Like every state, Oregon is struggling with the unsustainable costs of taxpayer-funded health care programs. In an attempt to tame this beast, Oregon recently established a system of coordinated care organizations, or CCOs, to (as the name suggests) coordinate medical, mental health, and dental care for residents enrolled in Oregon Health Plan, the state’s Medicaid program. The new system requires supervision of this coordinated effort by the participant’s primary care physician (PCP). Not one of the 15 newly-minted CCOs has credentialed a naturopath as a PCP even though naturopaths are licensed as such by the state. Needless to say, the naturopaths are not pleased by this development.
The big stumbling block appears to be the state’s requirement that CCOs practice evidence-based medicine as a cost control measure. Unfortunately for naturopaths, evidence-based medicine is not their strong suit. Apparently scientific plausibility is not much of a concern either.
As one chief medical officer of a CCO explained in a news report,
We have an obligation to the state and to the community that the providers on our panel will deliver the evidence-based care required by the Oregon Health Plan. . . . We need to make sure that all of the providers who are empanelled meet those basic standards of care.
Topics, as I noted a fortnight ago in my uniquely misspelled and ungrammatical way, never die**. Or even fade away. There are popular ideas that persist in the world that have little to do with reality. In the reality based world of medicine there are concepts that refuse to die. Atelectasis causing fever or the need to ‘double cover’ Pseudomonas. Neither are true, yet every year medical students tell me that is what they have been taught. It is said the only way new ideas take hold is for those that hold the old ideas to die off. So maybe 50 years from now those medical myths will be gone.
Popular culture also its myths. Take the immune system. Please. It is not a bicep that can be made stronger with a little exercise. It is a complex network of cells and proteins. There are antibodies (IgG (with five subtypes, IgM, IgA, IgE),the complement pathway, polymorphonuclear cells, monocytes, lymphocytes in a profusion that rivals beetles. God, I think, has an inordinate fondness for lymphocytes. There is the Toll system, the cytokines and lymphokines, the non-specific defenses like cilia and mannose binding lectin and on and on and on.
I have a journeyman’s understanding of the immune system, what is needed to understand why a given patient has an infection, although there is little I can do to reverse the immunologic defects: abnormal antibodies from Waldenström’s or low mannose binding lectin levels from liver disease are not amenable to clinical intervention. (more…)
As I mentioned recently, as hard as it is to believe, this blog is rapidly approaching the end of its fifth year of existence. Our first post was delivered to the anxiously waiting world on January 1, 2008; so thus upcoming January 1 will represent our fifth anniversary. In the blogging world, that’s almost the equivalent of a fiftieth anniversary, given how fast most blogs turn over. Something that is even more satisfying than mere longevity is that we really have found a niche in the medical blogosphere to the point where we’ve become quite influential. People notice us. Our targets notice it when we discuss them. Sometimes even the press notices us. This is all a very good thing.
Unfortunately, even though we’ve been at this for just shy of five years, there are still topics we haven’t covered, or at least haven’t covered in sufficient depth. The topic of my post today is one of the latter topics. We’ve mentioned it before; we’ve alluded to it before (for instance when discussing the antivaccine website Medical Voices and the Ayn Rand-worshiping Association of American Physicians and Surgeons; but there hasn’t been a post dedicated to this particular topic. I find this particularly odd because it was one a piece of misinformation promoted by elements of the antivaccine movement that truly shocked and disgusted me. Before I learned of this particular myth, I was surprised to learn that there are really people who think that vaccines are dangerous and cause autism, but I viewed it as being of a piece of a lot of other quackery I was discovering at the time.
Way back in the day, when I first encountered antivaccine views in that wretched Usenet swamp of pseudoscience, antiscience, and quackery known as misc.health.alternative (m.h.a.), there was one particular antivaccine lie that disturbed me more than just about any other. As I mentioned, it wasn’t the claim that vaccines cause autism, which is more or less the central dogma of the antivaccine movement. Even ten years ago, before the series of studies that have been released since then that fail to find a hint of a whiff of causation between vaccines and autism, that wasn’t a particularly difficult myth to refute. Indeed, given newer studies, refuting that myth has only gotten easier over the years. Emblematic of how far into the depths that particular myth has been pummeled, I know it’s gotten pretty easy when even the mainstream media start to accept that the claim that vaccines cause autism is a myth and report matter-of-factly on issues such as Andrew Wakefield’s fraud and don’t give nearly as much copious and prominent media time to the likes of Jenny McCarthy. Let’s just put it this way. When the hosts of a “morning zoo”-type radio show in Salt Lake City pummel the latest antivaccine celebrity to make a fool of himself, Rob Schneider, you know that, from an informational standpoint at least, the tide appears to have turned from several years ago, when the media took this myth a lot more seriously. That’s not to say that we don’t still have a problem. After all, “philosophical” exemption rates are going up based on a lot of this sort of misinformation, but at least the media are less insistent on “telling both sides” of a science story that doesn’t really have two sides.
It’s that time of year again, namely flu vaccine time. My very own cancer institute will be offering the flu vaccine for its staff beginning October 1, and I plan on getting mine just as soon as I get back from the American College of Surgeons Clinical Congress in Chicago early next week. In the meantime, it’s always great to read Mark Crislip’s take on the yearly flu vaccine kerfuffle, particularly this part:
I have little (actually none) respect for HCW’s [health care workers] who do not get vaccinated. We have a professional and moral obligation to place our patients first. I think those who do not get vaccinated, except for a minority with a valid allergy, are dumb asses.
Preach it, Dr. Crislip!
However, this time of year is also a vaccine time of year for another reason (well, actually it was about a month ago). That’s because in late August or early September, depending on your state, the little kiddies (and not-so-little kiddies) return to school and therefore have to be up to date on their required vaccines or face not being able to go to school. No wonder the antivaccine movement goes nuts this time of the year, given the double whammy of antivaccine parents trying to avoid vaccinating their children before going to school by hook or by crook and the yearly promotion of flu vaccines and mandates that health care workers get them. (For the record, my cancer center requires it, and if there’s one thing the administration of my hospital has done that I fully support it’s the yearly vaccine requirement. We’re a cancer hospital, fer cryin’ out loud, and we have lots of immunosuppressed patients that we take care of!) The only other time of year when antivaccinationists are even close to this actively ridiculous is every April, which is Autism Awareness Month, when they start trying to tar attempts to highlight autism and autism research with demands that antivaccine pseudoscience be thrown into the mix like the proverbial cow pie added to the apple pie.
Since Mark’s already covered the flu vaccine so well, let’s talk about the topic of nonmedical exemptions to school vaccine mandates. This topic came up when I noticed that the bloggers and denizens of that most wretched hive of antivaccine scum and quackery, Age of Autism, have swarmed over to a news story about how Washington State has made it harder for parents to obtain nonmedical exemptions to school vaccine requirements:
Flu season is upon us. If there is such a thing as flu season. H1N1 started at the furthest point in time you could get from the traditional start of the flu season. It is an interesting question as to whether global warming will alter the flu season, as it has the RSV season. Classically influenza is a fall/winter disease and fall started today.
It is perhaps worthwhile to review what is known about influenza. (more…)
There’s been a lot of discussion, both in the scientific literature and online, about recent pertussis outbreaks, which are the worst outbreaks in the US in the last 50 years. How could this possibly be, it is asked, when vaccine uptake for the pertussis vaccine remains high? True, there are pockets of vaccine resistance, where uptake of the vaccine is low, but it’s becoming increasingly clear that, unlike the case of measles outbreaks, low uptake of the pertussis vaccine does not appear to be nearly enough to explain the frequency and magnitude of the outbreaks. Given that it’s been a while since any of us has discussed the recent pertussis outbreak here on SBM, I thought that it would be a good time for me to do so, particularly because there have been some new studies and new developments since April, including a paper hot off the presses last Thursday in the New England Journal of Medicine. As a result, those of you who read me at my not-so-super-secret other blogging location might find some of the material in this post familiar, but given the new NEJM paper, I thought that now would be a good time to synthesize and update what I’ve discussed before in different forums in a more comprehensive way, even at the risk of some repetition of previous material I’ve published elsewhere. Hopefully, it will also provide materials for skeptics and supporters of SBM to counter the antivaccine movement, which has pounced on the recent pertussis outbreaks as evidence that the “vaccine doesn’t work.”
Without a doubt (to me, at least), the biggest difference between science-based doctors and quacks is a very simple one. When a treatment or preventative measure isn’t working as well as it should, we science-based physicians ask why. We try to find out what is not working optimally and why. Then we try to figure out how to make things better. So it is with the acellular pertussis vaccine. This vaccine protects against whooping cough, which is caused by Bordetella pertussis, and is administered to children in the form of a combination vaccine, the DTaP (diptheria/tetanus/acellular pertussis). Five doses are recommended for children, the first at age 2 months, and then at ages 4 months, 6 months, 15-18 months, and 4-6 years. There is also the newer formulation, the Tdap (tetanus, diptheria, and acellular pertussis), which is recommended for people between the ages of 11 and 64. The Tdap is now usually administered first at age 11-12, with additional recommendations for a Tdap booster in adolescents and adults summarized here, here, and here. Unfortunately, although the vaccine works, recent outbreaks have suggested that we need to change our approach to pertussis vaccination. Let’s see why.
Since the development of the vaccine, perhaps the most effective public health measure we have yet devised, only one human disease has been completely eradicated from the world – smallpox. The last case was reported in Somalia in 1977. Eradication was the result of a deliberate and intense campaign, requiring almost complete vaccination of the population, especially in certain population dense areas. Countries such as India and Nigeria were among the last to achieve eradication. Some of the lessons learned were that very high compliance rates were needed and that even small communities could harbor the virus and prevent eradication.
Several decades later, at the beginning of the 21st century, we are on the verge of eradicating a second major human infectious disease, polio. Like smallpox, polio is a virus that has no major non-human host, so eradication is possible. The polio virus enters the anterior horn cells of the spinal cord, the lower motor neuron – cells that connect the brain to muscles. When those cells die muscles lose their connection causing weakness and atrophy. Vaccine campaigns have successfully eliminated polio from most countries, but the wild type of the virus remains endemic in Nigeria, India, Pakistan, and Afghanistan.
We have the potential, with one final push (which is being spearheaded by the World Health Organization – WHO) to eradicate wild type polio from the world, but these efforts are being hampered by politics and ideology.
Earlier today, I gave you the blow-by-blow description of a debate that occurred on Thursday between Dr. Steve Novella and Dr. Julian Whitaker. After that debate, I got an opportunity to “discuss” one of Dr. Whitaker’s points, specifically a scientifically illiterate graph that he had constructed. Because Dave Patton was there doing photography of the event for Michael Shermer, I suggested that we do a picture, even though Dr. Whitaker was still on the podium. The picture came out…well, differently than I had expected. Looking at it again, though, I see that this is a perfect picture to have a little fun with, so I’m going to. Let’s have our SBM readers do something we haven’t done before on this blog. It’s a little thing called “Caption This.” In the comments, I’d like to see what sort of caption you think to be appropriate for this photo.
Have fun, and if I like any of them particularly well, I might add them to the picture and post them here and on Facebook.
Posted in: Humor, Vaccines
I’ve just returned from TAM, along with Steve Novella and Harriet Hall. While there, we joined up with Rachael Dunlop to do what has become a yearly feature of TAM, the Science-Based Medicine workshop, as well as a panel discussion on one of our favorite subjects, “integrative” medicine. Between it all, I did the usual TAM thing, meeting up with old friends, taking in some talks, and, of course, spending the evenings imbibing more alcohol than I probably should have so that I could look and feel my best for our morning sessions, particularly given my difficulty adapting to the time change. One thing I did was completely unexpected, something I learned about the night before our workshop when I happened to run into Evan Bernstein. He informed me of something that our fearless leader Steve Novella was going to do the next day right after our workshop. In a nutshell, Evan told me that Steve was going to debate an antivaccinationist. Evan didn’t know any details other than that Michael Shermer had arranged it and that Steve had been tapped at the last minute. Evan didn’t even know who the antivaccinationist was going to be or what the event was. Naturally, I was intrigued.
So, the next morning I asked Steve about it. I turns out that the event was FreedomFest, a right-wing/Libertarian confab that happened to be going on at the same time as TAM up the road a piece on the Strip at Bally’s. Steve didn’t know who the antivaccinationist was going to be either, which made me marvel at him. I don’t know that I’d have the confidence agree to walk into the lion’s den with less than a day’s notice not even knowing who my opponent is. Steve was more than happy to invite me along. Clearly, this was was an opportunity that I couldn’t resist. So we met up with Michael Shermer, and it was from him that I learned that Steve’s opponent was to be Dr. Julian Whitaker.
My eyes lit up.
Anti-intellectualism has been a constant thread winding its way through our political and cultural life, nurtured by the false notion that democracy means that “my ignorance is just as good as your knowledge.”
The first principle is that you must not fool yourself – and you are the easiest person to fool.
Richard P. Feynman
What would we do without it? It’s become so necessary, so pervasive, so utterly all-enveloping that it’s hard to imagine a world without it. Given how much it pervades everything these days, it’s easy to forget that it wasn’t that long ago that the Internet was primarily the domain of universities and large research groups. Indeed, the Internet hasn’t really been widely and easily available to the average citizen for very long at all. Go back 20 years, and most people didn’t have it. For example, Netscape Navigator, the popular browser that made the Internet accessible, wasn’t released until 1994. Amazon.com, an online store I can’t imagine living without now, didn’t sell its first book until 1995, and I didn’t discover it until 1996 or 1997. Google, that ubiquitous search engine that everyone uses, wasn’t incorporated until 1998. Now, less than 14 years after Google was incorporated most people have the Internet in their pockets with them in the form of mobile devices that have computing power undreamed-of in the 1990s and can access the Internet at speeds that increasingly blur the line between landline access and mobile computing. It’s been an amazingly fast social and technological revolution, and we don’t yet know where it will take us, but we do know that it’s not going away. If anything, the Internet will continue to become more and more pervasive.