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?

This Made Me Smile

Knitted Bacteria!

I Like Bacon

Disclaimer: I like bacon. And steak and chicken.

But I don't like antibiotic-resistant bacteria.

It's no secret that the reason US livestock producers can raise thousands of animals in close confinement is because they use antibiotics not to treat, but to prevent infections in animals. This means every animal receives antibiotics at certain ages as a matter of course. It also means that when bacteria ultimately learn how to survive in those conditions - and they always do - that they are resistant to the antibiotics that include many that humans use. And that spells trouble not only for the herds of animals but for humans who come in contact with the resistant microbes in their meat.

From a recent NYT article that outlines the issue and talks about possible enhanced regulations on livestock antibiotic use: 

"In a letter to Congress in July, Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, cited “compelling evidence” of a “clear link between antibiotic use in animals and antibiotic resistance in humans.”"

I understand the food economics argument, that the use of antibiotics keeps the price per animal down, which translates into cheap food to feed our citizens. But I also understand that Americans eat too much fatty food - and that includes bacon and hamburger. Maybe a small increase in price would encourage smaller portions, or meals without meat as a centerpiece, or more consumption of plant-based foods.

And I understand the commodity argument, that livestock growers make a slim profit per animal and that profit would be reduced if they could not use antibiotics in the current way. But it sounds as if Denmark farmers - who produce most of Europe's pork - have found ways to keep their animals healthy without antibiotics. Here is testimony given by a representative of the Danish Veterinary and Food Administration explaining their success.

I think limiting or eliminating the use of prophylactic antibiotics in animals is a step in the right direction. We have a decent model provided by our Danish friends, let's follow it.

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Mean People Suck

When my oldest son was beginning to take swim lessons, around age 4, we took the advice of many preschool moms and enrolled him with Miss B, a tough older woman with a large pool outside of her magnificent house on the banks of the Chattahoochee River here in Atlanta. We had heard about her tough-love approach to teaching swim lessons, so I was somewhat prepared for a no-nonsense, let's-do-this attitude. That's fine. I'm from the Midwest where no-nonsense is practically a middle name. But instead of the  familiarity of "my people," we found ourselves unexpectedly thrust into a foreign land of ridicule, abuse, and actually some danger. That's because Miss B's approach to teaching a shy, cautious child to swim boiled down pulling him into the deep end of the pool and then letting him go to find his own way to the side. She sidestroked alongside him, far enough away that he couldn't reach out to her, but close enough to barrage him with negative comments along the lines of "don't be a baby," and "big boys learn to swim."

When my son reached the side, crawled out of the pool, and then collapsed into a puddle of shrieking goo on the pool deck, she clasped her hands together, looked toward the sky, and said, "Please God, give me patience to deal with this child."

It happened so quickly that I was in shock. One minute, a sunny day, a swim lesson, a grandmotherly person. In my memory I can hear birds. See clouds. Admire the green of the trees lining the river. The next minute, my heart is pounding and I'm running to the side of the pool (she requested that parents stay away from the pool during lessons - warning!), this old lady is sarcastically praying, and my son is a mess. Ten years later, my feelings can still race from from serene to murderous just thinking about that day.

Needless to say, one "lesson" was all we took from her. But over the years I've been raising kids, I've seen more than one Miss B - nurses who are impatient, doctors who want preschoolers to "man up" and not be scared of shots, teachers who think the best way to learn is to sit down, shut up, and finish that work sheet. I've always wondered why these people wanted to work with children in the first place.

They seem especially crazy (and mean) when you run into professionals who really "get" working with kids.  Since the Miss B episode, our family has been fortunate to experience many gifted professionals who put the kids first. One first grade teacher I especially loved would simply open the door to her classroom, which was next to the playground, and shoo the kids outside when the wiggles got to be too much. A quick 10-minute expenditure of energy and the kids could resume the day's schedule with appropriate focus. Imagine that. Letting kids play. I also fondly remember an upper-GI specialist singing "drink chugalug, chugalug, chugalug" in order to help my son down the nasty drink that would provide contrast to the x-ray he was having of his throat and esophagus. There are good eggs out there.

So we've experienced bad, and we've experience good. But my kids are neurotypical and can bounce back from the bad (as long as it is an isolated incident) without losing a lot of traction. We still talk about how crazy Miss B was, but the following summer, my son willingly took swim lessons and ended up being a wonderful swimmer.

Parents of kids with autism can't be guaranteed of such a benign outcome. A bad run-in with a doctor may mean it is almost impossible to get the kid in the door the next time - a dire situation when a broken bone, cut hand or other medical emergency requires quick action. An impatient dentist could mean saying bye-bye to dental care for years. It takes a PhD in empathy on top of whatever other professional degree the person has to provide care or instruction to kids who live on the edge of fight or flight.

An Atlanta mom, who has a son with an autism diagnosis, has experienced her fair share of knuckleheaded doctors. Fortunately, she found an angel of a dentist, whose approach to working with  children with special needs should be taught in medical, dental, nursing, education, any school that is turning out professionals who will work with people. Here is her blog posting explaining what makes a good health professional for kids with special needs. She also has an example of a bad doctor visit a few entries earlier. Compare and contrast, if you will.

So for the Miss Bs, the bad doctors, the grumpy teachers, I say, find something else to do. You're doing more harm than good. But for those good ones, well, I hope you know how special you are.

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Tell me it ain't so

Please tell me that it is not novel for doctors to send unusual cases that stump them around to their colleagues, and their colleagues' colleagues, via online networks.

From the Diagnosis column in today's NYT Magazine: "If he was the second opinion, then the patient clearly needed a third. Suddenly Schumann had an idea. What if they opened the mystery of his symptoms to other doctors? What if they put his case on the Internet — on a blog read mostly by doctors — and let some new eyes and brains work on this problem? The patient was excited by the idea."

Hello, medical profession? There's this new thing called the Internet. We think you'll like it.