August is National Immunization Awareness Month. An annual observance held to highlight the importance of vaccinations for people of all ages. However, this year it feels a bit like an oxymoron, as certain high-income areas of the United States have vaccination rates on par with low-income countries around the world.

For example, until 2015 parents in California could elect to not vaccinate their children through what are called Non-medical Exemptions or Personal Belief Exemptions, whereby parents could be exempted from the traditional medical recommendations because of what they philosophically believe. Despite state-level changes, reports suggest parents in California are still opting at twice the rate as previous years from getting their children vaccinated. This has led to immunization rates in places like Santa Monica and Beverly Hills that are as low as the country of Chad and South Sudan.

According to the American Academy of Family Physicians, “The number of philosophical exemptions to vaccination has increased in two-thirds of the states that allow such exemptions. As a result, researchers suggest that these areas are becoming increasingly vulnerable to vaccine-preventable disease outbreaks.”

What this means is that Measles outbreaks and Whooping Cough, long eradicated from the U.S., are back. Clearly signaling a public health crisis.

Why Are Vaccination Rates Low?

Many point to the anti-vaxx movement in the U.S. and around the world for declining vaccination rates. And parents within that movement often note autism as the reason for avoiding vaccines for their children. However, this is despite study after study around the world, as well as statements by the CDC, indicating that vaccinations have no impact on developing autism.

That said, vaccinations are not perfect, and they sometimes do result in side effects like muscle pain, headaches, and in very rare cases allergic reactions. All of which need to be properly addressed by the medical community.

But the anti-vaxx movement is not the only thing at play when it comes to declining rates of immunity in the US. For example, the number of vaccines recommended by the CDC’s schedule for children entering school, has nearly tripled in the last decade. What that means is that the number of vaccines – often monovalent – or single doses that children need has increased. Consequently, the number of visits for parents, the number of shots, and therefore the costs have also increased. All making it more difficult to complete that schedule.

At the same time, providing vaccinations doesn’t pay well. Despite myths about doctors making money to push immunization shots on patients, on the doctor side of the equation providers have very little incentive to make vaccines a priority for their medical practices.
All these factors in tandem mean that we find ourselves in a public health crisis as we enter National Immunization Awareness Month in 2019. And the only way to solve this crisis is to use local, state and federal solutions together. As well as ensure that educational campaigns inform parents about the risks of not vaccinating.

At the end of the day, we all have to come together to get vaccination rates in the United States above 90%, in which herd immunity can protect children.
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• You can view, download, or print CDC resources to learn more about immunizations and vaccine-preventable diseases here.
• For parents wanting information or to make decisions on vaccinating their baby, please visit the American Academy of Pediatrics website.
• For the CDC’s child, adolescent and adult immunization schedules, go here.

When thinking about traumatic brain injuries (TBI), most people immediately conjure images of NFL players, car accidents or nasty falls. But there is a global public health epidemic  going completely unrecognized – and untreated: intimate partner violence (IPV). In fact, IPV is the most common form of violence against women in the world, with nearly 1 in 3 women age 15 or older experiencing physical or sexual IPV. And it occurs in all settings, amongst all socioeconomic, religious and cultural groups.

Shockingly, up to 90% of injuries sustained in IPV are to the head, face, and neck. And research has shown that 75% of women with a history of IPV sustained at least one partner-related TBI and nearly 50% sustained repetitive TBIs. Thus, it is sadly not surprising that the women who experience IPV report symptoms consistent with those who have sustained TBIs, such as problems with, “concentration, memory, headaches, depression, anxiety, fatigue, and sleep.”

According to Eve Valera, Ph.D., “The number of women sustaining IPV-related TBIs dwarf the combined number of military and NFL TBIs or concussions reported. Using annual estimates of severe physical violence (totaling 3,200,000 women), about 1,600,000 women are estimated to sustain repetitive IPV-related TBIs in comparison to the total annual numbers of TBIs reported for the military and NFL (18,000 and 281, respectively).” While she suggests that we need to learn more about all of these cohorts, she points out that there are only two IPV/TBI imaging studies published, compared to the growing body of literature on TBI in athletes and military populations. And she should know, because both of those studies are hers.

But what makes this epidemic so difficult to understand, is much greater than just a lack of research on brain injuries. The truth is, there are a number of confounding factors at play including a general lack of research on women, and thus extreme underrepresentation of sex and gender differences that exist in brain injury. Add in that women who suffer from IPV are often unable to join research studies either due to fear of their partner, societal stigma associated with domestic violence, or simply a lack of resources in their daily lives.

While IPV affects all socioeconomic strata, according to the Prevention Institute there is a multifaceted set of risk factors including, poverty, social marginalization, weak social support networks, gender and cultural norms that promote harming others that frequently accompany IPV – making resources and access to care and research extremely limited. Additionally, because domestic violence happens behind closed doors, many individuals are unwilling to get involved in what happens in other people’s homes.

"If brain injury is the “invisible illness” of our time, then within this invisible injury, women have been the invisible patients,” says Katherine Snedaker, Founder and Executive Director of PINK Concussions. And the data support Snedaker’s statement. Even if some estimates were overstated, and as few as half (50%) of women who are exposed to IPV suffer TBIs, that would still be one in every eight women – the same statistic as breast cancer. Yet we have very little existing knowledge and research exploring this intersection.

Although very little research has been done on the repetitive damage of IPV and TBI, the number of research faculty around the world is growing. And like Lin Haag and Dr. Valera, their voices are gaining volume and their body of work is growing. There is also a growing awareness amongst the general population that invisible injuries – whether sustained on the battlefield or the sport field – are real and dangerous. And they can be life changing due to the cognitive, emotional and physical challenges associated with a TBI.  The next step is making this same realization for women survivors of IPV-related TBI.

Improvements in combating stigma and shame associated with IPV are also making small strides in communities of every religion, race and socioeconomic strata, as mental health efforts grow in number. This also includes training community workers, shelter employees and medical staff to recognize the signs of TBI earlier – and be looking for it in women who present with complaints about cognitive troubles or behavior associated with trauma. Attempting to do just that, Lin Haag, Dr. Colantonio and their team, are just completing a web-based toolkit educating frontline workers about TBI in women exposed to IPV. And, as Dr. Valera hopes, that the education of police forces and judges will make a significant difference in the lives of women and their children. “As first responders and judicial personnel learn to ask about and recognize IPV-related TBI, women’s behaviors may be interpreted in the context of a TBI that occurred behind closed doors rather than simply ‘strange’ or ‘uncooperative’. This interpretation will ultimately help women receive appropriate care and legal decisions.”
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All the women in this article are open to being contacted by those with questions about IPV, TBI or how to get involved in their research. If you’re a survivor of intimate partner violence, there is a 24/7 hotline and online resource where you can get help here.