Are You At The Table?

In case you’re wondering, this is my piece for the Clark County Medical Society newsletter, summer 2013.

There are just under 900,000 licensed physicians in the U.S. Current AMA membership numbers about 224,500, rising up to levels not seen since 2009 when the AMA’s endorsement of Obamacare apparently precipitated a 5% drop in membership. Local Medical Societies are often loosely affiliated with the state and national medical association and can compare themselves to the national benchmark. Clark County has a better percentage than the national average, but barely. Nearly a quarter of the county’s physicians belonging to the medical society.  
In my few months as President of the CCMS I have watched with interest as some counties struggle without any physician cohesion as others have active and dynamic medical societies that contribute much to their communities’ well being.  It would be enlightening to understand what accounts for low membership in the AMA and local county societies.
The most significant drivers of membership seems to be related to the employment status of a growing number of physicians.  In the much storied  past of American Medicine it was necessary to belong to a local medical society as a source of referrals and recognition within that local medical community. As more and more physicians find themselves employed by large multispecialty groups, the relevance of a medical society diminishes. In addition most specialists seem to believe that their interests are better represented by their societies.
Perhaps at some point in the past couple of decades, the House of Medicine lost its ability to extract growing concessions from the rest of society and thus external conflicts became intra-professional conflicts. Despite the larger world relying on progressively greater degrees of specialization, it seems unwise to perpetuate internal conflicts. We each have a role to play in the larger system, including the generalist role in primary care and care coordination.
What seems self-evident is that a fragmented medical profession is easier to control and manipulate than a united one.  There was a time when a nationwide group of educated, professional healers were felt to be the best hope for advising on the population’s health. Some social theorists have suggested that the medical profession squandered its social capital on protecting its economic welfare. I would argue that a small minority of narrow-minded and short-sighted physicians temporarily hijacked an organization whose role has always been nobler than its own economic welfare.
We all have colleagues who will not join the AMA because of positions it had taken in the past. Well, the trouble with that is that no one has a voice who is not at the table. There should be no illusions about how political organizations work and how advocacy comes about; we may lose the occasional internal battles but still fight for common goals. A medical society works for the interests of its members but it would be a mistake to take a shortsighted view of what that means. Medicine based on scientific proof still safeguards the public’s health. Thus, there is no way of continuing to safeguard the public’s health, either by prevention or treatment  without a highly trained, professional force working to create a health system that is both effective and efficient improving the health of the entire population.
Health care has a knack of exposing the weaknesses of a free market system but I have also worked in a socialized health system that shared different weaknesses, but of equal magnitude.  It seems the US medical system is evolving into some sort of hybrid system midway between different ideologies. Anxiety comes with any change and we are being presented with a major change in the environment of medical practice.
Whatever your politics and personal philosophical structure, much of this change has happened with nominal input from organized physicians groups. It is important for the House of Medicine to speak with one voice whenever it can come to a consensus. My thoughts and opinions have been well-received at the state level where they have differed from the official position of the WSMA. Clark County has been particularly active at the state level, especially when it comes to advocating for the health of the Medicaid population. We have been involved in discussions regarding CUP, physician wellness programs, Prescription Monitoring Program funding (in the future, it will no longer be from your license fees), exempting physicians from the state B&O tax, the role of physicians in the state disciplinary body MQAC, and disseminating information about the upcoming state health insurance exchange.
We need to focus on what is best for the health of our population and not just what is best for ourselves. However, we must also stand up for ourselves because without a professional workforce, the population will suffer. We must face the fact that the industry of which we are an integral part extracts $2.7 Trillion from the general economy and we are being held accountable for the value we return in exchange for our share.  

One thing is sure. This is no longer your father’s AMA! It is YOUR AMA! And its actions depend on your participation at the local level in your County Medical Society.

Vaccine Objector Backlash

In March, a version of the following article appeared in Lacamas Magazine, a local lifestyle publication. It was very well received, and attracted an enormous number of hits. I need to rework something for the local daily paper, The Columbian. Until then, I offer you an opportunity to review and comment; it is a controversial topic but I believe science is the benchmark, not conspiracy theories. We are one epidemic away from the ostracization of people who object to vaccines. This is why my original title is somewhat inflammatory. It was softened for the actual publication.  

Many of the digital back-issues are online, but not the one containing this article. I will link to it if it comes back live.

Vaccines are the most effective tool of medical science to decreasing the burden of human disease since Edward Jenner in 1798 described a method of inoculating healthy people with cowpox to prevent smallpox. Countless lives have been saved worldwide with a record of remarkable safety and a miniscule degree of adverse reactions given the magnitude of the benefit. Despite the incontrovertible weight of the evidence, there remains an anti-vaccine movement and a persistent fear of immunizations of all sorts.[1]

Opposition to vaccines can be found as far back as 1905 when the case of Jacobson v Massachusets went to the Supreme Court. In that case, a father refused to be forced by the state to vaccinate his daughter in the midst of a smallpox epidemic. The Supreme Court found that despite a legitimate libertarian argument, there was a compelling reason to over-ride the rights of the individual when fighting an epidemic because there was direct link between the number of people who were immunized and the total spread of the epidemic. It turns out that interrupting transmission was a function of reducing the number of people who could transmit the virus. The benefit to the person was magnified when the effect on the community was examined.

More recently opposition started with Andrew Wakefield, an English surgeon, who became interested in vaccines and published a study that claimed to show a link between MMR (measles, mumps and rubella) and autism in 1996. Understandably, this captured the imagination of parents everywhere. Can anyone imagine causing brain damage to their children by accepting an injection which was supposed to protect them against a deadly disease? Emotions run high with autism; parents wonder if they did something wrong and grasp at any potential cause to explain he unexplainable.

There were problems with the hypothesis from the start. First, the assertion of a link between immunizations and autism rested on the observation that the increase in the occurrence of autism ran parallel to the increase in vaccinations. Of course many other things also increased in the same interval; there was also an increase in the number of doctors available who could diagnose autism and better diagnostic criteria to distinguish autism from other forms of developmental problems. One can make an argument that anything else that increased over the prior several decades was linked, but a link is not a cause. The number of cars on the road has also increased parallel to the increase in autism, and the lead in automobile emissions is actually biologically active when ingested in the form of dust by an infant. It is more plausible than mercury as a cause, but nobody would take the idea seriously.

The vaccine link was supposed to be thimerosal, a mercury-containing preservative in the MMR vaccine. Mercury is indeed neurotoxic, but not all forms of mercury are active when absorbed into the body. For example, it is the fumes that are the best absorbed and the most active. Inorganic mercury is found almost universally in the soil and water in nature and poses no hazard. Theoretically, someone could swallow elemental mercury and not suffer any effects, because it cannot be absorbed that way (of course fumes may be released before, during or after digestion, so no one will say swallowing mercury is safe.) The mercury in thimerosal is very tightly bound and probably inert. The same way, mercury in the soil behind dams cannot be released into the food chain until bacteria convert it into a form that can be absorbed by eating fish. But mercury in fish is a well-recognized problem and there is no connection between autism and ingesting mercury-containing fish. It is difficult to think about how a relatively inert form of mercury can have any biological activity when injected. In fact, it was found that babies excrete thimerosal much faster than would be expected from our knowledge of how the body handles the toxic forms of mercury. This is one more small piece of evidence suggesting that mercury in thimerosal does not have time to interact with tissue. Nonetheless fear and controversy won out and vaccine manufacturers responded to the concerns. Thimerosal was never universally present in all vaccines and has since been removed in most every vaccine available today, except where it is impossible to use something else for technical reasons. Rates of autism continue to increase.

Then Wakefield’s study blew up! The co-authors smelled something fishy in the results especially when information emerged that proper methods in conducting the study were not followed. Eventually, it became clear that the data had been falsified, Wakefield was accused of fraud and he lost his license to practice medicine. It is believed that he falsified data so that he could profit from being a consultant on all the lawsuits that would follow. He currently lives in Texas.

The damage he caused was in stirring up a controversy that was not based in any sort of fact, in spreading false information and fear leading people to refuse vaccination and suffer the burden of increased vaccine-preventable disease making a come-back, in intense efforts to remediate a problem that did not exist and untold research dollars that would have been better spent seeking the real cause of autism. We can see the traces of his misinformation when someone like Congresswoman Michelle Bachman says that she knows people who got autism from the HPV vaccine. The statement is appallingly ignorant, brutally stupid and horribly violent for the children who would benefit from the vaccine.

Some people seem to feel that the number of vaccines is an overwhelming assault on the immune system. The problem with this notion is that in each vaccine there are a handful of highly purified proteins designed to arouse a strong immune response. Purification may always introduce trace chemicals, but at levels less than the neighborhood pool. A bowl of chicken soup probably contains an order of magnitude greater number of proteins that the entire set of childhood vaccines from birth to the teen years. It seems much more likely that prematurely feeding an infant adult food would be more harmful.

The number of needles required frequently comes up with parents. It is easy to understand how five injections at one time can be heartbreaking, especially as the child begins to wail. Older doctors however remember the days that circumcisions were done on infants without anesthesia. Without condoning what seems like a barbaric procedure to some, there is some dissonance between insisting on a circumcision on one hand and worrying about an extra needle on the other. The pain is limited. The benefit is huge.

The immunization regimens are constantly being revised and changed as circumstances permit, including the increasing availability of combination vaccines to reduce the number of individual injections. We must also remember that vaccines have become victims of their own success. When polio is fresh in people’s memory — the paralysis, death and suffering wrought by a horrible disease — it is easy to convince parents that the vaccine is necessary. When the disease has become rare because of the widespread use of a vaccine, the benefit does not seem as significant. Until the disease starts coming back, that is.

Other accusations thrown around about vaccines are that they represent a conspiracy on the part of pharmaceutical companies. This is laughable to people who have been interested in vaccines since the decades that research had stalled. In the 80’s, fear of litigation led most manufacturers to withdraw from vaccine research and development and shortages were looming. In 1986 Congress created the National Vaccine Injury Compensation Fund so that people who were injured by vaccines could be compensated publicly  After all, there is a societal good to vaccination that makes even the rarest adverse reaction doubly tragic. Two things happened after establishing the fund; first vaccine manufacturers reinvested in developing vaccines and lawsuits plummeted. It seems the new fund was more rigorous in making awards, not subject to the vagaries of the “jury lottery” of super-sized awards and nuisance claims. In other words, vaccines do not have a history of being particularly profitable, at least until the past couple of years when prices have started to sky-rocket. In the mean-time the compensation fund is one government program that is significantly over-funded because there have been so few claims made.

Incidentally, the body that makes vaccine recommendations is the American Committee on Immunization Practices, set up by the CDC at arm’s length. It has representation from numerous medical, public health and consumer groups and has remained stubbornly independent. It accepts no money from industry, works only peripherally with the FDA, limiting its recommendations to FDA approved parameters and constantly weighs the risks and benefits of any immunization. All their deliberations are public, transparent and available online. With the National Science Foundation and The Institute of Medicine, the ACIP is one organization that is least likely to be swayed by the big pharma’s financial interests.

Clark County’s Public Health Officer Alan Melnick is fond of saying that “vaccines prevent diseases that kill kids.” This is also true for adults. The ACIP makes recommendations based on the best science and evidence available with the aim of saving as many lives as possible with the lowest risk of any adverse events. The science and the evidence demonstrate that there is a community benefit that exceeds just the individual protection. Diseases like whooping cough and measles can still occur in an immunized population if enough people remain uncovered. It is not enough to immunize your own kids if neighbors and schoolmates refuse their immunizations; your kids can still get sick. The risk is small but probably greater than the risk of a serious reaction to a vaccine. It is an inflammatory statement that may yet prove true; that not immunizing your own kids can allow diseases to spread that potentially can kill other kids as well as your own. Vaccine objectors have not yet faced this backlash, but it remains that human beings living in communities have a responsibility first to themselves and their families, but then also to the communities which sustain them.

[1] An immunization is an intervention designed to increase an immune response to a specific agent. Vaccines have come mean the same thing although historically the word vaccine refers to vaccinia, the cowpox virus used to prevent smallpox.