Smallpox: The Big Story (Part III)


 
 

Howard Rodenberg, MD | | Monday, November 26, 2007


(Continued from last week)

While people are willing to put themselves at risk, they most often do so for their own purposes. None of us really functions as a utilitarian being (if we did, communism would have worked quite well, and Garbo's Ninotchka never would have tried on that hat). Moments of heroism -- the soldier throwing himself on a grenade to save his fellows -- are glorified simply because they operate against the human fabric. Few rational people would go into battle with the desire to die as a human shield. But the government anticipated that people would be willing to subject themselves to discomfort to prevent an unknown attack by an unknown enemy at an unknown time. Politics aside, there seems to be little doubt as to why the plan failed to immunize large numbers of Americans. There was is no perception of an imminent threat.

The widespread practice of immunizing children against infectious disease is a case in point. We immunize our children because we perceive them to be at risk. All we need to do is turn on the television to see what havoc these diseases cause in the underdeveloped world. Many of us have suffered from the measles, mumps or chicken pox in our lives, and our elders recall a time when wards of polio-stricken children in iron lungs were commonplace. And in our own homes, the sight of our own kids feeling ill in any way, even from the most benign of illnesses, provokes our protective paternal instincts. We don't have that same feeling about smallpox because we don't see it. Horatio Hornblower may have, and Edward Jenner certainly did. But our successful efforts to eradicate smallpox from the globe have taken away any sense of personal risk. For my money, I'll take that trade-off as a public health victory any day.

(Regular readers of this column will be aware of my interest in philosophy, religion and all the other things that one is not supposed to talk about at the dinner table. I bring this up only to note that one of my very favorite theological arguments is also based on the concept of personal risk. It's called Pascal's Wager, and it sets up like this:

Do I believe in God?

Yes No

Does God exist? Yes Win Lose

No Neutral Neutral

You've got to think in terms of Las Vegas here. If I believe in God and God exists, then I win. If I believe, but he doesn't exist, or I don't believe, but there is no God, it's no big deal. But if I don't believe in God and there really is one, the deity's going to be really annoyed. So you believe in God based on the chance of winning whatever reward there might be, and on the possibility of bad things happening if you don't. It's the personal risk argument on a cosmic scale. (And you thought it was tough figuring out the smallpox vaccine.)

One might argue that if we follow the logic of personal risk, then why immunize children? We give infants shots for diphtheria, tetanus, pertussis (whooping cough), rubeola (measles), mumps and a host of other diseases we, thankfully, just don't see much anymore. These shots are generally benign, but occasionally produce side effects. If we don't have these diseases in society, then there is no personal risk. So why are we giving children these shots?

Even on the surface, this is backward logic. The organisms that cause these illnesses are scattered throughout the environment. They are not limited to laboratories or research stations (as smallpox mercifully is we hope). And the reason we don't "see" these diseases anymore is because we immunize against them. The extremely minor risk of side effects is clearly outweighed by the protection afforded to the entire population. One is welcome to look through the history books to learn what these infectious diseases did to generations of children and how someone could have this knowledge and still be opposed to immunization is beyond me. But opponents of childhood vaccinations still promote these arguments.

Another specious argument is promoted by those who did not immunize their children and the kids did "just fine." For the sake of the children, I'm glad they had that good fortune. But you'll also find that in those cases where children do suffer from a dreaded childhood infection, they inevitably occur in children who were not immunized. Some parents play the odds with their children's lives and win. It doesn't always happen that way.

The more sophisticated argument against immunization relies on the concept of "herd immunity". (By the way, I really like to use the term "herd immunity." It gives credence to my definition of most airline cabins as "cattle cars.") "Herd immunity" refers to a group of people's resistance to disease, when a large portion of the population is immune. When there are fewer possible hosts, there is less chance of an unimmunized person coming in contact with a carrier of the infection. The argument from those who oppose vaccination says that because of herd immunity, we no longer need to vaccinate children against infectious disease. The piece that's left out of the argument is that the benefit of herd immunity comes about because we immunize. It's the "NIMBY" (Not In My Back Yard) syndrome on a grand scale but, be sure to immunize everyone else so what they carry can't get my unprotected child. The fact that the exact levels of immunization required to attain herd immunity for a population is unknown is also used as an argument against immunization. If we don't know what percentage of the population needs to be immunized, then why are we doing it? Again, this represents backward logic. We may not know what the right level is, but we certainly know the results of not doing something. Better an error of commission than one of omission. As they say, lead, follow or get out of the way.

What's interesting, of course, is that, in the final analysis, both parties eventually get their way. If we immunize like crazy, snaring everyone in the net, we eliminate hosts for the infectious organisms. If we do that, the organism vanishes from our environment, and no one requires any further immunizations. And that, my friends, is exactly what happened with smallpox.

Ultimately, the choice of whether or not to receive the smallpox vaccine is up to you. But making an informed choice is key, and understanding both the clinical and psychological factors affecting your decision will aid the process. With the proper information in hand, you can make the best choice for you and your family.


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Related Topics: Industry News, PPE and Infection Control, Provider Wellness and Safety, Medical Emergencies

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