TCS Daily

Dr. Falstaff

By Sydney Smith - March 18, 2003 12:00 AM

Here is at least one poet whose words have had an effect on the war effort - Shakespeare. Not only did he aptly describe all of the conflict's major players, but his line from Henry IV about discretion being the better part of valor has been taken to heart by the healthcare professionals responsible for the pre-attack smallpox vaccination program - both those called to implement it and those called to receive it.

The plan was to have 500,000 health care workers immunized against the disease, the better to care for victims of a possible attack. By the end of February, only 7,354 people had volunteered, just a little over one percent of the goal. Three hundred and fifty hospitals decided unilaterally not to offer the vaccine to their employees, fearing reactions to the vaccine would leave them short-staffed, and that the cowpox virus used in the vaccine would be transmitted to patients. At least one San Francisco hospital has barred its staff members from vaccination, even if they get it elsewhere. The American Nurses Association has been a vocal opponent of the program. Their widely distributed decision tree for nurses contemplating the vaccine is heavy on the negatives, largely of the "what's in it for you?" variety. The nurses obviously spent more time studying the recommendations of the Service Employees International Union, a division of the AFL-CIO, than those of the CDC.

Meanwhile, public health officials claim that they're so busy vaccinating people, they could miss a smallpox epidemic. Around the nation, public health departments complain that the smallpox program costs too much. That despite a $1 billion infusion of federal money into the system, they haven't the manpower or the money to effectively implement the program. That it's distracting them from protecting us against other less deadly, less contagious threats such as anthrax and botulism, or less likely threats such as Ebola. That it's taking staff and resources away from their other, established programs. And worst of all, that it's preventing them from protecting us against sexually transmitted diseases and obesity.

None of this reflects well on the healthcare profession. Like Falstaff, the character who uttered that famous Shakespearean phrase, their concern is more for themselves than the greater good. Hospitals worry that they'll have to pay worker's compensation to employees with even minor side effects, that they'll be sued if a patient contracts cowpox from an employee, and that complications of the vaccine will leave them short-staffed. The American Nurses' Association and the Service Employees International Union, both of whom provide health-related insurance programs for their members, worry about the financial costs of vaccine side effects. They would prefer to have taxpayers bear the burden. And the regional public health departments? Well, no one likes to give up autonomy or to see their pet projects superceded by mandated programs. They're having a little trouble adjusting to the changing times.

But how realistic are these fears? In its most recent recommendations, the CDC says that keeping the vaccine site covered with a dressing eliminates the risk of transmitting the cowpox virus to patients. So far, in the U.S. there have been two cases of transmission of the cowpox vaccine to another person, both involving intimate contact. About a third of vaccine recipients become ill enough to miss work for a few days, due to arm soreness or flu-like symptoms, but serious reactions occur at a much lower rate. To date, vaccination programs in Israel and the U.S. military have had similar rates of side effects as those observed in the 1960's. - a death rate of .0001 -.0002%, and around .005% life-threatening reactions.

In comparison, smallpox, with its one in three death rate and its highly contagious and severe nature, has the potential to decimate hospital staffs and the patients they care for, both directly and indirectly. Far better to struggle with a few, short absences after vaccination than face an epidemic in an unprotected hospital. Far better to pay out healthcare, workman's comp, and disability benefits to a couple of hundred people nationwide than to pay healthcare and death benefits to several thousand after an attack. Far better to put sexually transmitted diseases and obesity on the back burner while vaccination is addressed than to put them on hold indefinitely to address a smallpox epidemic.

We may be a fat and promiscuous nation, but those character flaws aren't our immediate threat. Instead, it's our inability to see beyond our own narrow self-interests that's the greater threat. Like Falstaff.

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