Sunday, September 9, 2018

What do the Numbers Mean? A Story of Measles and Measles Vaccine

As I have mentioned previously, I'm getting email blasts every day from various medical news outlets I am connected to (some on purpose, some just come to me unbidden!), and this thing about "deaths from measles vaccines exceed deaths from measles in the U.S" plopped into my inbox at the end of August.

So I read it. Seemed like an "antivaxer" point of view so I fact checked it at a site called Ballotpedia, a source for fact-checking claims made by politicians and people running for office. The data are real, but the author points out that while there were 12 reported deaths between 2000 and 2016 from measles in the U.S., only 2 were verified as caused by the disease. In the same period, 104 deaths were reportedly caused after receiving the vaccine. However, they note, verification is sketchy because the Vaccine Adverse Event Reporting System (VAERS) takes reports from anyone, including lay-persons, and verification depends in large part on the contents of the individual reports.

This basically means we have numbers but no context. I'll try to provide some.

Measles is a leading cause of death among children worldwide. What this doesn't tell you is that measles deaths are connected to the level of development. Less development (clean water, good food, access to health care) is connected to a higher death rate. In simple terms it can be said that if you are poor, hungry, and exposed to lots of germs in your water source, or around untreated human waste, or exposed to high levels of pollution, and you are without access to doctors and nurses, you have a higher chance of dying from this infectious disease.

VAERS reporting just says that one thing happened (a vaccine) and then another thing happened (in this example, a death). By digging into each report, it is possible to sort out likelier cases of vaccine-caused-death and less likely ones, perhaps events that were linked in time to some extent, but there were other factors to consider as the real cause of the death.

In this, Ballotpedia is right, and so are doctors and public health experts. The Centers for Disease Control discusses this weakness right on the VAERS website. However, the difference between 2-12 deaths from measles and 104 deaths from the vaccine--no matter what the flaws in the VAERS reporting--is a big difference!

To antivaxers, these data would suggest that the "cure is worse than the disease", although that would be leaving out the millions of kids who were vaccinated without dying afterwards.

To vaccine advocates, this suggests that the vaccine-caused-death data are flawed, and even so, the disease is worse than the cure. Clinicians share horror stories of "unnecessary" measles deaths to drive the point home.

To me, both sides are wrong.

It is easy to blame a childhood death from a disease like measles on unruly parents who refuse to see the light of science, when it's possible that in any given case, there may have been other factors at work. Most measles deaths are caused by encephalitis, an inflammation of the brain, a condition difficult to treat with today's approaches (mainly steroids or immune globulins). It still works 95% of the time in kids and 75% of the time adults. Homeopathy has a number of remedies that may be helpful--although they don't get used much because most doctors don't "waste time" on such approaches. Belladonna (first stages), Stramonium, and Gelsemium are three remedies that have been used to good effect.

Measles encephalitis (ME) isn't the only potential cause of death, and ME itself can occur because of the direct effects of the virus or from the indirect effects of the immune system going crazy from the virus. Death can also ensue from pneumonia, shock, or other causes made worse by the measles infection. An early study found nearly 1/5th of deaths from measles were seen in persons with an underlying medical condition. Makes sense: if you're already sick, measles might make you sicker.

It is easy to blame a sequel, like death, on a vaccine if one thing (the vaccine) happened, and then another thing (death) happened, regardless of what mysterious process was actually going on underneath it all. The survivors of a death need a point of blame for the loss.

As many of you know, I'm not against vaccines. I'm not pro-vaccine either. For a lot of nurses and doctors, the broad strokes of the science and the potential for believing that one's work (i.e., immunizing large numbers of children) makes the world a safer, better place is enough to quiet any misgivings that arise from what are actually pretty isolated events. It is easy to see why doctors and nurses argue so urgently for scheduled vaccinations.

Parents, on the other hand, see only one kid--their own, and this focus can't accept the broad brush, the science of millions of other kids' experience with vaccines (other kids who are not their own). They want to untangle the matter, and if they cannot do so, it seems safer to avoid injecting their child with a product to prevent a disease they may never see. It is easy to see why some parents resist the pressure to vaccinate.

The email blast that started this blog entry is evidence that we aren't moving past this stage of the debate. It's still the same old thing. One side says the science is sound and that the aggregate good to the population outweighs the occasional catastrophe. The other side says, "Nope, not if that catastrophe might be my kid."

Interestingly, in a commercial for Bexsero, the moms argue that not vaccinating against meningitis-B "isn't a risk I'm willing to take." I commented on this in detail elsewhere in this blog. You know, when it comes to your kid, one's point of view could go either way. So whether one chooses the immunization route or not seems largely to depend on what risks, what threats, seem most immediate and dangerous.

This is the problem with this debate over vaccines.

I have yet to hear any public health advocates, politicians, parents, doctors, or nurses openly argue that individualizing approaches to immunization is a viable medical option. I have yet to hear any of these people argue that improving wealth equity, environmental science, and access to health care for all would also improve outcomes in measles--or any other of the many diseases we vaccinate against.

I suppose it is easier to carry on this fruitless argument than it is to come together to improve the foundational aspects of health that are so inequitably distributed in our world.

Sunday, September 2, 2018



People often ask me what sort of diet they should eat. Dr Samuel Hahnemann, the discoverer of homeopathy, had little to say on this matter. After all, considering how things were in the Eighteenth Century, just having enough food and clean water were significant enough issues. He hardly could have foreseen the glut of available food we have in the West today!

Florence Nightingale, founder of modern Nursing and head of the nursing staff at the field hospital at Scutari, Crimea during the Nineteenth Century, observed that food should be as fresh as was practical to obtain, and consist of good meat, starches, and the usual fruits or vegetables available at the time. Recovering soldiers who ate decent food recovered better.

When patients ask me about diet, I don't have a whole lot to say. Part of this is the practical matter of the visit: just taking a homeopathic case uses up the available time. But I suppose I could create a patient teaching tool about what constitutes a "good" or "healthy" diet. The problem with such an approach is that it's also important to know how a person eats now compared to what they think of as a goal diet. This is compounded by other issues.

What is their culture? Foods that may be culturally appropriate to one person clash with the culture of another. When I practiced HIV medicine in Reading, I had a lot of Puerto Rican patients, and I learned that the diet of Puerto Rico tends to be somewhat high in fats. That doesn't make it bad; it does present a different set of advisements about how to make such a diet healthier.

What comforts us? Doughnuts are not exactly health food, but once a week, on Sunday, I allow myself one, because I like doughnuts and they make me happy. Limiting my "doughnut happiness" to once a week has not harmed my mood, and has contributed to me maintaining a healthy weight. Foods we were raised on--back when the health of food consisted of just having what we thought was a "balanced diet"--nevertheless can evoke good memories and a good mood.

So for me, if a patient wants dietary advice, and depending on any existing medical conditions like diabetes or high blood pressure, I generally refer them to a registered dietician (insurance sometimes pays for this service) or a naturopath, if they want something more aggressively "alternative". The latter often involves avoiding certain things like gluten, whey protein or dairy, or a wholesale changeover to whole grains, raw vegetables and so on.

Having reviewed a lot of the scientific literature on this approach, I can safely say that...

1) Such radical dietary changes really work well for some people, and
2) They also don't seem to work well for everyone.

Part of the reason is purely practical. I often tell patients that "You've eaten a certain way your whole life. It's a hard thing to change when that is what you are are used to." And it's not just liking the food. It's finding it, preparing it--changing the very way you shop for and cook your food. It's a big change!

I've also run across countless specialty diets. Atkins, ketogenic, Zone, high-protein, Frances Lappe's Diet for a Small Planet--diets even come with political and social agendas! Such is the state of affairs in a society that has plenty of food (arguably too much food), and so much that is processed in factories, themselves fed by an industrial agriculture that relies on pesticides, herbicides, feedlot meat production, and genetic engineering.

What prompted this blog is an article I saw in The Atlantic about professor and speaker Jordan Peterson and his daughter's "all meat" diet, in which they eat literally nothing but beef and water. It's actually not the strangest thing I've ever heard of in that realm. Several years ago there was a fad of eating spoiled meat to relieve the symptoms of arthritis and other conditions. Spoiled meat stinks, so of course eating it indoors often posed a problem! An example is this report from Vice News. I gotta say, the guy doesn't look all that healthy to me, but if he feels it's working...

Anyway, I like the advice of author Michael Pollan: "Eat food. Not too much. Mostly plants." I don't follow it strictly, but it has guided me to reduce the kinds of things I was raised on and learned to love (burgers, doughnuts) and my diet has gradually become healthier. I'll add that it has taken years of little changes (and the help of my wife, whose diet is better than mine). Another author I like to emulate is Dr. Andrew Weil, whose advice generally points to a Mediterranean diet of more and varied grains, fruits and vegetables, smaller amounts of meat, and reduction of sugars, artificial fats, and foods that have been processed or raised with a lot of poisonous chemicals.

I've tried some of the "faddier" diets. Haven't stuck with a single one. I like the variety of a diet that borrows more from Mediterranean, Asian, and Central American cultures, who are less meat-focused. I've never tried a gluten free diet--I'm Southern Italian and the avoidance of really good artisanal breads and real Durham wheat pasta just doesn't fit. There's that "culture" thing again!

When patients tell me they feel better on a diet, especially avoidance diets (like gluten free, dairy free, etc.) I'm fine with it. In our society it's almost impossible to not have adequate nutrition if you supplement where needed with whatever's missing (vitamin D, vitamin C, etc.), so why criticize the diet if it makes people feel better. It's a trickier conversation whenever it is clear that the thing or things avoided are causing a person to feel unhappy, restricted, and afflicted though.

Take scallops, for example. For some reason they really make me ill. I avoid them. I can eat all other sorts of seafood like oysters, shrimp, and fish. Do I miss scallops? Maybe a little sometimes. Does it make me sad I can't eat them? Not really. But a nice loaf of handmade Italian bread? A hot, buttery croissant? A fresh baguette with goat cheese? If I started avoiding those things my life would feel like it's missing something. If I felt bad enough, I might reconsider, but I'd rather find another way to beat the problem.

Homeopathy takes another approach. Its theory and practice implies that we are, generally, genetically equipped to eat whatever we choose, and what we choose tends to be what we need--if we pay attention. Food allergies, food sensitivities, we propose, may owe more to regulatory imbalances that, in the absence of genetically-driven conditions like true lactose intolerance, if given the right homeopathic remedy, will resolve, leaving the person to eat as we were meant to.

Eating food. Not too much. And mostly plants.
Bon apetit!