The End of the End of Polio (and TB, and Measles...)

The elimination of smallpox is often hailed as one of the greatest triumphs of modern medicine and public health. It is a stunning achievement - with the concerted effort of the World Health Organization, a scourge of mankind was wiped off the face of the earth in a matter of one decade (well, almost eliminated). That success led to the belief that other diseases could likewise be eliminated, if enough effort, strategy and dedication was put to the task. The shortlist included yellow fever, polio, and measles.

Well, so much for good intentions. Turns out smallpox was uniquely suited to elimination - as a human-specific virus, it couldn't hide in another species, waiting for an opportunity to reappear. Alas, polio and TB and measles aren't quite so tidy. Last week, the WHO conceded that it's effort to eliminate polio may never work. Measles isn't gonna happen because it simply doesn't generate the passion (or fear) that smallpox once did. The simple fact is that disease is extremely agile, relentless, and tenacious. It is happy to wait us out. And it is expert at routing around our magic bullets.

It reminds me of the CDC's announcement in 1989 that designated 2010 as the target date for the eradication of tuberculosis from the US (not worldwide). Sure enough, within a couple years TB rates in the US were headed up, not down - seems drug-resistant strains, combined with HIV, gave TB a fighting chance.

It is, of course, disappointing to see the WHO scale back, or at least moderate its goals for polio. But perhaps realism is a better longterm weapon than idealism.

(image from The UC Atlas of Global Inequality)

HPV Vaccine: The Real Story

About two years ago, I took a course in epidemiology out of UCBerkeley extension. The instructor was an expert in HPV, and she frequently used the peculiarity of that virus - human papillomavirus - to illustrate the trickiness of combating disease on a population (rather than individual) level. The fundamental quirk of HPV is that it is largely benign - some 75% of women carry the virus (and conceivably an equal number of men, though no thorough studies on male carriage have been done as far as I know). But of those 75%, HPV is a major contributing factor for cervical cancer; indeed, the upswing in cervical cancers in recent decades can be almost entirely attributed to the spread of HPV. All of this is backstory to what's recently hit the front page: the availability of a HPV vaccine and, inevitably, the backlash against the vaccine from the Christian Right. The vaccine is controversial because it's most effective when given to girls (not women) *before* they start having sex. It doesn't do squat once you already have the virus.

And thus the conflict - from a public health POV, it makes absolute and total sense to deploy a HPV vaccine as widely as possible, as early as possible - thus warding off as much HPV (and hence cervical cancer) as possible. But from a "moral" POV, giving a vaccine to prevent a sexually transmitted disease - which is what HPV is, after all - is tantamount to granting permission to girls as young as 9 years old to go ahead and start having sex.

As I say, I've only become familiar with HPV in the past couple years, but it's interesting that it is only recently - like in the last 6 months - when HPV has become a widely recognized public health issue. That's obviously due to the FDA's approval of the Merck vaccine. But what's truly amazing is that the backlash took so long to happen.

What I mean is exemplified by this great story in Sunday's Washington Post: mandatory vaccine programs in Virginia, Texas, and elsewhere are facing a backlash from conservatives. What surprises me is that these vaccine programs got off the ground in the first place. I would've thought it would've gone exactly the other way. Typically the public health scare - the HPV virus - would've been noted, but conservatives would've headed off a vaccine program the way they defeated similarly common-sense programs to distribute condoms in schools. Such condom programs are verboten in most of America, no matter how effective they may be at preventing disease, because the specter of 'encouraging kids to have sex' always seems to trump a public health argument (Puritanism is alive and well...). But in this case, the vaccine programs were actually up and running in the most conservative of states, because the public health people got there first with their pragmatic, rational, and compelling argument - vaccinate, and you can elimate cancer.

My hunch: 'cancer' is a big factor in this. It's a terrifying word, and a terrifying disease that few Americans really understand. Having a 'cure' in the form of a vaccine is incredibly alluring - almost miraculous - and that notion trumps any prudery about teenage sex. Politicians can see a score by supporting a program that so clearly eliminates a cancer.

At least at first.

Now the backlash is up and roaring. It'll be interesting to see how this plays out, with the anti-sex conservatives playing catch-up for once.

Divine Retribution

So I know I'm not the only one smirking at this story: the possible hepatitis A outbreak after a swanky Hollywood party - the Sports Illustrated swimsuit issue party, no less - catered by Wolfgang Puck. This version of the story contains one especially telling detail: Beyonce isn't worried about getting infected because she didn't eat. Thankfully, of all the Hep viruses, Hep A is the easiest to treat.

Too Clean

Americans may be the cleanest people on the face of the earth. We bathe more frequently than any other nation. We spend $15 billion a year on household cleaning products, and another $2 billion on soap and $1 billion on antibacterial soaps, sanitizers and sprays. We have made hygiene into a national religion, with Proctor & Gamble as our Jupiter and Juno.

But our cleanliness is killing us. The huge growth of anti-bacterial soaps and other products may have spurred the growth of drug-resistant bacterial strains, strains that can’t be fought with traditional antibiotics. So with every squirt of Purell, we may be helping build super-bugs like staph or strep that doctors and scientists are hard-pressed to stop.

What’s more, there’s no evidence that people who use antibacterial soaps have better health than people who stick with normal soap. And meanwhile, recent studies have shown that our excessive verve for hygiene may be linked to increased allergies among schoolchildren. Meaning germophobia may be getting us sicker, not better.

So relax, America. Take a break from the anti-bacterial arsenal and try regular soap and water instead. Don’t start a war we can’t win.

List of Epidemics

Gotta start with a list of epidemics. Thank you, Wikipedians.