In the eighteenth century, yellow fever, originating in either Africa or Central America, ravaged the major port cities of the eastern United States. In the nineteenth century, cholera, brought from Central Asia to England and ultimately by ship to America, caused epidemics in urban areas, including Chicago (federal troops sent via the Great Lakes to fight the Black Hawk War brought cholera to the city). The successful battles to control cholera and yellow fever are two of the underappreciated heroic stories in American history.
The influenza pandemic of 1918 was the country’s worst infectious disease catastrophe. It is estimated that one-quarter of all Americans contracted the virus, and in only one year, an estimated 675,000 died, ten times as many as in World War I. The epidemic was fueled by the return of American soldiers who contracted the disease in Europe. Ships carrying returning doughboys and wounded veterans were a virtual incubation laboratory for the influenza virus.
Later in the twentieth century, the United States fortunately avoided an epidemic of avian influenza (bird flu), caused by a related influenza virus that originated in south China. Today the greatest fear of epidemiologists and infectious disease experts is the prospect of another lethally mutating influenza virus.
In our generation, the deadliest American epidemic has been AIDS, and the responsible virus, HIV, originated in central Africa. The HIV virus has been responsible for nearly as many American deaths as the 1918 influenza pandemic virus, albeit over a forty-year period. Since the beginning of the twenty-first century, the United States has also faced threats from the SARS virus, which originated in China, and the West Nile virus, first identified in East Africa. In all of these cases, the spread to America was abetted by global air travel moving infected victims or aircraft and ships moving mosquitoes or mosquito eggs.
We cannot roll back the clock on global travel and trade or their consequences. The Zika virus is merely the latest, but not the last, reminder of how advances in transportation leave us susceptible to once-unimaginable diseases. Luck is essential to avoiding these epidemics, but a famous scientific aphorism reminds us that chance favors the prepared mind. This will mean heightened levels of national and international preparation, including increased mosquito control, accelerated vaccine research, and advanced computer-assisted disease mapping and contact tracing.
53
EBOLA: HUMILITY IN THE FACE OF NATURE IS ESSENTIAL
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The perpetual enemies of the human race, apart from man’s own nature, are ignorance and disease.
—ALAN GREGG, MD
IN THE RESPONSE TO EBOLA, the medical community quickly addressed its initial errors, which included the failure to promptly diagnose the first domestic case in Dallas and the inadequate protocol for caregivers. Lapses of this sort aren’t likely to happen again. But what remains is an attitude from government officials that is sometimes condescending, bordering on arrogant. What message did the public receive when officials said they had no doubt they would stop Ebola in its tracks? Or when they quickly blamed a Dallas nurse for getting infected by breaching protocol, when the protocol was unclear?
During both the AIDS epidemic in the 1980s and the 1976 swine flu episode that really never materialized as an epidemic, the rhetoric of government officials damaged their credibility. To avoid a repeat of those missteps, officials should heed the following lessons from those medical crises:
1. Avoid patronizing the public. The unequivocal message delivered to the American public regarding Ebola was “don’t panic.” This is the right message, but the delivery of that message has frequently been the equivalent of a patronizing pat on the head. Rather than an admonishment, “don’t panic” should be an exhortation to the public. During the Great Depression, when President Franklin D. Roosevelt told Americans not to panic over the parlous economic environment, he used the famous phrase “The only thing we have to fear is fear itself.” He was exhorting citizens to engage in a communal effort, unencumbered by panic. That should be how officials reassure the public about Ebola.
2. Tell us what you know—and what you don’t know. We have limited experience with Ebola. There is a reasonably good understanding of how Ebola is transmitted; the risk of transmission is virtually negligible from an asymptomatic patient who is not shedding a large amount of virus. Some officials and journalists say Ebola is “hard to get.” By itself this means little. Hard, compared with what? It is quite hard to become infected with Ebola compared with exposure to measles or certain strains of influenza. But Ebola is obviously not that hard to get if you are caring for a patient; it is certainly easier than acquiring HIV during caregiving.
3. Understand and deal with the limitations of information. Computerized models are being used to analyze past Ebola outbreaks and are critically important to understanding how Ebola will spread in the future. But every model is based on finite information and is an imperfect predictor. Models also fail to account for human frailty—for example, an exposed health care worker who decides to fly—or unpredictable events like natural disasters or political instability in a stricken country. In contrast our ability to gather information is exponentially better than it was for the early years of the AIDS epidemic. The private information companies like Google and Apple should be enlisted to employ their information retrieval expertise in West Africa and gather data on viral migration patterns and details on affected populations.
4. Exude humility, not arrogance. In the future those infected with Ebola are likely to be identified and isolated quickly. So long as the reservoir of infected people is small, and their contact is casual and limited, widespread transmission is unlikely. However, if those infected circulate with more people and have longer and more intimate contact, the chance of viral spread increases.
Hospitals were the initial focal point of transmission in the United States, and spread was contained. Whether there will be a future danger in large gathering places (subways, stadiums, airports) remains an unknown. Ultimately the key to preventing a pandemic will be eradicating Ebola in West Africa. The late Nobel Prize winner Joshua Lederberg, one of the world’s leading experts in molecular biology, once observed that a microbe that felled a child in a distant continent yesterday can reach ours today and seed a global pandemic tomorrow. He warned, “The human race evidently has withstood the pathogenic challenges encountered so far, albeit with episodes of incalculable tragedy. But the rules of encounter and engagement have been changing; the same record of survival may not necessarily hold for the future.”
Humility, in the face of nature, is essential.
54
MEASLES:
A NEVER-ENDING THREAT
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It can be said that each civilization has a pattern of disease peculiar to it. The pattern of disease is an expression of the response of man to his total environment (physical, biological, social); this response is, therefore, determined by anything that affects man himself or his environment.
—RENÉ JULES DUBOS
THE DESERTED GRAVEYARD called Vunivesi sits silently by a small brook obscured by a mangrove canopy on the South Sea island of Fiji. The mass gravesite, abandoned decades ago, is unknown even to most Fijians. No one knows how many are buried there, but many of the dead likely spent their final moments lying in the nearby water for relief from fever and suffering.
Across the Pacific Ocean, five thousand miles away, are the trendy West Los Angeles enclaves of Santa Monica, Brentwood, and Beverly Hills, among the world’s wealthiest communities. What could these affluent neighborhoods possibly have in common with the quiet graveyard of Vunivesi?
Measles.
In 1875 one of deadliest outbreaks of measles in modern history devastated Fiji, killing one-third of the island’s one hundred thousand inhabitants. Ironically, measles was Fiji’s first gift from Great Britain upon becoming a member of the British Empire. To celebrate Fiji’s entrance into the Commonwealth, a British ship escorted Fijian leaders for a state visit to Sydney, Australia, then
the closest British government seat. The entourage stayed at Sydney’s finest hotel, amazed by the conveniences of the modern world. Unfortunately, they were also infected by a measles epidemic coursing through eastern Australia. They carried the disease back to Fiji, and within weeks measles swept over the island, killing thousands.
One medical historian wrote, “Death drums sounded incessantly in seemingly deserted villages. So many died so quickly that timely burial became impossible. Graves were only half dug because no one had the strength to dig.” Lacking the strength to find food, thousands more died of starvation. After the outbreak, one British missionary described the eerie stillness of the deserted villages.
One hundred and forty-three years is not that long ago. Many baby boomers’ great-grandparents, and some grandparents, could have been born around 1875. Among America’s greatest achievements in that time has been the near eradication of vaccine-preventable diseases. The numbers for measles are impressive; in the pre-vaccine year of 1958, there were 763,094 cases and 552 deaths. In 2004 there were thirty-seven cases—a historical low—and not a single measles death was reported. But measles is making a comeback, and one of the “hot zones” is Southern California. Researching the story, the Hollywood Reporter found
the local children statistically at the greatest risk for infection aren’t, as one might imagine, the least privileged—far from it. An examination by The Hollywood Reporter of immunization records submitted to the state by educational facilities suggests that wealthy Westside kids—particularly those attending exclusive, entertainment-industry-favored child care centers, preschools and kindergartens—are far more likely to get sick (and potentially infect their siblings and playmates) than other kids in LA.
The reason is at once painfully simple and utterly complex: More parents in this demographic are choosing not to vaccinate their children against the advice of medical experts. They express their noncompliance by submitting a form known as a personal belief exemption instead of paperwork documenting a completed shot schedule. . . . [In some schools] numbers are in line with immunization rates in developing countries like Chad and South Sudan.
The current anti-vaccine movement had its roots in a 1998 study by a British doctor, Andrew Wakefield. His now-discredited study was published in the world’s most prestigious medical journal, the Lancet. The Lancet retracted the paper after discovering Wakefield’s methods were sloppy and unethical, his conclusions unwarranted, and that he had failed to disclose significant financial interests. The UK General Medical Council declared he acted dishonestly and irresponsibly. Despite this, celebrities including Jenny McCarthy, Kristin Cavallari, and Robert Kennedy Jr. have spearheaded the anti-vaccine movement.
This marks a dramatic reversal from a time when Hollywood celebrities enthusiastically endorsed the fight against polio. In 1956, at the height of his popularity, Elvis Presley posed for his polio vaccination. Parents, witnessing the tragedy of death and paralysis, lined up to have their children inoculated with the still incompletely tested polio vaccine. The medical community must exert greater leadership. The former surgeon general Vivek Murthy, having been out of residency for less than a decade, may have lacked historical perspective when he said tentatively: “The most important message I have is to please, please, please get your child vaccinated. . . . I recognize that some of the concerns parents have about vaccinations come from a place of wanting to do the best to protect their children. . . . I believe that on this topic, the science is very clear.”
No mention of the lax immunization requirements in states like California. Murthy’s comments, like those of Republican presidential hopefuls Rand Paul and Chris Christie, may be tempered by political concerns. But Murthy should have drawn from the example of one of his predecessors, C. Everett Koop. Koop, surgeon general during the early years of the AIDS epidemic, infuriated many conservative supporters with candid, medically accurate statements about HIV. He was forceful and undeterred by politics. “Everything I ever said caused controversy,” he said. “That’s the nature of the job. . . . It’s a controversial job and you have to have a very thick skin, and you cannot let yourself be pushed by political pressures about what is politically correct and what is not.”
Right now that type of candor is needed. Those unfortunate Fijians at Vunivesi were victims of something they were unaware of and could not control. If future Americans fall victim to a severe strain of measles or another vaccine-preventable disease, then, in the words of William Shakespeare, we will have failed to “take arms against a sea of troubles and by opposing end them.”
55
ANTI-VAXXERS
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Disease is a fate of the poor, but also a punishment of the rich.
—IVO ANDRIC, NOBEL LAUREATE IN LITERATURE
ANTI-VAXXERS IS THE TWENTY-FIRST-CENTURY TERM that refers to those who oppose vaccination in preventing infectious diseases. Regrettably it’s only a matter of time before this new term enters the Oxford English Dictionary. During the 2016 presidential campaign, the issue went mainstream when two major candidates, Jill Stein and Donald Trump, neither an overt anti-vaxxer, both went on record as being at least somewhat suspicious of the vaccine process.
No longer a small band of cranks, anti-vaxxers are an organized group who proselytize in communities across the country—with effect. They certainly bear some responsibility for the recent measles outbreak in Minnesota, where there were at least sixty-nine cases, primarily children, with more than ten hospitalized. The majority of Minnesota cases have occurred in the Somali community, which has been actively targeted by the anti-vaxxers.
David Johnson, program manager with the Hennepin County Health Department, told NBC News,
What we have now is a community that was really influenced by these anti-vaccine groups. And they’ve performed a natural experiment: to forgo the measles vaccine based on this propaganda. . . . There has been ongoing contact between outside groups who have come in and wanted to do organizing within the community that’s affected here . . . and I think that’s really unfortunate because some of the anti-vaccine propaganda is largely to blame for what’s going on in our community. . . . They’ve preyed on parents’ concerns about the health of their children and they’ve provided them false hope that avoiding the measles vaccine will somehow prevent autism, when in fact not vaccinating only serves to increase the risk of a child getting a disease and then spreading it to others.
The anti-vaxxers do not confine their activities to immigrant communities. After a Disneyland outbreak of measles in 2015 that spread to seven states, Canada, and Mexico, a study revealed that some of the highest levels of vaccine skepticism and lowest levels of vaccination occurred in communities of largely graduate-level educated residents in affluent California counties.
With decades of overwhelming scientific evidence supporting vaccination and countless lives saved, how did the anti-vaxxers gain such traction? Ironically it was partly the success of vaccine programs in eradicating childhood diseases that were once fatal or that caused severe brain damage. The thinking goes, Why take a chance and vaccinate my child for a disease he or she won’t get or at worst will cause nothing more than a rash?
History has also played a role. The infamous Tuskegee Study, which played out from 1932 to 1972, saw public health officials withhold treatment from poor rural African American farmers in Alabama as part of an observational study of syphilis. This had a long-lasting effect in undermining confidence in the medical community, especially among minorities.
Likewise, the government and physicians lost credibility during the swine flu debacle of 1976, when officials drastically overestimated the chances of a swine flu pandemic and failed to anticipate a small but significant number of neurologic side effects of vaccination during a national immunization program.
The most egregious vaccination problem was the Cutter incident when polio gripped the United States in the early 1950s. Jonas Salk and his team developed a vaccine from inactivated polio
virus, and after testing they found it to be effective in hundreds of thousands of children nationwide. However, during the subsequent national immunization campaign in 1955, two hundred thousand children received a batch of defective vaccine manufactured at Cutter Laboratories in which live virus was still present. Thousands of polio cases were reported, two hundred children were left paralyzed, and ten died.
Some sources blamed the incident on Cutter, while others blamed the federal government for inadequate oversight. Julius Youngner, the last surviving member of the Salk team and one of the last people with direct experience with the Cutter incident, died recently, blaming Dr. Salk to the end for not preventing the tragedy (the two men had a falling out, which undoubtedly colored Youngner’s account).
Whatever the cause, the episode led to greater federal regulation of vaccines. Ironically, there was no public hesitation to receive the polio vaccine when it was reintroduced; back then we lived in a far less skeptical world.
Today virtually every study has failed to find any link between vaccines and autism. Just as important is the documented effectiveness of vaccines. When the grandparents of today’s parents were children, death from childhood diseases was a grim presence in every American community. According to the Centers for Disease Control and Prevention (CDC), in 1900 there were 21,064 smallpox cases and 894 deaths. There were 469,924 measles cases and 7,575 deaths in 1920, as well as 147,991 diphtheria cases and 13,170 deaths. In 1922 there were 107,473 pertussis cases and 5,099 deaths. Now vaccination has virtually eliminated these deaths.
Nevertheless, the anti-vaxxers are not going away. The most that can be done to counter them is better communication of reliable information by journalists and the health care community, along with a tightening of state laws making personal exemptions, a loophole anti-vaxxers commonly exploit, harder to obtain. After the Disneyland measles epidemic, the California State Legislature introduced more rigorous legislation regarding personal exemptions.
The Doctor Will See You Now Page 18