Purposely

A Short Story

The pen is a Cross ballpoint, black, given to him by his wife when he finished residency in 2014. The form is white with pale blue rules, four copies, carbon-backed, the kind the state still requires even though everything else has gone electronic. The kitchen table is oak. There is a scar near the left corner where his daughter dragged a kitchen knife across it when she was three. The photograph on the fridge is of his grandson, Eli, eight months old, in a yellow onesie, propped against a cushion on his daughter’s couch.

He has poured a bourbon. He has not yet drunk from it.

The cause-of-death field is the fourth box from the top. He has filled it in many times. For an eighty-seven-year-old with congestive heart failure. For a sixty-one-year-old with metastatic pancreatic cancer. For a forty-four-year-old after a motorcycle accident on Route 9. Never for a fifteen-month-old.

The shot was Tuesday. He gave it himself. MMR, varicella, hepatitis A, the fourth dose of DTaP, two in each thigh. The mother asked about spacing them out. He said the schedule was the schedule. He said combination doses had been studied extensively. He said this because it is what he was taught to say. He has said it perhaps four hundred times in his career. The mother nodded and signed the form. He gave the child a sticker shaped like a star.

The fever was Wednesday afternoon. The mother called the office. The nurse said this was normal, that Tylenol was fine, that she should call back if the fever exceeded 104 or went past 48 hours. The fever was 103.4 that evening. The mother gave Tylenol.

The seizure was Thursday morning at 6:47. The mother called 911. The ambulance took the child to the regional hospital. The mother told them about Tuesday. It was recorded in the chart. The ER physician wrote febrile seizure, simple, first episode. The child was admitted for observation. The seizure stopped. The fever came down. The child slept.

The death was Friday at 4:12. The nurse found him. He was not breathing. They worked on him for thirty-eight minutes.

The autopsy was Saturday. The pathologist found nothing. No anatomical cause. The brain was unremarkable. The heart was unremarkable. The lungs showed mild congestion consistent with the resuscitation effort. There was no infection. There was no congenital anomaly. There was no trauma. The toxicology screen was negative for everything it tested for.

The pathologist called him on Saturday evening. I have nothing for you, Tom. The pathologist said I’m sorry, I really am. The pathologist did not say the word vaccine. The pathologist did not say the word Tuesday. The pathologist said this happens sometimes, we don’t know why, write it up as SUDC, the family needs something to put on the certificate.

SUDC. Sudden unexplained death in childhood. He learned the acronym during residency, in a single lecture, from a pediatrician who said it was rare but real, the toddler equivalent of SIDS. Cause unknown. No preventive measures established. The lecture lasted forty minutes. There was a slide with a bar chart. The bar for vaccination status was not on the chart.

He thinks about the chart now. He thinks about why he is thinking about the chart now.

The kitchen is quiet. His wife is in the next room watching a baking show. The contestants are making puff pastry. He can hear the host counting down the time.

He writes sudden unexplained death in childhood in the cause-of-death field. He writes it carefully, in block capitals, because the form will be scanned and the OCR is unreliable with cursive. He writes the date of death. The time. The location. He signs his name.

He does not write MMR, varicella, hepatitis A, DTaP administered four days prior to death.

The vaccines are not on the form. There is no field for them. There is a field for contributing causes and he could write them there. He could write recent vaccination and the certificate would still be valid. The state would accept it. The funeral home would not refuse it.

He does not write it.

He thinks about why he does not write it. He thinks about it for what becomes, by the kitchen clock, eleven minutes. The bourbon is still untouched.

He thinks about the senior partner. He thinks about the conversation in 2016, his second year at the practice, when he asked about an older case. A six-month-old who had died three weeks after a well-child visit. The senior partner had said Tom, listen to me. You don’t put it on the certificate. You don’t put it in the chart as related. You document the visit, you document the death, you don’t draw the line between them. The line isn’t yours to draw. That’s what VAERS is for. If you think there’s a signal, you report it to VAERS. You don’t put it on the death certificate. The senior partner had said this kindly. The way a father tells a son how the world works. The senior partner had said the family will sue you, the practice, the manufacturer, everyone. The malpractice carrier will drop us. You will not be able to practice medicine. And for what? You don’t know that the vaccine caused it. You think it. You suspect it. That’s not the same. The certificate is for what you know.

He had nodded. He had not reported it to VAERS. He has never reported anything to VAERS. He does not know anyone at the practice who has.

He thinks about VAERS now. He thinks about the form, which he has never filled out, which he believes takes thirty minutes, which he believes goes into a database that no one reads, which he believes will not change anything but will mark his name in a federal system as a physician who associates vaccines with death. He thinks about his daughter. He thinks about Eli on the fridge. He thinks about the practice, which his daughter joined two years ago, and which his son-in-law’s loan is partly secured against. He thinks about the malpractice premium, which went up 14% last year for reasons the carrier did not explain.

He thinks about Tuesday. He picks up the bourbon and does not drink it. He thinks about the small hiss of the vial when he drew the MMR into the syringe. He puts the bourbon down.

He thinks about the pediatrician at the lecture in 2012. He thinks about what she would have had to say, if she had said it. He thinks about whether she knew.

He thinks about the senior partner, who is sixty-three, who has been practicing for thirty-five years, who is godfather to his daughter.

He thinks about the studies he was told had been done.

He thinks about Sarah, who held her son’s legs.

He picks up the bourbon again. He drinks half of it.

He thinks about the sticker. The sticker is the part he cannot get past. The sticker is what he gave the child after the four shots, while the child was still crying, while the mother was putting on the child’s pants. The sticker was yellow with a star. He has a box of three hundred of them in the supply cupboard. He orders them from the same company that sells the tongue depressors.

He thinks about what he would have to believe to write recent vaccination on the certificate. He thinks about how many people he would have to be wrong about. He thinks about it for a long time. The bourbon is finished.

He writes sudden unexplained death in childhood.

He signs the form.

---

In 1893, in The Birmingham Medical Review, a physician named Henry May described a case in which he believed vaccination had caused a child’s death. He wrote I purposely omitted all mention of vaccination from my certificate of death. He explained why. He explained that to write it would invite professional ruin, would distress the family, would feed what he called the anti-vaccinationist agitation, would accomplish nothing for the child, who was already dead. He published the admission in a medical journal because his conscience required it. He did not change the certificate.

The certificate, in the case Henry May described, said erysipelas.

The certificate, in the kitchen tonight, says sudden unexplained death in childhood.

The interval is a hundred and thirty-three years.

---

The fifteen-month-old’s mother is at this hour twenty miles away, in the waiting room of the Henderson Family Funeral Home, being shown caskets in three sizes. The director is kind. The director has done this before. The director tells her that what happened to her son is very rare and very mysterious. That the doctors do not know why these things happen. That she should not blame herself. That there was nothing she could have done.

The mother is twenty-six. Her name is Sarah. She nods because nodding is what her body does when words will not come. She is not asked about Tuesday. She is not told about Henry May. She is not told that the certificate, when it arrives at the state vital records office on Tuesday morning, will enter a database that will be queried, years from now, by researchers asking how often unvaccinated children die of unexplained causes compared to vaccinated children, and that her son will be counted as an unexplained death, and that the four-day interval will not be in the database, and that the answer the researchers find will be used to write the next pediatrician’s lecture, the one with the bar chart that does not include a bar for vaccination status.

She picks the middle casket. White with silver fittings. Her husband is not with her. He is at home with the dog, sitting on the floor of the nursery, holding a stuffed elephant. He is not crying. He has stopped being able to cry. He is waiting for the casket to be chosen because choosing it himself is not something he can do.

The director writes down the choice. The director says I’ll handle everything from here. The director hands her a folder of paperwork. One of the documents in the folder is a copy of the death certificate. The copy is for the family’s records, the director explains. The original goes to the state. The mother does not open the folder. She puts it in her bag. She drives home.

The folder will sit on the kitchen counter for three weeks before her husband opens it. When he opens it, he will read sudden unexplained death in childhood and he will read it again and he will sit at the kitchen table for an hour, and then he will put the folder in a drawer and he will not open the drawer again for two years.

---

The physician at the kitchen table is forty-one. He has a daughter, a grandson, a wife in the next room. He has a loan and a partnership and a malpractice carrier and a senior partner who is godfather to his daughter. He is what Henry May became when Henry May was repeated, in slightly different forms, in slightly different rooms, on slightly different Sunday evenings, for one hundred and thirty-three years.

He pours a second bourbon. He drinks it standing at the counter. He thinks about Eli on the fridge. He thinks about Eli’s two-month appointment, which is on the eleventh.

He puts the glass in the sink.

He returns to the table. The certificate is in its envelope. The envelope is sealed. He has not addressed it yet. He addresses it now. State vital records office. The address is printed on a sticker the office sends in batches of twenty. He uses one of the stickers. He puts the envelope in his work bag by the door.

He turns off the kitchen light. The photograph of Eli is still on the fridge. He does not look at it as he leaves the room.

In the bedroom his wife is asleep. The baking show is still playing in the other room. He turns it off on his way past. He brushes his teeth. He gets into bed. He does not sleep for a long time.

He thinks about Sarah, who he has not called, who he should call, who he will not call, because calling her would require him to say something, and he does not know what to say that would not require him to say more, and he cannot say more without becoming someone he is not.

He thinks about Henry May. He does not know the name. He has never heard of him. But somewhere in the long chain of Sunday evenings between 1893 and 2026, in the long chain of kitchen tables and certificates and pens, the practice he is part of was made what it is. He inherited it the way one inherits the shape of a hand or the slant of a signature. He did not invent it. He will not change it. He will pass it on.

On Monday morning he will take the envelope to the practice. He will give it to the receptionist. The receptionist will mail it. The certificate will arrive at the state vital records office on Tuesday. The four-day interval between the shot and the death will not be on the certificate. The certificate will be filed. The death will be counted as unexplained.

At the state vital records office a clerk will open the envelope and scan the certificate into the system. The OCR will read his block capitals cleanly. The certificate will be indexed under the diagnostic code R99 — ill-defined and unknown cause of mortality. It will sit in the database alongside other R99 deaths. The database will be queried, in 2031, by a graduate student writing a thesis on pediatric mortality trends. The graduate student will pull the R99 records for children under two and run them against an exposure variable. The exposure variable will be drawn from a separate database that records vaccination dates by zip code, in aggregate, not by individual record. The graduate student will find no significant association. The thesis will be published. The thesis will be cited in a CDC briefing paper. The briefing paper will be cited in a peer-reviewed article. The peer-reviewed article will be cited in the next pediatrician’s lecture, the one with the bar chart that does not include a bar for vaccination status.

The mother is not told about the chain. The mother is told that what happened to her son is rare and mysterious. The mother believes it because the people telling her have no reason to lie.

The people telling her have no reason to lie. This is the precise sense in which they are telling her the truth.

On Tuesday afternoon another mother will bring another fifteen-month-old to the office. She will be asked about spacing the shots out. He will say the schedule is the schedule. He will say combination doses have been studied extensively. He will say this because it is what he was taught to say. He has said it perhaps four hundred and one times in his career. The mother will nod. The mother will sign the form. The child will cry for forty seconds and then stop.

He will give the child a sticker shaped like a star.

---

In the kitchen, the bourbon glass is in the sink. The certificate is in the bag by the door. The photograph of Eli is on the fridge. The kitchen clock reads 11:47.

Henry May, in 1893, wrote I purposely omitted all mention of vaccination from my certificate of death. He chose the word. He thought about it. He wrote it down. He published it in a medical journal because his conscience required him to.

The physician at the kitchen table does the same thing Henry May did. He does not use the word. He does not write it down. He does not publish anything. The conscience that required Henry May to leave a record has been trained, over one hundred and thirty-three years, out of him.

This is what one hundred and thirty-three years accomplishes.

---

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