Philip Alcabes discusses myths of health, disease and risk.

Bugs in New York

I admit that I haven’t followed the story of the blossoming bedbug population avidly.  Not that I’m cold to the heartache (and itch) that bedbug infestations can bring.  It’s just that an epidemiologist always gets more worked-up about bugs like mosquitoes and ticks that are vectors for microbial pathogens — and bedbugs aren’t.

But this AP article grabbed me.  According to New York City, over 6 percent of residents who responded to a community health survey claimed to have dealt with bedbugs in the past year.  In response, the city will withhold half-million dollars normally budgeted for the city’s health department  and redirect the funds to an anti-bedbug campaign.

Some might argue that the $500,000 would be better used for preventing deadly illnesses and accidents, not just bug bites.  Still, the campaign seems right.  According to the AP story, environmental health people will work with a “top entomologist.” (Professionals collaborating across sectors:  One City, One Health.  Good.)  A note by Javier Hernandez at the NY Times‘s City Room blog is guarded, but some (like Molly Fischer at the NY Observer) seem relieved that there will be a big anti-bedbug crusade at last.

Not a very big crusade, but at least a multifaceted one, as the Bed Bug Advisory Board’s Report suggests.

By Philip Alcabes | July 28th, 2010 | Categories: Health Professions, News, Uncategorized, public health | Tags: , , , | Comments Off

Early Onset of AIDS Therapy

Late last week, the NY Times reported that the city of San Francisco’s Department of Public Health is going to begin advising people with HIV to begin antiretroviral treatment (ART) immediately, rather than waiting for the CD4 count to decline.

The policy seems to be based primarily on a secondary analysis of longitudinal data from a multi-center study of HIV-infected people in the U.S. and Canada, the NA-ACCORD study.  The results were reported in the New England Journal of Medicine a year ago.  In that analysis, people with HIV whose CD4 counts were between 351 and 500 who began ART immediately were compared to those who deferred ART until CD4 count was 350 or less.  The deferred-ART group was found to have a 69% higher risk of mortality (from any cause) than were those who began ART before CD4 count fell to <350.  Similarly, among HIV-infected people with CD4 counts above 500, those who began ART after CD4 count was <500 had a 94% higher risk of mortality compared to those who began ART immediately.

But is this a good basis for across-the-board policy for a city the size of San Francisco?  Some physicians worry about the development of drug resistance among viral strains.  Others are concerned about toxicity, always a problem worth considering.  Paul E. Sax tracks the history of the idea and includes a few quotes in his blog post yesterday.

Some commentators wonder whether the new policy is meant to be a boon to pharmaceutical companies.  That’s not a crazy concern:  the Bay Area Reporter noted a couple of weeks ago that San Francisco plans to shift to a “status awareness” policy, increasing HIV testing by 70,000 people per year in an effort to halve the rate of new infections by 2015.  If successful, the increase in testing combined with an increase in recommendations for early ART would expand the market for antiviral medications substantially.

A few aspects of the April 2009 report on NA-ACCORD raise worries about whether it should be the basis for broad-based policy.  First, people who deferred therapy were observed very briefly (median 1.3 years, many of them for only 6 months), so any advantage to early therapy appears to refer to the period immediately post onset of therapy.  That’s important because toxicity and/or resistance might not be evident right away.  Second, looking only at people with an initial CD4 count above 500 and holding constant self-reported history of drug injection, there was only weak evidence for a slight effect of early treatment on mortality (the relative mortality hazard was 1.28 (95% confidence interval 0.85 to 1.83)).  Drug users had a higher mortality risk, and this finding—on which the authors of the New England Journal paper do not comment—suggests that early ART did not reduce the hazard of death for drug users.

Also, the authors of the NEJM paper could not possibly account for some of the hard-to-regiment aspects of HIV infection.  These would include variations in cause of death, treatment adherence, and monitoring of treatment effects — all of which would either not be evident in a cohort study or could not be controlled in a secondary analysis.

Finally, the authors are slightly cagey about the effect of drug-injection history in the above-500-CD4-count group, reporting a twofold increase in death hazard for those who delay ART after excluding people with a drug-injection history – but never reporting information on the effect of ART delay among drug injectors alone.

Most important, observations on people who transitioned to the next-lower CD4 compartment (i.e., from above 500 to <500, or from 351-500 to <350) were censored after 6 months if the individual had not yet initiated ART.  Therefore, the real comparison the NEJM authors are making is between immediate-onset ART while CD4 count remains in the same CD4 compartment vs. immediate-onset ART after CD4 count has dropped to the next lower compartment.  It’s not really a study of immediate versus delayed onset ART.

There’s plenty of reason (including the 2009 NEJM paper) to think that suppressing HIV early rather than late should be helpful, and some reason to think that the reduction in viral load produced by ART will lower infectivity in a way that makes transmission to uninfected sexual or drug-sharing partners less likely.  That in turn could be of public-health value.

Of course, nobody is being forced to start ART before he or she wants to, no matter the policy recommendation. Still, it’s worth wondering whether the expansion of testing and extension of early treatment will substantially improve the public’s health in a way that makes the cost, and self-evident advantages to pharmaceutical (and test-kit) manufacturers, worthwhile.

By Philip Alcabes | April 5th, 2010 | Categories: Disease, Health Professions, public health | Tags: , , , | 2 comments

Desperation Play on Flu Vaccine

DHHS Secretary Sibelius spoke at Hunter College in New York on Thursday, part of her barnstorming tour to exhort Americans to get immunized against swine flu — and thereby avoid embarrassment to herself and her agency on account of  the extremely poor uptake of swine flu vaccine in the U.S.   As Mike Stobbe of AP reported on Friday, the latest estimates by CDC put the proportion of Americans vaccinated at 20 percent.

Federal agencies are already scrambling to spin the disaster as a victory.  “From our point of view, this looks very successful,” CDC spokesman Richard Quartarone tells Stobbe.  Despite the fact (also noted in the AP story) that vaccine uptake was barely better among the flu-vulnerable groups who were the focus of the immunization effort:  22 percent of personnel at health care facilities, 38 percent of pregnant women.  Some success.

Apparently, New York State Health Commissioner Daines doesn’t want to be left off the victory train.  He announced on Friday that the law requiring immunization of staff of health care facilities would be enforced — even though a restraining order was issued by state Supreme Court Justice Thomas McNamara in October prohibiting enforcement.

(A federal district court judge in San Diego ruled this week in favor of the Rady Children’s Hospital’s union of nurses and technicians, according to San Diego CityBeat.  The union had requested arbitration of the hospital’s mandatory flu-immunization policy which, they claim, violates their collective-bargaining agreement.)

Health officials’ pandemic-flu-disaster story was flimsy from the get-go.  The evidence for a serious flu outbreak was slim, despite the attempts by officials and some reporters to make the situation look dire.  But through autumn 2009, at least there were some hospitalizations and deaths that served to maintain the sense of impending catastrophe that the disaster story sought to achieve.  Now, though, with flu activity in the U.S. less than usual for this time of year and no widespread occurrence of H1N1 flu reported, officials are playing with the numbers in their desperate attempt to peddle vaccine.

In her talk at Hunter College, for instance, Secretary Sibelius noted that “over a thousand” infants and children had died from H1N1 flu.  The CDC’s latest flu update counts 300 pediatric flu deaths from April 2009 through the beginning of the new year.  And it notes that about a third of the 236 pediatric flu deaths in the current season had bacteria cultured from sterile sites — suggesting the question of whether more timely medical care, rather than immunization, might have saved many of those kids.  Where the remaining 700 of Secretary Sibelius’s thousand pediatric flu deaths are to be found remains a mystery.

What’s happening here?  The federal government ordered 250 million doses of swine-flu vaccine last year.   Vaccine makers were looking at terrific earnings from this outbreak.  But they are now worried about losses in the anticipated $7.6 billion worth of global sales — because so much vaccine has gone unused.  Western European countries are stopping their orders and seeking to off-load existing stocks.  Americans don’t want the vaccine, at least not when swine flu seems to be less damaging than regular, seasonal flu and they aren’t feeling reassured about the safety of the rapidly produced vaccine.

Federal and state officials won’t let go, though.  It’s dispiriting.

The disaster in Haiti put the spotlight on suffering this past week.   Not just the tremendous death and damage from the event itself, but the penury and misery in which many Haitians lived even before they had to live with, or die in, the earthquake.  And the earthquake should have reminded anyone who was watching — which is to say, nearly everyone — to be appalled at the amount and degree of suffering in the world, even on days when there are no natural disasters making the news.

The disquieting thing, especially this week, is that people who are in a position to devote themselves to alleviating illness and dispelling misery — health officials, I mean — are preoccupied with covering up for their mistakes on flu and satisfying the needs of the pharmaceutical companies.  Instead of looking at the suffering in our midst.

By Philip Alcabes | January 17th, 2010 | Categories: Disease, Health Professions, News, Physicians, Uncategorized, epidemics, public health | Tags: , , , , , , , , | 1 comment

Revolving door? Official agencies and the private sector

In late December, Effect Measure reacted to former CDC director Dr. Julie Gerberding’s hiring as President of Merck Vaccines. With customary cogency and insight, Revere addresses the problem of the so-called Revolving Door.

At The Great Beyond, Daniel Cressey notes that Dr. Gerberding, while at CDC, was accused of promoting the Bush Administration’s agendas at the cost of scientific accuracy.  Naturally, now that she is heading for Merck, many are concerned about what looks like a cozy relationship between official agencies and pharmaceutical companies.

Merck says that its vaccine arm is worth $5 billion.  It “markets vaccines for 12 of the 17 diseases for which the U.S. Advisory Committee for Immunization Practices currently recommends vaccines,” according to the company’s press release.

Dr. Gerberding was close to the vaccine world as head of CDC. In fact, during her tenure there CDC’s   Advisory Committee on Immunization Practices (ACIP) called for the implementation of immunization against human papillomavirus and varicella zoster (chicken pox) virus and the agency pushed for expanded immunization against seasonal flu; within 10 months of her (January ’09) departure from CDC, the ACIP had issued recommendations for the use of anthrax vaccine and Cervarix and Gardasil vaccines against HPV.  Gardasil  is a Merck product.

But the problem is more than the “revolving door” metaphor implies.  To have a door there must be a wall — a clear demarcation between inside and out.   As if corporations (pharmaceutical companies among them) were outside of the official system, eager to get the ear of those inside.

Whereas it seems that there isn’t really much of a wall between official health agencies and big business at all.  To be an official today means taking a veritable oath of loyalty to corporate solutions.  The official has to deal in risk.  She has to be ready to sell risk as a kind of debt:  people should want to avoid risk, just as they avoid debt; but if their behaviors put them “at risk,” they can relieve it through “lifestyle” correction.  You can refinance if you know how.

The correction that allegedly relieves risk usually involves the use of better products. Cut out trans fats,  lower your cholesterol, elevate your mood, hop on a treadmill, lose weight, drink responsibly, get seasonal flu vaccine, get swine flu vaccine, wait patiently while the full-body scanners are used at the airport, eat more vegetables, wear sunblock, use hand sanitizer.  Health officials’ job is to get the means for personal risk reduction to the sorry at-risk population.  Have hand-sanitizer dispensers installed in public buildings.  Distribute condoms.  Publish recipes for healthy meals.

Notably, health officials are not supposed to argue for any of the things that would actually make a difference to the public’s overall health:  redress wealth disparities, provide excellent primary care for everyone (including immigrants), or build more decent and affordable housing.  When was the last time you heard a health official call for a campaign against poverty?

The official has to pitch personal risk reduction, in other words.  She has to be ready to support high-cost, individualized approaches to improving the public’s health — or well-being, which, Dr. Michael Fitzpatrick astutely notes at Spiked!, has replaced health as the main objective of modern Good Works .

Health officials keep faith with the dogma of risk avoidance.  Corporations preach risk reduction and peddle the wares by which people can restructure their lives — and avoid risk.  The wall separating government policy makers from corporate solutions gets more and more flimsy.

By Philip Alcabes | January 1st, 2010 | Categories: Ethics, Health Professions, Risk, public health | Tags: , , , , , , , , , , | 3 comments

No Meeting of Minds on Flu

As the story of the flu pandemic of 2009 matures, it brings out the characteristic traits of each of the  many spheres of interest that it touches.  The physicians are certain that the news is bad, the social critics are skeptical, the official agencies are — in their usual collusion with biotech corporations (especially pharmaceutical companies) — happily promoting high-cost, high-tech responses.  And so on.

Joshua Holland’s post at AlterNet yesterday tries to explain why H1N1 swine flu shouldn’t be cause for hysteria.  He puts this outbreak in the context of flu history and the threat posed by other, more harmful, conditions — malaria for instance.  Holland plays a little bit fast and loose with the numbers:  it probably isn’t accurate to extrapolate, from the number of confirmed flu deaths so far, to get a total number of deaths that will be caused by the swine H1N1 strain this year — more efficient spread in the  cities of the Northern hemisphere in the coming few months is likely to produce fatalities at a higher rate than the more sporadic outbreaks here in April and May.  And he’s overly critical of the media — a point brought out by Revere in a response to Holland at Effect Measure today.

But, as Frank Furedi has been telling us (recently in Erasmus Law Review, for example), try to explain how people’s deep-seated anxieties drive perceptions that risk is extraordinary and unprecedented (and contribute to demands for more and better high-cost technology to deal with it) and you get some people riled up.  Disappointingly, even Effect Measure, whose assessments are consistently level-headed and cogent, slips here, flashing the moral-entrepreneur card at Mr. Holland:

Joshua Holland has never cared for a critically ill person with Acute Respiratory Distress Syndrome (ARDS), which is often the terminal event for flu patients. So I’ll tell him. It doesn’t matter if it’s caused by bacteria (many are). Half of them die no matter what you do and no matter what intensive care unit you have available to you or what antibiotic or what computer controlled respirator. We still can’t do much.

Nobody thinks it’s a good idea to let people get ARDS, and Holland acknowledges that flu is a problem that should be dealt with.  But that’s not always enough.  Question the intensity of perceived risk or the need for all the technology, and you find this out fast.

But Revere is back on track when noting that lots of problems — including malaria — are horrendous and deserve attention, and probably don’t get it because they happen to people far away.

Where would the impetus to deal with global problems besides flu come from?  A global organization that can keep things in perspective would be useful.  Poor W.H.O. isn’t positioned to do that.  Yesterday’s flu advisory from W.H.O. emphasizes the use of antivirals (oseltamivir and zanamivir) to treat people with severe or possibly severe flu:

Early treatment is especially important for patients who are at increased risk of developing complications, those who present with severe illness or those with worsening signs and symptoms.

Yet, the W.H.O. also warns against hastening the development of resistance.  This agency gets a lot of flak for not doing more and for panic-mongering when it does do more.  But, really, it’s only doing its job:  offer advice, and support interventions when invited.  It isn’t consistent, naturally.  It can’t make binding policy.  It faces a limitless and essentially insuperable legitimation problem.  In a way, W.H.O.’s hardest job is simply to maintain its own legitimacy.

Still, in a world poised to interpret signs of illness as evidence of risk and eager for technical fixes to alleviate the sense of vulnerability risk instills, the W.H.O.’s announcements can seem authoritative — and look like beckoning to the drug makers.  A Reuters story yesterday is entitled “Early Use of Antivirals Key in H1N1 Flu: WHO,” and highlights the value of the two antiviral medications more than the caution W.H.O. wants to instill.

Meanwhile, agencies that should be making real policy are focusing on immunization.  In today’s Washington Post, Rob Stein reports on health care workers’ resistance to mandatory flu vaccination.  New York State made flu immunization mandatory early on, not only for salaried health care workers but for anyone — including medical and nursing students — who might come in contact with patients, and is putting teeth into the requirement with sanctions for refuseniks.  The state resorts to high  moral rhetoric to justify its policy.  The state’s health commissioner told Stein that “the rationale begins with the health-care ethic, which is: The patient’s well-being comes ahead of the personal preferences of health-care workers.”

And at CDC, the director is cautioning that there might be a rough start-up to the swine flu immunization campaign, as the first doses of vaccine will be made available in early October.  According to the NY Times, there should be 40 million doses of vaccine available by mid-October.

We wonder whether immunization will be of any public health value at all, by the time there’s enough vaccine that it can be offered to anyone other than health care workers and a few of the people who really need protection (young people, infants’ caregivers, and pregnant women, especially — DemFromCT’s round-up at DailyKos is always worth reading).  Given the rapidity of spread of flu — in 37 U.S. states, H1N1 spread is already regional or widespread; flu is spreading locally in 12 more states, Puerto Rico, and Washington, D.C. — and based on the usual course of flu outbreaks, it seems possible that this outbreak will peak by mid November.  There’s no knowing if that will be so, obviously.  Even if it is, immunization would continue to be useful to prevent severe cases among people who are likely to get very sick if infected.

But mass immunization would no longer be of much use in preventing further incidence of infection on a population level if high levels of acquired immunity are reached across much of the population by the time vaccine is widely available.

That’s the problem with relying on mass immunization as the centerpiece of public health response: as in the old joke about comedy, timing is everything.  In 1976, there was too much immunization, too soon.  It might turn out that this year, there’s too little, too late.  The dynamics of vaccine availability and the dynamics of flu spread have to be watched in tandem, and policy updated accordingly.

In any case, with vaccine at the center, the rest of the story — the complex environmental interactions that allow flu genomes to recombine, the trade in animals and feed that allow viruses to move around, the problems of affordability and immune status and competing viral subtypes, the health care facilities to handle severe cases, and so on — gets shoved to the side.

By Philip Alcabes | September 26th, 2009 | Categories: Disease, Health Professions, Narratives, News, Outbreaks, Physicians, Risk, Uncategorized, epidemics, public health | Tags: , , , , , , , , , , | Comments Off

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