Sometimes the best way to understand a situation is to see a graphical representation of it.

Below is a graph of pediatric influenza deaths over the past 4 years. I have adapted it from a graph created by the CDC that can be found here. The graph shows the number of pediatric deaths each week for the past 4 years. The green bars represent seasonal flu deaths; the pink bars represent deaths from confirmed H1N1 influenza.

The graph represents in the starkest possible way the difference between the H1N1 flu and the seasonal flu.

Seasonal flu can and is fatal in some children. Each year, primarily from February to May, some children will die of the seasonal flu.After that, pediatric deaths typically drop off to almost zero until the next flu season.

Something entirely different happened this year. Not only did flu deaths not drop off, but H1N1 flu is claiming children in higher numbers than the seasonal flu ever did. The graph does not show it, but unlike the children who die of seasonal flu who typically suffer from underlying medical conditions, healthy children are also dying of the H1N1 flu.

Could the H1N1 flu still burn out? Certainly that could happen, but there is no evidence that the tide has turned. Based on the fact that incidence of the flu typically rises dramatically in the winter, we are on track for an especially deadly flu season.

We could wait and see what happens, or we can attempt to head off disaster with a vaccination program. Look at the graph. What would you do?

Healthcare conspiracies are powerful and long lived. How can we combat health conspiracies among people who don’t understand or don’t believe scientific evidence? I suggest a simple expedient. Insurance companies should refuse to pay for vaccine preventable illness and their complications.

Why are health conspiracies resistant to scientific evidence?

All health care conspiracies — vaccine rejectionism, claims that conventional medicine is suppressing inexpensive alternative “cures”, the insistence that obstetricians want to ruin women’s birth experiences — share one critical feature. They are unfalsifiable. They can never be proven wrong by factual evidence because conspiracy theories predict that there will be reams of evidence contradicting their claims, but that evidence is itself part of the conspiracy.

Basham in the paper Living with Conspiracy published in the Philosophical Forum, Fall 2001, offers a definition of conspiracy:

A “conspiracy theory” is an explanation of important events that hypothesized the intentional deception and manipulation of those involved in, affected by, or witnessing these events… [T]hese deceptions and manipulations are usually thought to express nefarious, even insanely evil, purposes.

Best of all, the conspiracy theory can never be proven wrong:

…[B]ecause conspiracy theorists naturally invoke the idea that the official explanations are in part or whole deceptions, they can rationally interpret evidence against their accounts — official reports, public statements and court of law testimonies … — as evidence for the conspiracy. Falsified evidence is precisely what a conspiracy theory predicts will be produced by the government and other players in ample amounts…

It’s an absolutely brilliant tactic. The vaccine rejectionist responds to the copious evidence against the claim that the government is deliberately poisoning people with vaccines by declaring that the massive amount of evidence proves that there is a conspiracy by the government to poison people with the vaccine. Only a nefarious actor could assemble such overwhelming evidence. The sheer volume of the evidence demonstrates that the evidence is manufactured as part of the conspiracy.

The unfortunate consequence is that it is impossible to show a conspiracy theorist that he is wrong. All evidence, whether bolstering his claims or undermining them, is viewed as supportive evidence of something. It either supports the claim of harm, or if not, supports the existence of the conspiracy to do harm.

Perhaps we should stop trying to prove anything to health conspiracy theorists. Instead, we should let them live with the consequences of their decisions. I have a modest proposal:

In the case of vaccinations, insurance companies should deny coverage for vaccine preventable diseases and their complications in anyone who did not get the recommended vaccinations.

If vaccinations are worthless or harmful, vaccine rejectionists have nothing to worry about. They will never have to pay because they won’t get sick. On the other hand, if they are wrong, they mistake will be illuminated in a way that is very easy to understand; they will literally have to pay for it.

On the face of it, suspicion of the new H1N1 vaccine is incomprehensible. Vaccination has been one of the biggest lifesavers of the past 200 years. It is the cornerstone of public health, directly responsible for the dramatic drop in infant and child mortality and the dramatic extension of lifespan we have enjoyed over the last century. Despite countless conspiracy theories advanced by vaccine rejectionists in the past 200 years, not a single one has turned out to be true.

True, there are side effects, some serious. However, serious vaccine side effects like brain damage or death are so rare as to be measured per 100,000 people or per 1,000,000 people. There has been no effort to hide these serious side effects. Indeed parents are required to sign consent forms acknowledging the risk of serious side effects before their children can be vaccinated.

So why are people suspicious of vaccines? There are many reasons including the American love for conspiracy theories, the public campaigns led by prominent celebrities, and the desire to assign causes to diseases like autism where the cause remains unknown. The most important cause of the suspicions, though, is one that is very easy to address. Most people don’t know how vaccines work.

To understand how vaccines work, you need to understand how the body defends itself from bacteria and viruses. Just like the body has a dedicated system to digest food (the gastrointestinal tract) or to remove waste products (the kidneys and urinary tract), the body also has a dedicated system to fend off bacteria and viruses; it’s called the immune system.

The body actually has three layers of defense against bacteria and viruses. The first is the physical barrier presented by the skin or the lining (mucous membranes) of interior passages like the mouth and nose. Although we are surrounded at all times by bacteria and viruses, most of them never make it beyond the skin. Of course the integrity of the skin and mucous membranes can be disrupted by a cut or puncture, allowing bacteria or viruses to be introduced directly into the body.

The second line of defense is a non-specific immune response. If bacteria colonize a cut on your hand, your body reacts in a predictable way. There will be swelling, redness, and pain, a response that does not depend on the identity of the threat. Special immune cells will race to the site and engulf the offending bacteria. When they die in the attempt, they accumulate as pus.

Even primitive animals have non-specific immune responses, but higher animals and human beings have an additional, more powerful response. We can produce antibodies. Antibodies are proteins that recognize specific bacteria or viruses and bind to them, thereby signaling to other immune cells that they are targets for swift neutralization. Each antibody binds to a specific site on a specific bacteria or virus.

We’re not born with those antibodies, though. We make them in response to a threat. For example, we are not born with antibodies to the chickenpox (varicella) virus. When exposed to the varicella virus, though, we can learn to make antibodies to it. It takes time, but gradually we can produce enough antibodies to fend off the disease.

Unfortunately, we don’t always get the time we need. We can make antibodies to smallpox, for example, but many individuals are overwhelmed and killed by the virus long before they could make enough antibodies to fend it off. Those who do win the race and manage to produce enough antibodies to survive are now permanently protected. That’s because the immune system retains the ability to make the specific antibodies against the smallpox virus. Whereas it may take days to produce smallpox antibody when first exposed, a second exposure will be met with rapid and massive production of antibody, generally preventing the individual from getting sick at all.

So in order to be protected from the disease, you had to get the disease, and you might die before you were able to make enough antibody to protect yourself. Imagine, though, if you could learn to make the protective antibodies without actually getting sick. That’s the theory behind vaccines.

In order to make antibodies to a virus (or bacterium) the body need to “see” the virus. In other words, it needs to have direct exposure to the virus, but that virus doesn’t have to be functional, and it doesn’t even have to be whole. A virus can be inactivated (live attenuated) or killed and still produce an immune response. It can also be broken down into its constituent parts and the parts can produce an immune response. Any future exposure to the live virus (though contact with others who have the disease) will be met with rapid and massive production of antibody, preventing the individual from getting sick at all. A vaccine is merely and inactivated or dead form of the virus, letting you learn to make antibody without getting sick in the process.

Vaccines do not produce perfect immunity. The dangerous part of the virus might be the part that evokes the most powerful immune response. Rendering the virus harmless by inactivating it, killing it or breaking it up, may remove that part and the immune response to the less dangerous parts might be weaker. So actually getting the disease may produce a better immune response than the vaccine … but only if you survive the disease.

Successfully fighting off a disease depends on being able to produce enough antibody before the disease kills you. Until vaccines, the only way you could learn to produce antibody was to actually get the disease. Now, instead, you can learn to make antibody by being exposed to a harmless form of the virus or bacterium.

Feminist scholar Michele Crossley’s recent paper in the journal Feminism Psychology raises important questions about breastfeeding, and by extension, about unmedicated childbirth. Breastfeeding as a Moral Imperative: An Autoethnographic Study makes a controversial claim:

…[F]ar from being an ’empowering’ act, breastfeeding may have become more of a ‘normalized’ moral imperative that many women experience as anything but liberational. Accordingly, an uncritical appropriation of the idea that ‘breast is best’ may not only be disempowering for women, but also problematic for babies.

Crossley begins by exploring the place of breastfeeding within our culture:

Many contemporary social movements … highlight the risks associated with modern technology with the consequence that the rhetoric of the ‘natural’ has proliferated… This whole idiom of the ‘natural’ has surrounded childbirth and child-rearing and has been a key theme in the ‘alternative birth movement.’ As Oakley argued, ‘like natural childbirth, natural infant feeding has become fashionable in a society that is technological “by nature”‘.

…[B]reastfeeding has been associated with women’s personal agency and empowerment. The promotion of breastfeeding has constituted part of an attempt to ‘demedicalize’ life events (such as pregnancy) and to return such processes to the ‘rightful moral domain under the control of women themselves.’

Crossley’s paper isn’t really a study. It’s just a description of her personal experience, which has led her to re-evaluate the rhetoric she previously accepted. Like many white, Western, well off women, Crossley uncritically embraced the bizarre notion that there is a “right way” to give birth and to “bond” with a newborn:

Related to my desire to establish a strong ‘bond’ was my desire for a ‘natural’ childbirth. I had read that if a delivery entails a lot of intervention, then the baby emerges into the world potentially traumatized by the effects of drugs and bright lights, all of which make the bonding process more difficult…

In preparing for labour, I totally discarded any notion of interventions such as a caesarean … After over fourteen hours of labour, when the baby was eventually delivered by emergency caesarean section … the first thing I remember was that I ‘had to get that baby to the breast’. Because I had not had the opportunity to bond at the moment of birth as I had been anticipating, it made me all the more determined to ensure that breastfeeding happened in the way I wanted.

But the actual experience of breastfeeding was nothing like she had been led to believe. From the very beginning, the baby did not appear to be getting enough milk. Despite growing evidence that the baby was failing to thrive (his weight had fallen from the 75th percentile at birth to the 5th percentile at 10 weeks), and desperate entreaties by the baby’s father, Crossley refused to relinquish the fantasies promoted by breastfeeding advocates.

…The message that had been ‘drilled into’ my head at the antenatal classes and from the books I had been reading was that ‘you always produce enough breastmilk’, ‘breastfeeding is a perfect system’. In fact, I had even asked the health visitor at the time if the baby’s constant screaming could be explained by the fact that he wasn’t getting enough milk. Her response was that ‘you always produce enough breastmilk, always, there’s always enough …’

The baby’s father became frantic:

…I had to confront you about the breastfeeding. I felt at that point that we were gonna kill him or do him some serious damage … and I just thought he is not gonna survive this. I felt as if I was, I suppose, I was the only person who could see this …

They began bottle feeding the baby and he began to thrive. Crossley, however, was torn by feelings of guilt and shame:

I felt like a failure because … I had ‘taken on board’ the message that breastfeeding was really difficult, it was hard work and ‘many people didn’t manage to do it’. One had to be ‘really determined’ to succeed, but if ‘you tried really hard, you could manage it’… [M]y experience was entirely consistent with a woman in Lee and Furedi’s study who commented that women who ‘succeed at breastfeeding are made to feel like it’s such an achievement, they have done so well, they deserve a medal…’ As Lee and Furedi argue, some women have come to view breastfeeding as a ‘measure of motherhood and consciously or unconsciously judge other mothers accordingly’…

Crossley’s personal experience has led to an epiphany:

…[A]s with other health-related behaviours, the act of breastfeeding can become inextricably interrelated with the construction of identity and the creation of a sense of morality, values and orientation to ‘the good.’

[T]he act of breastfeeding came to symbolize all that was important about being a ‘good’ mother. It meant ‘bonding’ and forming emotional connections, ‘being there’ for the infant, learning to ‘go with the flow’, ‘letting go of the instinct to control’ and ‘learning to trust in one’s own body’. Dykes has previously characterized this understanding of breastfeeding as deriving from the ‘natural’ discourse that has been popularized in recent years.

Crossley concludes:

Breastfeeding, far from being the ‘resistant’ body-project that advocates of demedicalization and ‘women-centred’ alternatives originally promoted, may have become more of a ‘normalized’ moral imperative that some women experience as anything but liberational …

Sarah Palin’s assertion that healthcare reform would bring “death panels” empowered to kill sick people in order to save money is pure fantasy, but the idea resonated with the American public. It speaks to people’s deepest fears, that when they are frail and ill, society will take the opportunity to do them in. The irony is that the fear is entirely misplaced. They don’t need to worry that the healthcare system will kill them deliberately; they should be worried that the healthcare system will kill them accidentally.

It is difficult to deliberately die within the American healthcare system. Far from convening “death panels” to withdraw care, providers and hospitals are ignoring the wishes of those who want to die. Advance directives and healthcare proxies have allowed Americans to forgo care at the end of life, yet the majority of these arrangements are ignored, primarily because of fear of lawsuits, and often in the face of intra-family conflicts.

Unfortunately, it is all too easy to die by accident within the American healthcare system. Although claims that “doctors are a leading cause of death” are vastly exaggerated, the number of healthcare errors is extraordinarily high, and the death toll from those errors is far too large.

Dr. Donald Berwick of the Institute for Healthcare Improvement detailed the experience of his wife Ann, hospitalized for a rare spinal problem:

An attending neurologist said one drug should be started immediately, that “time is of the essence.” That was on a Thursday morning at 10 a.m. The first dose was given 60 hours later, on Saturday night at 10 p.m… One medication was discontinued by a physician’s order on the first day of admission and yet was brought by a nurse every single evening for 14 days straight. “No day passed–not one–without a medication error,” Berwick remembers… “The errors were not rare. They were the norm.”

After he publicized his experiences, Berwick was besieged by other doctors saying, “If you think that’s terrifying, wait until you hear my story.” One distinguished professor of medicine whose wife was hospitalized in a great university hospital was too frightened to leave her bedside. “I felt that if I was not there, something awful would happen to her,” he told Berwick. “I needed to defend her from the care.”

The problem first received widespread attention with the publication of Dr. Lucian Leape’s paper in JAMA in 1994, Error in Medicine:

Autopsy studies have shown high rates (35% to 40%) of missed diagnoses causing death. One study of errors in a medical intensive care unit revealed an average of 1.7 errors per day per patient, of which 29% had the potential for serious or fatal injury. Operational errors (such as failure to treat promptly or to get a follow-up culture) were found in 52% of patients in a study of children with positive urine cultures.

Given the complex nature of medical practice and the multitude of interventions that each patient receives, a high error rate is perhaps not surprising. The patients in the intensive care unit study, for example, were the recipients of an average of 178 “activities” per day. The 1.7 errors per day thus indicate that hospital personnel were functioning at a 99% level of proficiency. However, a 1% failure rate is substantially higher than is tolerated in industry, particularly in hazardous fields such as aviation and nuclear power…

It is hardly surprising that errors have become a prominent feature of a system designed to “process” as many patients as possible, as quickly as possible. Doctors are being compelled to see more patients in less time, despite the fact that many more people are living with complex medical conditions. Nurses are compelled to care for many more patients at one time, despite the fact that their medical needs, particularly the need for sophisticated monitoring technology, have grown dramatically, and the patients themselves are sicker.

Most importantly, in an industry where mistakes are a matter of life and death, the underfunding of medical care means that hospitals do not have the money to acquire technology that can reduce errors.

In an update of his report on medical errors published earlier this year, Dr. Leape explains:

Errors and injuries can, in fact, be prevented by redesigning systems to make it difficult, and sometimes impossible, for caregivers to make mistakes. A classic example is the elimination of accidental (fatal) intravenous injections of concentrated potassium chloride by removing the medication from the nursing units and requiring it to be added to intravenous solutions when they are prepared in the pharmacy.

Another example is computerized physician order entry systems (CPOE), where the physician must enter all orders, including all prescriptions for medications, by computer. This ensures that the order is complete, it is not a medication the patient is allergic to, and that the dose is within usual limits… CPOE can reduce serious medication errors by 60–80%.

The healthcare system as it currently exists unwittingly conspires to increase errors. When it comes to medical errors, we should take Dr. Leape’s most important insight to heart:

We need to move from looking at errors as individual failures to realizing they are caused by system failures. This is the driving principle.

The ultimate irony of Sarah Palin’s “death panel” fabrication is that healthcare reform represents the best chance of reducing medical errors, while opposing healthcare reform virtually insures that medical errors will continue apace. No one should worry about being killed deliberately by a “death panel” but everyone should fear being killed accidentally by a medical error.

Vaccinations have been around for over 200 years and vaccine rejectionists have been around for nearly that long. Over the years, the basis for claims of harm from vaccines have changed, but one factor has remained constant. Vaccine rejectionists have never been right. The current fear mongering surrounding thimerosal is just the latest iteration in an ongoing effort. That fear mongering rests on two factors, ignorance of basic chemistry and ignorance of the existing research on thimerosal.

To hear vaccine rejectionists tell it, all mercury containing compounds are dangerous and therefore thimerosal is dangerous. But that’s not how chemistry works. The toxicity of a substance depends on how atoms are arranged, not simply which atoms are present. The fact that some mercury compounds are dangerous does not mean that thimerosal must be dangerous because it contains mercury.

Consider the example of sodium. Sodium is both poisonous and explosive. That does not mean that compounds that contain sodium are either poisonous or explosive. Table salt (sodium chloride) contains sodium, yet we do not worry that salting our food will result in an explosion at the dinner table.

Similarly, mercury is poisonous, but that does not mean that any compound that contains mercury is also poisonous. Some mercury containing compounds, like methyl mercury, are poisonous. Methyl mercury is the found in fish and is the reason why restrictions of fish consumption are recommended for certain groups. Thimerosal is ethyl mercury and is not poisonous.

Though methyl mercury and ethyl mercury might sound like they are very similar, one is poisonous and the other is not. How can that be? Consider the case of alcohol. Methyl alcohol (methanol), also known as wood alcohol, will lead to blindness or death if you drink it. Ethyl alcohol (ethanol) is the alcohol found in wine and spirits. Chemical structure is more important than the identity of the individual atoms that make up the compound.

The safety of thimerosal is more than simply theoretical. Contrary to the claims of vaccine rejectionists, thimerosal has been studied extensively in large populations. There have been many studies that demonstrate the safety of thimerosal.

Consider the study Thimerosal exposure in infants and developmental disorders: a retrospective cohort study in the United Kingdom does not support a causal association (Andrews et al. Pediatrics 114. 584-591.2004). This was a retrospective cohort study was performed of 109 863 children who received thimerosal containing DPT vaccines. The study found no evidence that thimerosal caused developmental delays.

Thimerosal exposure in infants and developmental disorders: a prospective cohort study in the United kingdom does not support a causal association (Heron et al. Pediatrics 114. 577-583.2004) followed 14,000 children for up to 7+ years. The authors found:

Contrary to expectation, it was common for the unadjusted results to suggest a beneficial effect of thimerosal exposure. For example, exposure at 3 months was inversely associated with hyperactivity and conduct problems at 47 months; motor development at 6 months and at 30 months; difficulties with sounds at 81 months; and speech therapy, special needs, and “statementing” at 91 months… CONCLUSIONS: We could find no convincing evidence that early exposure to thimerosal had any deleterious effect on neurologic or psychological outcome.

The bottom line is that the vaccine rejectionists are wrong once again. The fact that thimerosal contains mercury does not mean it is dangerous because the chemical structure determines the danger, not the identity of the individual atoms. More importantly, thimerosal has been studied extensively in large populations over time and has been demonstrated repeatedly to be safe.

I’m torn.

I can’t decide whether it was greed or stupidity that led the American Academy of Family Physicians to accept a corporate sponsorship from Coca Cola.

Greed is certainly behind the AAFP decision to create its “Consumer Alliance program.” I love the Orwellian title! AAFP is not allying with consumers. It is partnering with businesses. The businesses will provide money and the AAFP will provide legitimacy. Yet said AAFP President-elect Lori Heim, M.D. disingenuously claims:

The Consumer Alliance program is a way of working with interested companies to develop educational materials to help consumers make informed decisions so they can include the products they love in a balanced diet and healthy lifestyle.

No, it isn’t. The Consumer Alliance solicits money from corporate sponsors to enrich the AAFP coffers.

A partnership with Coca Cola defies comprehension. The American Academy of Family Physicians has been out front in calling attention to the link between soft drinks and obesity, particularly childhood obesity.

Soft drink consumption has increased dramatically in recent decades. The increase corresponds with the rise in obesity and diabetes in the United States. Some evidence suggests that sugar-sweetened beverages increase the risk of childhood obesity. No study has shown that these drinks increase the risk of diabetes, although this relationship is plausible not only because of the added sweeteners but also because the caramel coloring may increase insulin resistance.

The official position of the AAFP is to minimize Coke consumption; the official position of Coca Cola is to maximize Coke consumption. In fact, everything the Coca Cola Company does is designed to maximize Coke consumption and, therefore, profits. If they are giving money to the AAFP it is because they believe that the legitimacy they will gain in exchange will lead to increased profit. The conflict of interest could not possibly be more stark.

I suppose it shouldn’t matter how much you are asking for your soul when you auction it off, but I find it galling that the AAFP had sold its soul so cheaply. AAFP President-elect Heim says the payment “in the strong six figures.” In other words, it took less than a million dollars to convince the AAFP to ally with a purveyor of a product does not improve health and may actually impair it.

The AAFP has clearly learned nothing from the example of other medical organizations that have compromised their credibility with inappropriate corporate sponsorships. The American Medical Association suffered a major blow when forced to renounce a partnership with Sunbeam, a maker of home electronics. According to Quackwatch:

…[T]he American Medical Association announced that it would pay $9.9 million to the Sunbeam Corporation to settle a breach-of-contract suit… The suit was filed … after the AMA announced it would not honor an exclusive 5-year royalty agreement under which the AMA logo would have been placed on Sunbeam’s “Health at Home” products, which included heating pads and humidifiers. The endorsement plan, … had no requirement that the AMA test the products… An investigative report on the management decisions leading to the contract led the AMA’s chief executive officer and two other top AMA executives to resign.

The AMA has never fully recovered from the scandal and has seen its membership drop to less than one third of American physicians.

The American Academy of Family Physicians has made a terrible mistake. It has compromised its integrity and credibility by accepting money from Coca Cola. It should follow the example of the AMA and renounce the partnership. President-elect Heim has managed to besmirch the reputation of the organization even before taking office. Hopefully it is not too late for her to undo the damage.

I’ve been writing about the H1N1 flu for the past few days, and have been asked repeatedly if the Centers for Disease Control (CDC) has reacted precipitously by ordering the production of millions of doses of vaccine and strongly recommending that individuals at highest risk get vaccinated as soon as possible.

To understand why the CDC has taken the aforementioned actions, you need a little background in history, epidemiology and virology. No one including the CDC knows what is going to happen, but they are using experience as a guide. Let me share (in a simplified form) what is known, then you can decide what you would do if you were the CDC.

History shows that the influenza virus, while typically mild, can mutate to forms that are deadly. The great influenza outbreak of 1918 (the Spanish flu) killed tens of millions of people. Curiously, the hardest hit were those who were young and healthy. They would come down with the flu, develop lung complications, and quickly drown in the fluid that filled their lungs. So although such outbreaks are uncommon, recent history shows that a flu outbreak can easily and quickly kill millions.

Epidemiology has shown us that two important factors are necessary for influenza to kill millions. The first factor is that the specific influenza virus must trigger severe disease. The second factor is that the specific influenza virus must be able to spread person to person.

Influenza also occurs in bird, and pigs, among other animals, and it probably jumped to humans thousands of years ago when they domesticated animals. Various influenza viruses can still jump easily from animals to people. However, when that happens, the disease, which may be quite severe, is self limited. In our increasingly urbanized world, very few people have direct contact with animals. Those who do may pick up dangerous strains of influenza and may die of them, but they won’t pass them on to other people, and no epidemic will develop.

Virology holds the third, and perhaps most important clue. When we think of genetics, we think of offspring inheriting genetic material from parents. Viruses (and bacteria) can exchange genetic material with each other. If both your parents have blue eyes, you might have blue eyes, too. Imagine, though, if you could acquire blue eyes simply by standing next to someone who has blue eyes. Viruses can acquire new traits that way.

The “perfect storm” in the world of influenza viruses is when a virus that is particularly deadly in animals comes in contact with a virus that can easily be transmitted from one human being to another. When that happens, the result can be a new virus that is particularly deadly and is now contagious.

Fortunately, that “perfect storm” does not occur very often, but the possibility always exists that it will happen. The CDC is greatly concerned that the new H1N1 variant of influenza is a “perfect storm” virus. It has the three deadly characteristics that we would expect in such a virus: it is new, so people are not immune to it; it can cause severe illness and death; and it is contagious from person to person.

Viruses can mutate very rapidly. For that reason they can become more dangerous, but they can also become less dangerous. No one knows what is going to happen with H1N1.

So we know the virus is here and the virus is lethal. What should we do about it?

We could do nothing and wait to see what happens. The virus could become less deadly and the danger will be over. Of course, the virus could remain lethal or even become more lethal as it is transmitted from person to person.

You can think about it as if it were a house fire. The fire could burn out of its own accord. It could burn down only the house involved. Or it could jump to neighboring houses and burn them down, too. In fact, fire, like viruses, tends to expand exponentially. It doesn’t jump from one house to the one next door. It jumps to all the houses nearby and then jumps to the all the houses near those. Pretty soon, the entire town is on fire. So waiting to see what happens makes as much sense as waiting to see if a house fire goes out on its own. It means taking a terrible risk.

In the case of viruses, as in the case of fire, prevention is the best strategy. Obviously it’s better if the fire never gets started in the first place. Similarly it is better if no one else gets the H1N1 strain of influenza. Vaccination is the only way to protect people from getting the disease. So vaccination is the first and best line of prevention.

In large fires, firefighters don’t simply attempt to save the houses already on fire. They try to set up firebreaks to prevent the spread of fire before it happens. Vaccination, in addition to preventing individuals from getting sick, also acts like a firebreak. If everyone around an infected person is has been vaccinated, no one can catch the virus. The spread of the virus is stopped cold. Vaccination protects not only those who are vaccinated, but everyone else in the population.

So imagine you are the head of the CDC. You know that H1N1 is here, and it is a particularly deadly form of influenza. You know that it can be passed person to person. And you know from history that similar viruses have killed 10 of millions of people in one epidemic. What would you do? Would you wait to see what happened? Or would you vaccinate against the disease and hope to save lives and halt the spread of the virus?

Doctors are often compelled to make quick decisions in life threatening cases with only limited information. Unfortunately, pregnant women are now going to be put in the same situation.

The H1N1 flu has taken an extraordinary toll among pregnant women. A new vaccine will be available within the next few weeks. Because of the nature of the emergency, there has not been time to do any long term studies of the vaccine. Yet pregnant women will need to make a decision as soon as possible on whether to be vaccinated.

Many illnesses are more severe during pregnancy, but the H1N1 influenza has had an unexpectedly devastating impact among pregnant women. According to the CDC, there have been approximately 700 reported cases of H1N1 in pregnant women since April. Of these, 100 women have required admission to an intensive care unit and 28 have died. In other words, 1 out of every 25 pregnant women who contracted H1N1 died of it. By any standard, that is an appalling death rate.

There seem to be two reasons for the dramatically increased death toll. The first is the altered immune status of pregnant women making them particularly vulnerable to the virus. The second is that pregnancy compromises lung function. If a pregnant woman gets pneumonia as a complication of the flu, it is particularly difficult to insure that she gets enough oxygen.

We should ensure that pregnant women do not get H1N1 influenza and the best way to do that is by vaccination. The new H1N1 vaccine is similar to other influenza vaccines. We know that other influenza vaccines are not harmful in pregnancy, and there is no reason to believe that the H1N1 vaccine will have any side effects that differ from those normally expected after vaccination. There are no adjuvants added to the vaccine, either, so there will be no danger from adjuvants. However, there has been no time to study the long term effects of the vaccine, so no one can be sure about side effects.

Pregnant women are rigorously counseled to avoid any drugs, diagnostic tests, or treatments that might impact the developing embryo or fetus. Most women reflexively fear the idea of vaccination in pregnancy, although vaccination for many diseases presents no problems in pregnancy. The Centers for Disease Control and physicians are very concerned that pregnant women will refuse vaccination, with potentially lethal results.

How should pregnant women decide what to do? The best place to start is with what we know for sure. We have a great deal of evidence that H1N1 influenza is particularly lethal in pregnant women. To put it in perspective, the chance of a pregnant woman dying from H1N1 is greater than the chance of a heart patient dying during triple bypass surgery. That is not a trivial risk.

We have no evidence that the vaccine will cause any harm to pregnant women or their unborn children beyond the side effects associated with other flu vaccines, such as local irritation at the vaccine site, or the rare complication of Gullain Barre Syndrome. We have no reason to expect that the H1N1 vaccine will be any different.

It would be much easier to make the decision if we knew more, if we had some idea of how extensive the fall outbreak will be, if we had longer experience with the specific vaccine. Unfortunately, that information is not available to us and by the time it becomes available may more pregnant women may sicken and die unnecessarily.

Given the dramatic threat and the fact that we know of no unusual complications of vaccination, the decision seems clear. Every pregnant woman should get vaccinated as soon as possible.

The small minority of women who elect to continue Down Syndrome pregnancies have vigorously asserted that the burden of raising a DS child has been exaggerated and that there would be fewer terminations if women were given more accurate information. However, the scientific research does not support those claims and, in fact, demonstrates the opposite.

Physical and Mental Health in Mothers of Children with Down Syndrome by Bourke, et al, was published in the Journal of Pediatrics in September 2008. It showed that mothers of DS children scored lower on measures of both physical and mental health. Indeed, mothers’ the decrease in physical and mental was closely associated with the functional level of the child.

According to the authors:

This study found that the most important predictors of maternal health, particularly mental health, were the child’s behavioral difficulties, the child’s level of everyday functioning, the child’s progress in community participation involving shopping and travel, and to a lesser degree, the child’s current health status…

We found that the mental health of mothers was strongly influenced by child behavior and care-giving demands. These results are similar to studies of psychological stress in caregivers of children with disability or chronic disease… [T]he average mental health score of the mothers in our study was significantly lower than the average score reported for both South Australia and Western Australia. Interestingly, the effect of care giving on maternal physical health appeared less dramatic…

In our multivariate analysis for maternal physical health we showed that mothers of children who scored higher on the disruptive/antisocial subscale of the DBC displayed worse physical health… Our study has corroborated earlier findings that behavior problems are the single most important child characteristic that predicts maternal psychological well-being…

Intellectual disability appears to predispose individuals to emotional or behavioral problems… Eisenhower et al showed at age 3, behavioral problems in children with Down syndrome are comparable to those of typically developing children. However, over the next 2 years there was a relative increase in behavior problems in their Down syndrome cohort and, in turn, maternal stress.

In our study, mothers of children with higher everyday functioning experienced better mental health. In particular, mothers reported better mental health if their children required no help or supervision in dressing, problem solving and, for children over 12 years, using the telephone. Similarly, mothers reported better mental health if their child aged over 12 years required supervision but no help in using the telephone, using public transportation, and attending social events…

These results are hardly surprising. A child’s disability has an impact on the mother’s physical and mental health and that impact is correlated with the child’s level of functioning. Instead of experiencing a DS child as “enriching,” mothers experienced the child as a significant stress, particularly if the child was low functioning. The authors did not investigate the impact of a DS child on marital happiness or the well being of other children in the family. However, it seems reasonable to assume that a stress large enough to impact both the physical and mental health of mothers is likely to have effects that extend to her roles as spouse and as parent to her other children.

None of this is an argument for termination. That is a decision that is and should be left to the mother. However, it is an argument for opposing the attempts of current DS parents to “educate” women facing the termination decision. Those parents who are anxious to “counsel” others are not representative of DS parents and therefore, could not possibly provide unbiased, accurate information.