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Friday, September 24, 2004

We have met the enemy and he is us.

It seems like it's a bit of fad right now to criticize CBS News, what with selectric-gate and all. God forbid anyone accuse me of jumping on the bandwagon, but I'm afraid I have recently discovered a bone that needs picking with that news organization.

On September 21st, 2004 during their nightly news broadcast, CBS ran this story. The story deals with the disease Whooping Cough, known more technically as "Pertussis," which has been making a rather startling comeback recently. Infection levels in 2003 reached a new high of 11,647. This was the largest number of cases in thirty years.

According to CBS this disease was largely thought conquered following the introduction of a vaccine. Indeed, during an interview on the program it was observed:

"And the first thing that goes through your mind is, 'Where? How?'" [did my child get infected] says her mother Starla Sands. "I thought this disease was dead."

Indeed, whooping cough was one of the leading causes of death among infants in the developed world into the 1940s. The disease causes powerful, uncontrollable coughing and, in the process, can cause facial lesions, brain damage, lead to serious proctological complications (the force of the repetetive coughing is so extreme that internal muscles begin to be forced out through the rectum), malnourishment because the victim can't stop coughing long enough to eat, and death. Almost worse, pertussis is an airborne bacterium with an infectivity rate that fluctuates between 70% and 100%, making it not merely physically debilitating, at best, and lethal, at worst, but also a perfect disease for starting an epidemic. Thus a resurgence is cause for serious concern. Why is whooping cough on the make again? According to CBS News:

No one's exactly sure what's causing the surge, but pediatrician David Namerow is seeing cases every year.

Thus the return of whooping cough seems like quite a medical mystery. Except... maybe it isn't. What would you say if I told you that this isn't the first time pertussis has made a comeback? What if I were to add that this comeback wasn't in a developing country, but in an industrialized country? What if I told you it hadn't just been one such country, but not fewer than 5? What if I were to tell you that the causes of the resurgences in these nations appear known, and that there is an available solution to the problem? Does that seem like something CBS News should have reported on?

As a matter of fact, we have seen such resurgences in at least five other developed nations: Sweden, Japan, Russia, Australia, and the United Kingdom. Sweden has been particularly hard-hit by the return of whooping cough; in an epidemic between 1980 and 1983 incidence rates among pre-schoolers reached 3,370 cases per 100,000 individuals. To give comparison, prior to 1940, Sweden suffered under an infection rate of 300 per 100,000. In its return, pertussis is even more dangerous because our population has largely forgotten how to deal with it. It seems quite logical to ask, if pertussis has returned elsewhere before, maybe it is returning here for the same reason. The question logically follows: why did pertussis return in other countries?

For the answer, we turn to an article in the magazine The Skeptical Inquirer by William John Hoyt, Jr. This article, entitled Anti-Vaccination Fever: The Shot Hurt Around the World, makes a compelling case that the return of pertussis is not due to some new mutant strain of the bacteria- it is instead due to a failure of parents to properly vaccinate their children.

The reasons for this are many, and complicated. In the pertussis case, vaccination began to sag when studies were published in several medical journals that seemed to suggest that whole-cell petussis vaccines were correlated with neurological complications. These studies were rapidly seized on by anti-vaccination activists in Sweden and Japan, among other areas. Of course, in all cases these studies showing additional risks from vaccination were based on flawed data, methodological complications, and statistical errors that drastically inflated the risks of the vaccines. For example, when the Swedish academy of sciences investigated one such paper, they found that the author has over-estimated the complication rate by more than a factor of ten! Further, correlation has routinely been conflated with causation, leading people to believe that the vaccines are harmful themselves when in actuality they are not.

Added to this problem is the simple truth that parents believe that the disease is "dead." This makes sense in a "common sense" sort of way- after all if you've never heard of someone getting whooping cough, that means the disease is gone, right? Wrong. In a thoroughly vaccinated population the disease can still exist, it just doesn't cause epidemics. The mistaken belief that pertussis is no longer a threat, coupled with erroneous beliefs about the dangers of the vaccine, have caused vaccination rates to plumet at different times in all five of the above countries.

Predictably, as fewer and fewer vaccinations occurred, more and more serious epidemics of pertussis exploded through these populations. Also unsurprisingly, when vaccination rates began to climb again, epidemics became less frequent and far less severe. Pertussis is returning not because of some new innovation in the biological arms race between humans and infectious agents, but because we are forgetting the true horror of this disease. We are, in this case, not victims of pertussis, but of our own arrogance. We can protect against pertussis, yes, but we have not eradicated this deadly foe. It remains, ever watchful for a chance to reassert itself in our homes and schools.

In a broader sense, this issue can be linked into the rise of alternative medicine in recent years. There has been a growing sense that modern western medicine is flawed and, perhaps, even more dangerous than the illnesses it is supposedly fighting. Doubt about science is not necessarily a bad thing, science is after all a system that thrives on a certain amount of dissent, but to philosophically reject an entire field of scientific inquiry on principle is another matter entirely. Coupled with this growing doubt about modern medicine, we have witnessed the resurgence of things like homeopathy, and the growing popularity of naturopathy, herbal remedies, healing prayer, aromatherapy, and other such unconventional approaches to wellness. Such new, or resurrected, methods have come to be known under the rubric "alternative medicine."

The rise of these techniques can also, in all likelihood, be linked to a growing sense of western cultural imperialism. As scholars in literature, philosophy, anthropology, sociology, and elsewhere have challenged the assumption that western approaches are superior, alternative ways of seeing, and affecting, the world have been making inroads. This is a good thing, but unfortunately this new revelation has spread uncontrolled.

The principle that western culture cannot demonstrate its superiority to other, non-western cultures, has been extended to the products of science and medicine. Western science has increasingly been seen as merely an option in the treatment of disease, with no greater claim to efficacy than witchcraft. In many cases these non-scientific approaches to health and wellness are portrayed as competitors with equally-good, if not superior, records as traditional scientific medicine, thus side-stepping the comparability issue altogether.

This view of scientific medicine as merely one approach among many, with no particular claim to efficacy, is complete, total, and unmitigated bullshit. Alternative medicine as it is presently understood represents a threat to the public health not merely of our society, but to the world in general.

Hey, I take a stand, you know?

First off, let's consider the term "alternative medicine." Alternative, when used as an adjective, means, "a) Existing outside traditional or established institutions or systems: an alternative lifestyle. b) Espousing or reflecting values that are different from those of the establishment or mainstream: an alternative newspaper; alternative greeting cards." Note that, nowhere in that definition, does alternative mean "good." It means simply "different," and it should be immediately obvious that difference can be both a good and a bad thing. Indeed, just because a treatment is unconventional it doesn't mean that it is new, or more advanced, or even based on something other than a whim.

Secondly, let's consider the common assertion that western medicine is "unnatural." Well, yes and no. In one sense, all medicine is unnatural. The deliberate introduction of substances and behaviors meant to maintain or improve health is pretty unusual in the natural world. In a more complex sense, however, tool-making and using is, for humans, essentially a natural behavior. That we should turn our attention to tools for promoting health is hardly surprising.

So, obviously, the tools themselves must be somehow "unnatural." Again, we'll ignore the fact that for almost any other species besides humans (I am aware that chimpanzees, otters, and crows are all known to use "simple" tools) tools themselves would be pretty unusual. In any case, it isn't accurate to say that western tools are all that unnatural. Many pharmaceuticals are concentrated, refined forms of naturally-occurring chemicals. The difference is not in the substance, it's in the delivery system: commercial drugs concentrate the active ingredients into an efficient form. As for the more advanced medical machines like x-rays and ultrasounds- all of these devices are used to examine a patient in a way that human fingers simply can't, and make use of forces that exist quite naturally in the normal world. Again, the difference is that our machines harness and concentrate them.

Even if we assume, however, that western medicine is somehow "unnatural," does that mean that it's bad? Put another way, does "natural" equate to good? The answer, of course, is no. More accurately: HELL no. Many, many things are natural and are still very harmful. Hemlock is entirely natural, but it seemed to be quite up to the challenge of poisoning Socrates. Oleander is quite natural, and quite lethal. Natural substances, just from plants, are so frequently toxic that a full listing is quite beyond my ability to produce. Natural has never been in the past, and is not now, equivalent to good.

I could continue criticizing alternative medicine, but I won't. There are any number of places one could go and find information on the tradtional vs. alternative medicine debate. I do not need to reproduce them all here.

The thing is, I get heated about this issue because a person's decision to make use of questionable alternative therapies isn't just a personal choice. It has been said that your freedom of action ends when your choices begin to affect another person. As a sociologist, I understand that this point comes rather quickly. In case of disease, however, that point is reached almost immediately.

The true power of vaccinations is not that they keep the vaccinated individual safe from disease. Indeed, as CBS pointed out, pertussis vaccines often wear off by adulthood. Moreover, even at high rates of vaccine adoption, a substantial portion of the population remains unprotected. No, the power of vaccines is that they prevent the spread of an infectious agent.

Imagine for a moment a population in which a significant majority of the members are vaccinated. If the non-vaccinated are distributed more or less randomly in this population, then any time a vulnerable individual contracts the disease, they are surrounded by those with an immunity. The disease cannot spread, becoming an epidemic. Now, imagine a world in which a much greater proportion of the population is unvaccinated. As this proportion rises, the ability of the vaccinated to block the spread of the disease decays, eventually reaching the point where epidemics become possible, and even inevitable. Vaccination protects not merely the people who have been treated, but even those who have not because it halts the spread of a disease.

As Duncan J. Watts (Who, despite what it may seem from his writing, did not invent social network analysis. But that's a subject for another blog...) points out there is a tipping point in networks of infection. On one side, the infection falters and fades. On the other side, it explodes and becomes epidemic, or even endemic. The true power of vaccines is that they push us to one side of that tipping point- they isolate small groups of unvaccinated in a vast sea of the immune, preventing a disease from reaching even the full extent of the unvaccinated population. Vaccines are not merely a personal good, but a collective good as well. A society that adheres well to a program of vaccination will protect both vaccinated and unvaccinated members.

So, I get rather aggravated when people "free-ride" on the system by not vaccinating themselves and their children. It isn't just their choice, because they aren't just putting themselves at risk. As the proportion of those who are unvaccinated rises, we are all pushed closer to the point at which a disease can spread uncontrolled. Certainly the full blame for this tendency cannot be lumped on alternative medicine, a substantial portion must be laid at the feet of our own forgetfulness, and I readily concede that some very useful healing techniques may be derived from what is now considered to be unconventional treatment. However, by promoting a mindless rejection of scientific medicine, alternative medicine has been in essence aiding the cause of disease and placing us all at risk.

Equally important, I get pissed off when news organizations, like the one at CBS, don't do their homework well enough to know that a return of pertussis is NOT unique to the United States. This has happened elsewhere, we know why it has happened, and we have every reason to think that the same phenomenon is at work here. By failing to report it either CBS is guilty of alarming incompetence, or is deliberately refusing the tell the whole story for reasons I cannot imagine. I'm not asking CBS to advocate vaccination, but telling the whole truth about a such a serious issue demands that the history of pertussis resurgence be discussed.

Vaccines are not about culture, they're about life and death. When we vaccinate our citizens, people live. When we don't vaccinate them, people die. It's as simple as that. Yet, despite this simple equation, we have shown once more that the greatest risk to human survival is not some microorganism:

It is our own forgetfulness and stupidity. We have met the enemy, and he is indeed us.


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