Sunday, May 12, 2019

Measles Update

I'm interrupting my series on herbal and nutritional medicine to update my audience on the measles outbreak. Now the Centers for Disease Control reports 764 cases in 22 states.
How this compares to recent years...
And, writing this on a Sunday morning, I just heard that NPR's Hidden Brain will be running an episode on how we know what's "true", one story featuring a woman who was an "anti-vaxxer" and now has come around to the view that vaccines are important and that they work. In Washington State, New York City, and elsewhere health authorities and legislatures are tightening restrictions on both public-space access for the unvaccinated and exemptions to vaccination.

Interestingly--and despite the warning that measles is "deadly" and causes "severe complications"--the CDC reports that no deaths or encephalitis cases have been filed from any location in the U.S. There were 66 hospitalizations, and these include 3 cases of pneumonia. 71% of cases through April 2019 were in unvaccinated persons. 25% were in infants too young to be immunized with the MMR vaccine. And another 24% were too young to have been fully immunized (2 doses) at age 4. The remaining 51% were distributed among adolescents and adults.

One way to look at this is that 628 people who were unvaccinated or whose immunity status was unknown are now immunized against measles. Another interesting conclusion is that 11 cases of measles were in people who were fully immunized, much smaller than the number suggested by published reports of 98-99% long term protection in those who are immunized (that's good, right?). CDC data also suggest that the peak of this outbreak was in the 3rd week of March; by the end of April, measles had dropped to about 11 new cases nationwide. This is consistent with how most infectious disease outbreaks trend. Eventually, the epidemic fades.

I've written before (1, 2, 3, others) about what I believe are the real issues in the "vaccine controversy" or "vaccine debate" or whatever you want to call it, so I won't repeat all that here. But I thought that under the circumstances it might be a useful time to share snapshot of the reality of the current episode.

This outbreak is being sold as a failure. It's a failure of parents who don't "believe" in the science. It's a failure of doctors and nurses to sufficiently coerce parents into getting their kids immunized. It's a failure of state governments to restrict vaccine exemptions to only the most extreme circumstances (like an actual medical allergy). It's a failure of our society to "get on board" with this public health measure.

I think it is a failure too. For me it's a failure of our society to have a more effective conversation about health, disease, and health care. For anti-vaxxers whose kids just got over the measles without anything catastrophic happening, it just confirms what they already believed: measles isn't a very bad disease, and their kids turned out okay without the use of measles immunization. This news will spread throughout social media and further serve to undermine the messages of public health authorities, nurses, and doctors who promote immunization.

Stalemate.

What won't be discussed is that the reason this outbreak--so far--hasn't caused a wave of medical calamity (deaths, brain damage), is that this isn't a very serious disease. Older doctors who report how "devastating" measles was in the past, causing deafness, mental retardation, and of course death, don't address how much different public health and medical care were 40 or 50 years ago. That measles tends to cause complications in the poor, the undernourished, is not discussed. I have stated before that poverty, nutrition, safety, and hygiene are known to be key reasons for health problems and deaths that can occur from even simple illnesses like the flu, measles, or infant diarrhea.

This allows us to ignore the disparities in society. We can turn our sights away from systemic, societal problems--like racism, poverty, and hunger--and attribute disease outbreaks to stubborn parents who refuse to follow along in the hymnal like the rest of us righteous folk.

From NPR and ABC
Recently, I saw this report on how actress Maureen McCormick and other former cast members of The Brady Bunch are upset that the episode "Is There a Doctor in the House?" is being viewed by people who avoid vaccinating their kids as confirmation of the non-seriousness of measles. In that episode, the kids get the measles, and home-bound hijinks ensue (cue laugh track).

Interesting too is the story's report on how Merck Co. helped to shift the public's perception of the mildness of measles through educational campaigns like "Mission: Measles--The Story of a Vaccine." Of course, this was good for Merck. More immunizations = more dollars; witness this story from the New York Times about ever-higher vaccine costs.

I remember this episode of The Brady Bunch (we were a family of eight too, so we saw ourselves in that show), and although it can be argued that in the 1960s, there were worse diseases that did make measles seem less serious (smallpox, polio), maybe the impulse to make all diseases seem serious--no matter how little their real risk--does society a disservice. Maybe it distracts us from what we ought to be paying attention to, from what social and political policies really need to be changed.

And with that, I wish you all good health!

Monday, May 6, 2019

Herbs and Nutritionals Series: Allergies

The University's local Commencement was Saturday. As the graduates commence their journey forward, I commence with summer break. I'll start with some writing. Recently I promised a series on herbal medicines, so I'll start there.

Spring brings with it high pollen counts and if you are sensitive to it, it can be pretty miserable. I suffered from allergies (in the fall) for years, but no longer. I find the best treatment for allergies is a carefully-selected homeopathic remedy. If you're not quite there though, or still in the need-for-support stage, here are some things that can help. Caveat: This piece is educational and is no substitute for personalized medical advice.

Vitamin C
In high doses this vitamin is anti-inflammatory. "High" means several thousand milligrams a day. I learned that naturopaths prescribe this "to bowel tolerance" meaning you keep upping the dose until the bowels become a bit loose. However I find that 3,000-6,000 mg per day is often helpful. I tell patients to take it in "divided doses"--meaning one spreads that out over the course of the day, for example 1,000 mg three times a day. 

Quercetin
This is a naturally-occurring nutrient found in grapes, cherries, berries, kale, tomatoes, and broccoli, among others. Quercetin is a component of cell-walls, and having a diet with enough of this nutrient ensures that cell walls have all they need. The thinking is that strong cell walls means that they're less likely to break. "Mast cells" are in the body to protect against certain kinds of infections. When organisms try to get into the body, mast cells break open to release histamine which brings white blood cells to the area. Some studies have found that taking quercetin reduces the "breakability" of mast cells just enough to reduce histamine release. You can get this from foods or from supplements. The latter will often be compounded with plant-based digestive enzymes like bromelain or papain to help the quercetin be absorbed.

Image result for neti potNasal Lavage ("neti pot")
This is a nice, "nursey" hygiene measure. The neti pot is a specially-designed pot so the user can washout the nasal passages.
 It's been in use for thousands of years, and can wash away the inhaled pollen and collected mucus that leads to symptoms. There's lots of stuff on the internet one can look up for the details, but I always emphasize with my patients that the pot should be cleaned with hot water with each use, to reduce the risk of sinus infection. The washing solution is salt water, and there are premixed solutions available, or a person can make their own. I also emphasize lukewarm water! Very hot or cold water can cause problems. Saline nasal sprays are a less messy means to achieve the same "wash out", but may not be as effective.

Image result for stinging nettlesStinging Nettles (Urtica dioica)
This is a plant that actually suppresses T-cell function, which is one of the main causes of allergies. Without getting into too many details, T-cells are a type of cell that "memorizes" allergy and initiates the reaction that pops mast cells. 

One has to be a little careful with this one for two reasons. First, the plant must be picked and processed at a certain part of its life cycle to avoid the "cystoliths"--tiny hard bits of calcium carbonate--that are said to cause kidney and liver damage. Some sources dispute this, but it isn't hard to stick to young plants that are pretty much cystolith-free, so why take the chance? For my patients, I always recommend verified professional-quality nettles.

Second--and this is not in dispute--is that this stuff actually works to get at the source of allergy symptoms. T-cell suppression isn't as strong as some of the drugs that also do this (as in drugs for autoimmune diseases), but I have observed that when used for too long, sometimes the user will actually catch a cold! So for my patients, I tell them to limit daily use to only a couple of weeks at a time.

That's it for now. Look for a few more highlights of various herbs and nutritionals in this series.

Sunday, March 24, 2019

A Wave From the Fast Lane

This is one of my busiest times of the year, but I felt the need to reach out and just let all of you know I'm still here. We're coming to the last month of the semester, spring yard work season has just begun, and there's a lot going on. So here's a few things going on in science and medicine--just to keep you in the loop.

The Cannabis Debate Heats Up

In just a few short months since Governor Wolf's re-election, when he said recreational weed was off the agenda for the moment, to now, where Lt. Governor Fetterman has undertaken a "listening tour" to get a real sense of how Pennsylvanians come down on this matter, the debate has resisted being put "on hold."

Intuitively, a lot of us cleave to the notion that adding more intoxicating substances to the social mix just has to be a bad idea. Others of us choose a more libertarian way: let grown-ups do whatever they want, as long as it's properly regulated for the sake of the safety of the general public. What one thinks is one's personal view and is formed from any number of influences, including one's own experiences and reflections, as well as the resulting personal politics and spirituality.

But there's also a scientific debate and it's broader than just medical science, and includes criminal justice, sociology, psychology, economics, and political science. That's all over the place right now! One example currently flooding the internet is the link between schizophrenia and marijuana use. I'm seeing a lot of this on Facebook right now. I addressed this in great detail in my previous blog entry, so I won't do so further here. I will place this debate in the framework of a new debate that's emerged this week.

What is Science, Really?

The new debate is around the real meaning of positive or, by extension, negative results in scientific studies. In a piece published last week in Nature Valentin Amrhein and colleagues--as well as over 800 other scientists--argue that it's time to retire the concept of statistical significance. A discussion of this concept is nicely done in this article in Vox, so I won't get deeply into it here. But a very short version of the whole thing is that the culture of science has grown dependent on this very complicated and subtle concept. They argue that statistical significance has led us to many unsupported conclusions, conflicting study results that perplex the public, and a false dichotomy that suggests that a thing either "works" or it doesn't, that a thing is "there" or "not there."

I see this in my office when people come in and say something like "Last year medical science said that a little red wine is good for my heart. But last week I heard that it's bad for your heart. Which is it?" This is often followed by either throwing up of the hands as if to say "I give up!" or by a kind of defeated reconciliation that "nobody really knows what's true, so why should I care?"

Having taught research methods for many years, I can say that I heartily agree with Amrhein's group: there's too little nuance in interpreting scientific results, but good news bites require that nuance be tossed out the window. Click bait has no time for Deep Thought.

I find that one of the most useful services I provide for my patients, and my students, is to help them understand how to sort this all out. I'm not sure how this change of heart will play out over the next decade, but I like the direction we're heading. Science isn't a destination; it's a journey.

The Complicated Fabric of Science and Society

So there's other science-y stuff in the news: genetically engineered babies in a Chinese research lab, new data about daily aspirin use in people who have never had a heart attack or stroke, climate change and whether or not we should pursue or abandon nuclear power...as well as the whole medical/recreational marijuana thing. We are interested in science for its own sake, just the sheer beauty of understanding our world. We are interested in it because it leads to technologies that can improve our lives. And of course we are interested in it because it helps us make public policy.

It's on this last point that I'd like to emphasize that in policy matters, people have opinions that are wholly personal, religious, or aesthetic. A technocracy is governance based purely on objectively good science with a utilitarian aim. Alternatively such a government might serve an agreed-to philosophical or political good. Historian Loren R. Graham reported that nearly 90% of Soviet Politburo members were engineers--science in the service of a communist ideal was their aim.

While much of the world doesn't operate with technocratic governance, science is still used to tell us things about how fossil fuel use affects our climate, how vaccines affect public health, what sorts of medicine are effective for what uses, how to grow food, how markets work, and so on. It is what's in our hearts that determines how science is then used to inform what actions we take as a society. It is important to note that knowledge is constantly evolving. We learn new things. We develop better methods of "knowing" the truth of the world we live in. All the while, our hearts moderate the incoming information, and color our opinions of it with our personal views.

Knowing that's the case, and explicitly acknowledging that in any conversation about objective scientific information, could really improve our public discourse. And knowing that what we know now is only the best estimation of the objective truth right now, might remind us to reserve a little skepticism about what the future might hold.

Peace...and happy springtime!
Image: G. Hodan in public domain search

Sunday, February 3, 2019

Legal Marijuana--Is this a good idea?

My dad sent me an article from a little magazine, Imprimus, a publication of Hillsdale College, a private liberal-arts college in Michigan. I've linked its Wikipedia entry here, but I'll summarize two points here: first, that it's a true liberal arts college, with a curriculum based on the so-called "Great Books" of Western civilization (Ref 1), and second it has "worked to establish ties to the conservative political establishment" (Politico, cited in Ref 2). This latter fact alone doesn't negate arguments Hillsdale publishes, but it provides context.

The writer is a journalist, formerly of the New York Times, and more recently an author of spy and corporate thrillers. The article is from a speech he gave at Hillsdale this year.

In it he shares how he shares what he learned from his wife, a psychiatrist who formerly worked with severe mental illness among incarcerated inmates at a hospital for the criminally insane in New York. In a discussion, she off-handedly notes that all of the inmates smoke marijuana, and the conclusion to be inferred was that marijuana use led to their insanity. 

The author--a libertarian who admits that he was generally pro-legalization of drugs--investigated and came to the conclusion that marijuana use causes violence, and a lot of it, and he implies that the "elite media" (whatever that is) conspires to keep this fact out of the news, and further, that legalization moves us toward a more violent society. It's a pretty nicely written piece.

Except that like a lot of opinion pieces about cannabis, it cherry-picks data and draws unsupported conclusions from available research. So what's really the case?

Marijuana and Schizophrenia

As early as 1977 a scientific review by Ernest Abel published in the APA's Psychological Bulletin found that while the majority of people using cannabis are not prone to violence, a few susceptible individuals, and subject to certain situations of set and setting (Ref 3), marijuana use may result in violence. More recently a number of studies have found a correlation between marijuana use and schizophrenia, a condition in which people's brains falter, leading to psychosis. Psychosis includes hearing voices, hallucinations, and disturbances of thought that can include paranoia, altered perception of reality, and catatonia. It's a pretty serious psychiatric illness, and in some it does lead to violence, either reactive violence (acting out when feeling threatened) or proactive violence (homicide, suicide).

More recently there have been a number of studies that confirm an association but not a causation between marijuana use and schizophrenia. That is, yes, it does seem people with this illness use marijuana more, but does that cause the problem, or is it merely part of a multi-factor stage upon which this problem is built? Some researchers admit that those with schizophrenia may be using marijuana to self-medicate. Others note that the complex factors that can precipitate schizophrenia are simply also associated with marijuana availability and use. An example would be a poor person from a violent neighborhood where drugs are plentiful: Did the plentiful marijuana cause the disease, or was it caused by the surrounding violence and resulting fear, or is it a combination of several factors, including a local lack of mental health services?

A more recent article in Scandinavian Journal of Public Health found that for every 10% increase in cannabis use, they can project a 0.4% increase in violence. That's not the disease schizophrenia, but hey, we're probably all on the same page and agree that more violence in society is undesirable. On this argument, maintaining marijuana's status as illegal makes sense. 

But What Is It Really?

Is this all the just the interaction of a chemical--or chemicals--in marijuana causing a direct and predictable violence reaction in all humans? 

I'll begin by saying the author of the Imprimus article, Alex Berenson, is not equipped by background or education to decode scientific studies. That doesn't mean he can't read them and begin to draw some conclusions, but to be fair he should be more sensitive to his own level of training in this before drawing what end up being pretty dire conclusions. His wife, a physician, should know better, but as a clinician myself who has dealt with many people using drugs and also having mental illness, I'll admit that--in the trenches--it's easy to start seeing the whole world in one color.

Next, I'll note that almost all of the sound research out there on this freely admits that there's a lot we don't know. One example pertinent to this topic is a 2018 study in Molecular Psychiatry that demonstrated a link between variants in the serotonin 2B receptor gene and risk for psychotic reactions to THC, the psychoactive chemical in marijuana that gets people high.

I teach a class on drugs and drug abuse at Penn State, and one of the things I try to get across to my students is that yes, drugs have predictable effects, but only to a point. Some people will experience untoward effects, unpleasant symptoms, or even permanent damage from certain drugs. In my pharmacology class, I teach my students that pharmacogenetics--the science of studying genetic variations in how people respond to drugs--is still a very young science, but one that will certainly influence their future careers as nurses.

I use pharmacogenetic testing in my practice now, but there's still a lack of consensus on when and how it should be used. Indeed the vast majority of our allopathic drug prescriptions are written on the basis of a vague faith that most patients will respond as predicted. Only a handful of drugs in US have genetic testing routines that guide what we will prescribe, and the fastest-growing class of drugs in which this testing has been studied is among cancer treatment drugs.

Then Why Is Marijuana Legalization Expanding?

THC is a chemical very similar to the neurotransmitter anandamide, which is naturally occurring in humans, and bonds to special receptors in the brain--cannabis receptors! (CB1 and CB2) "Anandamide" comes from the Sanskrit word for bliss. People use cannabis because it makes them feel good, blissful, happy, whatever. Roughly a hundred years of tightening restrictions on all psychoactive drugs, marijuana included, have not led to significant declines in drug use or the criminality that defines its black market. I show my class a couple of diagrams, based on the science, of drug use harms. 
From: w:de:Benutzer:Dosenfant [Public domain], via Wikimedia Commons

From: Pmillerrhodes [Public domain], from Wikimedia Commons
As one can see from the above diagrams, none of these drugs is harmless, and none comes without some risks to society, but there is a definable scale of harms. Interestingly, caffeine, the most widely used drug on the planet (Starbucks, anyone?) isn't listed in either diagram, but does cause dependence and in some people causes physical symptoms, and rarely actual danger (mostly cardiac).

Marijuana legalization is expanding for several reasons.
  • It's fun, and people--voters--like to have fun. But this is nothing without the second reason.
  • It's not harmless, but demonstrably less harmful than other, legal, drugs in ours and other cultures.
  • It's not especially deadly--in fact no case of direct fatal overdose from cannabis alone has been reported. (This may change with novel delivery systems, and increasing cannabis potency.)
  • And as I tell my students: "Don't tell people drugs will kill them. If they try a drug, and it doesn't kill them, then they'll just think you're a propagandist and liar." Marijuana simply didn't live up to it's hype as "deadly" and "a gateway" to other drug use. 
  • And of course, there's the money. I put this last because for a long time, the money was there. It's why there was a multibillion dollar black market in cannabis. If the other reasons didn't obtain, we wouldn't be having this conversation.
In the textbook I use to teach my "Drugs of Abuse" course, the authors propose a theory of holistic self-awareness, which argues that the best way to be in the world is drug free, open and tuned in to all the sensations, thoughts, and experiences the world has to offer. I think this is an admirable argument, but ignores the tremendous variety in human bodies, human experience, and human potential. It is an ascetic argument. That's valid on its face, but only if one accepts it as so. It does not logically follow that it must be the only way to exist in the world.

I try to get my students to understand that the use of mind-altering drugs is very personal. I also try to help them understand that regulating a society is more complicated than simply saying "drugs are bad" or by arguing that all drugs are equally harmful, or that even the small harms from some drugs outweigh the benefits of particular drugs to some people. 

There is commonsense regulation available. Young brains are more adversely affected by cannabis than older brains. Driving while intoxicated is hazardous. And some people using drugs might benefit more if we redesigned our health care system such that people didn't feel compelled to self-medicate. Would a legal market improve the drugs we use (a wider variety of marijuana potencies, rather than the only very potent stuff on the black market now)? Could regulation and product testing improve safety?

As I tell my students, all mental health drugs can cause weird, unpredictable reactions in some patients. If they didn't, medical psychiatry would be way better than it is now. All mental health drugs come with a downside--which is why some people stop taking them (sometimes with tragic results!) but we don't outlaw those drugs. In a similar vein, why must we treat all, currently-illegal, mind-altering drugs with the same level of fear, disdain, and criminal sanction? 

Recreational marijuana is coming now. Almost a century of restriction is one cause of our relative lack of good, impartial data about how now-illegal drugs can be harmful and helpful. A century of political coddling and regulatory exclusivity given to the pharmaceutical industry has come with its own disappointments. I look forward to the new age of openness and hope that we can have a productive conversation about how to balance personal freedom and social safety, how to balance the possibilities in psychopharmacology and ethical regulation. 

Now go out and enjoy this glorious(ly not too freezing) day!
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Reference 1: "Great Books", at Wikipedia, accessed on February 3, 2019 at https://en.wikipedia.org/wiki/Great_books.
Reference 2: "Hillsdale College" , at Wikipedia, accessed on February 3, 2019 at https://en.wikipedia.org/wiki/Hillsdale_College.
Reference 3: "Set" is the mental state the user is in at the time of drug use. "Setting" is where and when the drug is used. Example: A person using cannabis to calm down before a stressful event has the mental set "This will calm me down" in the setting "before my stressful event." I'm not stating whether this is healthy or not, but as a way to understand the way mind-altering drugs work.


Sunday, January 13, 2019

Ethics & Medicine: A Philosophy Lesson

Ok, the title sounds a little pedantic, but the lesson doesn't have to be. Anyway, thanks to all who follow this, for your patience while I've been taking care of some business during the holiday break. The semester just began, so I'm back!

Photo credit CDC/Judy Schmidt
The inspiration here is an article I read online back around Thanksgiving Update on the Ethics of Mandating HPV [human papilloma virus] Vaccination. HPV is a virus that comes in many strains, and a few strains can increase risk for cervical cancer. Women, especially, will appreciate it as a concern that has driven regular check-ups--"Pap tests"--over their adult lives. Catching the cancerous changes early has a 100% cure rate, and numerous studies over the decades showed that regular Pap tests reduced the rate of cervical cancer to a rarity. HPV vaccines were introduced in 2006, and public health experts pronounced that this was "the first vaccine that prevents cancer" and that it should be used throughout the population.

In the following 12+ years there have been arguments pro and con. I shared the former above. The con arguments ran to these...

  • Use of the vaccine would lead young people to conclude that sexual activity outside of marriage is ok.
  • The vaccine probably had hidden dangers that would not be known for years "and my kid's not going to be a guinea pig!"
  • Big Pharma was making up reasons to sell us more pharmaceuticals.
  • The vaccine was too expensive.
  • Once again we're targeting women's sexuality for "treatment"--a feminist argument.
...and so on. Use of the vaccine languished for a number of years. Some state legislatures tried to mandate that HPV vaccine be included in the required immunizations for attendance at public school. That didn't always go over well with parents who were also voters. Since then, the Centers for Disease Control report that immunization rates have increased. There's more acceptance of it, and its use has been expanded to include boys. (After all, girls have to get the virus from somewhere!) 

From Merck, Inc.
Advertising helped. Check out this ad from Merck in which adorable young people ask their parents if they knew about this vaccine that can "prevent...cancers". I mean, what parent wouldn't feel guilty about not paying whatever it costs to immunize their kid against cancer? (In fairness: many insurance companies now cover the cost of HPV vaccination.) But this article is about the ethics of medical technology and medical decision-making, so let's go there next.

Ethical Theory

Our sense of right and wrong is governed by two things: ethics and morals. Morality is a personal framework for the determination of right and wrong, and guides us in how we should act in society. It may include our religious or spiritual beliefs, and so its application may be limited by some circumstances. For example, some Christians believe that God rules against abortion, and so for those folks, abortion is wrong. Someone who doesn't subscribe to that religious view may believe that abortion is a suitable choice in some circumstances, and what circumstances permit that choice may also vary among individuals based on even more specific values. Morality is determined by culture, religion, psychology, and a variety of other factors.

Ethics has a similar dictionary definition, but more precisely it's a body of theory that attempts to help people choose right from wrong using broader social and historical bases. It's a branch of philosophy and so it's unbound by any specific religion. Here are a few examples of ethical theories, some of which the reader may be familiar with, but this list is not exhaustive--just some examples!

Utilitarianism: the theory that suggests that we should do the thing that does the greatest good for the greatest number of people.

Duty: philosophers will recognize this as "deontology", the theory that suggests that formal rules of conduct--the laws of a society--determine what is right or wrong.

Contractarian: and if you recognize the word "contract" in there, you can see that this would be the theory that argues that what is right and wrong is based on what everyone involved agrees is right or wrong.

Making an argument on ethics means making an argument within a theoretical framework, and there are parts to that framework. Autonomy is something that most of us in America feel is an important feature of our personhood. Being able to "be ourselves", to pursue "life, liberty, and...happiness" is a thread that runs through medical decisions. We should be able to choose medical therapies based on what we want, not what we are told to do by a doctor or a nurse. In mainstream American ethical thinking, autonomy is very important. In some cultures, not so much. For example, some of my colleagues at Hershey Medical Center work with many Amish, and in some situations Amish families may decline life-saving medical treatment because the "greater good" (utilitarianism) is better served by foregoing expensive treatment that seems to go against God's will and can cost the community a lot of money, when that money could better used elsewhere. You get the idea.

Ethical Tension in the Immunization Debate

As I've suggested elsewhere in this blog, a lot of the passion about whether or not to immunize comes down to different ethical approaches to this issue of what's right and wrong. In the article I referenced above in Infectious Disease Advisor, lawyer and professor of medicine at Georgetown University, Lawrence Gostin, states "I think that mandating the vaccine has public health benefits far beyond the small intrusion on individual rights. Thus, a mandate should be in place for all recipients recommended by the CDC unless there is a genuine religious objection — that exemption should be quite narrow." 

Gostin is making a utilitarian argument. What's better for all should be chosen over what's thought by some to be better for themselves. He argues that giving up a little bit of personal autonomy is more right than wrong because it is in the "best interest of the children receiving it"--although I'll be quick to note that neither Gostin nor the article's author provides statistical estimates of just how many people would benefit. However, I dug around a bit and found that a team did use mathematical modeling to estimate how much disease and death could be prevented (Van Kreikinge, 2014). 















Here, I've just shared one part of one of the results they share that's relevant to Americans. Basically it says that the more people you vaccinate, the more lives are saved. I have a couple of problems with this estimation. First, I used to do gynecology and examined (literally) over a thousand women for cervical cancer surveillance. What I found was that if women were poor, without insurance, or otherwise limited in capacity for self-care, they could get full-blown cervical cancer. Women with good education, good health care, reasonable hope for a prosperous future, and so on would not get past the very early stages of cancerous change. Simple outpatient treatment was 100% effective.

Second, two of the study's authors are paid employees of Merck, Inc. Think there's any financial incentive to create a rosy mathematical model that underscores the importance of getting immunized? Do you think that the study included in its estimates the impacts of wealth inequality, war, food insecurity, unfair labor practices, or any of the host of social and economic factors that also have an effect on what kind of health girls--or boys--receive? It did not.

"Ethical" Pronouncements as an Excuse for Ethical Truth

I get it. Doctors, nurses, public health advocates and policy makers all want to believe they are doing the right thing. They take one little thing they can run with, whether that's vaccines, or medicines like statins, or healthy eating or whatever, and they use it as a pivot to make the argument that people should do this because it's the "right thing", and it may be small, but it will help.

Where this goes wrong is the argument that follows on: if you aren't doing this, then you are wrong. It's the same argument that doctors use to vilify alternative medicine practitioners. It is unethical to use homeopathy with patients, or to recommend supplements, or to suggest vaping over smoking. "There's no evidence" (well, there often is, but it's not "enough" evidence). 

Really, this is all just an excuse for moralizing over someone else's choices, when the evidence for harm from such things may be minimal. Ethical truth is a personal, moral state of thoughtful calculation that considers the autonomy of another person, and the importance of valuing imagination and cooperation, over a static moral framework and its use to dominate others in order to feel superior. 

While I am aware of the value of HPV vaccine in preventing some cancers in susceptible persons--as the author of the article I shared notes--I do not agree with the ethical calculus. I would argue that it's an excuse to avoid talking about bigger social problems that lead to the deaths they would like to prevent. Further, it's an excuse to write a prescription in a few seconds, rather than to work with people to understand and help them build upon their own health choices.

Be well!
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Reference: Van Kreikinge et al., 2014 in Vaccine, Feb 3;32(6):733-9. doi: 10.1016/j.vaccine.2013.11.049. Epub 2013 Nov 26.