Friday, October 16, 2009

Swine Flu In The Information Age

"Swine Flu Characteristics Becoming More Evident/Links to Pneumonia, Rapid Effects on Young Noted"--that's the scary headline in The Washington Post this morning. "It's very difficult to get this double-barreled message out that: 'Yes, most cases are mild, but in a small percentage of cases these cases are disastrous,' " Vanderbilt University's William Schaffner told the Post's Rob Stein. "But the message is: Don't underestimate H1N1."

People are dying of swine flu, in increasing numbers, but many are resisting getting the vaccine. And so we come to an important crossroad of public policy, at the intersection of public health, scientific research and the search for cures, "health insurance reform," the disseminating of information in modern governance, and, indeed, the structure of authority in our society.

In September, a survey by the University of Michigan’s C.S. Mott Children's Hospital survey found that a plurality of Americans said they would not get the H1N1 flu shot. No doubt some Americans have memories of the 1976 swine flu vaccine fiasco when 25 people died, apparently from the vaccine.

But as Christopher Beam observed in Slate, significant chunks of both the left and the right have staked out positions against the swine flu vaccine. On the other hand, most of the religious leaders surveyed by The Washington Post said that they saw a moral duty to get vaccinated.

Meanwhile, people are dying, especially the young. AFP, the French news agency, reported on Friday afternoon:

US health officials warned Friday that deliveries of swine flu vaccine are likely to be delayed even as influenza deaths climb, with children hit particularly hard.

Eleven more children were reported to have died of flu in a single week, 10 of them from swine flu, bringing the number of pediatric deaths from H1N1 flu since April to 86, Anne Schuchat, a senior official at the Centers for Disease Control and Prevention (CDC) told reporters.

In the worst of the past three flu seasons in the United States, which usually run from August to March, 88 children died.

As of mid-week, 11.4 million doses of H1N1 vaccine were available and around eight million had been ordered by the states.

Inoculation clinics got under way in several US states last week, targeting children, health care workers, people who work with infants, and young, healthy adults.

Long lines have been reported outside the clinics, as parents rushed to get their children -- one of the most at-risk groups -- inoculated against swine flu.

Let's sum up with five points:

First, vaccines are a great idea--a signature of scientific achievement. They are a true lifesaver; and saving lives is the best bender of the cost curve. But what about the argument that thimerosal, a preservative in some vaccines, causes autism? Most scientists, and most courts,have reject the imputed linkage between thimerosal and autism, but there's no need to get into that fight here. Suffice it to say that there is always room to improve medicine, including vaccines. But the opportunity for improvement does not obviate the immediate necessity, sometimes, of getting vaccinated.

Second, vaccines for the flu are not on a par with, say, the vaccine against polio. (Although the polio vaccine did not arrive in perfect form back in 1955; as this WaPo obituary of legendary health expert Ruth L. Kirschstein reminds us, deadly mistakes occurred during the evolution of that vaccine. That's the nature of science--you learn from mistakes, even tragic mistakes.) The various flu vaccines don't have the track record that the polio vaccine has now, but that's because we worked at it.

Third, even though recent flu outbreaks have been relatively benign, we never know when the flu is going to turn for the worse, as the WaPo reminds us. And we never know when or if it might turn into something as bad as the Spanish Flu, which killed 50 million or more worldwide in 1918-1919.

Fourth, in today's culturally libertarian age--everyone is empowered with information, everyone has rights, everyone has an opinion and a way to give voice to it--it's hard for government to get anything done, just as it's hard for people to trust the government. And let's face it: Much of the time, such mistrust is justified. And when, for example, 83 percent of Americans think that legislation should be put online before Congress votes on it, and the government simply ignores that overwhelming sentiment, well, that further degrades public confidence.

Fifth, vaccines, or anything else medical, won't get better unless they’re tested and tried, first on test subjects, then on larger and larger populations. So all of us interested in better medicine, and cures, have an interest in encouraging people to participate in these efforts.

OK, so where does that leave us? Here's the SMS view: We should encourage people to get the vaccine, maybe even incentivize them to get the vaccine. With money? Maybe. Or maybe we should launch some other sort of persuasion campaign; I still remember President Gerald Ford getting the swine flu vaccine, on camera, back in 1976; and while that particular public-health exercise didn't work out so well--either medically for the country or politically for Ford--one of the many reasons that we should admire the 38th President was that he was physically courageous. Whether it was heroism in World War Two, or getting that swine flu shot, Ford was always willing to lead by example, putting himself at risk, if need be.

So now to the present: Who will step forward, today, to lead by example? Will President Obama, for example, get a swine flu shot? He has said that he will get the shot, but that he will wait his turn in line. That's an admirable position--and let's be honest, he would have suffered heavy criticism had he received the shot ahead of others--but perhaps he should cut to the head of the line. Not for his sake, but for ours.

Why push this vaccine effort? For this reason: If flu vaccines today are not as good as they could be, we should always bear in mind that the only way to make them better is to keep pushing forward.

But in the meantime, we clearly need a better information effort, as part of our Serious Medicine Strategy. We need to convince and persuade people to support vaccinations--for themselves, and as part of a needed collective effort. But at the same time, we need thorough scrutiny, even muckraking, on these and all other health issue. (But probably not, except for the grossest cases, trial-lawyer buccaneering.)

And vaccines, of course, are just a small, albeit important, part of a Serious Medicine Strategy. As the WaPo story on swine flu this morning reminds us, sometimes doctors take extraordinary measures to save lives. Let reporter Rob Stein tell the tale:

And some of those who develop serious illness deteriorate soon after starting to feel ill. They require oxygen masks, ventilator machines to pump oxygen into their lungs to keep them alive, and drastic, often rarely used measures to try to save them within days of the first fever, ache or cough.

"The rapidity of it is striking," said Andrew R. Davies, deputy director of intensive care at Alfred Hospital in Melbourne, Australia.

Some of the cases in Australia and New Zealand were so severe that doctors resorted to a much more aggressive, less commonly used treatment known as extracorporeal membrane oxygenation (ECMO). It involves siphoning patients' blood into a machine to remove carbon dioxide and then infuse it with oxygen before returning it to their bodies.

"It's quite an extreme form of treatment," said Steve Webb, a clinical associate professor at the Royal Perth Hospital in Australia.

Other doctors have tried administering nitric oxide and putting patients in a bed that turns them upside down to help their lungs work better. "Our back was against the wall," Murphy said, adding that after the deaths of patients such as Hays his hospital is working to make ECMO available.

Now that's Serious Medicine. I am glad that they can do that lifesaving procedure in Australia, and I am glad that it can be done here. And I hope, of course, that nothing in the Obamacare legislation will crimp such heroic technology, or slow down the future introduction of even better technology.

What we really need is a public debate over a vision for a healthier future--a vision that renews our commitment to cures, a vision that builds on a public consensus on fighting a real war against illness, incapacitation, and premature death. I think that such a Serious Medicine Strategy would be a huge winner with the American people, but we need a solid and yet transparent process for getting there.

We have all these great tools available, from TV, to the Internet, to Twitter, to Google Wave and to the wave after that. Are we using them for good purposes--to save lives? Unfortunately, it would seem that the incumbent political class is so hung up on building a bigger bureaucracy that it has lost sight of the real goal of healthcare and medicine, which is to make people healthier.

So once again, we need a better strategy--a Serious Medicine Strategy. And once we get that strategy in place, the communications tactics needed to implement that strategy should become readily apparent.

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