The agency announced on Thursday that there have been 175 measles cases in the U.S. in 2013, whereas only about 60 are seen in a typical year lately. Measles, the CDC press release says, “still threatens health security.”
Are they joking?, you might wonder. At a time when nearly 50 million Americans can’t get medical care because they don’t have insurance, and about 30 million will continue to lack health insurance even if the Affordable Care Act is fully implemented — at this point in American history, do the wonks at CDC really expect Americans to believe that an extra 100-odd measles cases represents a threat to the nation’s health?
No, they are not joking. CDC Director Frieden says:
“A measles outbreak anywhere is a risk everywhere.”
That sentence doesn’t exactly parse in standard English, but we get the point: be on guard, be on edge.
“With patterns of global travel and trade,”
Frieden continues,
“disease can spread nearly anywhere within 24 hours.”
This is not true, but truth isn’t at issue. Frieden is settling comfortably into his role as Minister of Propaganda for the unending War Against Risk, that existential danger to our well-being in which we are all supposed to be foot soldiers.
The media have responded as per their wont. Measles is still a threat, there’s a spike in cases, it’s about lack of vaccination, and so forth.
Here, the real story is that there’s no grave threat. There were over 100 measles cases in the U.S. in 2008 and over 200 in 2011. So it’s not at all clear that this year’s toll is out of the ordinary. And, of the 175 cases in 2013, most were acquired abroad. Measles transmission in the U.S. occurred in outbreaks among people who weren’t vaccinated for religious reasons, including 57 people in a Hasidic neighborhood in Brooklyn who were infected by a traveler who acquired measles virus in England, and 22 in North Carolina infected by a traveler returning from India.
That these outbreaks occurred among people who were not vaccinated reveals little about vaccination campaigns in the U.S. — religious exemptions have long been recognized for people who do not want their children to undergo immunization. And they have not been severe: a pregnant woman infected with measles in the Brooklyn outbreak miscarried, but there is no way to know whether measles was the cause. One adult was hospitalized with respiratory complications in the North Carolina outbreak.
It’s probably a good idea to be immunized against measles. Measles rarely causes severe illness, but not never. And there is plenty of measles in the world, although it is extremely rare in the U.S. Immunization is like washing your kitchen counter tops.
But there’s no reason to sign up for Dr. Frieden’s army. Measles doesn’t threaten our health security (when it comes to threats to Americans’ health security, nothing comes close to Congressional Republicans!). We do not need to report our neighbors to the authorities if they aren’t getting their kids immunized. And we really don’t need any more inspections at airports. Our way of life is not under siege.
]]>This took place at about 6pm, in the Bronx. Which is to say, it took place in daylight on a residential street in a neighborhood where it’s usually unnecessary to look one’s door and where the biggest street-scene commotion is normally the recycling pickup performed by noisy sanitation trucks on Saturday mornings.
I’m grateful that few people in my neighborhood have guns. Nobody was hurt in this incident, frightening as it was. And, after all, the only thing the thief took was a car. If passers-by had been armed, or one of the neighbors, someone might have tried to stop the carjacker by opening fire, and then, most likely, there would have been mayhem and wounds, or worse.
I say this as a counterweight to the dismal response of most Americans to the mass shooting at the Navy Yard in D.C. on Monday the 16th. After 13 deaths, the obsession with the details of the shooter’s religious beliefs, psychiatric record, and security clearance seems bizarre and macabre.
The insistence by the main news media on covering firearm incidents as if there were somehow two sides to the story, as if it were a question of rights or ethics, is a betrayal of the public responsibility of journalists. And this betrayal includes, especially, the supposedly liberal New York Times, and Washington Post, and NPR, and so forth. And the willingness of the media to run with stories about psychology and brain scans and heroic school teachers and the virtuous souls of those who “sadly” (inconveniently, they mean) died after being shot is a camouflage for their cowardice, and their moral weakness.
Today’s Brian Lehrer show on WNYC featured Paul Barrett, the author of a book about guns in America, saying that some Americans simply like guns and the rest of us ought to be practical and learn to accept that.
Allow me to be clear, then. I do not accept that Americans should have guns. Gun ownership is a crude and barbarian residue of a less civilized time, and should simply stop. Gun owners may, as Mr. Barrett alleges, like their guns, and this affection for potentially deadly objects may arise for all sorts of interesting reasons (or in some cases it might be, as I sometimes suspect, for reasons of sexual perversion, which is really not very interesting and could surely be sublimated onto, say, weed whackers or egg beaters or fancy dildos). But liking deadly weapons is no reason that society must allow them. Not even if a majority of people like them. It may be democratic to learn to live in a society where people shoot other people, but it isn’t civil.
Barrett says that gun owners will be offended if we gun-averse people don’t understand their affection for their weapons. Fair enough. They are welcome to be offended. I don’t share this affection. I find it medieval, and bizarre, and, in a society with so much horror-engendering killing, I find the tolerance for the market in guns to be simply immoral.
Gun owners distract the conversation away from civility, turn it into a muddled discourse on rights. But there is no question of rights when it comes to guns, only a question of the wording of the second amendment, which is not at all the same thing as a right in the natural-rights sense, or in the human-rights sense. We should not be drawn into discussions of gun rights. We should discuss murder, we should discuss 30,000-odd deaths each year, we should discuss the acceptance of guns in America as a thinly disguised mechanism for our society to allow the intimidating and utlimately thinning of the population of black males. But we should not pretend this is about rights.
In a civil society, people do not own guns (except if they are going to hunt for food, which really doesn’t apply to most of us). Citizens of civil societies don’t shoot one another. Once the guns disappear, all sorts of supposedly thorny issues, like security clearances and mental-health records, will be revealed for the trivial conversations they are.
The carjacking outside my house worries me, the more so as the thief was armed. I’ve locked my door, and am going to be more watchful, I suppose. But I remain glad that there weren’t more guns involved, and wish there had been none.
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about morals, no matter what some self-important researchers claim. The debate is about who will be able to control scientific research and who will benefit from the consequences (including, presumably, vaccines or other marketable preventive agents). Don’t be misled by assertions that the debate over GOF research is about public health, or ethics. It’s about the usual: political power and profit making.
Now that a new flu virus, H7N9, has caused over 130 human flu cases in the far east, with 37 deaths (per WHO’s summary of 29 May 2013), the questions on GOF studies might seem to take on new significance.
The insightful Guenther Stertenbrink brought me up on my assertions about GOF research, saying
I don’t see that connection and motivation, how they (signatories) might benefit from flu-research reduction politically or financially, the “marketable agents”… And don’t you think this should be discussed by hearing both sides, giving them the opportunity to reply, with links etc. to support the claims ? Have you contacted them ?
I’m trying to estimate the pandemic risks and I’m in the process of contacting them to see the letter to the ethics commission, how the signatories and 200 nonflu researchers were selected and approached, what their expertise is to judge and weigh and assess and quantify flu-specific benefits and risks.
Stertenbrink is working assiduously to assess both real pandemic risks and the scientific issues involved in the GOF research debate. He is hosting a useful colloquy and has also posted a timeline of commentary and findings.
But I’m sticking to my guns. Guenther is perfectly correct when he intimates that many of the complainants who ask that GOF flu research be controlled or curtailed have nothing financial to gain. But it’s not true that they have nothing at all to gain. In science, and especially in science that bears on public health, controlling the narrative is of nonpareil importance.
The only reason why external commissions should be convened to assess the possible dangers of success of GOF experiments is to make sure that the “right” people get to control the narrative. Because, really, to claim that the actual danger to humans arising from transfering genes in flu virions is knowable and predictable is to misrepresent the deep uncertainty in assessing risk.
First, it creates a false voice of authority. “We know that bad things are likely to happen with probability X if experiment Y succeeds” implies that “we” (the experts?) have knowledge beyond what is actually available. People who have claimed to have exceptional knowledge have done some very, very bad things to the world. All claims of extraordinary knowledge of the future are to be rejected, on moral grounds, in a civil society.
Second, the claim to be able to assess the risks of successful experiments works against the inspired tinkering of science. If our civilization want to have science — and I think it should — we are going to have to live with some unwanted disasters, and with some people (scientists, I mean) doing unseemly things. We may reasonably regulate what they do, in order to prevent animals from being tortured or people killed for the sake of science. But we can’t expect that science will always be “well behaved,” in the sense of a well-behaved mathematical function.
Third, claims that GOF experiments are unethical are really assertions that some other kind of science is ethical. Some other science, in other words, is closer to an imaginary Platonic sort of correctness. Science, as Paul Feyerabend argued, is anarchic. Properly so. But that means there are no hard-and-fast rules of Truth.
I stand by my assertion. The debates over GOF research, just like debates over “ownership” of the MERS coronavirus sequence or the carefully constructed fear over whether the world is sufficiently frightened about MERS, aren’t about science, or public health, or ethics. They are about who controls the narrative.
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And the question about minding the experts just got more complicated.
The issue has been whether researchers should be allowed to conduct experiments with modified strains of H5N1 (avian) influenza virus, in order to find out more about the potential for bird flu to spread among humans. Concerned about possible dangers of experimenting with extra-transmissible bird ful, a moratorium on such research was declared. The moratorium ended in late January of this year.
But now some distinguished scientists are calling for fuller constraints on this kind of research — called gain-of-function (GOF) experimentation, because it involves creating novel strains of viruses with capabilities not known to occur in nature. The ostensible purpose of such research is to figure out how to prevent harm associated with inevitable genetic changes in viruses. Think of it as creating disaster scenarios at the molecular level, so as to determine how to avert damage if the disaster comes to pass.
CIDRAP gives a nice summary of the new controversy, reporting that the Foundation for Vaccine Research, an advocacy group, has written to Dr. Amy Guttman, chair of the Presidential Commission for the Study of Bioethical Issues, raising what the Foundation says are “moral and ethical” concerns about GOF research.
An editorial by Simon Wain-Hobson in Nature the other day advances reasons why scientists should get together to limit GOF research. Wain-Hobson questions the scientific validity of the predictions such research makes (since natural selection in the real world might produce changes in viruses quite unlike those manufactured in the lab), and criticizes WHO for failing to generate a broad discussion on the dangers of GOF research.
Then, he asks what will happen if the viruses created in GOF research leak out of a lab. Who will take responsibility, who should make decisions, who should own the information arising from the research? He says,
The global ramifications of GOF research have simply not been sufficiently explored and discussed. Influenza virologists are going down a blind alley and the powers that be are blindly letting them go down that alley, which is tantamount to acquiescing. So let’s be clear: the end game could be viruses more dangerous than the Spanish flu strain.
And Wain-Hobson goes on to propose a suspension of all GOF research until
virologists open up and engage in public discussion of their work and the issues it raises. Given that the flu community failed utterly to use the year-long hiatus to good effect, it is clear that an independent risk–benefit assessment of GOF work is needed.
Here is where it gets complicated. One group of scientists (Wain-Hobson and the FVR) is angry with another group (the so-called flu community, basically those influenza researchers who conducted the 2011 H5N1 experiments and their defenders).
At the same time, both groups are unwilling to have government regulate research. In fact, Wain-Hobson worries because
Officials in Washington DC are putting the finishing touches to new guidelines for the review, regulation and oversight of this kind of research. The chill winds that we can anticipate blowing from policy-makers as a result could affect all of us who research viruses and their pathology.
The terms of the debate aren’t scientific, that is. And they surely aren’t about morals, no matter what some self-important researchers claim. The debate is about who will be able to control scientific research and who will benefit from the consequences (including, presumably, vaccines or other marketable preventive agents).
Don’t be misled by assertions that the debate over GOF research is about public health, or ethics. It’s about the usual: political power and profit making.
]]>Why does CDC recommend (based on advice by the Advisory Committee on Immunization Practices in 2010) that all Americans — from infancy on up — get immunized against flu?
A few possibilities:
1. Public health benefit?
No. Over the past twenty years, flu-vaccine coverage — the proportion of the population that is immunized — has been going up progressively. But flu hospitalization and mortality rates have been basically constant. If mass immunization had any public health value, those rates should go down as coverage goes up
(A technical note: this means that coverage remains below the threshold needed to reduce influenza transmission population-wide, i.e., it isn’t high enough for herd immunity. But that’s the point. In order to be of public health benefit, flu vaccine would have to be accepted by almost everybody, every year. And even that might not be enough: For a nice explanation of why the efficacy of flu vaccine is limited, see Vincent Racaniello’s blog post.)
2. Exceptional efficacy of the vaccine?
No. Based on an observational study of acute respiratory illness patients published this month, the effectiveness of this year’s flu vaccine is 55% against illness caused by influenza type A (which accounts for about 80% of flu cases). Effectiveness is 70% against type B. Overall, the chances of being protected against symptomatic flu are less than two out of three.
Jefferson and colleagues found that the overall efficacy of flu vaccines at reducing influenza A or B infection in children aged 2-16 is only about 65%, and that inactivated vaccines (i.e., the usual injection) had little impact on serious illness or hospitalization from flu-like conditions in this age group.
As with this month’s observational study, Jefferson et al.’s meta-analysis of multiple studies on flu immunization found that the inactivated vaccine had about 73% efficacy at preventing infection in healthy adults — but that efficacy can be as low as about 50% in years when the vaccine isn’t well-matched to the season’s circulating viruses.
Importantly, the Jefferson studies found that effectiveness of immunization — the prevention of serious illness or hospitalization from influenza-like illness — is very low.
There’s no sound public health rationale for encouraging everyone to be immunized against flu every year.
People who are likely to develop serious complications if they are infected can benefit from immunization. But for most of us, immunization only reduces (by two-thirds) the already rather small chance of infection with influenza. And it doesn’t protect us much from serious respiratory illness during flu season.
I commented in 2011 on public officials striving to help pharmaceutical companies profit from flu fears. And that’s what we’re seeing again this season — with exaggerated warnings and declarations of flu emergencies. Even though the latest national summary from CDC shows that less than 30% of all influenza-like illness is actually caused by flu this season — and that’s likely an overestimate, since it’s based on testing of more severe cases of acute respiratory illness. And the surveillance data suggest that the season’s flu outbreak might already be past its peak.
Get immunized against flu if you’re worried. But keep in mind that vaccination against flu is not going to help the public’s health, and it isn’t highly likely to help yours — it’s primarily your contribution to the profits of Sanofi-Pasteur, Novartis, GSK, or Merck.
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If the government were to redefine normal weight as one that doesn’t increase the risk of death, then about 130 million of the 165 million American adults currently categorized as overweight and obese would be re-categorized as normal weight instead.
The report by Flegal et al., published this week in JAMA, is a meta-analysis of 97 studies on body-mass index (BMI) and mortality. This new analysis found that mortality risks for the “overweight” (BMI 25-29.9) was 6% lower than that for “normal” BMI (18.5-24.9) individuals. And those in the “grade 1 obesity” category, with BMIs from 30 to 34.9, were at no higher risk of dying than those in the so-called normal range. Only those with BMIs of 35 and above were at elevated risk of dying, and then only by 29%.
In other words, people who are overweight or obese generally live longer than those who are in the normal range. Only extreme obesity is associated with an increased probability of early death.
Flegal and colleagues already demonstrated most of these findings using administrative data, in an article appearing in JAMA in 2005. There, they reported no excess mortality among people labeled “overweight” by BMI standards, and that about three-quarters of excess mortality among the “obese” was accounted for by those with BMIs above 35.
What’s notable about this week’s publication is that it has attracted the attention of some heavy hitters in the media. Pam Belluck covered the JAMA report for the NYT. Although her article seems more interested in propping up the myths about the dangers of fat than in conveying the main points of the new analysis, Belluck does acknowledge that some health professionals would like to see the definition of normal revised.
Dan Childs’s story for ABC News gives a clear picture of the findings, and allows the obesity warriors, like David Katz of Yale and Mitchell Roslin at Lenox Hill, to embarrass themselves — waving the “fat is bad” banner under which they do battle. MedPage Today gives the story straight up. In NPR’s story, another warrior, Walter Willett of Harvard, unabashedly promoting his own persistently fuzzy thinking, calls the Flegal article “rubbish” — but the reporter, Allison Aubrey, is too sharp to buy it from someone so deeply invested. She ends by suitably questioning the connections of BMI to risk.
Campos’s op-ed piece does the favor of translating the Flegal findings into everyday terms (and without the pointless provisos that burden the NYT’s supposed news story):
This means that average-height women — 5 feet 4 inches — who weigh between 108 and 145 pounds have a higher mortality risk than average-height women who weigh between 146 and 203 pounds. For average-height men — 5 feet 10 inches — those who weigh between 129 and 174 pounds have a higher mortality risk than those who weigh between 175 and 243 pounds.
Is the hysteria about overweight and obesity is over? I’m sure not. In today’s article, Campos — who was one of the first to explode the fiction of an obesity epidemic, with his 2002 book The Obesity Myth — reminds us of a crucial fact about public health:
Anyone familiar with history will not be surprised to learn that “facts” have been enlisted before to confirm the legitimacy of a cultural obsession and to advance the economic interests of those who profit from that obsession.
There’s too much at stake with the obesity epidemic for our culture’s power brokers to give it up so quickly. One day, some other aspect of modernity will emerge to inspire dread (and profits). In the meantime, we might at least hope to see some re-jiggering of the BMI boogeyman.
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Attribute the 9 deaths and dozens of injuries in Aurora to the rash act of an unbalanced man if you wish. But what about the tens of thousands of other deaths caused by firearms in the U.S. each year?
If HIV infection (9,406 deaths in 2011) and painkiller overdose (estimated at 15,000 deaths per year, according to a report by Trust for America’s Health and the Robert Wood Johnson Foundation) are public health problems worth discussion, why not firearms? In 2009, the last year for which complete data are available, there were 31,347 deaths by firearm in the US, according to the US National Center for Injury Prevention and Control.
At The Pump Handle, Celeste Monforton — always worth reading — provides the data showing how out-of-scale America’s gun problem is on the global public health scene: Our gun-violence death rates are an order of magnitude higher than those of other wealthy nations.
At CNN, Daniel Webster calls for America to wake up to the public health problem of guns. “America’s high rate of gun violence is shameful,” Webster writes. “When will we change?”
NYC Mayor Michael Bloomberg can be a tyrant when it comes to personal habits that he thinks impair the city’s health, but he has been courageously forthright on the need to control firearms.
But, like me, Monforton and Webster are academics. And Mike Bloomberg is, well, Mike Bloomberg.
Where are the health officials?
Kathleen Sibelius, Secretary of Health and Human Services, has been silent. She’s been vocal on healthcare fraud, and earlier this week announced a new public-private partnership to keep people with AIDS in care. But not a word on guns.
Thomas Frieden, CDC director, can’t be accused of shying from the spotlight. But he has said nothing about guns.
Under these corrupt officials, gun violence has been cleaned from the public health radar screen.
Try finding an entry on firearm violence at the Department of Health and Human Services website. Or, go to the CDC’s “A-Z Index” (what other letters would bound an index, one wonders? well, anyway…). There’s no entry for “guns” or “gun violence.” Nor for “firearms.” The entry on “violence” leads to a page on injury prevention that includes links to entries on Elder Maltreatment and Intimate Partner Violence — but not a word on guns.
At Salon, Alex Seitz-Wald wonders whether the NRA has suppressed research. There’s some evidence for this: Paul Helmke of the Brady Center to Prevent Gun Violence wrote to Secretary Sibelius over a year ago, asking whether it’s true that Frieden’s CDC has agreed to tip off the NRA when researchers who receive CDC monies are going to publish anything on gun violence.
Seitz-Wald might well be perfectly right. Certainly, the NRA is unseemly, manipulative, and morally vacuous. But it doesn’t have the power to program anyone’s thoughts. It doesn’t cause our officials to be spineless in the face of the infestation of American homes and streets — and movie theaters, schools, colleges, and so on — by guns.
No, it can only be that Frieden and Sibelius — and a tremendous host of less prominent health officials — are all silent about guns because, really, they aren’t concerned about 31,000 deaths and upward of 400,000 injuries from firearms each year. Or, not as concerned about the carnage as they are about their jobs.
It’s self-evident that our health officials don’t care about the real health of Americans nearly as much as they do about their own continuation as officials. More important than saving lives or limbs, apparently, is the officials’ capacity to mount the bully pulpit in order to decry other dreadful scourges. Like big cups of soda, defrauding the insurance companies, or not exercising.
Our public health officials: put to the test, and found to be feckless at core.
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Yet, liberals are rejoicing at yesterday’s Supreme Court ruling, in which Roberts left the three arch-conservatives (Thomas-Scalia-Alito) and Kennedy, to join the usually liberal wing (Brier-Ginsberg-Kagan-Sotomayor) in order to uphold the Affordable Care Act, the health care financing law of 2010. Paul Krugman says that the “real winners are ordinary Americans — people like you.”
The celebration is misguided. After yesterday’s ruling, there will be no national health system. There will be no single-payer nonprofit insurance plan. For the foreseeable future, diagnosis, treatment, and corporate profit will remain the inseparable triumvirate of medicine. Hardly party-worthy.
Sure, there are a few things worth cheering about. As Josh Levs set forth yesterday in a particularly cogent summary of the new law, insurers won’t be able to deny coverage to people with pre-existing conditions (young people immediately, everyone from 2014 on). Until you’re 26, you will be able to get health insurance from your parents’ insurance policy, especially useful now with unemployment so high among the young. Some of the “doughnut hole” in Medicare prescription drug reimbursements will be closed.
But Roberts’s brilliance was revealed in his handling of the vexatious issue of the mandate — the requirement that each non-indigent American purchase health insurance coverage or be fined by the Feds. The fine would begin at $285 per family or 1% of income, whichever is higher, in 2014 but climb to over $2000 or 2.5% by 2016. Instead of looking at the mandate and accompanying fine for noncompliance as a regulation, Roberts picked up on the fall-back argument adduced by Solicitor General Donald Verrilli, Jr. — he asserted that it’s really a tax. And, of course, Congress can levy taxes.
At Slate, Tom Scocca explains that Roberts used his majority opinion on this case to undercut Congress’s right to regulate commercial activity. For Scocca,
the health care law was, ultimately, a pretext. This was a test case for the long-standing—but previously fringe—campaign to rewrite Congress’ regulatory powers under the Commerce Clause… Roberts’ genius was in pushing this health care decision through without attaching it to the coattails of an ugly, narrow partisan victory. Obama wins on policy, this time. And Roberts rewrites Congress’ power to regulate, opening the door for countless future challenges. In the long term, supporters of curtailing the federal government should be glad to have made that trade.
According to CDC’s summary of the latest Congressional Budget Office estimates, about 30 million uninsured Americans will gain coverage under the ACA in the next few years, leaving about 27 million without health insurance at all. That’s an estimate, because undocumented immigrants are untouched by the ACA. Ditto prisoners, who supposedly get health care in their institutions but, by all indications, often don’t.
And, the Roberts ruling opens the door to questions about the Federal government’s capacity to get the states to expand Medicaid coverage. Roberts and four justices say it’s limited. Four others say it doesn’t exist at all. As Charles Ornstein explains at ProPublica, that means that some states might simply refuse to expand Medicaid, which would undercut one of the aims of the ACA.
The final score is hardly a victory for “ordinary” Americans.
And the Roberts ruling accomplishes this victory for corporate power by upholding the law, not striking it down. That means that Congress won’t re-consider health care financing anytime soon. Which means that the single-payer system will rest in its grave for the time being.
Yesterday was no cause for celebration. It was a dark day for health care reform.
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It’s reassuring that the Department wants to be able to estimate how many New Yorkers lack health insurance and, separately, lack a regular health-care provider, and asked questions about those things. And I was impressed that the survey designers thought to ask whether, the last time I sought help for a medical problem, it took a long time to get an appointment.
And then came some predictable How Are We Doing? questions: Have I had a flu immunization in the past 12 months? (No, thank you, I’m not convinced that it works… Okay, I didn’t say that, the survey taker seemed young and too earnest for serious critique, so I just said “No.”) At least two doses of hepatitis B vaccine at some time in the past? When did I last have a colonoscopy?
But there was the question about whether I have used oxocodone or hydrocodone (OxyContin or Vicodin) without a prescription, or outside of the prescribed dosage. The Department has just announced a new campaign to stop people from using pain killers too much.
There was the question about whether I’m exposed to cigarette smoke in my household.
There was a question on whether my household has a disaster plan. No, we don’t. We have a couple of flashlights, some water, and a bottle of scotch. Will that do? We’re grown-ups, we don’t have pets or little children to look after. We’ll work something out.
(But I didn’t say that to my earnest interviewer, either. I have a feeling they don’t find whiskey to be humorous, over there at the health department. In fact, they had some very specific questions about alcohol consumption, amount and frequency.)
There were questions about how often I exercise vigorously. How often I exercise moderately. How often I exercise lightly. How long I engage in said exercise when I do do it. Very interested in exercise, our health department.
There was the question as to how many servings of fruit or vegetables I ate yesterday.
And then, onward to mayor Mike Bloomberg’s white whale: sugar-sweetened beverages! Mayor Mike is going to ban serving soda or other sweet beverages in large sizes — and he’s not asking for a new law (which might not pass), just a go-ahead from the city’s eleven-person Board of Health, all appointed by the mayor, chaired by the city’s cheerleader for “healthy lifestyles,” health commissioner Thomas Farley. A restaurant trade association, the Center for Consumer Freedom, responded to news of the mayor’s intention with an amusing ad in today’s NYT, portraying Bloomberg as The Nanny.
The survey questions: How often do I drink soda or bottled iced tea? What about beverages to which I add sugar myself, like tea or coffee?
And, now that we were deep into the zone of health officials’ self-stimulation: how many (a) women and (b) men had I had sex with in the past year? Did I use condoms? And, had I used the Internet to meet a sex partner in the past 12 months?
So much for health. Now we know what haunts the dreams of the self-righteous mayor and his bluenose health commissioner:
Pain relief.
Fat people.
Vigorous exercise.
Pleasurable foods.
Sex.
Reading this list, you would have to be forgiven for thinking that these men, Bloomberg and Farley, have been living in a monastery since, say, the 14th century. In fact, if they were really clergymen instead of officials, they would leave us alone about how we eat and sweat and screw. At least in between sermons.
But thanks for calling.
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As Martin Enserink reports at Science Insider:
Two groups of scientists who carried out highly controversial studies with the avian influenza virus H5N1 have reluctantly agreed to strike certain details from manuscripts describing their work after having been asked to do so by a U.S. biosecurity council. The as-yet unpublished papers, which are under review at Nature and Science, will be changed to minimize the risks that they could be misused by would-be bioterrorists.
The “biosecurity council” in question is the U.S. National Science Advisory Board for Biosecurity, an arm of the NIH’s Office of Science Policy. It has recommended censorship of research on genetic alterations of avian (H5N1) flu that might make the virus easily transmissible between humans and pathogenic as well — ingredients for a potentially serious human outbreak.
I attach little public health importance to the experimental work, carried out by Fouchier in the Netherlands and Kawaoka in the U.S. Flu’s behavior in human populations has been notoriously difficult to predict, even with relatively advanced molecular information about viral strains. Flu forecasters repeatedly predict bad outbreaks and even (as in 2009) devastating pandemics — which fail to materialize.
Even when it comes to the most studied flu outbreak of all, the 1918 pandemic, opinions still differ on why so many millions of people died.
This week, what concerns me is the biosecurity industry. It seems more than ever eager to terrify people. The Fouchier and Kawaoka experiments themselves are interesting but hardly recipes for disaster. And yet, some voices say the research shouldn’t have been carried out in the first place. Surprisingly, they include the respected D.A. Henderson, here much mistaken. He editorializes this week with two coauthors for the online publication Biosecurity and Bioterrorism.
It’s not opposition to science — it’s just the biosecurity “experts” making a living.
The move to suppress publication of research results because scientific findings might tip off some chimerical evildoers is ridiculous. Fouchier, Kawaoka, and their teams were obviously trying to contribute to the search for ways to make people safer. That’s what most people want science to do. Instead of urging caution, the many scientists on the NSABB should be standing up for the wide dissemination of scientific findings — not for suppressing them. Made-up concerns over “bioterrorism” should not trump public access to scientific research.
And the NSABB scientists shouldn’t be cowed by the self-professed biosecurity “experts” at the Center for Biosecurity.
The sole raison-d’etre of the “biosecurity” business is to keep itself in business — by keeping people terrified. It does that by continually invoking impossible scenarios that are supposed to (a) frighten the public and (b) cause the public to buy products that we don’t need or give up rights that we do need.
After being scared into thinking the 2009 H1N1 outbreak was going to be a reprise of the 1918 flu calamity and finding that it was exceptionally mild instead, surely the public is not going to be taken in by the biosecurity industry much longer.
It’s anybody’s guess as to whether the new findings about H5N1 are at all meaningful in (human) public health terms. Which is what happens with science. That’s why the point of suppressing the findings isn’t to make anyone safer – – it’s just to keep the biosecurity experts in business.
]]>The subject is a report published by CDC today claiming that obesity among NYC schoolkids in grades K through 8 has decreased 5.5%.
The city’s health commissioner, Thomas A. Farley has been true to the shades of history’s empty-headed warriors. Farley announced that the drop in obesity prevalence is a “turning-point in the obesity epidemic” although it “does not by any means mark the end.”
A missed photo opp: Dr. Farley standing on top of a fat child, holding up a sign reading, “Mission Accomplished.”
Farley is zealous about controlling people’s behavior and contemptuous of facts (nobody will ever accuse him of being an intellectual, either). He blogs about his own work for the exclusive reading pleasure of Department of Health staffers. This allows his staff to read the Farley-esque twist on truth. One example for now: in October of 2010, Farley’s blog exultantly told his staff that in 2009 the department had “immunized nearly 130,000 children [against flu] in more than 1,200 schools over a few months.” Of course, health department employees are smart — many of them knew that the 2009 H1N1 vaccine Farley was talking about was a fiasco, far too late to make a difference, and aimed at an outbreak that was more of a whimper than a bang.
What about today’s “turning point” in the obesity war? It’s worth noting that the supposed drop in obesity among NYC schoolkids is really just a very slight (1.2%) difference in the prevalence of obesity between 2006-7 and 2010-11.
A small difference between small numbers amounts to a large percentage difference. So the 1.2% actual difference magically turns into the advertised 5.5% — the proportionate change.
But the false advertising gets worse
1. The prevalence of obesity in NYC was not measured multiple times on the same group of kids (to use epidemiology jargon: this wasn’t a panel study). Nobody observed fat children becoming less fat. The city simply measured obesity prevalence each year on 5- to 14-year-olds who were in the school system. So a high proportion of the 21.9% of kids who were labeled obese in 2006-7 would have been out of the age range for the 2010-11 assessment.
Plus, lots of kids leave the NYC school system after grade school (this has to do with Bloomberg administration’s bizarre system for preventing children from attending local schools). So, even those children who haven’t aged out of the analysis by turning 15 would be absent from the data after a few years. And, there’s also natural immigration and emigration.
Did the 2006 fat kids get slimmer? Nobody knows. The 2006-7 obesity prevalence among NYC schoolkids (21.9%) can’t be compared to the 2010-11 prevalence (20.7%). If you were forced to compare these numbers, you’d say there had been a slight change — not a 5.5% decline. There’s the first lie.
2. The second lie is a little more complicated. Since there is no widely accepted functional definition for childhood obesity, children are labeled obese if their body-mass index (BMI) falls into the upper 5% of the expected distribution of weight-for-height. This expectation is based on an old-fashioned standard. Fair enough. But lots of distributions shift over time — SAT scores, human height, grades awarded at Ivy League colleges, and global average temperature, to name a few.
Sometimes the reason for an overall shift of this sort isn’t hard to specify (test prep, nutritional quality, relaxation of grading standards, generalized global warming, etc.). But the main effect causing a shift in the distribution doesn’t explain why the few people who are in the upper reaches of the distribution are so far from the mean. To say that fewer children are now above the high-BMI cutoff than in 2006-7 therefore the tendency of children to be fat is declining is a lot like claiming that because 2011 was cooler than 2009 and 2010, global temperatures are not really going up.
(Dr. Farley, I gather that statistics aren’t your strong suit, but surely when you witnessed that snowstorm we had this past October — an outlier if there ever was one — you didn’t conclude that the climate is actually getting colder, not hotter. So what makes you think that a very tiny decrease in the proportion of kids with high BMIs means that the city’s kids are getting slimmer?)
3. Claiming credit. Attributing to the health agency’s own efforts a minuscule change in the proportion of kids who are in the upper tail of the broad BMI distribution requires self-congratulation so acrobatic as to stretch credulity.
Maybe there really has been some change in the city’s children since 2006. Or in our food supply or buying habits. Or exercising. But to claim that such a change both caused the tiny decline in schoolkid obesity prevalence and that it was the result of the Health Department’s efforts — the exercising and the low-fat milk and the salad bars in the school cafeterias and so forth — is to commit the fallacy that Rene Dubos outlined (in his book Mirage of Health) nearly 50 years ago:
When the tide is receding from the beach it is easy to have the illusion that one can empty the ocean by removing water with a pail.
Is childhood obesity really a health problem?
It’s not crazy for health professionals to be concerned about body mass. Obesity might be really bad for some people, and somewhat bad for many.
But those people are adults. Why are health agencies like NYC’s so riled up about obesity in little children?
So far, there’s no strong evidence that obesity in younger children predicts any real harm later in life, other than being a fat adult. With adults, several signs of impending debility are more commonly found in the obese than the non-obese, such as hardening of the arteries, fatty liver, sleep apnea, and diabetes. And with adolescents, there’s some evidence that those who are obese develop similar warning signs. But not younger kids.
A 2005 BMJ paper reported only social effects in adulthood (being unemployed and being without a romantic partner) of early obesity. Similarly, one cohort study carried out in Newcastle upon Tyne found little evidence that fat children became fat adults, and no evidence for predictors of illness in adulthood among those who had been overweight as children — although other studies have shown correlations between adolescent obesity and adult problems.
For kids below age 15, the most visible problem with obesity is that it occurs most commonly among the poor and dark-skinned. This bothers the obesity warriors. In fact, not only is obesity more common in African- and Hispanic-American children in NYC, even the slipshod standards of today’s report on NYC schoolkids can’t be manipulated to show that obesity is declining among these children.
As with all holy wars, from the Children’s Crusade through the U.S. invasion of Iraq, the warriors aren’t really concerned about principle. Something about somebody got under their skin.
Here’s how I answer my own question: I guess the obesity crusaders don’t like it when the children of the wealthy look like the children of the poor. They think that white kids on the Upper East Side aren’t supposed to look like kids who live in the Bronx.
It isn’t about health, in other words. It isn’t even about obesity. The “childhood obesity epidemic” is about making sure society looks the way that the health crusaders want it to look.
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[t]he most popular contraceptive for women in eastern and southern Africa, a hormone shot given every three months, appears to double the risk the women will become infected with H.I.V.
and almost everybody else (as diversely situated in newsworld as the Atlantic, CNN health blog, Catholic News Agency, and Voice of America) joined the NYT in failing to examine it critically.
Gerdts and Vohra add the essential context that was missed by the newsmedia: about a half-million women die during or because of childbirth each year, almost all of them in poor countries.
At RH Reality Check, Jodi Jacobson summarizes the main cautions about the Heffron study, and points to a Guttmacher Institute white paper. She takes into account concerns about high maternal and infant mortality in parts of Africa, the harms associated with complications of pregnancy and unsafe abortions, and, of course, the substantial possibility of vertical transmission of HIV in places where antiretroviral therapy isn’t universally available.
To claim that poor women should give more weight to the rather remote risk of acquiring a virus that might cause serious illness years down the road than to the dangers of pregnancy itself in the near term is to reduce real women to automata. Facing dire straits they might be, but they’re supposed to be reasoning machines, programmed to engage in the AIDS industry’s preferred calculus, risk.
A quick summary of the shortcomings of the Heffron et al. research: comparing users of hormonal contraception to nonusers, the difference in actual risk of acquiring or transmitting HIV was very small, amounting to 1 to 3 new infections per one hundred contraceptive users over and above the infection rate for nonusers. And it’s impossible to say that these excess infections were actually attributable to the contraceptive — because the study wasn’t a clinical trial. A great many aspects of social setting, relationships, health, and welfare of the study subjects would have been different between contraception users and nonusers, some of which would undoubtedly account for differences in rate of HIV transmission.
And since all of the subjects were in so-called discordant couples — one partner infected with HIV, the other not — it would be unusual to expect no HIV transmission at all.
Unless, of course, the subjects had been offered antiretroviral therapy, ART. But this the researchers did not do. They referred eligible subjects to HIV clinics. They seem not to have checked whether people who needed ART were getting it. They seem not to have offered ART to women who got pregnant, either. Certainly, their Lancet article makes no report of doing so.
I wondered if this was too much to expect of researchers — so I asked the students taking my course on global AIDS and human rights. Undergraduates, I find, generally have a clearer sense of ethics than most medical researchers.
Even the students who felt that the Heffron study was worth doing and basically sound were troubled by the researchers’ lack of curiosity as to whether HIV-infected subjects were getting the ART drugs they needed. And most of the students thought this was a disabling ethical fault, which should have caused human subjects committees to make the researchers redesign the study. One student pointed out that the Bill and Melinda Gates Foundation, one of the study’s funding sources, could easily afford to pay for antiretroviral therapy for all of the roughly 2,000 HIV-infected people in the study.
In the end, my students had the questions that Marcia Angell raised in her editorial in the New England Journal of Medicine in 2011 (PDF at this link angell editorial nejm 2000 ): Don’t physician researchers have the same responsibility to study subjects that they do to their own patients? And therefore, when their subjects lack resources to obtain effective therapy for treatable conditions, don’t the researchers have a moral obligation to make the therapies available?
Heffron et al. didn’t do this. They watched HIV-infected people transmit HIV to their partners (the researchers provided HIV testing and counseling about avoiding transmission — but they don’t make clear whether they notified uninfected partners that they might be in harm’s way). They did little to prevent transmission. Notably, they didn’t offer ART to people with low CD4 counts. Nor did they offer post-exposure prophylaxis to uninfected people who had had intercourse with an infected partner. They just watched.
On this account, the Heffron study wasn’t only flawed — it was so questionable on ethical grounds that the Lancet should be ashamed to have published it. And the funders — the NIH as well as the Bill & Melinda Gates foundation — censured.
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The occasion was CDC’s publication in PLOS One of new figures claiming that the annual number of new HIV infections in the U.S. is only around 50,000.
And if you read the CDC’s new Fact Sheet on HIV infection, just posted, you find out that
The current level of HIV incidence in the United States is likely not sustainable. Prevention efforts in recent years have successfully averted significant increases in new HIV infections, despite the growing number of people living with HIV and AIDS who are able to transmit the virus.
CDC English is a little difficult for native speakers to interpret, but I think that the translation of “likely not sustainable” is: “we need more money or else the incidence is going to go up.”
Now, 50,000 new HIV infections each year is bad news for 50,000 Americans. But on a population basis, it’s not a very high number. The HIV prevention industry will wring its hands, and perhaps Mr. Kramer will, too. They can all grumble that after 30 years of AIDS there should be no new infections at all. But that’s ridiculous. A pipe dream. HIV is a sexually transmissible infection. And STIs can’t be eradicated — because, well, people have sex. No matter what. And sometimes the kind of sex that isn’t recommended by the experts. With the wrong people. And so forth.
Really, that there are only 50,000 new infections each year is a sign of (a) the low inherent infectiousness of HIV and (b) Americans’ sharp awareness of how to protect themselves from HIV infection. It’s not really clear that any new prevention is needed.
What is needed: get effective treatment into more HIV-infected people. Obviously, to slow the progression of HIV-based impairment in the individual — but also as a public health measure, to reduce the HIV carrier’s infectivity and thereby reduce the probability of transmission. It would have medical value and public health value. But there’s not much policy on that.
CDC officials are bean counters, not policy makers. That’s why, Mr. Kramer, your expectations are too high. The CDC’s job is not to do anything about AIDS. CDC’s job was never to do anything about AIDS. CDC’s job was, and is, and presumably will always be: to keep CDC in business.
They’re terrific bean counters, obsessive, scrupulous, punctilious, completely absorbed in their own assumption that their data are a source of truth, committed to deciphering the supposedly unequivocal message the data send.
The message, always, is “CDC needs to do more of what it’s been doing.”
I gave the CDC a hard time in August 2008, when the agency published its estimate that there are 56,000 new HIV infections in the U.S. each year. That seemed too high, I told the NY Times at the time. Of course, it was useful for the CDC’s rudderless AIDS division to claim that HIV incidence was higher than everyone thought: suddenly, lots of people were urging that HIV prevention programs be beefed up.
Now, the agency has backpedaled. The 2006 incidence wasn’t 56,000 after all, the CDC now figures, it was only 48,000. And anyway 56,000 is the same as 48,000, the agency now says.
Let me summarize: Back in 2008, the CDC’s estimate supposedly showed that prevention wasn’t working, so the agency needed to do more of it. The new estimate, which is almost the same as the old estimate, shows that prevention does work, so the agency needs to do more of it. All CDC calculations point to the same conclusion: keep CDC in business.
If CDC were interested in the nation’s health, more so than maintaining its meager status quo, it would be advocating for more treatment (to Donald McNeil’s credit, he makes that point in today’s NYT article).
And if CDC were interested in HIV as a public health problem, and not just in bean counting for the purposes of keeping itself in business, it would stop putting its beans into 30-year-old jars. What’s the point of the tired “race/ethnicity” breakdown? Does anybody know anymore how to categorize people into the ancient non-Hispanic-black/Hispanic-including-black/non-Hispanic-white codification? Does anybody know what it means?
And the famous transmission categories, the MSM-IDU-heterosexual-other breakdown: that was useful early on, when we weren’t sure that the modes of communication of HIV were fully known. But that era ended in 1985.
Dear CDC: Could you please put your beans into some useful jars?
No, it’s asking too much. Because CDC’s aim isn’t to be useful. It’s to keep counting beans exactly the way it knows how to count them, and put them into the same jars as always, and keep on concluding that the data — the beans — show that CDC must keep on doing exactly what it has been doing.
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In an article in the July issue of Emerging Infectious Diseases, just out, Piarroux and colleagues assert that (quoting from their abstract) “Our findings strongly suggest that contamination of the Artibonite [River] and 1 of its tributaries downstream from a military camp triggered the epidemic.”
So the mystery is solved, more or less. The news media have taken note: articles on the EID report have already been written by the AP, Guardian, and other sources, and are being picked up fairly widely today.
The news, based on a report ordered by UN Secretary-General Ban Ki-moon, is being treated as an about-face on the UN’s part — because the organization, along with WHO and CDC, refused last fall to do an in-depth investigation of the origin of the outbreak. So, according to the media’s coverage, this week’s report exposes some hypocrisy on the part of the health organizations.
That’s silly, and wrong. I’m usually critical of WHO and CDC, but in the case of the Haitian outbreak they were completely correct to refuse to “investigate.” As I wrote last fall, cholera isn’t a detective story, it’s a disaster. To investigate the so-called origin of an outbreak that is as self-evidently the result of calamitous conditions, state poverty, and helpless officialdom is to shift the blame. Dodge the truth.
The work by Piarroux and colleagues in establishing a clear description of the origin and progress of the Haitian outbreak is impressive, often elegant, quite convincing. But to believe, as some do, that it somehow proves that the UN and WHO are responsible for a catastrophe, or that sending foreigners into Haiti is always bad, or even that (as the authors of the EID paper say)
Putting an end to the controversy over the cholera origin could ease prevention and treatment by decreasing the distrust associated with the widespread suspicions of a cover-up of a deliberate importation of cholera
is to misunderstand public health.
The problem in Haiti is, and has been, a problem of predisposition — nature out of balance, people on the move, dire straits of all kinds (food, medicine, clean water, toilets, housing, etc.) too tolerable to weak leaders. Colonization by one aid group after another (UN included). It was inevitable that cholera was going to break out.
To take the Piarroux report as definitive is to mistake the germ for the disease, mistake the outbreak for the problem, mistake the detective story for the real disaster — the real disaster being self-explanatory and not in need of “investigation”: not enough money and not enough political will to keep the public from getting sick.
]]>Phillips’s focus in that post is on a new WHO Atlas on headaches
and the problem that headaches cause people to stay home from work, or work less productively. The agency estimates that Europe-wide, the lost productivity from migraines alone is worth 155 billion euros each year. It isn’t that you feel crummy when your head hurts, and that chronic headache makes your life miserable. It’s that you might not perform your expected per-capita service to the expansion of wealth.
Here’s how EP-ology assesses the agency:
The WHO is not the humanitarian organization that many people might think it is. It is a special-interest medical-industry-oriented organization with an emphasis on the interests of governments, not people. Its emphasis on productivity in looking at headaches … ignores people’s welfare…
Now, I can’t agree with Phillips’s analysis that the WHO’s ethical system is either “communist” or “fascist.” For self-described public health agencies like the WHO to be concerned primarily with productivity and the generation of wealth — and only secondarily, if at all, with suffering — has been a hallmark of capitalism since the British Parliament passed the world’s first Public Health Act in 1848.
In fact, the laws institutionalizing public health in Britain in the late 1840s were passed by the Whig (liberal, more or less) government of Lord John Russell. Public health was a legacy of efforts not by the nascent socialist and communist movements, but by radical capitalists — who sought to secure a moderately hale labor force to serve British industry with little cost to the factory owners. And aimed to blame individuals for their own misery.
But it’s impossible to disagree with the main point of Phillips’s post: WHO’s aim is to serve industry.
As further evidence, consider this follow-up note on Tamiflu by Helen Epstein, published in the May 26th issue of NY Review of Books (I discussed Epstein’s main article in a post last month). It seems more and more apparent that potential dangers of Tamiflu (oseltamivir) in children were ignored. Epstein reports that
the risks of delirium and unconscious episodes were indeed significantly elevated in children who took Tamiflu, especially if they took the drug during the first day or so after influenza symptoms appeared…. If these results are confirmed, they are especially worrying, since the World Health Organization and the US Centers for Disease Control both recommend that Tamiflu be taken as soon as possible after symptoms appear.
I was not the only one unaware of this important study; neither, apparently, were the World Health Organization, the US Food and Drug Administration, and the US Centers for Disease Control. When I contacted these agencies in January and February 2011, their spokespeople assured me that there was no evidence that Tamiflu causes neuropsychiatric side effects in children. [emphasis added]
In the rush to move taxpayer monies into the hands of wealthy private corporations, the WHO (with CDC and other agencies) proclaimed a flu emergency in 2009. And ignored evidence on possible dangers of the products they were touting as part of the “preparedness” response.
]]>I’ve covered the profit-motivated thinking behind vaccine recommendations generally and specifically with regard to flu immunization. Epstein’s main interest is in the role of pharmaceutical companies in promoting oseltamivir (Tamiflu®) and other neuraminidase inhibitors as public health responses to flu fears. Her story features the brilliant work of Tom Jefferson and colleagues, and the shady behavior of the global biotech firm Roche in trying to block Jefferson et al.’s efforts to investigate the safety of neuraminidase-blocking agents.
Jefferson was lead author on the Cochrane Collaborations’ main paper on neuraminidase inhibitors for flu prevention and treatment. But when reports of adverse effects of these drugs emerged and he and colleagues tried to re-assess the underlying reports on which the effectiveness of oseltamivir and similar drugs was based, Jefferson was stymied. His colleague, Peter Doshi, related the story in BMJ. The journal’s editor-in-chief, Fiona Godlee, along with Cochrane director Mike Clarke, wrote in an accompanying editorial:
The review and a linked investigation undertaken jointly by the BMJ and Channel 4 News cast doubt not only on the effectiveness and safety of oseltamivir (Tamiflu) but on the system by which drugs are evaluated, regulated, and promoted.
The take-home message is that while there is evidence that Tamiflu can be effective in treating flu, the evidence is shakier than it seems, and troubling reports point to potentially serious adverse effects.
How does a questionable medication get to be the basis (or part of the basis) for public health policy? The answer is that the policy makers and the money makers work hand in hand.
Maryann Napoli at Center for Medical Consumers tried to point out the troubling links between WHO and big pharma last year, and Steven Novella at Science-Based Medicine brought it up around the same time.
But most of the coverage focuses on the involvement of individual scientists and/or physicians who are receiving payments or other forms of remuneration directly from drug companies. It’s not hard to police such straightforward conflicts — and so it was easy for Margaret Chan, WHO Director-General, to say last year that “at no time, not for one second, did commercial interests enter my decision-making.”
Epstein’s great contribution is in showing that obvious conflicts of interest aren’t the main way that for-profit companies influence policy. It’s done through stonewalling, as Jefferson encountered when he tried to examine Roche’s data. It’s done through widely accepted collusions.
For instance, the CDC Foundation — “Helping CDC Do More, Faster” is its motto — is a nonprofit organization, created by the U.S. Congress, whose job is to
connect the Centers for Disease Control and Prevention (CDC) with private-sector organizations and individuals to build public health programs that make our world healthier and safer.
Of course, calling them “private-sector organizations” suggests that these are not-for-profits — and some, like the District of Columbia Department of Health, the Medical College of South Carolina, and UNICEF, really are. But most of the private-sector collaborators who are linked with CDC’s policy makers by the CDC Foundation are big corporations. They include all the giants of Pharma world: Merck, Pfizer, Roche, Sanofi-Pasteur, etc. (They also include some who are just giants: Google, Dell, YUM! Brands, and IBM, to name a few.)
So when CDC’s updated flu response plan now recommends antiviral (i.e., neuraminidase-inhibitor) treatment “as soon as possible,” it’s worth asking whether this is because it has any public health value (answer: no) or just because CDC is cozy with companies that make money when people get sick.
]]>A paper by David Leon in this month’s International Journal of Epidemiology showed the dramatic increase in life expectancy — the median age at death, that is. It has reached over 85 years for women in Japan, but it’s high even in countries where longevity was relatively low a generation ago. Cheeringly, US life expectancy at birth is now 78 years; in the UK it’s 80. And it’s even higher in some countries of western continental Europe. Here are the graphs for different parts of the world from Leon’s paper, showing trends since 1970:
Lyons has gone after the anti-obesity crusaders before (as well as related topics at his smart blog on contemporary food confusion, Panic On A Plate). Now, he’s particularly disturbed by the sermonizing about eating. “You can’t even have a pie and a pint without someone telling you it will kill you, it seems,” Lyons writes at Spiked.
And, really, it’s even worse than that — because it’s not just eating that’s the subject of the lecturing. It might be true that you will live longer if you give up smoking, cut your salt intake, drop your BMI down to 24.99, exercise four times per week for at least 20 minutes each time, get immunized against flu and human papillomavirus, drink in moderation, and take naps. But unfortunately there’s not a bit of evidence that any of that — apart from the decline in smoking — has contributed to increasing longevity.
And of course, even with smoking cessation, there’s no telling whether it would make any difference to you — only on average.
So why are the public health messages so far away from what really matters — basically, prenatal care, postnatal care, and wealth (with its concomitant, standard of living)? Well, there’s a puzzle.
What’s the point of having an industry whose main aim is to make sure that people are constantly in fear that they are doing something that will kill them — even as it becomes apparent that most of what people do is only making us live longer? Lyons calls it Good News Omission Mentality Syndrome (GNOMES).
I ask you: could it have something to do with control? And the desire to sell products?
]]>But I confess I’m no fan of her work. Kolbert’s sky-is-falling! rhetoric is a little too florid, and her criticism of people who don’t act environmentally a little too pointed.
Yet, her short piece in this week’s New Yorker, “The Nuclear Risk,” is terrific. It’s worth reading. She gets at a central lesson of the radioactivity crisis that followed on the earthquake + tsunami disaster: you can only plan for the disasters you’re able to conceive of. The Japanese catastrophe, she writes
illustrates, so starkly and so tragically, [that] people have a hard time planning for events that they don’t want to imagine happening. But these are precisely the events that must be taken into account in a realistic assessment of risk. We’ve more or less pretended that our nuclear plants are safe, and so far we have got away with it. The Japanese have not.
That the nuclear crisis is supposedly under control now, or might be under control if some new problems are dealt with, doesn’t change the planning problem (and have a look at this blog post by Evan Osnos for a worrying take on what happens to people who are facing such a triplex disaster scenario).
Kolbert relates the problem of nuclear planning in the U.S. to corporate interference with regulatory agencies, quoting the Government Accountability Office’s finding that the Nuclear Regulatory Commission has based its policies
on what the industry considered reasonable and feasible to defend against rather than on an assessment of the terrorist threat itself.
It’s disturbing that industry and regulators are on intimate terms, but it isn’t exactly news — not in regard to energy policy, nor health policy (for example, consider the CDC’s Advisory Committee on Immunization Practices, which I wrote about a year ago). The comfortable collusion between corporations and government agencies is an issue — but it’s not the most troubling lesson of the Japanese crisis.
Rather, the main event is the inevitability of unforeseen and unforeseeable disasters. And the simple impossibility of making plans to avoid what can’t be imagined.
Which is where I part company with Kolbert. Would better planning (or stricter regulation of industry) have avoided the near-catastrophic radioactive release at Daichii? Yes, perhaps. But nobody could have foreseen an earthquake of this magnitude, or infrastructure so destabilized by a tsunami as fast-moving and destructive as this one, or the double-punch effect occurring where it did and how it did. There’s only so much you can plan because there’s only so much you can envisage.
And that’s the problem with the idea of planning to reduce risk. You plan for what you know. Maybe you plan for something a little worse than what you’ve seen before — but even that is basically what you know, with a little juicing to make it livelier. Even the pure-fantasy regulatory agency — the one with firewall immunity from influence by industry, perfectly competent engineering of its plans, and state-of-the-art technology — can’t foresee every eventuality. Therefore, even the best planning won’t eliminate risk.
In the end, the question isn’t just how to keep the energy industry away from the regulators. It’s how to live in a universe that isn’t completely predictable, no matter how good you think your “science” is. And is ruled by random, implacable, and sometimes highly destructive nature.
]]>Recently, Paul Sax reported at The Body on a plan to issue guidelines on the use of pre-exposure HIV prophylaxis (PrEP) using a combination of antiretroviral drugs, announced in the January 28 issue of CDC’s Morbidity and Mortality Weekly Report. The effect of issuing guidelines is to endorse the procedure, which will help enrich pharmaceutical companies — the first being Gilead, which makes Truvada (combination of tenofovir + emtricitabine).
Here’s the CDC’s rationale for issuing interim guidelines now, with formal guidelines to follow:
CDC and other U.S. Public Health Service (PHS) agencies have begun to develop PHS guidelines on the use of PrEP for MSM at high risk for HIV acquisition in the United States as part of a comprehensive set of HIV prevention services… [W]ithout early guidance, various unsafe and potentially less effective PrEP-related practices could develop among health-care providers and MSM … [including]
1) use of other antiretrovirals than those so far proven safe for uninfected persons;
2) use of dosing schedules of unproven efficacy;
3) not screening for acute infection before beginning PrEP or long intervals without retesting for HIV infection; and
4) providing prescriptions without other HIV prevention support (e.g., condom access and risk-reduction counseling).
Translation: if CDC or another USPHS agency doesn’t do something now, homosexual men might not buy as much medication as they could.
What’s the impetus for this guidance? Results of the iPrEx study, which was supported by the National Institute of Allergy and Infectious Diseases at NIH, were published in the New England Journal of Medicine in December. The study purported to show a 44% reduction in HIV incidence among men who had sex with men who were taking Truvada prior to sexual exposure. But the study was so deeply flawed, and the authors so cagey about their methods, that it’s impossible to conclude that Truvada makes any difference to the chances of acquiring HIV.
As the iPrEx trial’s logo implies
it was multinational, involving almost 2500 HIV-negative people who were male (at birth) and adjudged to be at high risk of acquiring HIV because of their pattern of sexual activity. It involved sites in Peru, Brazil, Ecuador, South Africa, Thailand, and the U.S. The comparison was between subjects taking Truvada and subjects taking a placebo.
The famous 44% reduction, however, was clearly not obtained in each site — and the authors don’t state which sites showed more effect. More importantly, the reduced HIV incidence among those taking Truvada occurred only for a small subset of subjects who stayed on the drug for more than a year without becoming infected. And it only lasted for about one additional year.
In other words, in the iPrEx study, people who took Truvada and remained HIV-negative for a year were slightly less likely to acquire HIV in the following year than were those who took placebo and remained HIV-negative.
Finally, even the small, second-year-only effect of Truvada is of questionable use to men in the U.S. Because the study was based on men living in places with extremely HIV prevalences — higher than those in much of the U.S. — and involved men having a large number of partners, it provided essentially no evidence for any utility in the U.S.
As other trials of pre-exposure chemoprophylaxis are going on now, other companies’ products are likely to be included in the final version of the CDC guidelines. So more corporations can benefit from the largesse of the Public Health Service.
Condoms are very effective at interrupting HIV transmission. Obviously, you have to use them (properly) in order to benefit from that effect. Because people don’t like them very much, condom promotion is a poor public-health strategy.
But as a matter of guidance for men who have sex with men, in what way is it better for the USPHS to suggest Truvada, which has to be used consistently even when you’re not having sex, probably won’t take effect for a year or so, and even then will only give you a minor reduction in the chances of acquiring HIV — rather than condoms?
Answer: it is if you’re trying to promote profits for the pharmaceutical industry.
]]>Still, it’s hard to avoid wondering: is Wakefield right when he alleges that he’s being persecuted by the vaccine industry?
Last week, I discussed the BMJ article by Brian Deer asserting that Wakefield’s research was fraudulent, and the accompanying editorial supporting immunization. At that point, I thought that the BMJ pieces were, together, a one-off.
I was wrong. In fact, it looks this week like the vaccine industry has armed some of its main warriors and sent them out to do battle.
The Battle Against Anti-Vaccinationism
In the Jan. 13th issue of the New England Journal of Medicine, two powerful chiefs, Gregory Poland and Robert M. Jacobson, claim that there’s an “age-old struggle” to make vaccines available. Their aim is to vilify the “antivaccinationists” who “have done significant harm to the public health.” [Note the use of the holy article in this phrase, to signal just how sacred these warrior-priests hold “the” public health to be.]
The Poland-Jacobson piece is pure propaganda. Theirs is a tale of heroic struggle on the part of ever-embattled Believers against the satanic forces of Antivaccationism — who have been trying “since the 18th century” to shake people’s faith in the vaccine gospel. And nowadays the nasty antivaccinationists are using scarily modern forms of communications, such as TV and the Internet, in order “to sway public opinion and distract attention from scientific evidence.”
Wow: TV and the web. Sounds satanic alright.
I guess I shouldn’t be surprised that a couple of crusaders make their own work sound salvationist. What troubles me is that they make it sound like they’re disinterested do-good-ers.
In fact, Poland and Jacobson are in bed with Big Pharma. Poland runs the Mayo Clinic’s Vaccine Research Group. Although as far as I can tell, Poland and Jacobson are not currently in the direct pay of the vaccine manufacturers, they and the VRG have benefited handsomely from vaccine makers’ largesse.
For instance, Poland’s and Jacobson’s work on human papillomavirus vaccine, as they acknowledge in a 2005 Mayo Clinic Proceedings paper, was funded by Merck, and their co-workers were Merck employees. Later, in conjunction with a continuing medical education module on meningococcal vaccine in 2009, Poland disclosed the following ties:
Sources of Funding for Research: Merck & Co, Inc, Novavax, Inc, Protein Sciences Corp; Consulting Agreements: Avianax, LLC, CSL Biotherapies, CSL Limited, Emergent Biosolutions Inc, GlaxoSmithKline, Merck & Co, Inc, Novartis Vaccines, Novavax, Inc, PowderMed Ltd
And on his disclosure form for this week’s NEJM article Poland acknowledges funding from Pfizer and Novartis for vaccine studies.
So when Poland and Jacobson write that our society “must continue to fund and publish high-quality studies to investigate concerns about vaccine safety,” they’re really talking about preserving their livelihood. It’s very much in their interest to ensure a steady flow of such funding.
And when they say that “society must recognize that science is not a democracy in which the side with the most votes or the loudest voices gets to decide what is right,” they’re being completely disingenuous. Because Poland and Jacobson know quite well why science is not a democracy: in the type of research they do, it’s the big money that decides what is right.
A High Priest of Vaccine “Science”
Then there’s Paul Offit making the rounds. Offit has been the subject of lots of attention by Age of Autism, most recently as a “denialist.” Offit probably profited somewhat from the licensing of Rota Teq vaccine, which he helped invent — although AofA’s allegation that he is therefore beholden to Merck seems unsubstantiated.
What’s obvious about Offit is that he is contemptuous of people who don’t agree with his version of truth.
Offit appeared on Lenny Lopate’s radio show in New York yesterday, and presumably will be appearing elsewhere. His aim is to explain the “grave public health problem of vaccine avoidance.” The “anti-vaccine movement threatens us all,” he says. In fact, that’s the subtitle of his new book, Deadly Choices.
Where Poland and Jacobson are militant and sanctimonious, Offit sounds a note at once sentimental and officious. It’s “tragic” that there have been measles outbreaks because of parents refusing to have their kids vaccinated, he says. And the problem is that people just don’t understand science. In fact, Dan Olmsted at AofA gets it quite right when he critique’s Offit’s blinkered version of science:
Anyone concerned about [possible harms of vaccination] fits Offit’s definition of anti-vaccine, because vaccines don’t cause any of them, because Paul Offit says so, a solipsism that is really quite breathtaking: “[B]ecause anti-vaccine activists today define safe as free from side effects such as autism, learning disabilities, attention deficit disorder, multiple sclerosis, diabetes, strokes, heart attacks, and blood clots — conditions that aren’t caused by vaccines — safer vaccines, using their definition, can never be made.”
I had the same reaction to Offit’s self-important — and, to my mind, unscientific — claims. Offit shows no interest in the open inquiry that marks science. People who don’t agree with him are uneducated, poorly informed, maybe just stupid. And, of course, dangerous.
“Tragic” Consequences of Unbelief
On the Lopate show, Offit resorted to the now-common formula of the “tragic” consequences of parents’ belief in Andrew Wakefield.
What’s the tragedy, exactly? It’s true that there have been outbreaks of measles in the British Isles that have been traced to parents’ refusal to have their children immunized. An excellent review in BMJ in 2006 provided some of the data for the U.K. — including that one child died in a 2006 measles outbreak that was related to poor immunization coverage. A few children died in Ireland in 2000. A CDC account of a measles outbreak in California in 2008 reports that it hospitalized a few children, although none died.
It would be great if nobody ever died from an infection that could be prevented in any way. It’s surely tragic to the parents of a child who dies from a preventable infection. The sympathies of each of us should go out to such parents, as to those whose kids are killed by bad drivers, sports injuries, or infections for which there’s no vaccine.
But in what sense is one child’s death more of a collective “tragedy” for all of us than the other deaths that go unremarked every day? Why is it tragic when one child dies of a vaccine-preventable infection and not when a lot of them die of poorly regulated handguns or as troops fighting wars that never endanger our leaders, only our young?
The Ramp-up of Aggression by the Vaccine Crusaders
Why are the vaccine warriors rampant now? Perhaps the vaccine makers are terrified that the low uptake of H1N1 flu vaccine despite all the hype in 2009, along with low MMR compliance in some places (the U.K. especially), means that their profits are going to slide. Maybe their friends, like Offit and Poland, are worried that reduced uptake of vaccines will translate into diminished research funding or fewer conferences in delicious places.
Or maybe the vaccine industry finds Wakefield so obstreperous that they can’t rest until he is destroyed. Wakefield’s no choir boy, but he might not have realized just how much control the pharmaceutical industry can exert in the U.K.
In a review essay in last week’s New York Review of Books, Simon Head points out that Big Pharma is “the only major segment of the British economy that is both world-class and an intensive user of university research,” and implies that it exerts control over both the substance and volume of U.K. research productivity, especially in medicine. Head sees reason to believe that Pharma will “tighten its hold over scientific research in the UK” in the future.
It’s Not a War
There need be no either-or about vaccines. If our society can live with guns and automobiles (together accounting for roughly 50,000 American deaths a year), if we tolerate alcohol, processed foods, acetaminophen, high-rise construction, and all the other things that occasionally cause harm but mostly contribute to the way of life we prefer — then we can stop calling it “tragic” when a few parents don’t have their kids immunized.
Because to call one measles death “tragic” is to further the vaccine warriors’ campaign — the campaign that pretends to be on behalf of science or healthy kids, but is really fought to protect the fortunes of vaccine makers.
The campaign protects the power of shiftless public officials who claim to be protecting the public from harm when they serve up millions of taxpayer dollars to vaccine manufacturers for barely useful vaccines (H1N1 2009), or for vaccines that are undoubtedly helpful but might be harmful in some cases and haven’t been thoroughly examined (HPV vaccine). And who, to this day, won’t even consider the very good question that Andrew Wakefield posed in the 1990s: is it a good idea to give kids three immunizations in a single preparation?
I had my child immunized when she was the right age for that. But I’m not certain that absolutely everyone has to do the same. Neither are the courts, which is why they allow exemptions from immunization for personal belief.
I don’t think measles is a menace to civilization. I know that only a very tiny percentage of children who contract measles get dangerously sick from it, that flu vaccine doesn’t work for everyone (and isn’t an effective public health measure to stop flu outbreaks even though it can protect individuals from illness), and that varicella vaccine can make the problem of shingles worse even though it reduces the problem of chicken pox. And so forth.
I mean that immunization is complex and fraught. Not everyone can be expected to agree with every vaccine recommendation. Even while some people are opposed to vaccination and refuse to immunize their kids, life will go on, and society will continue to thrive, and Paul Offit can continue to say arrogant things about “science.”
So, could someone please call off the crusade?
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