TCS Daily


A Pox on Paternalism

By Sydney Smith - January 7, 2003 12:00 AM

The news lately has been full of stories about the "confusion and ignorance" of the American public. According to a survey in the New England Journal of Medicine, we don't understand the smallpox issue. We think that smallpox isn't as fatal or as contagious as it really is, and that the vaccine is much more dangerous than it really is. Gee, I wonder where we got that idea?

Since the terrorist attacks of 9/11 and the anthrax mailings that followed it, our public health experts have repeatedly downplayed the risk of smallpox and highlighted the risks of the vaccine. Last June, Dr. Ruth Katz, associate dean at Yale University School of Medicine and member of the National Vaccine Advisory Committee which advises the Centers for Disease Control on immunization policy, wrote in an op-ed in The Washington Post that, "Implementing a sound policy is further complicated by misperceptions, with many physicians and lay people believing that smallpox is almost always fatal (it actually kills about 30 percent of its victims) and that the vaccine is as safe as most childhood vaccines (it may be the most dangerous one available)." In keeping with that theme, the CDC's website describes in vivid detail the potentially life-threatening side effects of the vaccine in language that makes them sound inevitable, while describing the disease in mild terms, as "sometimes fatal" and requiring "direct and fairly prolonged face-to-face contact... to spread...from one person to another." The site also states that when a smallpox victim first becomes contagious, they "are usually too sick to carry on their normal activities." It would appear that the American public has learned their lessons well. If we are misinformed, we have our public health officials to thank for it.

It's true that the smallpox vaccine is the riskiest of immunizations. That's because our current vaccines are extremely safe. No one dies after having a polio or tetanus shot, but one or two per million could die after getting the smallpox vaccine. In the past about 770 per one million first time vaccine recipients experienced inconvenient, but not life-threatening reactions to the vaccine. Fifty-two per million developed potentially life-threatening complications. There is also the very real risk of transmitting the vaccine virus to others, especially those who have weakened immune systems. Unfortunately, that's a risk that has never been quantified.

The assertions of the CDC website about smallpox as a disease, however, aren't necessarily true. Smallpox is highly contagious. It can spread by a sneeze or by contact with dried up scabs. It can survive for weeks outside the body. It spreads more rapidly and is more deadly in populations with no immunity, which today is half the world. In the 1500's it killed over half the population of the Aztecs. In the 1700's and 1800's it did the same to native North Americans. And, according to Smallpox and Its Eradication (pages 21-22), by the World Health Organization, it is possible for someone to be infective before showing outward signs of the disease.

Unfortunately, the misinformation campaign continues now that the Bush administration has announced its smallpox preparedness plan. The plan mandates vaccination of the armed forces, suggests that healthcare workers be vaccinated, and will eventually make the vaccine available to the general public. Almost immediately, the public health community reacted. Dr. Paul Offit, a member of the CDC's Advisory Committee on Immunization Practices, told The Washington Post, "What worries me about offering this to the general public is that they do not understand the risks of the vaccine." Dr. Carlos del Rio, chief of medical services at Grady Hospital, an Atlanta hospital closely associated with the CDC, decided his hospital would not offer the vaccine to its employees, telling the media, "Number one, this is not a safe vaccine. This is a vaccine that has known complications and known side effects...I don't like to cause disease. If, say, a patient with AIDS became infected, that would be a disaster." The vice-president for academic affairs at Emory Medical Center, another Atlanta hospital with close ties to the CDC, told The New York Times that, "When push comes to shove, we are dealing with an eradicated disease that we haven't seen a case of since 1977," adding that reports that Iraq and North Korea have stockpiled the smallpox virus didn't warrant the risk of the vaccine. (Is that the sound of an axe grinding? The vice-president happens to be Dr. Jeffrey Koplan, lately the head of the CDC, who resigned abruptly after public criticism of the CDC's handling of the anthrax mailings, and who also came under criticism from conservatives over other issues.)

Meanwhile, at the Virginia Commonwealth University, the other hospital that won't provide its employees with vaccine, Richard Wenzel, the chairman of internal medicine echoes that opinion, "There is a lack of logic to the current proposal. If our government in all its intelligence thinks smallpox exists in enemy hands, why would we creep up on that policy? We would rush to vaccinate everybody right now."

There's a lack of logic here alright, but it isn¹t in the Bush administration's plan. It's in the public health community's second-guessing of defense intelligence and their stubborn adherence to the belief that post-exposure mass vaccination of the general public is both feasible and effective. Not only are the logistics of vaccinating over two hundred million people within the space of a few days mind-boggling, but obtaining truly informed consent during an emergent, hurried, nonvoluntary campaign is virtually impossible. Ditto for "rushing to vaccinate everybody right now."

In contrast, the administration's plan is a model of prudence and effectiveness. It begins with the mandated vaccination of a select group of people at highest risk for smallpox exposure in about as controlled an environment as possible - the armed forces. It gradually expands to include others at less risk, in less-controlled situations. Such a graded approach allows careful observation and documentation of many of the unknowns of smallpox vaccination. How easily is the cowpox virus used in the vaccine transmitted to others? What is the incidence of side effects in a carefully screened and healthy population?

Offering it next to healthcare workers also makes sense from a public health perspective, some authorities not withstanding. Offering protection now, before exposure, allows staggering of vaccinations to minimize the impact of side effects on staffing levels and to minimize the possibility of transmitting the vaccine¹s virus to high-risk patients. It also provides further protection for the public from future attack. The first case of smallpox is going to be discovered in a community emergency room or doctor's office. It isn't going to show up at the offices of some bioterrorism response team. Vaccinating healthcare workers now decreases the likelihood that they'll unknowingly carry smallpox to other patients, to their families, and to their friends and neighbors.

Finally, the most controversial element, making the vaccine available to the general public, is perhaps also the wisest. It rejects the paternalistic approach that is so prevalent in the public health community. It recognizes that smallpox vaccination is not only a matter of public health and national defense, but also a matter of self-defense. By the time the vaccine becomes available, sometime in 2004, we'll know more about its risks and side-effects. And we'll know better how to protect others from our vaccines.

Under the Bush plan, when members of the general public opt for vaccination, it will not be done lightly. It will done with truly informed consent, by a public who has had time to weigh the vaccine's very real risks against the equally real potential for a bioterrorist attack. And as we weigh those risks against that potential, we would do well to keep in mind another 9/11 - September 11, 1978. That's the day the last smallpox victim died. She caught it in England, a full year after the last natural case of smallpox occurred half a world away. She caught it by inhaling a few wayward virus particles - from a nearby laboratory.

The author is a family physician who has been in private practice since 1991. She is board certified by the American Board of Family Practice, and is a Fellow of the American Academy of Family Practice. She is the publisher of MedPundit.
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