Friday, May 4, 2012
Measles: Back to the future of public health
A recent USA Today cover story was "Measles Outbreak Could Hit the USA" as a result of rising rates of measles in Europe, and declining rates of vaccination here.
If measles does make a meaningful comeback, it would imply public health is sliding back as we head into the future. We don't want to go there.
We live in a culture where it is highly fashionable to question all authorities, and to presume guilt rather than innocence with regard to others' motives. There are still those who believe the HIV epidemic was manufactured by the government, and others who believe the CDC's support for flu vaccine is actually an effort to kill lots of people and reduce the population.
This is crazy nonsense, of course. But in the Internet age, crazy, paranoid nonsense and hard-earned, thoughtful, evidence-based expertise have the same megaphone. Anyone can post a blog or video, and it is, in fact, the more radical opinions that are most likely to "go viral," for the very reason that they stand out.
The concept that immunization causes autism went viral, and won't go away, even though the evidence has been thoroughly debunked, and the principal scientist behind it all formally disciplined for fraud.
Why is it we are apathetic about vaccines, and less concerned about the diseases they prevent than with the side effects they do, or even might, cause? For one salient reason: because they work. It may sound paradoxical , but the reason we don't seem to have any love for vaccines is because they are so effective.
In general, when prevention works, there is literally nothing to see. The good results are things that don't happen. This undermines public and political support for prevention, and costs us all, in the currency of both dollars and human potential. I have lamented this before.
But this problem may be epitomized by immunization. When an immunization campaign works, a disease can literally disappear, as smallpox has. And once a disease has been gone a while, you start to wonder why you should put up with the "dangers" of immunization. The disease the vaccine is preventing is invisible, and in contrast, any modest danger associated with the vaccine looms large. It's like wondering why you should pay for an alarm system in a house that never gets robbed, while ignoring the possibility that that the alarm system is the reason the house doesn't get robbed!
There is, admittedly, always some danger associated with immunization. Truly "no risk" options generally do not exist in medicine, and probably don't exist in life. There is some danger in going outside, and some danger in never doing so.
What matters, then, is the ratio of risk to benefit, or how one danger compares to another. Measles is highly infectious, and out of every thousand kids who get it, one to two will die. Any decent vaccine is vanishingly less dangerous.
Our grandparents had to worry about letting our parents go swimming every summer, for fear of poliomyelitis. We are now privileged to be all but free of polio, and have thus become complacent about the vaccine.
And, of course, immunization resulted in the one case of intentional extinction in history: the eradication of smallpox. Smallpox formerly ravaged our species, killing as many as one in three infected.
Measles is not that bad, but it's bad enough.
We are unintimidated by measles because we haven't seen much measles in our lifetimes. We haven't seen much measles because vaccination works.
If measles makes a comeback, it would represent the classic bungle summed up so nicely in a song we all know: "Don't it always seem to go that you don't know what you got 'til it's gone."
The diseases vaccines prevent, measles, polio, influenza and others, pose serious risks, as prior generations knew all too well. Vaccines pose trivial risks in comparison. We need to see the value in what isn't there, and know what we've got before it's gone.
Otherwise, we may well go back, instead of forward, to the future of public health, and pay, quite literally, with some of our lives.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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One of the most popular anonymous blogs written by an emergency room physician.