Wednesday, February 28, 2018

The Luxury to Choose

By Travis Bias, DO

Dr. Bias’ blog post first appeared on THCB.

The 82-year-old woman lay on her mat, her legs powerless, looking up at the small group that had come to visit her. There were no more treatment options left. The oral liquid morphine we had brought in the small plastic bottle had blunted her pain. Nonetheless, she would be dead in the coming days. The cervical cancer that was slowly taking her life is a notoriously horrible disease if left undetected and untreated, and that is exactly what had happened in this case.

We had traveled hours by van along dirt roads to this village with a team of health workers from Hospice Africa Uganda, the country’s authority on end-of-life care, to visit the woman. She was the second patient of a similar condition I would see that afternoon.

Photo of Mbale, Uganda. Photo credit: Travis Bias, DO.
Back home, seeing an 80-year-old woman with advanced cervical cancer, let alone two in the same day, was exceedingly rare. In high-income countries, cervical cancer is a largely treatable disease, especially when caught in the early stages. And it is now preventable thanks to Gardasil, a widely accessible vaccine against Human Papillomavirus (HPV), the infectious agent that causes most cervical cancers. Physicians and other health care experts recommend the vaccine for all pre-teens in the United States.

“If only she had had access to Gardasil,” I thought to myself.

Just months earlier I was busy in my private primary care practice in Austin, Texas. In one of the richest countries on the planet that spends more on health care per person than anywhere in the world, I was putting forth my best effort to explain to a mother why her 14-year-old daughter, who had never before had any sexual contact, needed the series of three shots against HPV. “So this HPV is sexually-transmitted, and she still needs the vaccine even though she is not sexually active? And she does not need this shot to attend school?” Gardasil was a difficult sell in the conservative state that was careful about adopting what government, or anyone for that matter, recommended an individual do for the sake of public health.

It is now February 2018 and news reports are sounding the alarm about the strain of influenza making its way around the U.S., causing remarkably high rates of hospitalization and death. This disease can be easily prevented by one vaccine each flu season, yet patients decline this vaccine due to any number of excuses. “Won’t I be sick or sore for several days after?” “I am very careful about what I put in my body.” And the online “anti-vax” echo chamber encourages this behavior, turning one anecdote of a less-than-desirable reaction into several stories of harm attributed directly to a single shot in the arm.

What a luxury to choose from a menu of technological advances to protect one’s health. What a luxury to have an employer or taxpayer fund these ubiquitous means of preventing disease; whether it is a vaccine, a blood test, or a basic treatment. High-income societies have at times taken for granted life-saving resources. All to the detriment of their communities. What a luxury.

Considering the Centers for Disease Control and Prevention’s list of the top ten greatest public health feats of the last 100 years, we are on an incredible backslide to the year 1899. Measles was declared eliminated from the United States in 2000 thanks to widespread immunization, yet we now have outbreaks at Disneyland and anticipated future outbreaks due in part to conscientious objectors to the vaccine. Thanks to advancements in water treatment we no longer have major outbreaks of diarrheal disease, yet we now have entrepreneurs selling “raw water.”

What a luxury.

It is a cruel reality of inequality and resource mismatch across the globe when those without resources are clamoring for them, while those with resources refuse. Whether based on religious or individuality protests in conservative communities or “natural” ways of life in more liberal communities, the result is the same ignorance of science and reason. What a luxury.

But a heavily and densely populated globe interconnected by the increasing ease of international travel means that one person’s declined influenza vaccine might mean another person’s influenza death. The case of Ebola virus disease transported from Liberia to Dallas, Texas in 2014 highlighted how quickly and easily infectious diseases can spread across borders.

In a world of finite resources (yes, even in America) when does the conversation about personal responsibility turn to demand that individuals implement what is available to him or her to benefit their global community?

In a decade as a family medicine physician in the U.S., I had never before seen a death due to cervical cancer. With our suite of widely used screenings, diagnostic technology, and range of surgical solutions, cervical cancer-related deaths are exceedingly rare. And now that we have deployed the vaccine, Gardasil, cervical cancer rates worldwide have been cut in half.

“If only this woman had had access to Gardasil,” I thought to myself. Instead, the 82-year-old matriarch tried to maintain her dignity in the face of a spreading cervical cancer, urinating on a plastic tarp in her niece’s concrete open-air house and controlling her pain with ibuprofen and oral liquid morphine. If only she had had access to that luxury to prevent her cancer. With a little public will, perhaps her great-granddaughters — and mine — will.

Travis Bias, DO, is a family medicine physician who once practiced in Texas and now practices in California. He also is a medical and public health educator. Dr. Bias was an active member of the Texas Medical Association while in the Lone Star State. Connect with him at his blog, The Global Table, or on twitter @Gaujot.

Wednesday, February 14, 2018

Spread the Love, Not the Disease

By Arathi Shah, MD, Dallas 
TMA Be Wise — Immunize℠ Physician Advisory Panel member

Love is in the air! It’s February, the month of celebrating love and our loved ones. We can fully embrace this caring spirit, going beyond candy and flowers, by keeping the air as free of germs as possible. The best ways: covering our coughs and sneezes, following handwashing hygiene, and staying current on our family’s vaccinations — and our own.

Vaccinations are our best allies to prevent and limit the spread of debilitating and life-threatening diseases. When we get vaccinated, we are protecting ourselves, our family, and our community. Physicians and other health experts call this “community immunity” or “herd immunity.”

When more of us are vaccinated, germs can’t spread as easily within a community, so fewer people are likely to get sick. And if someone does get sick, the chance of an outbreak is less. The goal is that vaccine-preventable diseases, like polio, can be wiped out.

Community immunity protects everyone from illness. Even people who can’t get vaccinated have some protection — such as newborns, pregnant women, elderly people, and those with weak immune systems (like people who have cancer). Community immunity also is important for a very small group of people for whom vaccines are less effective.

The vaccination rate to achieve and maintain community immunity varies by disease, but usually ranges from 83 to 95 percent. So, eight or nine out of 10 people have to be immunized.

Prevention is always better than cure. For the sake of our loved ones and our communities, we all need to stay current on our vaccinations. Consult your physician to make sure your family is up to date on recommended vaccinations.

Protecting our world from serious, vaccine-preventable diseases such as measles and whooping cough requires a community-wide effort. In this day and age, when the world has become one large family of people traveling near and far, it is important for us to remember to bring home the love, not the disease.

Be Wise — Immunize is a service mark of the Texas Medical Association.

Tuesday, February 6, 2018

Learning From the Past: The Flu at Its Ugliest

Sandra Dickerson, MD, Lubbock
TMA Be Wise — Immunize℠ Advisory Panel member

In a year when hospitals and emergency departments are overrun with patients and the news reports children dying from influenza, I cannot help but think of 15-year-old Pierpont Balderson.

Who was the young Balderson? The first person to die in Dallas — 100 years ago during the Flu Pandemic of 1918.

One-third of the world population, then estimated at 500 million, was infected with Spanish Flu, a particularly deadly strain of the flu virus, in 1918. In the span of one year, 20 to 50 million people died, mostly young people and mostly from the pneumonia that followed the flu.

This was three times the number of deaths in the “War to End All Wars,” — World War I.

1918 Spanish influenza ward at Camp Funston, Kansas. Image via U.S. Army.

Dallas was lucky. The death rate from the Spanish Flu was “only” 286 per 100,000 residents. New Orleans suffered even more fatalities, with 734 flu deaths per 100,000 people.

But the most disturbing statistic is the deaths were mostly in young people who died from pneumonia, a secondary infection that followed their infection with the flu.

Public health physicians still don’t know where this virulent virus came from, so they don’t know when it will happen again. They only know it will happen again — and that’s the bad news.

The good news is, back then we didn’t have anti-viral drugs to lessen the symptoms of the flu or antibiotics for pneumonia. And we didn’t have the influenza vaccine, nor the capability to develop one.

Now we do.

So this year as we see another scourge of flu (and every year), follow these tips to help keep yourself healthy:

  • Wash your hands.
  • Cover your sneeze or cough.
  • Don’t go to work sick.
  • Augment your immune system to fight off the virus: Get your flu shot!

By doing these simple things, you might save the world.

Be Wise — Immunize is a service mark of the Texas Medical Association.

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