And So It Begins

CDC, Public Health Image Library

I am fortunate to have the Dengue Vaccine Initiative as a client. Through this group, I have traveled the world, meeting with doctors and scientists, working to lay the groundwork for a coming vaccine against dengue fever. As our work has progressed from discussing issues with surveillance and diagnostics, we have moved into communication issues - the need to raise awareness among politicians, healthcare professionals, and consumers of a coming vaccine, and the lifesaving (and cost saving) benefits such a vaccine will confer on countries in which dengue sickens hundreds of thousands of people annually.

One of the issues that confronts us is anti-vaccine activism. This is a worldwide phenomenon. Activists' concerns range from what we see in the United States - concerns about autism - but also include cultural-specific worries. For example, in Argentina, a branch of the Catholic church warns that vaccines will cause women to abort their fetuses. In parts of Asia with large Muslim populations, there are concerns that some vaccines are made with cells from dogs or from pork gelatin. It is stiff opposition that can usually be satisfied with factual answers.

But overall, countries outside of the United States are hungry for vaccines. When PATH and The Gates Foundation worked with India to quickly distribute a vaccine against Japanese Encephalitis - a mosquito-borne disease common in rural areas that causes paralysis and death in high numbers - they were able to vaccinate 32 million children in a year and a half because people were desperate for protection. From the safety of the United States, it may be difficult to understand that polio still cripples hundreds of children in India each year or that measles killed over 160,000 people worldwide in 2008. We have become used to a childhood without those terrible diseases.

This is likely a generational issue. My mother remembers having to stay indoors during the hot summer months, away from other people, when polio epidemics were raging throughout the countryside. Isolating her family was the only way my grandmother could protect her children.  As a kid, probably around 3 years old, I stood in line in a school gymnasium - a very long line snaking around the gym and outside the door - to receive a dose of the Sabin polio vaccine on a sugar cube. I have a fuzzy memory of the darkness of the gym but really what I remember is the solemnity of the occasion. Granted, it was a long time ago, but I like to think I was feeling the resolve of all those moms who brought their kids in to protect them against the seasonal fear of fever, paralysis, iron lungs. And I, too, am part of the generational divide: I have a round and dimpled scar on my upper left arm from a smallpox vaccination, a badge that signifies me as a woman of a certain age, to be sure, because today's kids don't get vaccinated against smallpox because it is no longer a threat.

Unlike smallpox, most vaccine-preventable diseases are not eradicated, just kept under control. That control, however, is tenuous because we rely on herd immunity - keeping a high proportion of our population vaccinated in order to prevent diseases - to protect our society. In other words, all those families who don't vaccinate their kids can be reasonably assured that their kids won't get childhood diseases because so many other families do vaccinate their kids. However, there is always a tipping point, where diseases can race through unvaccinated kids and infect those with partial immunity, such as the elderly who have lost their immunity, children who have not received boosters, or infants who have not received vaccinations.   Recent news carried a report of a death from whooping cough, not in Nigeria, not in Bangladesh, not in Cambodia. But here, in the great state of California. And it's the 10th one in California this year. This infant's death is attributed to families not vaccinating their children against pertussis, thus allowing this potentially deadly disease to spike again.

Recent estimates show that over 7.0% of children entering kindergarten in Marin county, a wealthy suburb of San Francisco, have waivers exempting them from childhood vaccinations based on their parents' beliefs. A private school in San Diego reports that 51% of its kindergartners had such exemptions. These are shockingly high numbers because once these percentages reach the tipping point, we will lose our herd immunity. And evidence is growing that we are approaching that that point: For each one percent increase in exemptions at a school, the risk of having a pertussis outbreak went up by 12%, a 2000 study in the Journal of the American Medical Association found. The study, which was conducted in Colorado, also found that at least 11% of the vaccinated children in measles outbreaks were infected through contact with somebody who was exempt.

Epidemics start with a whisper. A case of pertussis here, a few cases of measles there. But make no doubt about it: we are on the cusp of an epidemic of many diseases that we thought we left behind. What is it about human nature that makes us reinvent the wheel again and again? If you don't want to vaccinate your kids, I recommend you travel to poor countries around the world. Tell a mother who fears seasonal outbreaks of diseases that you turned down the opportunity to vaccinate your kids against those diseases. Of course, many who don't vaccinate their kids point out that we don't live in developing countries, and that many vaccine-preventable diseases are rare in the United States. That is true. These diseases are rare because people vaccinate their kids. And they won't stay rare if we don't.

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Hurts So Good

Welcome to the month of pink. For those who have been living in a cave for the past decade, October is National Breast Cancer Awareness Month.  It's the one month out of the year in which the word "breast" is spoken freely and clearly and without any tinge of sexuality and pink is everywhere: on hats, billboards, and the shirts of the evening news anchors.

I know the ad I chose to illustrate this post isn't pink (except for the tasteful pink ribbon in the word "breast"). But it is funny! And it played off of my second point about how breasts are icons of sex. The fact that the ad is from India also points out how ingrained this month is in the world's consciousness. Way to go, India!

Anyway.

In honor of this great month, I got my annual mammogram.

Mammograms have to be in the top 10 of weird diagnostic tools. Most medical procedures find you sitting, or reclining, with only the part in question exposed to light. But for a mammogram, you have to stand up while your breasts, one at a time, are clamped in a vice. The rest of your body is free to move (as if!), but you are literally held in place by a machine that is gripping your boob. So there you stand, in your regular shoes (which in my case happened to be high heels) while your top half is draped in a hospital gown, in a cold room (the machines have to stay cool). In summary: you're half naked, in heels, with your nipples announcing the temperature. Maybe breast cancer awareness month is about sex after all?.

Hmmm.

But that's all foreshadowing of what's to come. Because once the real procedure begins, the train of mild discomfort and indignity moves on into the station of painful because mammograms hurt. Like holy heck. But, not to sound all twisted about it, it's a good hurt. Because a mammogram that captures the bits off to the sides - the chest wall, the underarm area - requires a lot of pulling and squeezing and manipulating of the breast tissue. And squeezing. And more squeezing. But all those machinations are important because you really want those parts shown on your mammogram. So I don't mind.

Fourteen years ago, when I was pregnant with my first child, I felt a lump in my breast. As my pregnancy progressed, the lump grew. Daily. I brought it to my doctors' attention, we decided that an excisional biopsy - one that would remove the entire lump - was the way to go. I remember being on the operating table under local anesthesia thinking how strange it was to be carrying new life while being worried about my own. I remember the smells - the sharp, medicinal smell of the sterilizing fluid followed by the warm, metallic smell of blood as the surgeon first sterilized, then sliced into my breast. I turned my head away from the surgeon, while he engaged me in chatter. Fortunately, the lump was not cancerous. But it was a very scary time.

So that's why I don't mind that mammograms hurt. Because I want every inch of my mammary tissue exposed so the radiologists can look for cancer.

Over the years, as I've aged, mammograms have become a fact of life for me. Every other year at first, and now, every year, with a scary year during which I had one breast checked three times because of irregularities on the mammograms. So far so good.

Why don't all women get mammograms? The reasons are as varied as the women themselves. Some women don't have time (or don't think they have time). Some women don't have insurance and don't realize there are places to get free, or reduced price, mammograms. Some women are afraid: of the procedure, or of the possible bad news it can bring. All completely understandable reasons, but not very valid. Because catching cancers early gives you the best options for treatment.

So, happy October, friends. Take care of yourselves, and get your mammogram. Even though it hurts, it really could save your life. And that's good.

The Drumbeat Grows Louder

More on overuse of antibiotics in livestock production.

Typical push/pull of health vs economics. At some point, we're all going to have to take the long view and realize that health = economics. We're going to have to pay for all those sick people somehow, so we might as well avert problems when we can. Right?