Autism and Autistic Spectrum Disorders (ASD)
seem more common among young Somalis in Minnesota and among
immigrant communities in several western countries. At least as late
as 2003, Ethiopian-born immigrants to Israel had no recorded cases
of autism. [That is correct: Not a single one!]
***
The medical literature contains several reports of a higher
prevalence of autism among immigrant communities worldwide.
The earliest report I could find was published on March 6, 1976 in
the Australian Medical Journal. According to Haper and Williams,
relatively more New South Wales children who had at least one
foreign-born parent whose native language was not English, carried a
diagnosis of infantile autism. The authors attributed the behavioral
changes to environmental stresses, adjustment difficulties and a
confusing language environment leading to de-compensation of an
already vulnerable child.
[i]
Autism was a purely psychiatric disorder at the time. Just nine
years earlier, Bruno Bettleheim had published his
widely read The Empty Fortress: Infantile Autism and the Birth of
the Self, where he promoted his sad and offensive
"refrigerator mother" theory of autism.
Gillberg and Gillberg reported in 1996 that of 55 thirteen-year-old
children with autism they investigated, 15 (27%) were born to
parents, “at least one of whom had migrated to Sweden”. In several
cases, the affected child was the first born in Sweden after the
mother’s arrival to the country.[ii]
In 2006,
Maimburg and
Vaeth
[iii] reported results of a “population-based, matched
case-control study of infantile autism” in Denmark and stated that
the risk of infantile autism was increased with foreign citizenship.
Across the Atlantic in 2007, Canadian physicians were reporting
similar findings from Montreal to Vancouver and some complained that
there was “little research to understand why.”[iv]
At the time, I talked to a few informed parents in Montreal and
reviewed with them the local situation.
I was told that for years, the “mother tongue” of students in
Montreal schools was French 42%, Non-English 36% and English 22% and
that most if not all non-English-speaking immigrant children
attended “French” schools.
The parents also claimed that the city’s French schools enrolled a
significant number of children with Pervasive Developments Disorders
and provided me with school year 2001-2002 data from a “Special
Needs School” in a Montreal French School Board. Of the 185 students
aged 4 to 13 in that French school, 56 (30.3%) carried a diagnosis
of Pervasive Developmental Disorder (PDD).
The demographic data are illustrated in the following table.
|
Students in a
“Special Needs School” in Montreal – 2001-2002 |
| |
Mother-language
French |
Mother-language
Creole (Haitian) |
Mother-
language
“Other” |
Total |
|
No. of Students |
85 |
39 |
61 |
185 |
|
Students with PDD |
17 |
18 |
21 |
56 |
| %
with PDD in Group |
20 |
46 |
34 |
30 |
Table I
The above data
very strongly suggest that in Montreal French schools, children of
immigrants had a relatively higher prevalence of PDD than
French-Canadian-born children.
To please the genetic crowd, I will concede that Haitian, Arab and
Asian children are genetically different from French children. But
it is also a fact that they have different vaccination patterns.
As an example, the Regional Program of Vaccination for the Province
of Quebec
[v] states that Hepatitis B vaccination is
recommended and available free of charge to children whose families
(or at least one parent) immigrated from regions where hepatitis B
is highly endemic. The lists of hepatitis B-highly endemic countries
that followed the above recommendation included 47 countries from
the Sub-Sahara, 18 from Asia, 4 from the Middle-East, 24 from the
Pacific Islands, 5 from the region of the Amazon in addition to
Haiti and the Dominican Republic.
According to the Canada Communicable Disease Report of May 1, 2002,
"the only thimerosal-containing vaccine in routine use in the
infant immunization schedules of some Canadian jurisdictions is
hepatitis B vaccine."[vi]
More recently, the Public Health Agency of Canada reported that “The
influenza vaccine and most hepatitis B vaccines are multi-dose
vaccines, which contain thimerosal as a preservative. For
immunization of infants against hepatitis B, parents or guardians in
some provinces and territories have the choice of a thimerosal-free
vaccine.” [Updated 12/2/2010]
[vii]
The Federal Canadian Immunization rules
[viii]
are in effect in all Canadian Provinces including the Province of
Quebec. Part 3 of the Canadian Immunization Guide exclusively deals
with “Immunization of Persons New to Canada”.
It includes the following statements:
-
New
immigrants, refugees and internationally adopted children may be
lacking immunizations and/or immunization records because of
their living conditions before arriving in Canada or because the
vaccines are not available in their country of origin.
-
Only written
documentation of vaccination given at ages and intervals
comparable with the Canadian schedule should be considered
valid.
- Therefore health care providers in Canada who see persons
newly arrived in the country should make the assessment and
updating of immunizations a priority.
*****
Section 341 of the Illegal Immigration Reform and Immigrant
Responsibility Act of 1996 imposed certain vaccination requirements
on all persons seeking green cards in the United States. These
requirements apply to persons seeking to adjust their status to
permanent residence in the U.S. as well as to those who apply for
immigrant visas to enter the U.S.
Under “New Vaccination Criteria for U.S. Immigration” the CDC
[ix] presently lists vaccines for the following diseases as
currently required: Mumps, Measles, Rubella, Polio, Tetanus
and diphtheria, Pertussis, Haemophilus influenzae
type B (Hib), Hepatitis A, Hepatitis B, Rotavirus, Meningococcal
disease, Varicella’ Pneumococcal disease and Seasonal influenza.
The human papillomavirus (HPV) and zoster (Shingles) vaccines were
removed from the list of required
vaccines for immigrant applicants in December 2009.
After carefully reviewing the Canadian and United States vaccination
practices related to immigrants, the following is very evident:
-
Both countries take vaccination of
immigrants very seriously
-
Immigrants and refugees will
likely have a 100% compliance with US vaccine requirements and
Canadian “recommendations”
-
Improperly administered or poorly
documented vaccinations WILL be repeated as needed
The following is quite evident in most Western
and developed countries:
- The present generation of children is the most vaccinated
ever
- The present generation of young parents is also the most
vaccinated ever.
This is particularly
relevant to this discussion where both immigrant children and
children born to immigrant parents in Canada, Israel and the United
States are discussed.
*****
In 2008, Somali parents in Minnesota were alarmed and devastated
when they started noticing disproportionally high rates of Autism
Spectrum Disorders (ASD) among their children when compared to their
schoolmates in preschool programs.
As expected, those parents asked a simple question: “Why was this
happening?
They also hoped to get an answer.
The situation attracted a lot of attention
[x] nationwide. Any mention of some relationship to vaccination
among immigrants was promptly squashed with the argument that many
Somali children born in Minnesota also had a high prevalence of
autistic disorders.
As of July 24, 2008 the Somali tragedy in Minnesota was still a
mystery
[xi] and the Minnesota Department of Health was still
“scrambling to put together a "pre-pilot program" to assess autism
in the general population.” The DOH claimed that its failure to
assess the situation and come up with accurate statistics about
autism among immigrant children with autism was “in part because of
laws restricting access to school data.”
The Minnesota Department of Education on the other hand had no
difficulty stating that “in the Minneapolis' early childhood and
kindergarten programs, more than 12 percent of the students with
autism reported speaking Somali at home. According to Minneapolis
school officials, more than 17 percent of the children in the
district's early childhood special education autism program are
Somali speaking.”
At the time, Somali-speaking students constituted almost 6 percent
of the district's total enrollment in early childhood/kindergarten
special education programs.
A special education official in the Minneapolis school district was
quoted as saying “I've been working to get somebody to look at this
and pay attention because it feels like this is too specific [to
Somalis]. It's got to be preventable.” The same official also
reported that she knew of an apartment building in the city were
almost every Somali family has “at least one autistic child” and
added “They're given more [vaccines] then we get, and sometimes
they're doubled up. Then their children are given immunizations. In
Somalia, their generations have not received these immunizations,
and then suddenly they're getting just a wallop of them in the moms
and then in the babies. That's certainly a concern that's been
expressed to me by the Somali population.”
On March 31, 2009, the MN Department of Health published “Minnesota
and the Somali Community - Report of Study.”
[xii] Only one statement was highlighted in “Bold” character:
“This study did not attempt to identify possible causes or risk
factors for ASD.”
The following paragraph was the only mention of the Somali issue in
the 2-page report:
"Administrative prevalence of Somali
children, ages 3 and 4, who participated in the MPS ECSE ASD
programs was significantly higher than for children of other
races or ethnic backgrounds. This is consistent with what
families and others observed. Because of the study’s
limitations, it is not proof that more Somali children have
autism than other children; however, it does raise an important
question of why Somali children are participating in this
program more than other children.”
On January 15, 2011, the Minnesota Autism Spectrum Disorder Task
Force that included two state senators and two state representatives
in addition to delegates from several agencies and professional
organizations issued an “Interim Report"
[xiii] in which the Somali tragedy was discussed in the
following sentence: “However, a Minnesota Department of Health and
CDC report showed that Somali American children enrolled in
Minneapolis Public Schools had an administrative prevalence of up to
seven times higher.”
*****
The Israeli Paradox
For those who do not know the terribly sad
story of the Jews in Ethiopia, I would like to suggest “History of
Ethiopian Jews”, a remarkable review.
[xiv]
Page 2 of the review is particularly relevant to the present
discussion.
It is unlikely that vaccines or medications ever reached the poor
Ethiopian Jews who had been isolated for years under atrocious
conditions and were waiting to be secretly evacuated to Israel, in
the dark of the night. Certainly their concerned saviors could not
care less whether they were vaccinated and had completed, signed and
stamped “Yellow cards”.
For their part, the government and social organizations looking
after the refugees during their first months in Israel had plenty to
do treating their diseases, improving their health and nutrition,
providing them with much needed psychological support and
“relocating ” them in general. Whether or not the refugees were “up
to date” vaccination-wise was certainly NOT a priority: These new
citizens had in all likelihood survived all the infectious diseases
that Israel had vaccines for.
*****
I recently discovered a remarkable Israeli “File Review Study” by
Kamer, Zohar et al
[xv] that was published in 2003 and that I
somehow had missed all these years.
For accurate reporting, the authors reviewed a national Israeli
registry of 1,004 Jewish children who were diagnosed with PDD. (Arab
children were not included)
They also examined relevant data available from the Israeli National
Bureau of Statistics and found that those Jewish children
born in the years 1983–1997 and living in Israel at the time
belonged to four distinct groups:
Group 1: Native Israelis of non-Ethiopian extraction: 1,198,300
Group 2: Native Israelis of Ethiopian extraction: 15,600
Group 3: Immigrants of non-Ethiopian extraction: 110,300
Group 4: Children born in Ethiopia: 11,800
Data related to the prevalence of Pervasive Developmental Disorders
among those groups are summarized in Table II.
|
PDD Prevalence among
Jewish children in Israel 1983-1997 |
|
|
Born Abroad |
Israeli-born |
|
|
Ethiopian |
Other |
Total |
Ethiopian |
Other |
Total |
|
PDD |
0 |
59 |
59 |
13 |
991 |
1,004 |
|
Total |
11,800 |
110,300 |
122,100 |
15,600 |
1,098,300 |
1,113,900 |
|
Rate/10,000 |
0 |
5.3 |
4.8 |
8.3 |
9.0 |
9.0 |
Table II
There were significant differences in PDD prevalence between
Israeli-born children and immigrant children. But unlike the
situation in Canada and the United States, the estimated prevalence
of PDD among first-generation Ethiopian children in Israel at the
time was 0 (Zero) per 10,000 while among Israeli-born children who
were not of Ethiopian origin, the estimated prevalence was 9 per
10,000.
Not to belabor the point, not a
single immigrant child of the 11,800 born in Ethiopia and living at
the time in Israel carried a diagnosis of PDD.
Native Israeli children had a
higher prevalence of PDD than foreign born children. Among the
children who were born in Israel, those born to non-Ethiopian
parents had a higher prevalence of PDD when compared to those
children who were born to Ethiopian parents.
A genetic immunity to autism among
the Ethiopians is unlikely because:
1. Autism does occur in Ethiopia
2. Children of Ethiopian
extraction born in Israel do develop autism
Trying to explain every aspect of
the paradox is not easy.
I do propose that Jewish Ethiopian
immigrants to Israel, both infants and adults, probably received no
vaccinations in Ethiopia in the rural distant areas where they
lived. Their immigration journey was hasty, at night and cloaked
with secrecy unlike Somali refugees who stayed in pre-immigration
camps for relatively long periods of time waiting to come to the
United States and certainly available for “catch-up measures.”
The Ethiopian infants may also
have been older when they started their pediatric vaccinations in
Israel.
Group 3 included children of
non-Ethiopian origin who came to Israel in the 1990s. These children
had more PDD than Ethiopians but less that “Native Israelis”. A
plausible explanation could be that many if not most children from
that group came from post-USSR countries, where vaccination programs
were limited when compared to those of Israel.
Conclusions
There has been a
continuing barrage of attacks on Dr. Andrew Wakefield and on anyone
who dares to say that a vaccine–autism connection has not as yet
been properly ruled out.
It is evident that the CDC and its supporters have not done, and
will never propose to do, a vaccinated v unvaccinated study, the
only way to rule out such a connection.
A thorough discussion of the subject requires attention to the
child’s and his or her mother’s vaccination profiles.
In this review, I have shown that Autism and Autism Spectrum
Disorders seem to be more prevalent among children of immigrants in
some western countries.
The fact that such disorders have not been reported among Israeli
children born in Ethiopia, and in all likelihood differently
vaccinated, speaks for itself.
Similarly, the fact that children born in Israel to women of
Ethiopian origin (who may have had different vaccination profiles)
are relatively less likely to carry a diagnosis of PDD than children
born to non-Ethiopian and Israeli mothers is also worth noting.
This review is as close as anyone can get to an unvaccinated v
vaccinated study without undertaking such a study and a Zero PDD
count among Ethiopian-born children in Israel should be convincing
enough that the issue is by no means settled, as some would like us
to believe.
References
xv
Kamer A,
Zohar AH,
Youngmann R,
Diamond GW,
Inbar D,
Senecky Y. A prevalence estimate of pervasive developmental
disorder among Immigrants to Israel and Israeli natives. Soc
Psychiatry Psychiatr Epidemiol. 2004 Feb;39(2):141-5.
F. Edward Yazbak MD, FAAP
Falmouth, Massachusetts