and do special tabulations for 1984, so they could use 1984 as their baseline or “benchmark” year.

TABLE 1. PERCENTAGE OF CHILDREN AGES 0-17 WITH ACTIVITY LIMITATION RESULTING FROM ONE OR MORE CHRONIC HEALTH CONDITIONS BY AGE, 1984

Table 2 shows prevalence rates from 1990 to 1996, when the NHIS question about limitation of activity due to chronic disease was the same as in 1984.

TABLE 2. PERCENTAGE OF CHILDREN AGES 0-17 WITH ACTIVITY LIMITATION RESULTING FROM ONE OR MORE CHRONIC HEALTH CONDITIONS BY AGE, 1990-1996

(Source: National Center for Health Statistics, National Health Interview Survey, 1990-1996.)

It looks like there was a jump in the prevalence rate between 1990 and 1991. Then the rates remained essentially stable between 1991 and 1996. Before you get all excited and conclude that “something happened” between 1990 and 1991 to “cause” these rates to increase, sit back and take ten deep breaths while I explain a few things. First, the entire increase occurred in 5 to 17 year-old children — not in infants and pre-schoolers. Second, these are not birth cohorts. The 5-17 year old children in the 1990 NHIS were born duing the period 1973-1985 and the 5-17 year old children in the 1991 NHIS were born in the perid 1974-1986. I hope you get the point.

Table 3 shows prevalence rates after 1996, when two things happened with the NHIS. First, as I mentioned above, the question on limitation of activity due to chronic illness changed enormously. Second, and equally important, between 1996 and 1997 a major NHIS Redesign occurred, which means that the sampling frame, sampling methodology, and many other statistical aspects of the survey changed. In short, both subject matter experts on childhood chronic disease and disability and statisticians agree that prevalence rates calculated from the NHIS in 1996 and before, and in 1997 and after, are not comparable.

TABLE 3. PERCENTAGE OF CHILDREN AGES 0-17 WITH ACTIVITY LIMITATION RESULTING FROM ONE OR MORE CHRONIC HEALTH CONDITIONS BY AGE, 1997-2006

(Source: National Center for Health Statistics, National Health Interview Survey, 1997-2006.)

My interpretation of this trend between 1997 and 2006 is that the overall prevalence rate is fairly stable. The same goes for the rate stratified by age: the prevalence for both infants and pre-schoolers and for 5-17 year olds seems pretty stable. I’ve provided tables with the actual prevalence rates, instead of a chart, so you can make your own charts, argue with me, and argue with each other to your heart’s content. (If you’re interested in statistical significance: For American’s Children NHIS staff did significance tests for difference between years for the period 1997 to 2005. No significance differences were found between years (p > 0.05). This means that differences between 1996 and ‘97, ‘97 and ‘98, etc. were all nonsignificant — adjacent years, in other words. As far as I know, no other significance tests have been done, e.g., for non-adjacent years or for trends.)

So my conclusions about the data on time trends in activity limitation due to chronic illness are: first, based on the 1984 paper by Newacheck et al. there was probably nearly a doubling of the prevalence rate between the early 1960’s and the early 1980’s. Second. based, on the data shown above, I think the prevalence rate has remained fairly stable between the mid-1980’s and 2006.

The ramifications of this are extremely important, especially regarding children of the 1990’s.

1. Children who were born and who grew up in the 1990’s aren’t any “sicker” than the previous generation, at least using this particular overall measure of chronic illness. The same thing seems to be true about children born during this decade — at least so far. I cannot disagree with the JAMA Commentary’s statement that chidhood asthma prevalence has doubled since the 1980’s. And there’s no doubt that childhood obesity has more than tripled since the early 1970’s. The JAMA commentary also points out:, “Approximately 6% of school-age children have a reported diagnosis of attention-deficit/hyperactivity disorder (ADHD), which represents a dramatic increase, although changes in diagnostic practices are clearly one reason. For example, there was no entry for ADHD in the American Psychiatric Association manual until 1968…Similar questions arise for autism spectrum disorders; whether or not there have been true changes in prevalence, it is clear that rates of diagnosis have increased.” (The JAMA commentary also cites a great review article entitled, “Is there an epidemic of child or adolescent depression?”, which I highly recommend. The simple answer is NO, there not an epidemic of child or adolescent depression.)

2. The focus of the National Health Interview Survey is obviously health, health care, and illness. The focus is not on neurodevelopmental disabilities such as ADHD, autism, and so forth, even though there definitely are questions that pertain to these health issues. I think that it’s extremely important that in this context, when parents are questioned about limitation of activity, NHIS data do not show a rising trend in line with the marked increase in autism and ADHD — or in the diagnoses of autism and ADHD.

Perhaps I’m making too much of this last point. After all, the reported prevalence of autism is still only 6.6 per 1,000, which is 0.66%. On the other hand, to estimate rates of parent-reported ADHD diagnosis, the CDC analyzed data from the 2003 National Survey of Children’s Health and reported that 7.8% (95% confidence interval 7.4-8.1) of U.S. children aged 4 to 17 years had had ADHD diagnosed at some point. However, according to some additional tabulations in Health, United States, 2007, of the 8.2% of 5 to 17 year old children whose parent reported them to have activity limitation resulting from a chronic health condition in 2004-2005 (see Table 3 above), in about 25% at least one of the chronic health conditions causing the activity limitation was reported to be ADHD. In other words, according to recent NHIS data the prevalence of ADHD that results in activity limitation is about 2% in 5-17 year olds. Contrast this with the overall ADHD prevalence from the CDC study just mentioned above.

Anyway, I stand by my major point above, that the kids growing up today — those born in the 1990’s and in this century — are not a “sickly” generation.

So I’ll leave you with the profound words of Pete Townshend, written in 1965 (and perhaps you can ponder how I wasted my wild, impetuous youth):

I don’t mind other guys dancing with my girl
That’s fine, I know them all pretty well
But I know sometimes I must get out in the light
Better leave her behind with the kids, they’re alright
The kids are alright!

*Note: I’ve shortened the series of questions to make them more readable. For the exact questions, skip patterns, etc., you can see the questionnaire at ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Survey_Questionnaires/NHIS/2006/English/QFAMILY.pdf

Get a load of this. David Kirby has rewritten and re-posted his story from Friday (June 20). The new June 21st story is entitled, CDC: Vaccine Study Used Flawed Methods. It starts with the following:

(NOTE: My original post on this topic mischaracterized the 2003 CDC vaccine investigation as an “Ecological Study,” which it was not. I am reposting this piece to reflect that information accurately, but also to point out that many of the weaknesses identified in the CDC’s data and methods apply to the published 2003 “retrospective cohort” study, as much as they do to any future “ecological” ones. I regret and apologize for the error.)

I hope I’m not getting a big ego, but I have a suspicion that Kirby read my post critiquing his story of yesterday, decided he had been confused about ecologic studies, and decided to create a new story. The damn problem is that Kirby’s new article is now even more confused and erroneous than the first one. The first sixteen paragraphs’s of Kirby’s new article are devoted to the Verstraeten et al. 2003 study that found no link between mercury in vaccines and autism, ADHD, speech delay or tics. Kirby claims that this study was a major issue in both the 2006 Report of the NIEHS Expert Panel and in the CDC Report responding to the NIEHS report.

So here’s some cutting and pasting from my previous post, to remind you of some of Kirby’s major misinterpretations of the NIEHS Report, expecially regarding the Verstraeten et al. 2003 study.

Nowhere in the 2006 report did the NIEHS panel conclude that the CDC’s 2003 thimerosal safety study was riddled with “several areas of weaknesses” that combined to “reduce the usefulness” of the study. In fact, in the NIEHS panel meeting that generated the 2006 report, the quality of the CDC’s 2003 thimerosal safety study was not even discussed. This can be seen clearly if you carefully read the NIEHS Report of the Expert Panel.

Earlier this week Epi Wonk had a long discussion with one of the Expert Panel Members (who adamantly insisted that he/she remain nameless), who confirmed three things for me:
(1) The purpose of the NIEHS Expert Panel was exactly as stated in the report:

It has been proposed that the Vaccine Safety Datalink could be used to look at the association between autistic disorder (AD) or autism spectrum disorders (ASD) by means of an ECOLOGIC ANALYSIS (emphasis mine) that would compare rates before and after the removal of thimerosal from most childhood vaccinations. To determine the feasibility and potential contribution and/or drawbacks of such a study, and to consider alternative study designs that could be conducted using the VSD database, the NIEHS convened a panel of experts…

(2) The quality of previous epidemiological studies of the association between thimerosal and autism was not discussed.
(3) The overall quality of the 2003 Verstraeten et al. study was not discussed. Indeed, in the section of the report in which the expert panel considered research panels other than ecologic analyses, which they did dismiss as riddled with several areas of weaknesses that combined to reduce the usefulness of ecologic studies, the expert panel “…recommended that further consideration be given to conducting an extension of the Verstraten study that would include additional years for follow up, would add more managed care organizations and reexamine the criteria for exclusion of births and/or take a sensitivity analyses approach to examining the impact of various exclusion criteria.”

And we still have these discrepancies between the new story and the actual CDC Report:

KIRBY: …the NIEHS had criticized CDC for failing to account for other mercury exposures, including maternal sources from flu shots and immune globulin, as well as mercury in food and the environment. CDC acknowledges this concern and recognizes this limitation, the Gerberding reply says.
ACTUAL QUOTE FROM CDC REPORT: NIEHS Finding: Difficulty in estimating cumulative exposure of child to organic mercury: The panel expressed concern that VSD adminstrative data or medical charts would not be accurate in recording or estimating a childs total mercury exposure from sources other than vaccines, such as diet, air and water. CDC Response: CDC acknowledges this concern and recognizes this limitation. In addition to administrative data and medical chart review, CDC has employed parent interviews to identify total cumulative mercury exposure from sources other than vaccines, such as diet. Often, however, parent recall, for events several years in the past, poses limitations as well.

KIRBY: “The NIEHS also questioned why CDC investigators eliminated 25% of the study population for a variety of reasons, even though this represented, “a susceptible population whose removal from the analysis might unintentionally reduce the ability to detect an effect of thimerosal.” This strict entry criteria would likely lead to an “under-ascertainment” of autism cases, the NIEHS reported. Again, this would have been an issue in the Verstraeten data. “CDC concurs,” Gerberding wrote, again noting that VSD data are “not appropriate for studying this vaccine safety topic. The data are intended for administrative purposes and may not be predictive of the outcomes studied.”
FACT: The NIEHS Expert Panel did not “question why CDC investigators eliminated 25% of the study population.” On the contrary, when discussing potential alternative designs (other than ecological studies), another possibility that generated support by the panel was an expansion of the VSD study published by Verstraten et al. The availability of several additional years of VSD data was seen as an opportunity to provide a more powerful test of any potential association between thimerosal and AD/ASD and would enable reconsideration of some aspects of the original study design (e.g., exclusion criteria) It was unclear to the panel what effect exclusion of low birth weight infants and those with congenital or severe perinatal disorders or born to mothers with serious medical problems of pregnancy had on the results of the Verstraeten et al. study; an expanded future study in which sensitivity analyses both including and excluding children with perinatal problems was recommended. The quote that begins with CDC concurs has no bearing on the Verstraeten et al. study, as implied by Kirby. Gerberding is responding to an NIEHS Expert Panel point about case ascertainment. Here is the entire quote from the CDC report: CDC responds: “CDC concurs with the recommendation that broader ICD-9 codes should be considered. The weakness further emphasizes why an ecological design is not appropriate for studying this vaccine safety topic using the VSD. The VSD data are intended adminstrative purposes and may not be predictive of the outcome studied. Because the outcomes have not been validated and considering the sensitivity of this issue, any VSD study of vaccines and autism, including a broader list of ICD-9 codes, would require chart review.”

Kirby ends his new article with the following postscript:
“This revised piece does raise two new questions, I think:
1) If the VSD is not necessarily appropriate to help determine the effect of reducing mercury levels in vaccines, are taxpayers getting their money’s worth?
2) If studies done in Denmark, Sweden and California were also “ecological” in nature, are they subject to some of the same weaknesses and limitations?”

Epi Wonk Response:
1) Neither the NEIHS Report nor the CDC Report state anywhere that the VSD is not appropriate to help determine the effect of reducing mercury levels in vaccines.
The relevant summary statements are:
(A) The NIEHS panel identified several serious problems that were judged to reduce the usefulness of an ecologic study design using the VSD to address the potential association between thimerosal and the risk of AD/ASD.
(B) “CDC concurs”, Dr. Gerberding wrote, “that conducting an ecologic analysis using VSD administrative data to address potential associations between thimerosal exposure and risk of ASD is not useful.”
(C) The NIEHS “panel identified several major strengths of the VSD to be: its ability to detect infrequent, vaccine-related adverse events of modest size; the possibility to supplement the MCO administrative data with reviews of medical records, interviews with parents and children, and additional diagnostic assessments; and the availability of demographic information about the MCO members.”
(D) “CDC agrees with the panels assessment of the strengths of the VSD Project to evaluate vaccine safety concerns. The VSD is a unique public-private collaboration that provides a model for the study of patient safety concerns by using individual-level data. In addition, CDC recognizes the tremendous value of the VSD as a national resource of expertise in vaccine safety research.

2) The NIEHS Expert Panel recommended that ecologic studies should not be done using the U.S. Vaccine Safety Datalink. Are completely different types of data from Denmark, Sweden, and California on which ecological analyses have been done subject to some of the same weaknesses and limitations? The answer is NO, but I suppose I’ll have to do a an entire instructional post on this for Mr. Kirby’s benefit.

“Medical reporter” David Kirby has delivered a potentially explosive report to his unfortunate and misinformed minions at the Huffington Post, in which he shows a startling string of misunderstandings and complete lack of knowledge of basic epidemiologic design and methods. Furthermore, he writes that Dr. Julie Gerberding “admits to a startling string of errors in the design and methods used in the CDC’s landmark 2003 study that found no link between mercury in vaccines and autism, ADHD, speech delay or tics,” when, in fact, the CDC report admitted no such thing about the 2003 study.

Gerberding was responding to a 2006 Report of the Expert Panel on Thimerosal Exposure in Pediatric Vaccines: Feasibility of Studies Using the Vaccine Safety Datalink to the National Institute of Environmental Health Sciences (NIEHS). Nowhere in the 2006 report, however, did the NIEHS panel conclude that the CDC’s 2003 thimerosal safety study was riddled with “several areas of weaknesses” that combined to “reduce the usefulness” of the study. In fact, in the NIEHS panel meeting that generated the 2006 report, the quality of the CDC’s 2003 thimerosal safety study was not even discussed. This can be seen clearly if you carefully read the NIEHS Report of the Expert Panel.

In addition, earlier this week Epi Wonk had a long discussion with one of the Expert Panel Members (who adamantly insisted that he/she remain nameless), who confirmed three things for me:
(1) The purpose of the NIEHS Expert Panel was exactly as stated in the report:

“It has been proposed that the Vaccine Safety Datalink could be used to look at the association between autistic disorder (AD) or autism spectrum disorders (ASD) by means of an ECOLOGIC ANALYSIS (emphasis mine) that would compare rates before and after the removal of thimerosal from most childhood vaccinations. To determine the feasibility and potential contribution and/or drawbacks of such a study, and to consider alternative study designs that could be conducted using the VSD database, the NIEHS convened a panel of experts…

(2) The quality of previous epidemiological studies of the association between thimerosal and autism was not discussed.
(3) The overall quality of the 2003 Verstraeten et al. study was not discussed. Indeed, in the section of the report in which the expert panel considered research panels other than ecologic analyses, which they did dismiss as riddled with “several areas of weaknesses” that combined to “reduce the usefulness” of ecologic studies, the expert panel “…recommended that further consideration be given to conducting an extension of the Verstraten study that would include additional years for follow up, would add more managed care organizations and reexamine the criteria for exclusion of births and/or take a sensitivity analyses approach to examining the impact of various exclusion criteria.”

In the HuffPost story, David Kirby quotes Julie Gerberding as writing that her agency “does not plan to use” the Vaccine Data Safetylink (VSD) for any future “ecological studies” of autism. “In fact”, Kirby continues, “Gerberding’s report said, any continued use of the VSD for continued ecological studies of vaccines and autism ‘would be uninformative and completely misleading.’”

Well, yes, that’s what the CDC thinks about using the VSD for ecologic analyses. I couldn’t agree more. At this point I obviously need to step back and explain about ecologic analyses. Fortunately, I taught epidemiologic design and methods for about 35 years, I had some students almost as clueless as David Kirby, but I’m a patient teacher. Another interesting fact is that there has only been one ecologic study published using the VSD, and I’ve written extensively about the study on this blog. Guess what? It wasn’t done by the CDC, who knew better long before the 2006 NIEHS Expert Panel. I’m speaking of the infamous Young-Geier Autism Study. So let me paraphrase from my explanation of “ecologic” in my previous critique of that paper:

KIRBY: “…the NIEHS had criticized CDC for failing to account for other mercury exposures, including maternal sources from flu shots and immune globulin, as well as mercury in food and the environment. ‘CDC acknowledges this concern and recognizes this limitation,’ the Gerberding reply says.”
ACTUAL QUOTE FROM CDC REPORT: “NIEHS Finding: Difficulty in estimating cumulative exposure of child to organic mercury: The panel expressed concern that VSD adminstrative data or medical charts would not be accurate in recording or estimating a child’s total mercury exposure from sources other than vaccines, such as diet, air and water. CDC Response: CDC acknowledges this concern and recognizes this limitation. In addition to administrative data and medical chart review, CDC has employed parent interviews to identify total cumulative mercury exposure from sources other than vaccines, such as diet. Often, however, parent recall, for events several years in the past, poses limitations as well.”

KIRBY: “The NIEHS also took CDC to task for eliminating 25% of the study population for a variety of reasons, even though this represented, ‘a susceptible population whose removal from the analysis might unintentionally reduce the ability to detect an effect of thimerosal.’ This strict entry criteria likely led to an ‘under-ascertainment’ of autism cases, the NIEHS reported. ‘CDC concurs,’ Gerberding wrote, again noting that its study design was ‘not appropriate for studying this vaccine safety topic. The data are intended for administrative purposes and may not be predictive of the outcomes studied.’
FACT: These four sentences are outright lies. The NIEHS Expert Panel never “took the CDC to task for eliminating 25% of the study population…” On the contrary, when discussing potential alternative designs (other than ecological studies), “another possibility that generated support by the panel was an expansion of the VSD study published by Verstraten et al. The availability of several additional years of VSD data was seen as an opportunity to provide a more powerful test of any potential association between thimerosal and AD/ASD and would enable reconsideration of some aspects of the original study design (e.g., exclusion criteria)” It was unclear to the panel what effect exclusion of low birth weight infants and those with congenital or severe perinatal disorders or born to mothers with serious medical problems of pregnancy had on the results of the Verstraeten et al. study; an expanded future study in which sensitivity analyses both including and excluding children with perinatal problems was recommended. The quote that begins with “CDC concurs” has no bearing on the Verstraeten et al. study, as implied by Kirby. Gerberding is responding to an NIEHS Expert Panel point about case ascertainment. Here is the entire quote from the CDC report: “CDC responds: ‘CDC concurs with the recommendation that broader ICD-9 codes should be considered. The weakness further emphasizes why an ecological design is not appropriate for studying this vaccine safety topic using the VSD. The VSD data are intended adminstrative purposes and may not be predictive of the outcome studied. Because the outcomes have not been validated and considering the sensitivity of this issue, any VSD study of vaccines and autism, including a broader list of ICD-9 codes, would require chart review.’”

KIRBY: “Another serious problem was that the HMOs changed the way they tracked and recorded autism diagnoses over time, including during the period when vaccine mercury levels were in decline. Such changes could ‘affect the observed rate of autism and could confound or distort trends in autism rates,’ the NIEHS warned. ‘CDC concurs,’ Dr. Gerberding wrote again, ‘that conducting an ecologic analysis using VSD administrative data to address potential associations between thimerosal exposure and risk of ASD is not useful.’
FACT: This is correct. Believe it or not, Mr. Kirby has got it right this one time. The charge of the NIEHS Expert Panel was to determine whether the VSD should be used to to do ecological studies. The expert panel concluded, “No.” The CDC concurs.

I’ll leave you with the most important summarizing quote of the CDC report:

NIEHS Finding: Strengths: The panel identified several major strengths of the VSD to be: its ability to detect infrequent, vaccine-related adverse events of modest size; the possibility to supplement the MCO administrative data with reviews of medical records, interviews with parents and children, and additional diagnostic assessments; and the availability of demographic information about the MCO members.

CDC Response: CDC agrees with the panel’s assessment of the strengths of the VSD Project to evaluate vaccine safety concerns. The VSD is a unique public-private collaboration that provides a model for the study of patient safety concerns by using individual-level data. In addition, CDC recognizes the tremendous value of the VSD as a national resource of expertise in vaccine safety research.

I can’t help but agree with Kirby’s recommendation, “I hope everyone will read these documents, including the recommendations to make the VSD better, and the CDC’s agreement with all of the suggestions.” As the waning weeks of Omnibus Autism testimony get underway, I can’t help but wonder if a little housecleaning might be going on at Huffington Post and other news outlets looking for real medical reporters, rather than outright liars.

In this week’s issue of Nature, there are three articles relevant to the above theme:
1. Sandra Titus of HHS’s Office of Research Integrity and two colleagues surveyed 2,212 researchers throughout the United States. Titus’s team found that almost 9% of the respondents in their survey, mainly biomedical scientists, had witnessed some form of scientific misconduct in the past three years, and that 37% of those incidents went unreported. Titus et al. outline a number of measures to address this situation, including better protection for whistleblowers, and promotion of a “zero tolerance” culture in which scientists have just as much responsibility to report others’ misconduct as they have for their own behavior.

2. There’s a news brief about a researcher suspended for falsifying data. Two of the scientist’s papers have been retracted, and the Office of Research Integrity barred her from receiving any US government grants for five years.

3. There’s an editorial, entitled “Solutions, Not Scapegoats,”, in which the editors of Nature argue that “the solution [to scientific misconduct] needs to be wide-ranging yet nuanced”

Believe it or not, anti-vaccinationists have already begun to grab onto these stories. If you fail to see the connection, here’s a direct quote from a post referring to the above three articles: “For some people, to vaccinate or not is an issue of trust. When government/pharma sponsored research is so obviously self-serving and unreliable, it is no wonder people have been shunning vaccinations.” I still think this is a non sequitor, but some members of the ant-vaccination crowd love to collect stories of research fraud (even if completely unrelated to vaccine research).

One of their favorites is the case of Anne Butkovitz, “ex-clinical study coordinator,…who [in 2005] pled guilty to falsifying case report forms, and has been debarred permanently by the FDA. The study was a multi-site pediatric study of a rotavirus vaccine and was sponsored by a… pharmaceutical company. ([Note that]…the drug company apparently did nothing wrong.). According to the study protocol, the clinical study coordinator at each site was supposed to contact subjects parents at specified intervals to determine whether any serious adverse events had occurred. At one of the sites, however, Butkovitz failed to contact parents but stated on case report forms that she had contacted them and that no serious adverse events had occurred. The pharmaceutical company sponsor reportedly disregarded data from her site.” (This quote is from the now defunct blog Regulatory Affairs of the Heart, which tried to report objectively on “drug regulatory affairs and FDA compliance” and was certainly not an anti-vaccination blog.)

Are these cases evidence that Modern Science is failing us, “research is unreliable,” and people shouldn’t put their trust in scientific research? I would argue just the opposite. If you’ll allow me a paragraph of intellectual digression (so I can enter this post in the Carnival of the Elitist Bastards), outside of Communist countries where Lysenkoism was practiced, Modern Science has been an “open society.” What do I mean when I say that Modern Science has been an “open society”? I think the concept was best summed up by Robert Merton, the “father of the sociology of science,” in what he described as the CUDOS set of scientific norms: Communalism, Universalism, Disinterestedness, and Organized Skepticism. Communalism is the common ownership of scientific discoveries, according to which scientists give up intellectual property rights in exchange for recognition and esteem. According to universalism , claims to truth are evaluated in terms of universal or impersonal criteria, and not on the basis of race, class, gender, religion, or nationality. According to disinterestedness, scientists are rewarded for acting in ways that outwardly appear to be selfless. By organized skepticism, Merton meant that all ideas must be tested and are subject to rigorous, structured community scrutiny. (Merton wrote in 1942. For a 2005 constructive critique of CUDOS, see The Public Value of Science, Or how to ensure that science really matters.)

But let’s get back to a few “evidence-based” arguments for why I think the Nature articles and the Anne Butkovitz case provide facts in favor of keeping our trust in Modern Science. Let me count the ways:
1. The study by Sandra Titus and colleagues was published in Nature, one of the two major general science journals. The results weren’t hushed up, nor were they uncovered as part of a world-wide conspiracy by a Freedom of Information Act request. The same is true of the news brief about the researcher who falsified data.
2, In the United States there is an Office of Research Integrity (ORI), which promotes integrity in biomedical and behavioral research. ORI “monitors institutional investigations of research misconduct and facilitates the responsible conduct of research through educational, preventive, and regulatory activities.”
3. In the case of Anne Butkovitz, she was permanently debarred by the FDA, and the pharmaceutical company sponsor disregarded data from her site.
4. Most scientists, especially those in supervisory positions, do try hard to create an environment where fraud and misconduct will occur very rarely, hopefully not at all. A fascinating example of this is the consulting firm, P. Below Consulting, which provides clinical research services for the pharmaceutical and medical device Industries. One of the activities they specialize in is helping investigators to avoid fraud and misconduct. I highly recommend taking a look at their web page on this subject. It includes Powerpoint presentations and links to several worthwhile references.

In sum: Researchers aren’t perfect. However, to lose all trust in science is going way too far. The Office of Scientific Integrity, the FDA, and others are clamping down on questionable research practices. Nature and other scientific journals are urging scientists to go even further in their vigilance.

Another hat tip to Steve D. There’s an anti-vaccination troll who visits his blog and who inspired this post.

It may surprise you to learn that I’m relatively new to the blogosphere, both as a writer and as a reader. For example, when I started this blog in the middle of April, I had no idea there were so many science blogs. I was also naive enough to think that that any scientific question about a causal association between vaccines and autism had been definitively settled in favor of the null hypothesis. (When I tell my epidemiologist friends that I’m spending time on this, they act as though I’ve joined some weird cult whose sole purpose is to convince people to stop using leeches for bloodletting.)

One of the consequences of this novelty for me is that I spend far too much time surfing the blogosphere. On the other hand, it’s fun and I’ve learned a lot, especially about the way people think. For example, in my last post I talked about my observation that some anti-vaccination commenters (on other blogs) don’t seem to understand the scientific method. I certainly got a lot of comments agreeing with this statement and expanding on it.

I’ve also come across another kind of anti-science argument that’s quite different. Paradoxically, this type of argument seems to use scientific and mathematical ideas to attack someone else’s scientific reasoning, but the attack isn’t truly scientific at all. Example: On the blog One Dad’s Opinion, there’s a nice summary of an interview with Dr. Saad Omer, a physician and vaccine epidemiologist at the Johns Hopkins School of Public Health. The interview in its entirety can be found in the online magazine Science Progress.

In the summary of the interview with Dr. Omer, there’s no math. Nevertheless, one commenter goes on the attack:
“Doing the math according to Dr. Omer and assuming 3% Unvaccinated for measles (9,120,000) and the number of current cases (64)
Rate (64/9,120,000) * 33 = .02%
Odds of being struck by lightning: 1/5000 = .02%
If you don’t worry about being struck by lightning, you shouldn’t be worried about getting measles either.”
(This commenter calls him or herself “Anonymous,” but for the sake of this post I now rename him or her MathAttack**, in memory of an old MS-DOS game my grown-up kids played when they were in grade school.)

In response, commenter HCN points out that the problem with above the “math” is that the unvaccinated usually hang around in the same groups. HCN gives examples from San Diego, Washington State, Switzerland, and Salzburg, Austria — all outbreaks involving clusters of unvaccinated children — and concludes (correctly, in my opininion), “Your math only works if the numbers were evenly spread out. They are not.” MathAttack is right back on the warpath: “Is the number of individuals that are too young evenly spread? Is the number of individuals that are immune deficient and cannot be immunized evenly spread? Is the number of elderly too old to have ever received a vaccine evenly spread? Is the remaining pool of unimmunized a minority of these other populations? Are you determining distribution based on a city block, a state or the country? My numbers are fine. If anything they are conservative, making lighting MORE dangerous.” Epi Wonk (yours truly) also makes a comment, the main point being that, MathAttack’s “math is ridiculously simplistic” and “the spread of measles in extremely complex…” MathAttack responds to me, “I will gladly update my calculations from estimates to actual when someone can provide the actuals. Exactly how many people do not have immunity to measles for every reason? Explain spontaneous outbreaks if there is no foreign exposure? Explain why foreign exposure defeats herd immunity? Explain how reducing risk of exposure, other than vaccination, is included in the calculation? Justify your calculations to demonstrate all the necessary variables, both positive and negative, that arrive at the current number of case and reasoning for the locations noted on the CDC web site.”

Then MathAttack goes back on the warpath against Dr. Omer: “I haven’t been approaching Dr.Omer’s statements from the right perspective. Let’s reverse engineer what he has said: “For example, in a national-level study it was found that kids who are exempt from vaccination requirements had thirty-three time — not percent, its times higher risk of acquiring measles with those who are vaccinated.” When was the study done and what was the risk of acquiring measles if vaccinated at that time? Has the risk of acquiring measles changed since that date? If so, why? Science Progress also started the interview with ambiguity by asking about exempt from vaccination without defining if exempt is ONLY by choice or all individuals that are not vaccinated. Two very different numbers.”

I then suggested that MathAttack carefully read the paper cited by Dr. Omer, which was published in JAMA and is entitled, “Health Consequences of Religious and Philosophical Exemptions From Immunization Laws: Individual and Societal Risk of Measles.” (which, incidentally, should be read along with a paper in Pediatrics entitled, “The Cost of Containing One Case of Measles: The Economic Impact on the Public Health Infrastructure–Iowa, 2004” and another paper in JAMA entitled “Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the U.S.”) MathAttack seems to have read the article, and is smarter than JAMA’s peer reviewers, editors, and readers (given that there were no letters to the editor critiqing the study): “There were MANY assumptions that were normalized, or used statistical modeling rather than actual data. The math of the study may not add up according to some…”We assume that the vaccine reduces the transmission probability to each child by a given fraction, which is the vaccine efficacy. Estimation of efficacy also may be biased if vaccination is not random or if a vaccinee and a nonvaccinee do not have the same exposure to the infecting agent.” Definitely changes the risk of exemptors if they actively assure they are not exposed to the infecting agent. The distribution of the transmission probabilities over the communities was determined so that the overall numbers of expected cases in exemptors and nonexemptors were close to the observed frequencies. We used age-specific population data from the Bureau of the Census to extrapolate the percentages into estimated numbers. Thus, we were able to estimate age-specific measles incidence and the relative risk of measles for exemptors compared with vaccinated persons.” Would the individuals that do not respond to a census requests most likely be vaccinated? Does the Bureau of the Census accurately report that population over time?

Wow. Now it might seem to the naive reader that MathAttack is making scientific arguments. But you don’t have to read very carefully to realize that, in the context of this mini-debate, this person absolutely cannot tolerate uncertainty. Indeed, I would argue, with Karl Popper and R.A. Fisher and many others, that uncertainty is an essential hallmark of the scientific approach. Moreover, any approach to knowledge that insists on certainty and claims to be scientific is pseudo-science.

This insistence on certainty seems to me to be related to what Daniel Engber, in a recent article in Slate, has called “The Paranoid Style in American Science,” although it would be more correct to call it “the paranoid style in American pseudo-science.” I highly recommend reading the entire three-part article, in order to understand the context for the following quote, which comes from part 3. The author, Daniel Engber, likens today’s “radical skeptics of science” to the “conspiracy-minded, radical right” of the 1950’s and early 1960’s that historian Richard Hofstadter wrote about in his famous 1964 essay, “The Paranoid Style in American Politics.” Engbar writes:

The paranoid style, Hofstadter wrote, “is nothing if not scholarly in its technique.” In his mainstream enemies, the conspiratorial thinker sees “a projection of the self”–he’s just like them but more discerning and more rational. Indeed, for the paranoid skeptics, it’s not that science is wrong but that the scientists aren’t scientific enough. (Emphasis in original.) …If nothing can withstand our critical scrutiny, then everything seems equally probable. (You can’t prove a conspiracy … but you can’t prove anything, can you?) Thus manufactured uncertainty has devalued the real thing: The less sure we are of the world, the more precision we crave. Skepticism sells itself, and the scientific consensus—no matter how considered or probable–starts to seem a little cheap…Exactitude may sound like good science–atomic clocks, sub-micron optical tweezers, and all that good stuff we use to keep satellites in orbit and Web sites streaming. But an obsessive fear of uncertainty is the opposite of science…Organized science engenders trust, and…requires the acceptance of some degree of doubt.

See also the recent article in the Annals of Internal Medicine that discusses certainty and uncertainty in evidence-based public health.

*Special thanks to Kevin Leitch for pointing me to the Dr. Omer on Vaccines post at One Dad’s Opinion and to James Hrynyshyn at Island of Doubt for blogging about the three-part series on radical skepticism and the rise of conspiratorial thinking about science by Daniel Engber, in Slate.

**In all seriousness, this post is not meant as a personal ad hominem attack on Anonymous/MathAttack, who seems highly intelligent. I just chose this as a beautiful example of this type of reasoning and argumentation.

A recent article by Deirdre Imus on The Huffington Post is long tirade against Alice Park’s Time magazine cover story, How Safe Are Vaccines? It’s been pointed out on other science blogs (and I wholeheartedly agree) that the the Time magazine article is one of the better pieces of medical journalism this year. I really do recommend reading the entire article as an example of fine reporting. Also take a look at the excellent chart that Time designed, showing data on U.S. measles cases from the first four months of 2008 with CDC’s recommended childhood immunization schedule.

The purpose of my post today is not to argue with Deirdre Imus’s article, although it would be easy enough to deconstruct it sentence by sentence. No — what caught my eye was something I noticed as I was looking over the comments in response to the article. First, to get the general tone of Ms. Imus’s article, I’ll quote the concluding sentence: “…the government has not proven the number of vaccines given to children today are safe, or that injecting our babies with mercury, aluminum and formaldehyde is safe.” (See Orac’s patient nine-part critique of this absurd claim regarding mercury, aluminum, formaldehyde and other “toxins” in vaccines.)

A commenter who calls themself ThinkForYourself2, who obviously is in agreement with Ms. Imus, states, “Some people want ’science’ to tell them that these vaccines actually caused harm to these innocent children and families so here it is: Parents of autistic children once had full-functioning, happy, outgoing children who then get vaccinated and immediately regress into autism. Is this science enough for you or do you still need more? Let us ‘ignorant’ and ‘dangerous’ parents have the choice to poison or not poison our children. That’s all some of us ask. And let me send my unvaccinated child to school with your higly vaccinated and therefore highly ‘immune’ child. Isn’t this why you vaccinated your child in the first place to protect them? So don’t force me to vaccinate mine if your is immune! Where is the God Damn Outrage?”

It’s the reply to the above comment, by someone named pkafin, that caught my eye, especially since the comment was chosen as “HuffPost’s Pick“:

“Parents of autistic children once had full-functioning, happy, outgoing children who then get vaccinated and immediately regress into autism. Is this science enough for you or do you still need more?” That is actually not science at all. Science requires empirical studies that are both repeatable and subjected to peer review. What you mention is anecdotal evidence that can be used to form a hypothesis that becomes the basis for the design of a scientific study. But that observation, in and of itself, is not scientific in any way. The “G-d Damn Outrage” cuts both ways. Industry should not be the main source for scientific studies on their own products. But, equally outrageous, American education should not be so entirely dumbed down that we don’t actually know what “science” is anymore.(Emphases mine)

This observation by pkafin is quite interesting. The gist of the entire comment, especially the last sentence, is that Deirdre Imus and ThinkForYourself2 and much of the “Green Our Vaccines” movement and others who believe that vaccines cause autism, have one basic problem. That problem is that they simply don’t understand science and scientific thinking. But pkafin is saying more than this. He or she is saying that the burden of this ignorance about science and the scientific process lies with the American educational system.

So readers, I leave you with this question. I don’t know the answer myself. Is this the problem? I assume that you know that I’m not talking about memorizing the anatomy the of the frog or the periodic table. Is a lack of education in science and scientific thinking the major issue here? I’d be interested to see your comments.

This title isn’t quite correct, but I couldn’t resist, since it sounds so catchy, evoking images of harmonica playing in the Blue Ridge Mountains. Rock Hill is located in beautiful York County, South Carolina, just off Route I-77, about 30 miles from Charlotte, North Carolina. From my nerdy scientist’s point of view, the people of Rock Hill have a lot to be happy about. They have a good local online newspaper, the Herald Online, and an up and coming medicine/health reporter named Mary Jo Balasco. On the 1st of June, Ms. Balasco published two stories. One story was entitled, “The experts weigh in…,” and in this article she interviewed “two experts about the pros and cons of vaccinating children against common diseases and what is known about the causes of autism.” The experts were Dr. Jennifer Shu, spokeswoman for the American Academy of Pediatrics, and Marguerite Colston, spokeswoman for the Autism Society of America. Both Dr. Shu and Ms. Colston gave rational answers to questions about recommendations on vaccines, whether vaccines cause autism, why some people think vaccines cause autism spectrum disorder (ASD), whether vacines can cause adverse reactions in children, whether thimerosal in vaccines is a concern, whether combination shots are dangerous, the possible causes of ASD, the causes of “the rapidly rising rates” of ASD’s, and whether children with ASD can recover.

A half-hour search on the internet reveals three things about Herald Online reporter Mary Jo Balasco. First, just a few short years ago she was a reporter for The Johnsonian, the campus newspaper of Winthrop University. Second — no surprise — reporting for the Herald Online isn’t enough to make ends meet. It seems she also runs Mary Jo Balasco Catering on Main Street in Rock Hill.* Third, the very day the story came out (actually two stories; see below) Mary Jo Balasco was at the receiving end of the snake oil venom of the folks over at Age of Autism. The Media Editor at Age of Autism laments,

Why couldn’t reporter Mary Jo Balasco find even one expert on our side? Why couldn’t she contact any of the national organizations who do link vaccines to autism? Why is she seemingly unaware of the Poling case, the upcoming rally in Washington, the latest vaccine research from the U. of Pittsburgh, or the comments made by former NIH head Bernadine Healy on CBS News?

I’m going to make a guess here. I’ll guess that Mary Jo Balasco is an intelligent human being who stayed awake in high school science classes and knows how to tell the difference between evidence-based knowledge and unscientific rubbish. That perhaps she did consider contacting “any of the national organizations who link vaccines to autisms,” but decided that the idea was wacko. That she was aware “of the Poling case, the upcoming rally in Washington, the latest vaccine research from the U. of Pittsburgh, or the comments made by former NIH head Bernadine Healy on CBS News,” but decided that a court case, people in green shirts on the DC mall, a non-peer-reviewed poster presentation, and a political appointee from the first Bush administration with zero scientific credentials are worthless when a medical reporter is preparing a story involving science. In fact, I think CBS News should be embarrassed that a reporter for a local newspaper is doing a better job than Sharyl Attkisson, who, in her reporting on vaccines and autism, has stooped lower than the lowest of British tabloid newspaper reporting. (More on this in a later post.)

Anyway, for the story on autism discussed above, and a story on vaccines (discussed below) Mary Jo Balasco wins Epi Wonk’s Local Health and Medicine Reporter of the Month Award.

Now to the second story, which is entitled, “A risk to vaccinate? Some parents are asking that as concerns are raised over links with autism.” In this article, we learn that a lot of parents are worried about vaccinations — that there are “too many, too soon.” Fortunately, for the good of the public’s health, it seems that most pediatrician’s in the Rock Hill area follow the CDC/AAP schedule, although they’re very willing to spread the shots out at the request of parents. So they have Palmetto Pediatrics, Rock Hill Pediatric Associates, and Sunshine Pediatrics — all group practices that follow evidence-based guidelines on childhood vaccinations, but are willing to bend at parents’ request.

Then they have Dr. Anthony Castiglia. Dr. Castiglia is board-certified in Family Practice and has an office in Mooresville, North Carolina, which is about an hour’s drive from Rock Hill. Mary Jo Balasco did interview him, so I assume he has pediatric patients from Rock Hill. He said most of the parents with vaccination-age children who visit his practice opt not to immunize their children. He also said, “The most important thing is to have a good immune system and do it naturally, not to do it with vaccines.” In case you’re wondering whether Dr. Castiglia is a graduate of the Jenny McCarthy School of Medicine, I was able to determine that Dr. Castiglia is a 1957 graduate of the Georgetown University School of Medicine. I really couldn’t bear to do more than three minutes of research on the guy, but I do know that Merri and Gary first learned about healing with light from Dr. Castiglia, and that the doctor does “chelation and other IV therapies.”

Meanwhile, last week there were seven cases of measles in children in DuPage County, Illinois.

So here’s my final question today: With regard to immunizing children, how many Anthony Castiglia’s are there in the U.S? And what will be the long term consequences?

*CORRECTIONS: Mary Jo Balasco does not run a catering business on Main Street. Her husband had one and named it for her, but it only ran for six months — many years ago. She graduated from York Technical College School of Nursing at the age of 20. She then worked in Intensive Care Units and Emergency Rooms for 14 years. For the last four years she has been staying at home with two children (age 17 and 15) and taking classes at Winthrop University. In 2006, she decided to “put her nursing license on inactive” to pursue journalism. She was also an intern at the Charlotte Observer. Her “dream is to write for science publications such as National Geographic and Discover.” (I learned all this from e-mail communications from Mary Jo this morning. Apparently, she’s a better reporter than I am.)