I’ve been involved in several boisterous Twitter debates about vaccines, at least to the extent that one can debate using snippets of 140 characters or less. I’ve also been a Super Moderator at a very large Internet message board (AbsoluteWrite) for many years and have seen my share of passionate vaccine debates there. I’ve been a pediatrician for over 30 years and trained in the subspecialty of pediatric infectious diseases before I went into critical care. So I think a lot about vaccines and have watched controversies about them come and go for a very long time. It’s been interesting. One very interesting aspect for me is trying to understand how parents think about the relative risk of medical treatments and procedures for their children. It’s different from how physicians think of risk, and I think this difference is key to understanding the continuing ferment over vaccinations. I’ve previously written about the risk of a vaccine injury (about 1 in a million at worst) compared to the risks of everyday life, but there is another aspect to the issue: in my experience parents are uniquely worried about vaccine risk in ways they are not about other medical procedures and treatments. A few examples illustrate my point.
Stevens-Johnson syndrome is a severe skin reaction to something, most commonly a medication. It varies in severity but can progress to a very bad condition known as toxic epidermal necrolysis. This is a life-threatening condition and often requires a prolonged stay in the intensive care unit. I have seen several life-threatening cases over the years. The drugs that can cause it are quite common ones. Many are antibiotics; sulfa drugs, for example, are well-known offenders. How common is this condition? There are about 300 cases per year in the USA. This makes it much more common than vaccine injury, yet nearly all parents think of antibiotics as safe drugs. On balance, they are — but they are not risk free.
Medications like antibiotics can cause other kinds of allergic reactions, which can be severe or life-threatening. A very conservative estimate is that about 0.01-0.05 % of all people — about 1-5 per 10,000 individuals — will have such a serious drug reaction in their lifetime. Yet parents accept prescriptions without worrying about that.
Another example is anesthesia. As part of my practice I anesthetize many children for procedures, such as MRI scans. The risk of doing this is low, but it is well above zero. The actual risk of death from an anesthetic is around 1 in 250-300,000 — about 3 times the risk of a serious vaccine reaction. There also may be neuro-developmental risks to young children who receive anesthetics. That risk is very low, too (there are many studies ongoing to define it), but it is not zero. Of course if a child needs emergency surgery the balance of risk versus benefit overwhelmingly favors using the anesthetic, but there are many other situations that are not so clear-cut. Yet virtually all parents willingly allow me anesthetize their child.
My point is that vaccine risk, compared with the risks of other medical interventions, causes particular concern among parents, and I am not sure why that is. However, it is not new. Since the introduction of the very first vaccine, Edward Jenner’s use of smallpox vaccine, people have been particularly suspicious of vaccines. (The name “vaccine” itself is derived from Jenner’s use of the vaccinia virus, the cowpox virus, as a protection against smallpox.) As noted in the essay linked above:
Although the time periods have changed, the emotions and deep-rooted beliefs—whether philosophical, political, or spiritual—that underlie vaccine opposition have remained relatively consistent since Edward Jenner introduced vaccination.
I suppose the notion of putting a foreign substance into a child’s body with the intention of provoking the body to react to it is philosophically distinct from giving a child a medication that is not intended to do that. But I would be very interested in what other people think makes vaccines unique.
Now and then physician and nursing colleagues, parents, and random e-mailers ask me how to get a book published on a medical topic for a non-medical audience. Since I’ve published two moderately successful books of that sort and have a third one coming out next spring, they think I’ve got some understanding of the process. I think I have some of that.
All of us who work in medicine have a storehouse of stories and experiences from what we’ve seen. Parents of children who have had a lot of medical issues have important first-hand knowledge, too, in how medicine and medical care works. Many believe, as I did when I got started doing this, that other people would be interested in and could be helped by whatever insights we’ve gleaned over the years. They want to write a book about it. If you’re one of those people, great, but here are a few things you should understand.
A good book brings value to the people who buy it — enjoyment, useful knowledge, and, the author hopes, a combination of the two. What a potential author should really, really understand, though, is that book publishing is first a business. Publishers need to make money to stay in business, and profit margins in this business are extremely thin. This means no matter how wonderful your insights or compelling your stories, you need to write a book that people will buy. The prospective author must convince hard-headed business people that the book will make money. Thus what the author is pitching is as much a business plan as anything else.
An author who wants to publish a novel must first write the entire novel before anyone will look at it. Nonfiction, such as a medical book, is different; it is sold on the basis of a proposal. The proposal describes what the book will be and the audience of readers who will buy it. It also contains the author’s credentials to write the book and, very importantly these days, the author’s plan of how to market the book. The proposal ends with one or two sample chapters, typically the first ones, to show the publisher you can write well.
Nearly all people who ask me about these things don’t know that none of the large publishers, and very few of the middle-sized ones, will even look at a proposal if you send it to them. They only consider proposals submitted by literary agents. Small publishing houses often allow authors to submit to them directly, but if, like most authors, you want to reach the largest audience, then you want one of the bigger presses because they have the distribution channels, particularly to book stores.
Finding an agent can be a long and often disheartening process. Agents work on commission. This means they do not charge authors anything. If someone who says she’s an agent wants you to pay them, they aren’t legitimate, and there are many, many shady folks out there claiming to be agents who are happy to take your money. The agent only gets paid if the book sells to a publisher, so for that reason agents are very, very picky about what they take on. Like publishers, agents are asking a simple question: will people buy this book? If they don’t think it will sell, they will reject your proposal, even if they think it is a wonderful book in many ways. Agents reject the large majority of proposals sent to them, often 95% or more of them. Part of being an author is learning not to take these rejections personally.
Before you even send an agent your proposal, though, many of them want you to send them a brief query letter describing the project. If they’re interested, they’ll ask for the full proposal. (Some agents say you can send them the proposal directly with a cover letter.) Expect to pitch your project to many agents before you land one — it took me about 40 queries to get my agent, and many authors I know of queried many more than that. I don’t know how many prospective authors give up before they get an agent, but I suspect it’s the great majority of them. Once you get the agent you’re not there yet; she has to sell it to a publisher, and many proposals don’t sell. When a publisher actually buys your proposal, then you can sit down and write the actual book. It’s not a good idea to write much more than the sample chapters until that happens, because the publisher often wants major changes.
There is a vast amount of information on the internet about this entire process, and some of it is even correct. There are also many books about how to get yourself published. One of the most useful books to me when I began was Thinking Like Your Editor: How to Write Great Serious Nonfiction — And Get It Published, by Susan Rabiner and Alfred Fortunato. The authors are agents and former publishing editors, and they know what they are talking about. It has great advice about how to write query letters and proposals, complete with examples. There are also books that catalog literary agents — who they are, what kind of books they represent, and guidelines for submitting to them. Jeff Herman’s guide is a good one. A great online site about agents is Agent Query.
There are also many, many online sites for writers’ groups where you can get advice, get someone to read your query letter and critique it, and commiserate with other published and aspiring authors. I’m a Super Moderator at one of the biggest of these, AbsoluteWrite (my screen name is ColoradoGuy), so naturally I think that is a good source.
There are also several highly-regarded blogs maintained by prominent literary agents. Several good ones are those by Kristin Nelson, Jessica Faust, Nathan Bransford, and Janet Reid. They are useful and even fun to read, but realize that most of the people who read (and comment on) them are fiction writers. But a nonfiction writer can still learn a huge amount about the publishing industry by giving them a look. Jessica Faust has a good summary of what to put in your proposal here.
It’s interesting and fun to write books of the sort I do. Even if you are successful in getting published, however, don’t expect to make much money doing it. Even so, it’s well worth the effort, I think, and you might even do some good in the process.