"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
CDC Update: Only 75 members of the public attended the CDC public forum on smallpox vaccine in San Francisco Thursday night. It sounds like none of them wanted the vaccine to be offered, but according to the report, it also sounds like the CDC panel has already made up its mind:
"Five doctors advising the federal government on its smallpox vaccination policy appear unanimous in their opposition to a mass inoculation of all Americans, arguing the chances of a terrorist smallpox attack are remote and the vaccine is harmful to many people."
I'm still mystified by this attitude that the chance of an attack is small. That's the trouble with terrorism and war in general, attacks are meant to be a surprise, not a certainty. posted by Sydney on
6/08/2002 07:29:00 AM
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Natural Family Planning on Trial: The makers of a device that measures urine hormone levels to tell a woman when it is safe and unsafe to have unprotected sex are being sued by fifty of their customers. The device, called Persona (not available in the US), has a 94% effectiveness rate. That means that if 100 women use it for one year, six of them will get pregnant, or as the British version of the FDA helpfully points out, one in seventeen users will get pregnant. Put that way, it's not surprising that these fifty women got pregnant. What is surprising is one woman's response to her unwanted pregnancy:
"The Kings were so concerned about the age gap between the daughter and her siblings that they decided to have a fifth child."
C-Section Boomlet: I have always been taught that vaginal birth is superior to Caesarean birth, and that the latter should be avoided at all costs. Vaginal births require less medical intervention and supposedly have fewer complications for both infant and mother. They are certainly less expensive. Women recover more rapidly from vaginal deliveries than Caesarean sections. The supremacy of vaginal deliveries has become the dogma of hospitals, medical societies, and insurance companies. For years hospital review boards have scrutinized obstetrician's rates of C-sections. Too many, and they were reprimanded. Yet, despite all of the scrutiny, C-section rates are rising. The story says that it is largely due to the number of women who are opting for second C-sections instead of trying for a vaginal delivery the second time around. Vaginal deliveries after a previous C-section are just a little bit riskier than the average natural birth, but they're still considered safe. I can understand why women would chose the C-section route. It certainly saves them a lot of pain and suffering. It's ironic, though. The initial condemnation of C-sections had its genesis in activist women's groups who saw the procedure as unnecessarily invasive and an attempt by male doctors to control their bodies. They waged a campaign against the procedure and the medical establishment listened. Now, a significant proportion of doctors are women and the C-section rate is climbing again by popular request. Hmmm, could it be that those activists from twenty or thirty years ago were biased against men? posted by Sydney on
6/08/2002 07:04:00 AM
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What Would Mrs. Thurber Think? In James Thurber's quasi-autobiographical book My Life and Hard Times he portrayed his mother as living in constant fear of the ions falling out of the electrical wall sockets onto her floor. Well, in Japan, they pay big money for machines that pump ions into the house. The human body may be a delicate machine, but it isn't so delicate as to be influenced by environmental ions. posted by Sydney on
6/08/2002 06:43:00 AM
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Friday, June 07, 2002
Correction: I added a correction to my post of June 4 on the article from Science about the smallpox vaccine. I underestimated the number of first time recipients who would have a potentially fatal complication from the vaccine. The actual number is 294 per one million first time recipients. The article, therefore, only overestimates the risks of fatal complications by a factor of four, not ten. The number of potentially fatal complications in second time vaccine recipients would be 16 per one million vaccine recipients. Sorry for the mistake. Forgive me. Mea culpa, mea culpa, mea maxima culpa. posted by Sydney on
6/07/2002 07:39:00 PM
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Bioterror Blinders: Peggy Noonan's op-ed today in the Wall Street Journal wonders why we are concentrating on our past failures to prevent terror instead of focusing on efforts to prevent future attacks, especially bioterror attacks:
"Here is a great irony: We are distracting ourselves from our predicament by obsessing on our tragedy. We are investigating the systems failure of Sept. 11, and while we investigate it we are contributing to the next systems failure. Every minute, every bit of energy and focus we give to Sept. 11 is stolen from the amount of time we have to concentrate on how to avoid the next Sept. 11--and what to do if we fail and it happens.
What should we be giving our attention to? What should we be passionate about, dedicated to, focused on? Here is one of many things: making sure our children are inoculated against smallpox. We know bioterrorism is more than possible, and we know few Americans under 30 have been vaccinated; we wiped out world smallpox, and stopped vaccinating in 1972. My son was born in 1987. When were your kids born?
Here is another thing. Why isn't our government telling people, through television and pamphlets and speeches and announcements, what they need to do to survive a potential nuclear attack? Why aren't they launching a great campaign now to tell us what we can do in case of one? Is the government getting together the medicines and protections necessary to help the poor of the cities who, in a moment of terrorism, would have nothing to protect them? If not, why not? What should mom and dad in the suburbs do if they see a flash of light and a two mile high cloud in the city 22 miles away?
Why aren't we addressing these things? In part I think because humans just aren't good at facing terrible things that are future things. They face today and think of yesterday. And in part because we are distracting our officials with the demand that they make their lame explanations for how they failed last time. Yesterday Mr. Mueller testified most of the day. I would rather he had spent the day concentrating on finding terrorists. Wouldn't you?"
Immunization Update:The New Republic has picked up on the immunization shortage story. I agree with the author that immunization against infectious diseases like measles and whooping cough is a public health concern that should not be left to the free market. We really should do more as a nation to make sure those vaccinations are available to all children. However, this is not of the same magnitude as the threat of smallpox. Measles and whooping cough are neither as deadly nor as contagious as smallpox. And they aren’t likely to be used as a weapon of mass destruction. The vaccine shortage is not a new development. There has been a shortage of tetanus for over a year now, and the CDC has failed to take any action.. They spend far more time obsessing about lifestyle diseases. The CDC could stand the same level of scrutiny right now that the FBI is getting. posted by Sydney on
6/07/2002 07:33:00 AM
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Smallpox Vaccine Update:The Washington Post has a summary of the smallpox vaccine debate, including this revelation about the current thinking of the experts vs. the general public:
"At a meeting last month of members of ACIP and a related body, the National Vaccine Advisory Committee (NVAC), there was little support for making smallpox vaccination available to anyone who wanted it. Nevertheless, there appears to be public support for just that.
Interviewers hired by the Harvard School of Public Health and the Robert Wood Johnson Foundation last month asked a sample of 3,000 Americans whether they would get a smallpox vaccination if it were offered. Fifty-nine percent said yes."
Evidently, the average man on the street has a better feel for the risks we face than the experts.
The article also contains a couple of incorrect assumptions that deserve correcting:
"Historically, ring containment worked for smallpox for several reasons. All infections are obvious because of the disease's dramatic, bumpy rash; people don't transmit the virus until the rash appears; and, most important, if someone is vaccinated within seven days of exposure, the risk of becoming infected is reduced substantially (by as much as 70 percent, according to old studies). The disease is less contagious than some viral infections, such as measles and influenza, with data from pre-eradication outbreaks in Asia suggesting that infection usually requires days of close exposure to someone who is sick."
There is, actually, a window of two days when a person is infectious but does not yet have a rash. During those two days they may have nothing more than a flu-like illness. Ring containment worked in the eradication campaign because of high levels of background immunity which made it more difficult for the virus to find susceptible hosts. It does not require a few days of close exposure to contract the disease. In a non-immune population it spreads very easily. It is not less infectious than measles or influenza, and even if it were, it is much more fatal.
UPDATE III: The CDC held its public comment forum in New York last night. The consensus there was that they should vaccinate health care workers. That's not surprising, the audience was largely made up of health care workers. The meetings, quite frankly, haven't been widely publicized. I certainly think healthcare workers should be vaccinated, but I don't see why we should deny the same protection to ordinary citizens. They will be at just as much risk in the community, and at even more risk if they happen to be in a hospital or a physician's office where a smallpox patient walks in for treatment.
UPDATE IV: I found this great site on the history and basic science of smallpox while web surfing last night. The information is accurate and comprehensive, and it has great pictures.
YET ANOTHER UPDATE: Only eight citizens of New York spoke up at the CDC's public forum on the smallpox vaccination. "Only a handful" showed up in contrast to the 150 members of the CDC who were there. That's not so surprising, the media haven't really publicized these forums, which means that the CDC hasn't been sending out press releases about them. Not only that, but they haven't been publicizing the issue at all. There have been few articles on the risks of smallpox or of the vaccine in the popular media. My local paper, which takes most of its national stories from the New York Times, hasn't covered it at all. That's a shame. The CDC could do better than that, if they wanted to. posted by Sydney on
6/07/2002 07:23:00 AM
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Pricey Drugs: This story about aspirin being superior to and less expensive than another anti-clotting drug is a bit off base. The more expensive drug is usually used when aspirin has failed, such as when someone has a stroke when taking aspirin once a day, or in conditions that don’t respond all that well to aspirin, such as severe hardening of the arteries. The study the story is based on assumed that the more expensive drug, Plavix, would be given to everyone after a heart attack. This just doesn’t happen, at least not in my neck of the woods. The average heart attack patient goes home with instructions to take aspirin once a day. The only ones who go home with Plavix are those who had a stent placed in their coronary arteries, and even then they only take it for about six weeks. The media are on a rip about drug prices. The issue certainly deserves attention, but the media should be more selective in the stories they decide to run with. Not all pricey drugs are bad or overused. posted by Sydney on
6/07/2002 07:20:00 AM
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Screen or Else: Medicaid is threatening to suspend doctors' Medicaid payments if they fail to screen for lead poisoning in children under six. That won't help. I order lead screening routinely in children on Medicaid, but less than fifty percent of them ever get the test. Their parents don't take them to the lab. Now, the government is talking about penalizing the physician for the patient's non-compliance. I've got news for them. Medicaid has such a poor re-imbursement that no doctor is going to miss it. Doctors who accept Medicaid patients do it out of altruism, not for profit. Withholding payments from doctors will only make them more likely to drop the program altogether. The poor certainly won't be served by such a policy. They won't be able to get needed care for illnesses and for immunizations, all because the government has a bee in its bonnet over a screening test. The last time I had a patient with a high lead level was fifteen years ago. It isn't that common a problem in every neighborhood. If they really want to eliminate lead poisoning, they could hire public health nurses to go out to the high risk areas and do testing at homes and in neighborhoods. Oh, but that would take money, whereas their current plan would save them money. posted by Sydney on
6/07/2002 07:09:00 AM
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Analyzing Their Reproach Among Women: After all that publicity last month for the Sylvia Ann Hewlett book about the misfortunes of childless women, here, finally, is a book that approaches the issue of motherhood with some sense. Personally, I think the author is a little too kind in her description of the peer pressures women place on one another regarding the issue. She suggests in the interview that the isolation childless women often feel stems more from a lack of commonality than from anything else. I disagree. A large part of those pressures come from the aura of superiority that women with children too often assume over the childless.
This has been going on for as long as women have been having children. Mary Chestnut commented on it in her diary, written during the Civil War:
"I did Mrs. Browne a kindness. I told those women that she was childless now, but that she had lost three children. I hated to leave her all alone. Women have such a contempt for a childless wife. Now they will be all sympathy and kindness. I took away "her reproach among women."
Things haven't changed much in the one hundred and forty odd years since she wrote those words. Despite all of our gains in the world, women still reproach one another for their reproductive choices. It's often subtle, but it's there nonetheless. Just look around you at the next large family gathering you go to. If you happen to have among you a woman who has no children after a year or two of marriage, watch how the other women treat her. They'll all gather together in a group, talking, making meal preparations, or cleaning up after a meal. At first, the childless woman will join them, but she'll quickly be driven from the group because they will simply ignore her. This isn't just a matter of conversation topics. Those women aren't exclusively talking about children and motherhood. It's insulting to women to suggest that they can't discuss topics beyond the domestic once they have children. It's equally insulting to suggest that the childless woman can't discuss domestic issues. The reason it happens is that, sadly, for a significant number of women, the only measure of adulthood is motherhood. They won't recognize that childless woman as a grown up, even if she is the CEO of a Fortune 500 company.
The most astonishing and troubling aspect of this attitude among women is its source. When I was pregnant with my first child I was told by countless women that having the baby would be "the greatest thing I ever did." They didn't mean the challenging and time-consuming task of raising a child. They meant the actual physical act of having the child. For some reason, they think that surviving the pain and suffering of childbirth is the pinnacle of human achievement. It isn't. Any mammal can push a baby out of its body. There's no denying that labor is painful and ardurous, and that the act of delivering a baby into the world is hard work, but it doesn't confer greatness. And it isn't some rite of passage that has to be endured to turn a girl into a woman.
I wish there was some easy way to change this attitude, of taking away our reproaches; but it's so deeply ingrained that there is no easy way of eradicating it. So, what I do, is make sure my daughter knows that happiness does not depend on marriage and motherhood, in the hopes that when she encounters the contempt of women with children she'll have the fortitude to ignore it. And when I'm with a group of women, and the division between those with children and those without becomes apparent, I join the childless. If nothing else, it gets me out of washing the dishes. posted by Sydney on
6/06/2002 08:44:00 AM
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Now It's My Turn: Newsweek is celebrating the thirtieth year of its "My Turn" column that provides a voice for the ordinary Joe. I'm all for giving ordinary people a platform for their views, but for some reason I'm more often annoyed by that column than by anything else in the magazine. The selected voices, of course, are invariably ordinary Joes who share Newsweek's particular bias. You aren't going to find a paen to George Bush by the common man in that column. You will, however, find an atheist whining about God Bless America, or an elderly woman taking offence at an innocent remark made by her doctor. She goes on and on about all the wonderful things she has done in the past, as if that negates the frailty of her body at what must surely be close to eighty years of age.(She mentions her role in World War II.) Her physician is right to try all conservative means possible to treat her arthritits. Knee surgery puts a huge stress on the body, and one that the very elderly don't always come through successfully. In fact, they often don't do well with it at all. It doesn't matter how good she feels now, or how active she has been in the past. The risk is still the same just based on the time she's spent on this earth and the inevitable toll the passage of time takes on all our bodies. And why should she be insulted by his assuming she wants to go on a cruise? Is a cruise beneath her dignity? Get real, lady. Cut your doctor a break. He's trying to help you enjoy your remaining years while doing you the least possible harm. posted by Sydney on
6/06/2002 08:39:00 AM
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Promulgating Stereotypes: I never know what to make of studies that assert an innate difference in the minds of men and women, like those mentioned in this article from Scientific American. My gut instinct is to disbelieve them. They reek of the same odor as the studies done at the end of the last century and the beginning of this one that supported the eugenics movement. Any study of intellectual abilities relies on averaging the results of their test subjects, and so end up only promulgating stereotypes instead of showing any hard core proof of innate differences. The truth is that intellectual ability is varied among any group of people. Some women are good at the same sorts of tasks that many men are good at doing. Some aren't. Some men aren't either. posted by Sydney on
6/06/2002 08:23:00 AM
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Wednesday, June 05, 2002
Cato Institute: The Cato Institute came out with a recommendation for voluntary smallpox vaccination in April. Here it is. The crux of their reasoning: "Terrorism is a serious threat that deserves serious attention." Yes, indeed. posted by Sydney on
6/05/2002 08:15:00 PM
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A Professional Society Speaks: One of my recurring gripes lately has been that the professional societies of organized medicine have been silent on the smallpox vaccine issue. Well, the American Academy of Family Physicians has spoken up at last. Sort of. They favor vaccination only of public health professionals who would be sent out to do the vaccinating in case of an outbreak. If the government changes their warning level about the threat of an attack, then it's OK to thinkabout a different approach. Hmmm. Why would they think the government could predict such an attack any better than they predicted 9/11? posted by Sydney on
6/05/2002 08:02:00 PM
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Meetings of Minds: The Journal of the American Medical Association has an interesting article on media coverage of medical meetings this week. Turns out that a full 25% of those breakthroughs you read about in the papers never make it to publication. Only 50% of them make it into quality journals. That means that something goes wrong between the presentation at the meeting and the fine-tuning of the research - perhaps the research is just plain badly done, or the preliminary assumptions turn out to be wrong. An excerpt:
"I'm pretty well plugged in to what's going on in research," he remarked. "I hear on the news 'Major breakthrough in cancer!' And I think, Gee, I haven't heard anything major recently. Then I listen to the broadcast and realize that I've never heard of this breakthrough. And then I never hear of it again." -Dr Richard Klausner, Former Director, National Cancer Institute
"The press translates medical research into news. How the press chooses stories to cover and how they present the findings are important, since the media can have a powerful influence on public perceptions. Research abstracts presented at scientific meetings often receive prominent media attention. It is easy to understand why. The general public has a strong desire to know about the latest developments in science and medicine, and the meetings hold the promise of dramatic stories about new cures, discoveries, and breakthroughs. Press coverage also may be attractive to the sponsors of the meetings, the scientists, their institutions, and funding agencies; such coverage generates publicity that may help the organizations raise funds, and may help the scientists advance in academia."
Remember that the next time you hear a breathless report about the next great cancer cure hailing from some conference in Florida. posted by Sydney on
6/05/2002 06:05:00 AM
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Good Drugs, Bad Press: Two arthritis drugs, Vioxx and Celebrex have come under fire this week, for several reasons. The makers of Celebrex evidently fudged their research, got it published in a well-respected journal (JAMA), then circulated reprints of the study widely to promote their drug. Both Vioxx and Celebrex are agressively advertised to consumers as new and improved arthritis medication, and both cost a lot more than the older arthritits medications which are also just as effective. The result is that a lot of people take these drugs when they could get along with the cheaper, older drugs just as well. So why do doctors prescribe them at such high rates? It would appear that we have succumbed to the two-pronged assault engineered by the drug makers. We were given evidence that the drugs were easier on the stomach, although probably not any better for inflammation than the older drugs. Our patients were influenced into thinking that the drugs were better because they were newer via a slick ad campaign. No one wants to end up causing a bleeding or perforated ulcer while treating a nonfatal condition like arthritis, so it was easy to succumb to patient requests for the drugs they had seen touted on television. They seemed safer. The British Medical Journal now reveals evidence that the incidence of bleeding and perforation aren't that different between these drugs and the older ones after all. We were bamboozled.
The Washington Post article, however, takes the issue a step further than necessary or even warranted. It gives too much credence to all the other bad news reports about the drugs:
"Last year, research indicated that Vioxx patients ran four times more risk of heart attack than patients taking aspirin or ibuprofen. Last summer, a study published in the British journal The Lancet associated Vioxx with kidney failure. In March of this year, the FDA reported that five people taking Vioxx had been hospitalized with aseptic meningitis, an inflammation of the membranes covering the brain and spinal cord. And just last week came a report showing that Vioxx and Celebrex slowed the healing of bone fractures in lab animals."
All of the nonsteroidal anti-inflammatory drugs used to treat arthritis, including all of the older, cheaper ones, are capable of causing kidney failure. Considering the number of people who take Vioxx, it is almost impossible to pin the incredibly small number of five cases of meningitis to the drug. The study on delayed bone healing was performed on rats, not people. (Although it's probably true that anti-inflammatories delay healing in general. Inflammation serves a purpose in nature, and one of those purposes is to get all the body's healing mechanisms flowing to the site of injury.)
The drugs shouldn't be completely condemned outright. The fact remains that there are a lot of people out there who get nausea and stomach discomfort when using the older and cheaper arthritis medicines who don’t get those symptoms on Vioxx and Celebrex. There are also, people who have failed to respond to the older medicines and have found relief with one of these two medications. Unfortunately, media reports like this one convince them the drugs are too dangerous to take, which isn't true. They just aren't as superior as we were led to believe. posted by Sydney on
6/05/2002 06:02:00 AM
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Teenage Smoking: Turns out that outlawing sales of cigarettes to minors has no effect on teenage smoking. The study, published this week in Pediatrics found:
"..there was no detectable relationship between the level of merchant compliance and .. smoking prevalence. There was no evidence of a threshold effect. There was no evidence that an increase in compliance with youth access restrictions was associated with a decrease in ...smoking prevalence. There was no significant difference in youth smoking in communities with youth access interventions compared with control communities"
I'm by no means in favor of selling cigarettes to teenagers, but it seems like aggressively pursuing merchants for accidentally selling to an older teenager is overkill. It also apparently doesn't work. posted by Sydney on
6/05/2002 05:55:00 AM
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Tuesday, June 04, 2002
Healthcare Analysis:Jane Galt has a long and very thoughtful post about why a single payer healthcare system wouldn't work so well here. ( via Derek Lowe) posted by Sydney on
6/04/2002 08:53:00 PM
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Smallpox Update: The anti-mass vaccine contingent have been busy circulating among the media. First, there was the piece by Dr. Katz, a member of the National Vaccine Advisory Committee. Now there are two articles from the May 31 issue of Science that cover the subject with more than a whiff of anti-vaccine slant. (Registration and subscription is required for the links below. You can probably find it at a good public library or any college library, however. Also, any paranthetical phrases below are mine.)
The first article is about the search for a safer vaccine. It opens with the description by Dr. James Koopman of a complication of the vaccine in a small child in India:
"James Koopman saw the last 16 cases of smallpox in the Indian district of Azhagar in the early 1970s, but by now they blur together. Crystal clear, however, is the memory of a child, about 1 year old, who suffered from an uncontrollable infection called progressive vaccinia after receiving a smallpox vaccination in 1973. "It completely destroyed her arm, right down to the bone," says Koopman, now a researcher at the University of Michigan, Ann Arbor."
He is describing progressive vaccinia, a complication of the vaccine that can be fatal. It occurs at a rate of 1 to 2 per one million first time recipients of the vaccine, and 6 to 7 per one million repeat vaccine recipients. It occurs most frequently in children with cellular immune deficiencies, a condition that is not necessarily easily recognized or diagnosed. This is a very real and possible side effect, and one that must be weighed in the decision whether or not to undergo vaccination.
"Vaccinia--known in the United States as a Wyeth product called Dryvax--works by producing a local infection on the arm, a so-called take, which normally heals in 2 to 3 weeks. But in progressive vaccinia, it grows out of control. Other serious side effects include eczema vaccinatum, a localized or systemic infection in people with a history of eczema, and encephalitis, a brain inflammation. During the smallpox eradication era, about 1250 in every million vaccinees--many of them children under 2 years of age--suffered one of these side effects, and about one in a million died. Researchers expect that those numbers would be significantly higher today, as millions of people have compromised immune systems as a result of HIV or immunosuppressive drugs. Eczema rates have also shot up, for unknown reasons."
Encephalitis happens in roughly 12 out of one million people who are vaccinated for the first time, and in two out of one million who are vaccinated for a second time. Progressive vaccinia occurs at a rate of 1 to 2 per one million first time recipients of the vaccine, and 6 to 7 per one million repeat vaccine recipients. Eczema vaccinatum happens in 122 per million first time recipients of the vaccine and in 6 per million second time recipients. That means that the total of potentially fatal complications was at the most in 149 per million vaccine recipients, not, as this story suggests the enormous 1,250 per million recipients. The reporter has magnifed the side effect incidence by nearly a factor of ten. It was an honest mistake, he just failed to read the footnotes to the table from the issue of the Morbidity and Mortality Weekly Reports that these figures came from. The figure of 1,250 side effects per million vaccine recipients includes all side effects, including those which are common but not fatal, such as local reactions to the vaccine and secondary bacterial infections at the site of vaccination. (Click here to see the table yourself and compare the figures with the report. Scroll down to Table 3.) And yes, it's true that there are more people these days with compromised immune systems, but they would not be getting the vaccine. It is contraindicated in those situations.
The article went on to speak glowingly of the research efforts being put into a safer vaccine. There was one voice, however, who expressed doubts about the new vaccine's effectiveness (it's never been tested in people or in a time of contagion):
"But others are not so sure. Donald A. Henderson, former head of the World Health Organization's eradication effort and now a top bioterrorism adviser to the Department of Health and Human Services, for instance, says he'd be leery of relying on anything less than the tried and true to protect the population. "I don't know how you could ever be completely sure of [MVA's] efficacy," Henderson says."
I would listen to him. He's our leading expert on smallpox. He saw just what it can do, even in communities with high levels of immunity.
"Smallpox is a barely contagious and very slow-spreading infection," says James Koopman of the University of Michigan, Ann Arbor, who helped fight the disease in India in the early 1970s. Indeed, the way it spread in Dark Winter ( an exercise in bioterror preparedness held last summer by the government) was "silly," says Michael Lane, a former director of the smallpox eradication unit at the Centers for Disease Control and Prevention (CDC) in Atlanta. "There's no way that's going to happen."
Oh, really? "Barely contagious and very slow-spreading?" Then why was it once called the "devouring monster?" Why does the US Army's Bluebook on Medical Management of Biological Casualties estimate that only 10 - 100 organisms, and on average only 12, are needed to transmit an infection? (download the chapter on bioweapon agent characteristics for the chart.) I'll put my money on the US Army estimates over some academic in Ann Arbor. The Army is known for being practical and realistic when it comes to practicing medicine. Academics aren't.
"Already, in briefings for state and local officials, CDC's senior adviser for smallpox preparedness and response, Harold Margolis, is trying to "demystify" smallpox. "We know this disease," says Margolis. "We have eradicated it once, and we can do it again."
Yes, Dr. Margolis, you did eradicate it once. But that was after 150 years of worldwide vaccination efforts mixed with naturally acquired immunity from infection. There were record levels of immunity around the world back then, which made your task much easier. We no longer live in that same world, and your task will be much harder and come at a much higher price this time around. You are coming across as a little too cocky for our own good.
"For instance, these outbreaks took place in winter, the season terrorists would choose because it's peak transmission time for smallpox; infected people had lots of interaction with others; and doctors were slow to recognize the disease, as they would likely be today. (He's referring to "Dark Winter" an exercise in bioterror preparedness that the government did last summer.) They settled on an R 0 of 10--although they think that may be on the low side. (The R0 refers to the number of people an infected person would give the disease to.) In one famous and "particularly instructive" case, they wrote in a paper, a patient who returned to Yugoslavia from a trip to Iraq in 1972 infected 11 others, who in turn caused 140 "second generation" cases. The same number--10--had also been suggested in several papers (including one in Science, 26 February 1999, p. 1279) by the former head of the smallpox eradication effort, Donald A. Henderson, who served as a consultant to Dark Winter.
But a team led by CDC's Martin Meltzer, which published a smallpox outbreak model in Emerging Infectious Diseases last fall, concluded after a similar analysis of many more past outbreaks that the average rate of transmission was lower than 2. The CDC group recognized that today's citizens might be more vulnerable but not all that much more, so they ran scenarios in which R 0 was 2, 3, or 5, resulting in outbreaks that were easier to contain than the one in Dark Winter. Raymond Gani and Steve Leach of the Centre for Applied Microbiology and Research in Porton Down, U.K., reached a conclusion somewhere in the middle after analyzing historic outbreaks. R 0 was usually somewhere between 3.5 and 6, they wrote in Nature last December. In reality, says Koopman, the transmission rate may be much lower than past publications suggest. The published literature contains a skewed record, he says, tending to register significant outbreaks, whereas small ones were never written up. Koopman puts smallpox's R 0 at "barely above 1." If true, a small attack may well fizzle after a handful of additional cases."
In other words, the CDC is just guessing. They're ignoring evidence from our foremost smallpox expert, D.A. Henderson, that the disease is highly communicable, and downsizing the degree of communicability based on a time in history when background immunity was at an all-time high. At the same time, there is no way of knowing which form of smallpox was responsible for the outbreaks they are including in their studies: Variola minor which is less devastating and less communicable, or Variola major which is very contagious and has a thirty percent mortality rate. This is very reckless of them. They cannot assume the same numbers today, after thirty years of no natural smallpox in the world. And we can assume that any bioterror weapon is going to use the more dangerous Variola major. We are a particularly vulnerable population. And this Dr. Koopman, my goodness, he must have slept through his history lessons to think that one infected person only infects one other person, and that a "small attack may well fizzle after a handful of additional cases." Has he never read about the conquest of Central and South America and the role smallpox played in the European victory?
"Again, past experience suggests that the risks are much smaller than most people would think. Most smallpox infections were the result of several hours spent in close contact--usually 2 meters or less--to a patient, says Lane. Indeed, Koopman says some patients did not infect anybody at all. "In India, we got very worried sometimes, because a patient had gone into a big crowd, or boarded a bus--and yet there was no secondary transmission," he says."
Again with this Dr. Koopman. He's basing all of his conclusions on his experience in India. Has he never entertained the thought that no one on that bus caught smallpox because they were all immune already? Let me tell you something. I attended a lecture by D.A. Henderson on smallpox before September 11, and he didn't pull any punches about just how contagious this disease is. He showed us a map of a hospital that housed a smallpox patient and where each of the subsequent victims were in relation to the quarantined patient's room. Some of them were on the same floor, some of them were on completely separate floors with no direct contact, and one man caught it simply by opening the door to the hallway that had the patient's room in it and asking for directions. That is how contagious the disease can be.
It's frustrating to listen to these people play up the risks of the vaccine, which are very real, but play down the risks of the disease. We would all be much better off if they were honest about both. That's why I don't think it's in our best interest to have some committee from the CDC decide whether or not we can be vaccinated. It would be much better for all of us if they just gave us the choice, and the right facts.
CORRECTION: I made a mistake in the calculation of the total number of potentially fatal side effects from the smallpox vaccine. The number is 294 per million vaccine recipients, not 149 as I wrote. That means that the Science article overestimates the side effects by a factor of four, not ten. Sorry for the mistake. Forgive me. Mea culpa, mea culpa, mea maxima culpa. posted by Sydney on
6/04/2002 05:42:00 AM
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Aha! This week's Annals of Internal Medicine has a study that calls into question the validity of the techniques used by the Institute of Medicine in their infamous study on medical errors. I don't subscribe to the Annals, so I can't access the full report, but they have a public access version that is easy to read. The upshot is that the Institue of Medicine's figures aren't reliable.
AFTERTHOUGHT: A reader e-mailed about this link with the comment, "Who cares?" His point was that we should always be on the lookout to correct our mistakes and find ways to make the least mistakes possible in the future. This is true, of course, and a point that I've made often in the past when discussing the IOM report on medical errors. However, as RangelMD so eloquently puts it in his blog today, the trial lawyers have made much of those misleading statistics, so we should care. posted by Sydney on
6/04/2002 05:41:00 AM
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"The sun shall not smite thee by day:" The editors of Pediatrics must have done a good job of circulating this press release that contains a synopsis of a report in this week's issue about children and sun exposure. Exhibit A is this story from USA Today. Exhibit B. Exhibit C. Exhibit D.
The CDC, meanwhile, has this kid friendly page to help educate us about the dangers of the sun. As my own public service announcement I direct you to this article from the American Family Physician. It has good pictures of the different types of skin cancer, and a chart near the end that helps you identify malignant melanoma. posted by Sydney on
6/04/2002 05:35:00 AM
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Monday, June 03, 2002
I Married a Doctor:Howard Kurtz has this story in his media column today about a television news anchor who married a plastic surgeon. Love wasn't her motivation:
"Seems that Bobbi Silvernail, the 28-year-old morning anchor on WHO-TV, had just married Ronald Bergman, a prominent 53-year-old plastic surgeon in town. They met, Bergman told the paper, when Silvernail came to him to have her breasts augmented.
"By marrying a plastic surgeon, I can stay 28 forever," Silvernail told the Register." posted by Sydney on
6/03/2002 08:09:00 AM
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Smallpox Update: The Washington Post has some info on the state of smallpox research. The thing to remember, though, is that all of these experiments are going to take time to bear fruit. Time is not on our side. What we do have is an effective vaccine that is available now to prevent the infection, although at a higher cost in side effects than what we have become used to. Even then, the side effects aren't as overwhelming as they are being made out to be. The CDC and the media should be giving the general public more information on the vaccine so they can make an informed decision, not scaring people with vague hints at the dangers of the vaccine, like they do in this article:
"The smallpox vaccine itself causes serious side effects that would kill several hundred people if it were given to all Americans"
The real figure is perhaps a couple of hundred. Not several hundred. But, if we continue unprepared and smallpox is used against us, the death rate will be in multiples of a thousand.
UPDATE REMINDER: Don't forget that the CDC now has its public comment form up and running. Let them know how you feel about the use of smallpox vaccine. posted by Sydney on
6/03/2002 05:45:00 AM
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Long Distance Medicine: A chain of hospitals in Virginia uses electronic surveillance to care for critically ill patients by long distance. Vital signs, heart rhythm monitoring, oxygen levels, lab results, are all monitored by a team far away and connected only electronically to the hospital and the patient. Talk about your distant and remote doctor. There are other potential problems with the setup, aside from the threat of power outages:
"On a recent visit, two patients' emergency room reports, also transmitted by fax, were inadvertently stapled together. Aggarwal, the eICU doctor, briefly confused two patients, looking at a patient who he thought was in hypertensive crisis and seeing a man lying placidly in bed with bruises on his hands. He focused the camera on the IV pole and saw no anti-hypertensive drugs hanging.
This time, the picture didn't fit the story. He was looking at an elderly man who had hit a tree on a scooter. He quickly diagnosed a paper mix-up."
Whew. Good thing he took the time to focus his video camera on the guy. Is this kind of thing going to make patients trust us more? posted by Sydney on
6/03/2002 05:41:00 AM
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Influential Television: A study from Harvard (published in Britain, so it has made their media, not ours), claims that television causes eating disorders. The researchers surveyed a group of girls from Fiji before they had television, and again three years after the introduction of television to their community:
"The study found the percentage of girls who said that they induced themselves to vomit to control their weight was zero in 1995. By 1998 it had reached 11.3 per cent.
Subjects living in a house with a television set were three times more likely to show symptoms of eating disorders.
By 1998 dieting had become common among the studied group with 69 per cent stating they had dieted to lose weight at some time and 74 per cent reporting they felt "too big or fat" on occasion. The girls also admitted, in interview, that they admired the fictional characters and tried to copy them."
From the Edge of the Sea: Here's some basic science research from Australia that suggests seaweed may be able to cut down on infections in artificial body parts (knee replacements, hip replacements, heart valve replacements, etc.). It's very preliminary and hasn't yet been tested in people, but it sounds promising. And it's "natural"! posted by Sydney on
6/03/2002 05:36:00 AM
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Those "Natural" Herbal Medicines: A woman in Singapore died this weekend after taking Chinese herbal diet pills. The pills were not labeled as containing fenfluramine (once available but now banned in the US because of toxicity). It's tempting to dismiss this as something that could only happen in the Third World, but this stuff can also be shipped here and sold, since no one regulates the dietary supplement industry. Of note is that it's not just deadly drugs that lurk in these "herbals" but deadly contaminants as well:
"China agreed last month to begin regulating its multi-billion dollar traditional medicine industry, including tightening controls on pesticide residues and heavy metal levels in herbs."
That's right. Those "natural" products just might be laced with lead, mercury, and pesticides. Remember that the next time you're tempted to buy something from the "natural health" shelf. posted by Sydney on
6/03/2002 05:34:00 AM
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UPDATE REDUX: For a clue to the approach our so-called experts are taking to the smallpox vaccine issue, look at this piece from yesterday's Washington Post. It's by Ruth J. Katz, a member of the National Vaccine Advisory Committee and a dean of the Yale School of Medicine. Some excerpts, which deserve comment:
"There is strong public demand for the vaccine but no consensus on whether access should be given to anyone who wants it. Implementing a sound policy is further complicated by misperceptions, with many physicians and lay people believing that smallpox is almost always fatal (it actually kills about 30 percent of its victims) and that the vaccine is as safe as most childhood vaccines (it may be the most dangerous one available)."
Thirty percent fatality is very high. Higher than any of the infectious diseases we encounter today. In addition, those who do not die are almost always disfigured by the disease, and they are very seriously ill when they have it. We know the vaccine isn't as safe as other childhood vaccines. Even if we aren't experts in infectious disease. Make the dangers of the vaccine known. Let people make an informed decision.
"The multiple dimensions of the issue, and the stakes involved, argue for thoughtful decision-making. The advisory committees studying the smallpox vaccine had expected to complete their expert review in the fall of this year. Between now and then, an ambitious schedule of regional meetings had been established so we could hear from professional medical organizations and groups representing patient populations, health care workers, public health officials, emergency response workers and the public. Now the Bush administration is asking for an abbreviated process leading to recommendations by the middle of this month."
Good for the Bush administration. Just what do these experts think they are going to gain by debating and debating the issue for months and months? None of them have ever had to deal with smallpox, so it's doubtful that any of them feel all that comfortable making a decision. They can debate and debate until the cows come home, but that isn't going to increase their degree of comfort with a decision. Nor is it going to increase their knowledge. The fact is, no one has had to deal with smallpox among a non-immune population since the Native Americans of North America succumbed to it two and three hundred years ago. Maybe the Bush administration has reason to believe that Iraq or some other hostile nation has smallpox ready for use as a weapon against us, and wants to protect us from that. If so, the CDC and the Vaccine Advisory Committee should stop this turf protecting behavior of theirs and act for the greater public good. They know the side effects of the vaccine, they know the dangers of smallpox on a non-immune population. But, they are stuck in the experience of the late 1960's and 1970's when the world was widely immune and the contagion could be contained with ring vaccination and quarantine. They need to look further back in history for the example of just how devastating smallpox can be.
"The official response to the recent anthrax scare was equally unimpressive. No one seemed in charge, and no one spoke to the public authoritatively about what was and was not known concerning the danger. The result was widespread fear and an erosion of faith that can only weaken future capacity to address the genuine threat of bioterrorism appropriately."
Exactly. Which means that their response to a smallpox attack is likely to be just as abyssmal. It would be much better to prepare and take measures to prevent the devastation that smallpox can wreak by immunizing now. If she's worried that we won’t be able to implement a mass preventive vaccine program, how does she think we'll be able to respond if we wait until it's a national emergency?
"The Bush administration is now pushing hard on the smallpox vaccine, and it may well have valid reasons for doing so. But public health, not politics or public relations, needs to be the driver here. If the administration is only seeking to show that it is "tough on smallpox" and prepared for anything in the struggle against terrorism, health experts, elected officials and the American public should protest the hijacking of a carefully formulated policymaking process. Planning for a smallpox epidemic is not an event being staged for television."
As I said before, I suspect the Bush administration does have valid reasons for pushing for the vaccine. It just may be what's holding them back on Iraq. The "experts" should stop stonewalling. They are not going to gain any more knowledge of our risks by delaying their decision making process. It’s all speculative. We are at war. The debate can not proceed at the slow pace to which academics are accustomed. This is not the same as a routine childhood vaccine. When you consider that the portion of our population at greatest risk are those under forty, those who are at the prime of their lives, and who are the future of our nation, the risks are much too high to wait. The entire tone of this paragraph speaks volumes. It's obvious that the infectious disease experts feel that the government is stepping on their turf, and they don't like it. Doctors never like having their authority questioned, and they are circling the wagons here to try to prevent it.
"The eradication of smallpox worldwide ranks as one of the great triumphs of public health. If there is a chance of its return, we need to combat it with the same wisdom and determination used to vanquish it in the first place. But in the absence of a clear and present danger, we can surely take the time to exercise care and to be thoughtful."
No, Dr. Katz, we do not have the time. The threat is a clear and present one that can strike at any time, with just as much suddeness as the World Trade Center attack. posted by Sydney on
6/02/2002 07:23:00 AM
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