Lessons from the Wakefield Case

I was almost at a loss for words today, besides having read the morning paper on the upcoming ESP study in a major psychology journal with questionable stats, and my having seen last night the first story on the British Medical Journal‘s report that completely, and maybe finally, discredits Dr. Andrew Wakefield’s anti-vaccine crusade which has caused needless morbidity and deaths in children from preventable illnesses in the U.S. and elsewhere.

So many others have written on Wakefield’s fraud, and considered the role of the press in perpetuating the notion that vaccines cause autism, I wasn’t going to cover it here on ML. But I do think there are a few instructive points from this “lesson” about medical communication and news:

1. People aren’t always rational in their decisions about health care. (This is an understatement.)

2. When most of the population (including journalists and, sadly, some doctors) are ignorant in basic science and statistics, misinformation spreads easily. In effect, our limited educations render us vulnerable to speculation and hype. A result “sounds good” or plausible, so we believe it, never mind the details –

3. Sometimes even educated people are so desperate for an explanation, or for a solution to a medical problem, that they’ll believe a smooth-talking scientist or doctor because they want to believe what he’s saying is true. If vaccines were to cause autism, that would give people a sense of control, i.e. a way to avoid autism.

The truth is that, for the most part, we still don’t know why diseases occur in some people and not in others. Not understanding can be a frustrating, unsatisfying circumstance, because it makes us feel powerless.

That’s it for today.

—-

Related Posts:

Notes on Cholera, Old and New

Cholera was a far-away kind of affliction, almost an abstraction, when I first studied microbiology in 1984. The legendary, infectious scourge still affected people in places like Bangladesh or Indonesia, but was a treatable condition that, surely, would be eradicated within a decade or so through progress, if you could call it that, like basic plumbing and sanitation.

The tiny comma-shaped bacteria, Vibrio cholerae, tend to thrive in brackish water, the kind that’s just a bit salty from a mix of ocean and fresh sources. These sometimes stagnant watery places crop up in river deltas, like the Ganges, and coastal estuaries such as those along the U.S. Gulf Coast. We learned that you might, very rarely, pick up a case of cholera by eating contaminated shellfish like crabs or oysters.

The most common symptom of cholera is diarrhea, so rapid and voluminous that a person can die, quickly if without remedy, by straightforward dehydration. The diagnosis of cholera can be tricky, as many people are afflicted with severe gastrointestinal diseases worldwide, but most don’t have this particular, potent toxic germ. Cholera spreads by contamination of infected human feces in the water supply. The disease can afflict people who drink tainted water, who touch it and then put unclean fingers into their mouths, as children do, and who eat food prepared by those with affected hands.

illustration by Robert Seymour (1831), image from the National Library of Medicine, image A021786

Choleraphoby, illustration by Robert Seymour (1831), lithograph from the National Library of Medicine, Image #A021786

Dr. John Snow, an anesthesiologist and founder of public health, recognized the means of cholera’s spread more than 150 years ago in London, where he became famous for mandating the closure of the Broad Street Pump. Snow died at the age of 45, of what was said to be apoplexy, old jargon for a stroke.

In 2009, there were 221,226 cholera cases reported and 4,946 cholera deaths in 45 countries, according to the CDC. Based on information put together by the World Health Organization, the case-fatality rate is 2.24%. A trend in recent years is that the overwhelming majority of cases, roughly 99 percent, are reported in Africa.

According to the 17th edition of Harrison’s Principles of Internal Medicine, there have been seven global cholera pandemics since 1817. The current rage, attributed primarily to the El Tor biotype, started in Indonesia around 1961. That strain spread, eventually, as far as coastal Peru in the early 1990s. There have been no cholera epidemics in North America since the middle of the 19th Century.

What’s happening in Haiti now is the real deal, says the CDC. Thousands are infected, mainly in towns along the Artibonite River, which squiggles on the map and in real terrain through the western section of Hispaniola, north of Haiti’s capital, Port-Au-Prince. Among other concerns are the vast numbers of people living without toilets in tent cities and slums outside of the capital, especially since an earthquake devastated the region last January.

The CDC offers some very practical tips for people who live or travel in areas where cholera is endemic. Most people who are exposed to cholera and survive become immune, although infectious strains vary and immunity may not be long-lasting. In the U.S. there is no available vaccine for cholera, according to the CDC. Treatment consists primarily of giving electrolyte solutions, for rehydration, and antibiotics in some cases.

Now, the mortality rate from cholera in Haiti is running just under 10 percent, according to today’s news. Hopefully, doctors from MSF and other agencies working in the region will get this epidemic under control. But already it’s clear that hundreds of lives have been lost to an illness that it seems should have been eradicated long ago.

Related Posts:

Cooking With Universal Precautions

A half-billion or so eggs were speedily pulled off semi-cooled supermarket shelves this week. The concern is that bacteria-laced eggs can cause serious and even deadly illness. The companies that produced and disseminated those marked eggs fear more lawsuits. Some people who usually enjoy their eggs in the morning, sunny-side up, are thinking twice.

The greatest egg recall ever set off alarms on CNN (Paging Dr. Gupta), on the front page of my newspaper’s business section, on some health blogs and in some homes. I’m concerned and saddened by this, about the cost of all this – the frank wastefulness of it. Our food supply is not infinite.

But I’m not particularly worried about getting sick from eating eggs at this time. Rather, I’ve been aware of this potential problem at least since 1984, when I took classes in microbiology. That raw or undercooked, runny eggs can effectively deliver salmonella to the digestive tract is something doctors learn in medical school. (And, maybe, the rest of the population should be taught in what used to be called home economics?)

In my home we don’t eat a lot of eggs, mainly because of my personal aversion and fear of cholesterol-lowering drugs. We go through perhaps a dozen eggs in most months. But when I do cook with eggs, whether that’s in baking a quiche, vegetable soufflé or cake, or rarely, for breakfast in omelet or scrambled form, I cook them thoroughly, applying heat through-and-through, and keep any utensils that have touched raw egg apart from anything else in the sink or on the kitchen counter.

Shifting gears, just a bit – this story reminds me of a gradual change in how we practiced medicine in the years after the start of the AIDS epidemic. In 1983, when I entered medical school, few doctors wore gloves except when they were performing surgery. At Bellevue Hospital in 1985 and 1986, my classmates and I helped to deliver babies with our bare hands.

Gradually, and as fear caught on, some doctors started to discriminate – they’d wear gloves while drawing blood from a patient with obvious risk factors for HIV, such as a promiscuous homosexual man or an intravenous drug user. But I always thought to myself, you never know who’s got what virus, we should be careful more often.

A few years later, when I was a resident physician and pregnant fellow, the concept of universal precautions came into widespread practice.  Doctors and nurses learned – had to be instructed – to don gloves whenever they drew blood or potentially came into contact with any patient’s body fluids because, the idea emerged, anyone might have HIV. Better to be careful in general, without prejudice.

These practices annoyed some at first. For doctors, they cost us time and the value of touch. Among other problems, it became suddenly more difficult to insert an IV catheter in one shot because feeling a patient’s vein is a lot harder when there’s a layer of material between your fingers and the patient’s skin. I suspect, also, that some hospital administrators must have resisted, too, because of all the money needed to buy all those gloves and new-fangled needle-dispenser boxes.

Some food-minded folks and editorialists suggest that risk might be reduced by buying less-travelled eggs from local producers. But regardless of where you live and shop for food, local farmers vary in their practices and habits. As for organic farms, there’s no real evidence that those are cleaner than other agricultural sources. (Some may be, but which? It could go either way.)

This situation bears some analogy to the reason why doctors implemented universal precautions in medicine. Some of us harbor prejudice (and maybe even some anger or resentment…) against efficient, industrial-sized food-growers and may be, accordingly, biased and even lenient in attitudes on standards and regulations for local farmers’ markets. And so the danger is, we may be less careful with eggs from a small-scale farm down the road. Those eggs seem OK, or at least we feel better about their purchase.

My point is, it’s generally better to behave without bias.

I think it would be smart for cooks to use universal precautions when handling eggs. There’s always some risk of contamination by salmonella and other disease-causing bacteria. I cook eggs well, regardless of their source or what’s picked up in today’s news.

Related Posts:

The High Cost of Food-Borne Illness, and Some Steps To Avoid These in Your Home

A new report from the “Make our Food Safe” project, based at Georgetown University, makes clear that food-borne illnesses – from bacteria, parasites and a few viruses – are ever-present and costly.

The study, authored by Robert Scharff and funded by the Pew Charitable Trusts, finds that food-borne illnesses tally nearly $152 billion per year. This measure includes some subjectively-measured expenses like pain, suffering and missed work. Even without those, the toll registers above $100 billion – a huge sum, either way.

The main culprits are familiar: salmonella, that commonly reside in uncooked poultry and eggs, sometimes lace vegetables and lately tinge peanut butter, causes some 1.5 million illnesses per year. E coli 0157:H7, a dangerous bacterial strain that turns up disproportionately in ground beef and recently on fresh spinach leaves, is less prevalent but more often damaging; it takes kidneys and sometimes lives.

The Centers for Disease Control (CDC) provides a lot of useful information on its website regarding food safety.

As a doctor, and as a mom, I see this report as a nudge to be mindful in our kitchens, to follow what should be obvious advice from a collectively-conjured grandmother.

1. Before starting to prepare food, wash your hands with soap. Do this again after handling any raw meat, eggs or fish.

2. Keep raw meat, especially poultry, apart from any surfaces where cooked food is placed, stored or served. Cook chicken thoroughly, always.

3. The same goes for eggs.

4. Salad is one of the most dangerous foods we eat. It’s loaded with dirt from the ground. To wash lettuce for salad, let water pass over each leaf and rinse, fully, at least three times. Tomatoes should be handled similarly. Carefully peel carrots, cucumbers and most other vegetables if they’re to be eaten raw.

5. Unpeeled fruits like grapes and berries are handled like vegetables for salad; they’re washed at least three times.

(N.B.: this method of aggressively washing produce 3x is hardly full-proof; it reduces the amount of dirt on the surface of fruits and vegetables but does not completely eliminate germs.)

6. It’s hard, if not impossible, to adequately wash leeks, scallions, potatoes, mushrooms and most other vegetables. These are best washed and then cooked by sautéing, roasting, steaming or another method. The point is to cook with heat – of sufficient duration and intensity – to kill most bacteria, parasites and other germs.

7. Hygiene matters, especially around the kitchen and eating area. It’s a good idea to wipe down the table and kitchen counter surface after each meal.

These are just some suggestions for ways we can reduce the likelihood of being affected by food-borne illness at home. For people whose immune systems are compromised, such as those undergoing chemotherapy, with HIV and some other conditions, there’s reason to take extra care with salad and raw produce.

Knowing what we do about food-borne illnesses can influence choices we make when we eat outside of our homes. For example, in a restaurant, I’ll eat cooked but not raw spinach, because I know how difficult it is to properly wash that vegetable. If I order a burger, I’ll ask that it be very well-done, to minimize the risk from e. coli.

When traveling, I sometimes avoid uncooked fruits and vegetables entirely – but that’s another story.

Related Posts:

newsletter software
Get Adobe Flash player