Vol. 225 January 15, 2020 Hubslist’s 2019 Recap – Part II

January 13, 2020

Click on date to read the whole blog.

June 1: Juuling and Schooling  -All vaping solutions contain nicotine despite the label that says “contains no nicotine”, or even more cleverly “contains no nicotine tar”, which means of course “no tar”. Juul (jewel) is the most successful vaping company, so successful that it has become a verb, as in “Do you Juul?, Lets Juul.” Tobacco companies are investing in vaping because they know that the younger a person is when nicotine is introduced the more likely they will become a life-time tobacco user.

June 15: Hospital Readmission Reduction Program – At first blush it looked like this Medicare cost reduction program actually worked because “preventable” readmissions decreased for cardiac disease and pneumonia, but further analysis revealed five reasons why that wasn’t true.

July 1: Public Opinion About High Health Care Costs –Two-thirds of the U.S. public thinks that reducing health care costs is a top priority for both President Trump and Congress in 2019.  The expert opinion consensus is that the over $500 Billion (yes, that’s a “B”) cost of “unnecessary services”, “inefficient delivery” , and “excessive administrative cost” is a significant cause of the high cost of our health care, but only 23% of public poll respondents thought so.  The U.S. remains unique as the only developed nation lacking universal health care insurance for its people.

July 15: Tidbits for Summer Cookouts Fitbits- People walking only 4,400 steps a day (not the recommended 10,000 steps a day) had a lower “premature death rate”. Where did the 10,000 steps a day target come from?— a 1960 marketing campaign by a Japanese pedometer manufacturer that recognized that the Japanese character for 10,000 resembled a man walking! Screen Time – Research by Nielsen found that Americans aged 35 to 49 used social media 40 minutes more each week than millennials.  A researcher interviewing elementary school children uncovered a lot of complaints from the kids about prying their parents away from their screens. “Parents”, she sighed, “are the worst.”

August 1: Parenting “Unconventional Wisdom” – Breast feeding – The benefits of breast feeding infants are generally found in studies of mothers with a higher IQ and in a higher educational and economically class than non-breast feeding mothers. “So what is the real cause of breast-feeding benefits?” Sleep training – Many studies of sleep training show sizable improvements in maternal depression, family functioning, and no negative effects on infants. Working Moms – There is very little data about the pros and cons of mothers working outside the house except for the evidence supporting longer maternity leave which is beneficial to mother and infant in those first months.

September 1: Understanding Medical News About Famous People What is the prognosis for Andrews of the Patriots (pulmonary embolism) and Ginsburg of the Supreme Court (multiple cancers)? It is relatively save to say that Andrews will not play NFL football this season and that Ginsburg, a champion statistical outlier for 86 years, will probably be sitting on the bench when the Supreme Court resumes in October. After that, who knows? Doctors may guess, but they really don’t know either.

September 15: Vaping and Fatal Pneumonia – There are so many additives in vaping solutions that it is not absolutely certain that vitamin E acetate oil causing lipoid pneumonia is the culprit, but some of the counterfeit vaping solutions used by recent respiratory-distress patients contained more than 50% vitamin E oil!  Who would guess that we would ever say, “It appears to be much safer to just smoke a joint!”

October 1: Vitamin supplements – Here’s more evidence-based skepticism about the benefits of both vitamin C and vitamin D supplements. I have cautioned against vitamin E . . .at least the inhaled form. Is there a vitamin F supplement to continue my alphabetic progression? Yes.  Vitamin F is an outdated term for omega-3 and omega-6 fatty acids,  but I think I’ll let that subject “sleep with the fishes” for the moment.

November 1: Vaping Disease, Medical Marijuana, and CBD –  Pathologists from the Mayo Clinic in Scottsdale, Arizona found no expected microscopic hallmarks of lipoid pneumonia in patients with vaping lung disease, but did find a chemical “burn” or reaction to a toxic gas. Medical marijuana resulted in minimal decrease of pain, little improvement in sleep, and virtually no effect on anxiety or depression. Despite the fact that patients were told by the sellers that there was CBD in the purchased product one third of the study patients had NO detectable CBD in their urine!

November 15: Climate Change Deja Vu from 1996 – “We are still a long way from stabilizing the global climate, a far more complex challenge than repairing the ozone layer. Even with quick action, some greenhouse gases will linger in the atmosphere for centuries. Still, close observers note that a climate of hope has crept into negotiations recently. Insurance companies, small island nations, and others with major interests in a stable climate have re-shaped the diplomatic playing field. Finally, the time for serious policymaking may be at hand.” (1996 Report)

December 1: Top 10 Dangerous Toys and Hazardous Vaping Pods – Though not lethal, yet, if ingested by toddlers the concentrated pods of marijuana for vaping devices can cause significant ICU stays for them. The even more concentrated forms of MJ in edible “dabs” (up to 90% THC) can really cause trouble. Ingesting the concentrated nicotine in vaping pods can actually be lethal to toddlers.

December 15: Changing My Medicare Health Insurance Plan Is Just like Placing a Bet  –  “Youse pays your money and youse takes your choice.” Or as one of my medical student buddies said when we were a lot younger, “Life insurance? You lose (die), you win ($). You win (live a long life), you lose ($).” Did I make the right choice in changing plans?  I’ll know in a year if I won the bet, or the house did.

 


Vol. 221 November 15, 2019 “Cassandra Speaking of Climate Change “

November 15, 2019

Cassandra: one who speaks a prophecy that no one heeds.

A friend of mine (actually his wife) was cleaning out his collection of many years of books, cowboy boots, framed certificates, and other cherished stuff when he found three 1996 pamphlets published by The Worldwatch Institute, an independent, nonprofit environmental research organization in Washington, DC. founded in 1974 and still going strong.  My friend thought I might be interested in them.  One of them, “Climate of Hope: New Strategies for Stabilizing the World’s Atmosphere” published in June 1996, prompted me to think about what were their predictions and did they come true? That is the subject of today’s blog.

Quotes directly from Worldwatch Paper #130 “Climate of Hope” June 1996:

  • “Climate change is likely to be erratic, disruptive, and unpredictable. . . The incidence of floods, droughts, fires and heat outbreaks is expected to increase in some regions.”
  • “Recent changes in global climate trends are almost certainly related to the rapid buildup of greenhouse gases.”
  • “Carbon dioxide is a greenhouse gas, letting in visible light from the sun but trapping heat near the earth’s surface.”
  • “Since carbon dioxide is a virtually inevitable product of fossil-fuel-based energy system, efforts to stabilize the climate will at some point have to require a fundamental revamping of that system. Exactly how to do this and at what cost have been subjects of considerable uncertainty and vehement debate.”

There are several greenhouse gases, including methane (hence the “target” on the backs of farting cows) and chlorofluorocarbons (CFCs, HFCs) which are manmade chemicals that have been largely phased out because of their depletion of the ozone layer. Sulfur gas, also from fossil fuel burning, is not a greenhouse gas but does produce acid rain. Stringent emission standards in the 90’s by most industrialized countries have significantly reduced the amount of sulfates in the atmosphere. Carbon dioxide is the largest greenhouse gas by volume in our atmosphere, and carbon dioxide level measurement have become a standard proxy for predicting world-wide temperature increases.

Prior to the industrial revolution in the 1800’s carbon dioxide levels in the atmosphere hovered just below 300 parts per million (ppm). In 1996 the level was 360 ppm. In order to slow global warming the carbon dioxide level will have to be below 500 ppm. Our world-wide carbon dioxide level is currently 420 ppm. “A 450 ppm target means cutting emissions by more than half by 2050. A level of 500 ppm, which would accelerate global warming, could be reached by 2050 if carbon dioxide emissions are not reduced.” (1996) Because carbon dioxide is a “long-lasting” gas in our atmosphere it’s effect on global temperature is cumulative over decades, so that if we (the world) wanted to return to 1996 levels we (the world) would have to go to zero carbon dioxide emissions, an impossible task.

More words from the 1996 Cassandra:
“We are still a long way from stabilizing the global climate, a far more complex challenge than repairing the ozone layer. Even with quick action, some greenhouse gases will linger in the atmosphere for centuries. Still, close observers note that a climate of hope has crept into negotiations recently. Insurance companies, small island nations, and others with major interests in a stable climate have re-shaped the diplomatic playing field. Finally, the time for serious policymaking may be at hand.”

Remember, these words are from 1996. As Yogi Berra said: “It’s like deja vu all over again.”

Meanwhile, as Stephen Colbert says occasionally,
Cause of the Vaping Lung Injury
In my last blog I reviewed a pathological study of lung tissue in 17 patients with the vaping related lung injury which showed no damages indicative of lipoid or oil-caused pathology. The researchers concluded that vitamin E oil was not the culprit, and that the lung injury was similar to that seen from inhalation of a toxic gas and not the inhalation of oil. They did not know what that “toxic gas” was.  The CDC has just released a study of 29 patients suggesting that the offending agent might actually be inhaled vitamin E acetate because they found that in the injured lungs. They also admitted that other unknown agents might be causing the injury.
Meanwhile, hospitals are reporting an increase (one a week in some places) of a hyperemesis syndrome, (persistent, prolonged vomiting), in heavy users of recreational marijuana. First identified in 2004 it can be difficult to diagnose as several other causes have to be ruled out with x-rays and lab tests, but it is increasing in states that have legalized recreational marijuana.

 

 


Vol. 220 November 1, 2019 Update on Vaping Lung Disease, Medical Marijuana, and CBD.

November 1, 2019

“We thought vaping was safe, and it wasn’t. . . it isn’t.”
-Charlie Baker, Massachusetts Governor, justifying his state-wide 3 month ban of vaping

 

What Causes Vaping Associated Lung Disease?
The plot thickens as to the cause of the nation-wide epidemic of vaping-associated lung injuries, including deaths. Our immediate “conventional wisdom” was that it was probably related to inhalation of the vitamin E oil  used to cut the black market THC. (You may have read it here first) Oil inhalation associated injury is now doubted after examination of lung biopsy tissue and/or autopsy specimens from 17 patients. Pathologists from the Mayo Clinic in Scottsdale, Arizona found no evidence of inhaled oil or the expected microscopic hallmarks of lipoid pneumonia in the lungs of patients with the lung injury after vaping. What they did find was evidence suggesting a chemical “burn” or reaction to a toxic gas. There was no sign of an immune response (like an allergic reaction) that would have suggested that only certain individuals could develop the lung injury disease. The researchers did not speculate as to what could have caused the injury, except they are clear that it doesn’t appear that vitamin E oil is the culprit. It puts us back to considering all possibilities: something added to black market vaping material (both THC and nicotine vapers have been injured or killed), noxious gas produced by the device itself, or a combination of the two. This lung injury epidemic began in August 2019 despite several previous years of vaping use, so “something has changed”.  Stay tuned, and don’t vape.

Are There Any Benefits of Medical Marijuana?
Despite the many claims of the benefits of medical marijuana for a variety of conditions, current scientific evidence supports benefits in only three situations: 1. reduce nausea and vomiting after receiving chemotherapy, 2. subjective decrease of spasticity symptoms in multiple sclerosis, and 3. improve chronic pain in adults. The benefit seen in a very rare form of childhood epilepsy is due to CBD alone, not THC. The old idea of benefit in glaucoma treatment was disproven a while back (remember folks? you may have first read it here). A current controlled study of the benefits of medical marijuana is underway at MGH and one of its researchers gave a interim report of their early findings at a conference I attended last week.

The researchers are attempting to do a randomized study of the benefits of medical marijuana in patients 18-55 yo.already holding a medical marijuana card (obtained from a marijuana-use certifying physician for $300 for a single visit). Neither of the researchers, and, in fact, not one of all the MGH physicians are marijuana-use certifying physicians. Since these patients view the marijuana as a treatment for their condition it is unethical to randomize some into a control group who would receive none. Since the clinic can not handle all comers at once they assigned about a third of the patients to a 3 month waiting list for their medical marijuana card. Tests and questions of both the waiting list patients (“control group”) and the patients receiving medical marijuana immediately (“treatment group”) should reveal reveal any benefits or harms from medical marijuana use. A previous study showed that obtaining a medical marijuana card caused holders to double the number of days per month that they used marijuana for their symptoms (from 7 1/2  to 15 days per month).

Since the researchers (along with everyone else) don’t really know what exactly is in the products purchased at a marijuana dispensary, they test for 11 different cannabis metabolites (including CBD) in the patient’s urine each visit. Preliminary data on 84 patients reveals minimal decrease of pain, little improvement in sleep, and virtually no effect on anxiety or depression. Despite the fact that patients were told by the sellers that there was CBD in the purchased product (a “marketing plus” since CBD is touted to reduce adverse effects of THC), one third of the patients had NO detectable CBD in their urine!

Spoiler alert: Today’s cannabis is not your father’s kind of cannabis. Joints at Woodstock had about 1-2% THC. Today the average joint has 6-12% THC. A new edible form of cannabis oil or syrup, called a “dab”, can be 60-90% THC. So “a little dab could really do you.”

What About CBD?
We know even less about the medical benefits of CBD despite the many advertising claims, wide spread ease of purchase, and Gronk’s testimonial endorsement. Cannabis contains over 200 cannabinoids. CBD is one and THC is another. Stay tuned. (Remember, you may have first read it here.)


Vol. 219 October 1, 2019 Vitamin D Supplement; Take It or Leave It?

October 1, 2019

Ever since the French sailors, weakened by scurvy, lost control of the seas to the British navy which was scurvy-free by vitamin C in the lime juice added to their daily ration of grog (hence the name “Limeys”), vitamins have been a subject of great interest and, even now, a lot of mystery. Everyone agrees that a little bit of them is essential for good health, but even two-time Nobel Prize winner Linus Pauling couldn’t convince all of us that a lot of vitamin C  could cure a cold. (1)

Vitamin D is currently the most popular vitamin to study because of some past research suggesting that vitamin D protects us from heart disease, particularly the elderly. A 2012 survey reported that about 20% of respondents were taking vitamin D supplements (multivitamin supplements were not included).  Supplemental vitamin D AND supplemental calcium have long been touted for preventing loss of bone density, or osteoporosis, especially in post-menopausal women. 

It is clear that Vitamin D deficiency can cause growth retardation and bone disease, particularly in the first years of life. It is a bit unclear as to how much of vitamin D we need. The American Academy of Pediatrics recommends vitamin D supplements of 400 units a day for breast-fed babies. Recommendations for minimum doses in other than infants range from 400 units to 2000 units a day. It is said to be almost impossible to be “vitamin deficient” on a normal diet nowadays, but certain very restricted vegan diets can cause some problems in rare cases.  Also, studies of Northern urban  children (less sun exposure) revealed “low” Vitamin D blood levels which stirred up a lot of discussion about its significance and about “what level was normal”. Too much of most vitamins can’t really hurt you too much. Most “excess” of vitamins ingested ( the amount over the minimum required to prevent a deficiency disease)  just ends up in the toilet via your urine.

A recent systematic review of a large number of peer-reviewed research studies on the use of supplemental Vitamin D to reduce the risk of cardiovascular disease was recently published. (2) This meta-analysis (our trade name for such huge reviews) of 21 randomized clinical trials with over 83,000 participants (mean age, 65) followed for 1 to 12 years showed that using a variety of Vitamin D supplements did NOT lower the risk for myocardial infarction, stroke, cardiovascular-related deaths, or all-cause deaths. This is “the best evidence to date that fails to support use of vitamin D supplementation for lowering cardiovascular risk.” (3)

Of course, the results of that meta analysis was muddied just a bit by another meta analysis of 52 clinical trials with over 75,000 participants (mean age, 74) with 1 year follow-up which showed that Vitamin D supplements was associated with 4 per 1000 persons fewer deaths from cancer in a small sub-group of participants. (4)  To further confuse the issue, it was noted that this small but significant difference occurred in only those people taking the D³ form of oral Vitamin D, not those taking the D² form. But, this review also revealed no cardiovascular benefits.

What about effects of vitamin D supplements on bone-density? If the recommended daily dose of vitamin D is from 400 to 2000 units, what if we took twice that? About 3% of U.S. adults take over 4000 units of vitamin D daily. A Canadian randomized study of 311 adults with pre-study normal vitamin D blood levels took either 400, 4000, or 10,000 units per day of supplemental vitamin D for three years.  Bone density actually DECREASED in those taking the higher doses. Also, the vitamin D blood levels in those taking the 400 units (recommended minimum) did not increase above normal. “The findings point to no benefit for bone integrity—and even harm—with high dose vitamin D supplementation in patients with adequate vitamin D blood levels.” (5) 

In today’s blog I offer evidence-based skepticism about the benefits of both vitamin C and vitamin D supplements. In my last blog I cautioned against vitamin E . . .at least the inhaled form. Is there a vitamin F supplement to continue my progression? Yes, there is! Vitamin F is an outdated term for omega-3 and omega-6 fatty acids,  but I think I’ll let that subject “sleep with the fishes” for the moment.

References
1. “Vitamin C and The Common Cold”, Linus Pauling, 1970 and 1976.
2. JAMA Cardiology 2019 Aug; 4:765
3. NEJM Journal Watch cardiology,vol.39, Oct. 2019)
4. NEJM 2019;380:33
5. JAMA 2019Aug27;322:736

 


Vol. 217 September 1, 2019 Understanding Medical News of Famous People

September 2, 2019

David Andrews, veteran center for the New England Patriots, and Ruth Bader Ginsburg, veteran Supreme Court Justice, have both been in recent newspaper headlines (in different sections of the paper, of course) due to their new medical diagnoses, “clots in the lung” for Andrews and “pancreatic cancer” for RBG. Most articles devote significant space to speculation about their prognoses, i.e. when can Andrews return to play in the NFL and will Ginsburg outlast Trump’s presidency? Why do the answers seem so elusive, and almost always end up with “it depends”?

 

“Clots in the lung” are pieces of blood clots that travel through the blood steam after breaking off from blood clots in the legs (deep vein thrombosis or DVT). In the lungs the clots can clog or drastically slow down the flow of blood through lung vessels and is called pulmonary embolism (PE). PE may often produce no symptoms or cause chest pain, cough, difficulty breathing, and sudden death.

PE is treated with so-called “blood thinners” aiming to reduce the risk of more emboli traveling to the lungs. Neither of the two classes of anti-coagulation drugs actually thin the blood. Both interfere with the multiple steps of coagulation needed to form a clot, thus reducing the chance of more pieces of clot breaking off and traveling to the lungs.

How long is drug treatment necessary? It depends. The shortest duration of 3-6 months is recommended for “provoked” PE, an embolism from a leg or pelvic clot provoked by an injury, surgery, infection, cancer, or other recognizable event. An “unprovoked” PE, one without a recognizable event, is usually treated for longer periods.

It is probable that Andrews’ PE was related to a football injury, a “provoked” PE, so that anti-coagulation treatment will last for at least 3-6 months. Hence he is out for the season, since it would be dangerous for him to play football with an intentionally defective blood clotting mechanism. If his PE was not the result of an injury, then it was “unprovoked” and treatment duration may be even longer.

RBG just completed treatment for her third bout of cancer. She was treated for colon cancer in 1999, “early” pancreatic cancer in 2009, and a cancer in her lung was surgically removed in December of 2018.  This recent treatment consisted of 3 weeks of highly focussed radiation to a small malignant mass in the part of the pancreas (the “head”) that surrounds the bile duct that goes from the liver to the small intestine. A stent was placed in the bile duct presumably because even this highly focussed radiation could cause the duct to swell and obstruct resulting in her becoming jaundiced. Her doctors did not identify the mass as colon, lung, or pancreatic cancer, but reported that it was localized with “no evidence of cancer elsewhere”.

That last bit of news is significant since the prognosis of pancreatic cancer depends on the stage of disease, from 1 to 4. Stage 1, local disease, has a 5 year survival rate of 12-14% while Stage 4, widespread disease, has a 5 year survival rate of 1%. Survival rates are statistics based on the outcomes of hundreds of patients and can not be reliably applied to an individual patient. RBG has especially proved that herself. In a recent interview RBG remarked that “a certain Senator who predicted my early demise after my 2009 diagnosis of pancreatic cancer is now dead himself while I’m still alive.”

Because of the fallacy of applying the mortality statistics of hundreds of patients to an individual, the honest doctor realizes that a prognosis often can not be given accurately. That knowledge is also colored with the emotion of difficulty breaking bad news. One study showed that only about 37% of oncologists were able to give an “honest” prognosis to a cancer patient under treatment. When the doctor did give a prognosis, it was often overly optimistic. 

So, what is the prognosis for Andrews and Ginsburg? It is relatively save to say that Andrews will not play NFL football this season and that Ginsburg, a champion statistic outlier for 86 years, will probably be sitting on the bench when the Supreme Court resumes in October. After that, who knows what will happen. The doctors may guess, but they don’t know either.


Vol. 215 June 15, 2019 Sometimes Even Good News is “Fake” News

June 16, 2019

A lesson in evaluation of a cost-reducing health care program:
a learned, scientific critique of a controversial Medicare reimbursement program.

 

“The Hospital Readmissions Reduction Program (HRRP) was established in 2010 by the Centers for Medicare and Medicaid Services (CMS) with a “goal of reducing ‘preventable’ re-hospitalizations by imposing financial penalties on hospitals with higher-than-expected readmission rates in the 30 days after a hospital discharge”. This was one of several new “Pay For Performance” (PFP) programs aimed at lowering federal health care costs by tying Medicare reimbursement to hospitals, physicians, and even home care agencies to the use of more appropriate (read “lower cost”) medical care delivery settings.

After implementation of the HRRP, hospital readmission rates did decrease nationwide for the targeted diagnoses of heart failure, acute myocardial infarction, and pneumonia. So, the federal government ended up reimbursing less money to those hospitals that had higher-then-expected “preventable” patient readmission rates . “Great!”, said some policy makers, “it saved us some money. Let’s expand the program to ALL conditions treated in the hospital.”

“Whoa”, said by a group of research physicians from Harvard and Washington University Medical Schools, both known as liberal academic institutions, ”let’s look at the data.”

  1. The proportion of patients that returned to the hospital within 30 days after discharge actually did NOT change.
    .        .Patients returned to the hospital within 30 days after discharge for care, BUT they weren’t “readmitted”. Instead a significant number of those returning to the hospital were treated for up to 3 days in Observation Beds/Units or overnight in an Emergency Room bed. HRRP did not measure use of Observation Units or overnight stays in the ER. No wonder the “readmission” rates went down.
  2. If a patient dies within 30 days after hospital discharge they obviously can’t be “readmitted”.
    .         .The HRRP statistics did not measure mortality rates. A hospital keeping sicker patients alive by readmitting them for appropriate care rate might have the better outcomes, i.e. a lower death rate, but it would be penalized for having a higher readmission rate. In fact, the financial penalties for higher readmission rates under HRRP are much higher than the penalties for a higher death rate under Hospital Value-Based Purchasing program (HVBP), another federal PFP program.
  3. “Risk adjustment” of patient illness severity is notoriously varied and difficult to standardize.
    .          . “Risk-adjusting” of illness severity, for example, recording the different illness severity between the heart failure patient on two drugs and slightly swollen ankles versus the patient on multiple heart drugs for decompensated heart failure, is very difficult to standardize. Some of the early enthusiasm for HRRP and its reported improvement of risk-adjusted readmission rates may have been the result of improved medical record coding of co-existing conditions. (This is well-known as “gaming the system”, legal and even ethical, sort of like taking advantage of tax code loopholes, but it does nothing to improve the quality of care.)
  4. Social risk factors like patient poverty and poor community resources like lack of public transportation and diminished access to primary care were omitted from risk-adjustment factors.
    .          .Safety-net hospitals (those in poor areas) can be penalized under HRRP as a result of such factors. “The evidence that social risk factors influence readmission rates is incontrovertible.”
  5. HRRP may even have increased the death rates for patients with heart failure.
    .          .Four independent studies showed that the death rates for patients with heart failure INCREASED significantly after implementation of HRRP. The increase was concentrated among the patients who were NOT readmitted, suggesting that the use of ER beds and Observation Units “may adversely affect patients who would benefit from higher-level care.” Two other studies found different results which suggested that HRRP was more beneficIal to patients with acute heart conditions rather than patients with chronic heart failure.The three authors urge several steps to correct what they consider a faulty, positive evaluation of HRRP before jumping into expanding the program to ALL patients admitted to a hospital. This failure to correctly evaluate HRRP “underscores the consequences of implementing national policies after [evaluation that does not include] a control group.”They also urge “policymakers to seek input from frontline clinicians and patients who understand the real-world effects of HRRP. . . . If HRRP is improved it might be transformed from a regressive penalty program to a progressive program that improves patient care.”

    Q.E.D.

    Reference:
    “The Hospital Readmissions Reduction Program—Time for a Reboot”, Drs. Wadhera, Yeh, and Maddox, NEJM 380;24 June 13, 2019.


Vol. 211 April 15, 2019 A Modest Proposal To Eradicate Measles In The U.S.

April 15, 2019

Measles was declared “eradicated” in 2000. Since then we have had unexpected U.S. measles outbreaks in 2014 and presently we are breaking all records for new cases (78 cases just this very week). In 2014 there were 667 cases of measles in Amish country of Ohio. Since January 1, 2019 the U.S. has had 465 cases in 19 states.

For those of us who are used to hearing big numbers every day—size of the national debt, baseball player salaries, number of immigrants pounding on our door, etc.—these numbers don’t sound very compelling. BUT, measles is a preventable disease. One measles vaccine shot protects the recipient 93% of the time. When you add the second shot years later the individual’s protection goes to 97%. 

 Measles, the most infectious disease we know, can cause debilitating encephalitis (brain swelling), pneumonia, and, very rarely in the U.S., death in both infants and adults. Madagascar is not so lucky. Because of its poverty Madagascar has a vaccination rate of only 58% despite the population’s desire for vaccination. They had 1200 deaths in the115,000 who got measles last year. Europe had 41,000 measles cases in 2018. A community vaccination rate of 90-95% is necessary for effective “herd immunity” in which the vaccinated keep the un-vaccinated safe just be reducing their chances of exposure.

You are not likely to be exposed to a case of Madagascar measles, but if you happen to be in the Williamsburg section of Brooklyn, or Rockland County, NY, or  Portland, Washington, or near Sacremento, California, you may be exposed. These four hot spots of current measles outbreak apparently share an unintended consequence of easy-access global travel.  Unvaccinated Orthodox Jews returning from the September annual Hasidic Pilgrimage from Israel to Uman, Ukraine unexpectedly brought measles back to their unvaccinated, ultra-orthodox Jewish U.S. communities.

There is no aversion to vaccination in the Bible, the Quran, or even Sanskrit texts. It is speculated that these communities have low measles vaccination rates because of “anxiety about science”, “concern about risks of new technology”, and, especially in Soviet emigres, “distrust of the government”. 

In 1896 a Jewish man in Britain refused vaccination contending that it was against his religion. The prosecutor, also Jewish, asked the opinion of the Chief Rabbi of Britain who answered, “Hogwash.” The London court agreed.

Anti-vaxxers don’t respond to facts, They reject scientific data. They are apparently immune to dreaded stories about sick, dying children but appear to believe dreaded stories of assumed vaccine reactions. The mayor of New York City has declared a public health emergency and wants to fine any Williamsburg orthodox Jew who refuse the measles vaccine $1000. He has threatened to even close non-compliant Yeshivas. Rockland County tried to bar unvaccinated persons from public places including . . . gasp, . . . malls! A judge with a cooler head put that on hold.

After reading about the British 1896 court case a modest proposal just sprang out of my head: We should sue an anti-vaxxer, the parent of an unvaccinated child, for civil damages!

It has been recently and repeatedly affirmed that one way to get things done in America, to effect change, is to sue somebody—your spouse, your neighbor, the police, the National Enquirer, the President, whomever. 

So, all we have to do is wait until an unvaccinated child with measles exposes a vaccinated child. Since we know that the measles vaccine is not truly 100%  effective, the vaccinated child has a small chance (probably 3% – 7%) of getting measles. If the vaccinated child now with measles develops the more common complication of pneumonia, or the rare one of encephalitis, or the even rarer one of death, his or her parents could sue the unvaccinated child’s parents for all present and future medical bills, loss of school days, future loss of income due to brain damage, loss of companionship, and other compelling emotional stresses dear to personal injury lawyers. If encephalitis were the complication, the huge jury award would be enough to get the attention of even the most adamant anti-vaxxers. They would learn that their stance is not just a risk to society; it could be a large monetary risk to them personally.

References:
1. “A Modest Proposal”, Jonathan Swift, 1729 


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