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
iv
http://www.cbc.ca/health/story/2007/06/06/autism-immigrants.html
Accessed 01/14/11
vii
http://www.phac-aspc.gc.ca/im/q_a_thimerosal-eng.php
Accessed 01/19/11
viii
http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-11-eng.php
Accessed
01/11/11
ix
http://www.cdc.gov/immigrantrefugeehealth/laws-regs/vaccination-immigration/revised-vaccination-immigration-faq.html#whatvaccines
Accessed 01/11/11
x
http://www.nytimes.com/2009/04/01/health/01autism.html
Accessed 01/16/11
xi
http://www.minnpost.com/stories/2008/07/24/2687/a_mysterious_connection_autism_and_minneapolis_somali_children
Accessed 01/17/11
xiv http://www.jewishfederations.org/page.aspx?id=791&page=1
Accessed 01/17/11
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
