Tattoos and medicine may seem an unlikely pairing, but medical tattoos are nothing new. Religious tattoos of ancient Egyptians honored the gods and, possibly, directed divine healing to ailing body parts. Circa 150 CE, Galen, a Greek physician working in the Roman Empire, tattooed pigment onto patients’ corneas to reduce glare and improve their eyesight. In the past century, more and more people have tattooed their medical histories, such as blood type, hereditary conditions, and even medical requests such as “do not resuscitate,” on their wrists and chests. Modern doctors have also used tattoos in reconstructive and cosmetic procedures to disguise scars and restore the appearance of lost body parts, such as nipples for mastectomy patients.

Today, that history comes full circle—as researchers now try to determine if tattooing could be used as a medical tool, giving healthcare providers a better way to administer drugs and vaccines.

It was only recently, in 2018, that scientists figured out exactly what happens in the immune system when you get a tattoo. They identified macrophages, a type of immune cell, as critical players in the process. Macrophages are part of the first responder unit of immune cells, also known as innate immunity. To understand what macrophages do, look no further than the Greek roots of its name: Macro–phage means “large-eater.” These pliable cells, which develop deep in our bone marrow, travel through the bloodstream and target microbial invaders in tissues, engulfing and “eating” them through a process called phagocytosis, thus clearing infections. Often, the response is so fast and effective that we don’t realize we’ve been infected at all.

Macrophages are also the accomplices that make tattoos permanent. When a tattoo needle punctures the skin, it tears apart the skin, fat, and connective tissue in its path. As they’re damaged, these cells release chemical distress signals, which travel into the bloodstream and surrounding tissue. The signals attract immune cells to the damage site and put adjacent cells on high alert. Depending on its size and complexity, a typical tattoo will inflict hundreds of thousands, and possibly millions, of these puncture wounds. Macrophages near the tattoo site, ever on the prowl, ingest any mysterious, foreign substance they happen to find—in this case, targeting the ink the tattoo artist has applied with the tip of their needle. In a twist that researchers still don’t fully understand, the macrophage “eats” the ink but cannot destroy it (one theory is that tattoo inks, which nowadays are usually carbon-based and suspended in a carrier fluid such as distilled water, isopropyl alcohol, or glycerin, are simply resistant to the cell’s enzymatic breakdown strategies).

The macrophage then does one of two things: 1) carry the ink away to a nearby lymph node for disposal or 2) sit there. “Sitting there” is a strategy macrophages sometimes employ with trickier foes. Macrophages and other immune cells will try to engulf as much of the invading material as possible but can’t fully destroy it, so the macrophages hunker down and form a blockade structure with their bodies, called a granuloma, to isolate the pathogen from the uninfected tissues (the macrophage motto: “If you can’t destroy them, trap them.”). When you get a tattoo, some of your macrophages sit and hold the ink to “protect” you, in the process becoming inadvertent guardians, preserving your tattoo design.

Your tattoo design, then, is an artful, exterior display of your body’s immune response.

Tattoo artists have harnessed the body’s defense network to inscribe and preserve art within your skin. It begs the question: Why can’t researchers leverage the same approach to advance medical treatments?

In 2016, the American Academy of Dermatology estimated that one out of every four people in the U.S. is impacted by skin ailments such as microbial infections or various cancers. Another study, in 2019, reported that Americans spend $13.8 billion dollars battling skin and soft tissue infections each year. Physicians today treat serious skin infections by giving patients intravenous or oral medication, which can be costly and can cause side effects. Minor infections may respond to topical ointments and creams, but these don’t always work well because the drugs may have to penetrate the skin barrier to reach the target site, resulting in variable absorption.

Tattooing medications into infected tissues might work better. A fluid dynamics study from 2021 (preliminary version here) used a gelatin block to simulate flesh, and characterized how needles deliver ink to skin. As a needle punctures tissue it creates a brief opening, which draws ink in as the wound closes back. Repetitive needling over the same puncture increases the total volume drawn in. The mechanism yields interesting possibilities for difficult-to-deliver drugs and vaccines.

In a proof-of-concept study using laboratory mice with cutaneous leishmaniasis, a parasitic skin infection marked by inflamed lesions, researchers administered an anti-parasitic drug using three routes: administering it topically as a cream, injecting it into the torso with hypodermic needles (the kind widely used in healthcare) to mimic drug circulation through the bloodstream, and using a commercial tattoo needle to inject medicine directly into the infection site. Tattooing treatment directly into the wound decreased parasite numbers within infected tissues and decreased lesion size and tissue inflammation more effectively than the other techniques. It ensured high drug concentration at the target site, while using less of the drug than other methods. Researchers and pharma companies are also evaluating a similar mechanism, microneedles, for treating skin infections. Microneedle patches for common woes such as acne are already available on the consumer market.

Tattoos may also ease the delivery of vaccinations to prevent disease. Today, most vaccines are administered by hypodermic needles that inject into the muscle. The thicker the vaccine, the larger the needle—and often, the more painful the injection. Human skill impacts pain levels, too. An injection may hurt more if an administrator is inexperienced, and doesn’t know, for instance, how much pressure to apply to the plunger. Tattooing eliminates such problems. Tattoo needles are small compared to traditional hypodermic needles, and are designed to puncture the skin superficially, potentially eliminating the discomfort and pain associated with intramuscular injections. And since puncture frequency is automated by machinery and puncture wounds naturally draw in fluid, tattooing may also reduce human error. One research cohort has designed microneedle patches with needles coated with vaccine to “tattoo” it into the recipient.  Such designs, which can be stuck to the skin like a simple adhesive bandage, can eliminate administration problems created by human error as well as the risk of disease transmission from needle handling and biohazard waste disposal. Solid vaccine patches are also easier to transport and store, as they take up less space than liquid-based vaccines.

It behooves the medical and research community to innovate when existing techniques fail; as a tattooed immunologist myself, it seems to me that developing tattoos for medical applications just makes sense. Tattoos, research, and medicine share a rich history, and the convergence of tattoos and science is a continuation of the human desire to explore and innovate—and beautify and prolong our lives.

If medicine is an art, then art too can be medicine.

The post Could a Tattoo Cure What Ails You? appeared first on Zócalo Public Square.

It is early August 2022 and I am in San Francisco for a few days. In urban areas with large gay populations such as Los Angeles, where I’m from, and here, monkeypox is on the mind of all my gay friends, and a topic of great interest among my straight ones. As with the first days of COVID-19, this consciousness seems to have come out of nowhere. Only weeks ago monkeypox seemed like a minor issue. Now there are more and more stories of friends of friends who have contracted it—experiences of the worst pain ever, like broken glass scraping on skin, and of the horror when the lesions travel to the genitals and anal canal, where the pain is constant and agonizing.

For those of us who are sexually active gay men, the timing seems particularly cruel. It was only recently that the shadow of COVID lifted a bit, giving something of a return to normalcy in regards to sexual practices. Monkeypox spreads through close contact, particularly sexual contact, and many gay men have contracted it. Sex and physical intimacy are dangerous again. It’s time to once again limit sexual contact—to heave another sigh, accept the new reality, and try and find a way to get the vaccine.

It isn’t easy. I had registered for the vaccine in Los Angeles and in nearby Long Beach, but had been unable to obtain it. Now, in San Francisco, at a little after 8 in the morning on a Tuesday, a friend texts me that he’d gotten out of bed at 4:30 a.m. to get in line at Zuckerberg San Francisco General Hospital. Rumor was, they had a batch of monkeypox vaccine—maybe 600 doses, no one knows for sure—which they were going to start giving out at 8 a.m.

When my friend arrived at 5:30 a.m. there was already a two-block line, and he was lucky number 125—assured he would get the vaccine that day. His text urges me to get down to SF General ASAP. I pull on some clothes, call a Lyft, and rush out the door. I haven’t had my coffee yet, and I have a work Zoom scheduled later, but this may be my only chance.

When I get there, the line is down to one block long, and there is a moment of joy and relief when a smiling health outreach worker hands me a paper slip: number 531. I will get my first monkeypox vaccine dose that day! She also gives me a questionnaire to fill out and a small, bright yellow pencil, as if I were about to commence a round of miniature golf. I try to remember the last time I have used or even held a pencil. Filling out the form in faint graphite feels somehow inadequate to the importance of the moment.

The vaccine line snakes along slowly but constantly. It is a warm day in the city, and it’s nice to be in the sun. I look around at my companions in line. We are all of us gay men, most alone, some in pairs. I have flashbacks to the early days of the AIDS crisis. The desperate waiting for initial treatments, taking an early HIV test and waiting an unnerving two weeks for the result, struggling to get the first doses of combination therapies. We were stigmatized in those early days, and we fear we could be stigmatized anew.

And of course there are more recent flashbacks, to COVID-19—the confusion and anxiety for everyone seeking to get vaccinated and the glorious memory of getting that first dose, and the sense of liberation and newfound safety that came with it.

About halfway through the line, an earnest young activist hands each of us a card urging us to sign a petition demanding the government take more urgent steps to fight monkeypox, including making more vaccine doses available immediately. Later, near the vaccine site entrance, I come across a huge pile of petition cards discarded on a bench. Political apathy will always exist to some degree, but I wonder how much this castoff mound may also speak to the number of gay men who feel exhausted and overwhelmed in the face of a seemingly endless barrage of political and health threats.

Getting the vaccine goes amazingly smoothly. I walk to a numbered table where an intern in scrubs greets me warmly and transcribes the information on my penciled questionnaire into a database. I go upstairs to receive my vaccine. An older, jovial male nurse smiles broadly at me, offers me a seat, and asks: Which arm? The injection is painless, and I do not at first realize it is over. I see the nurse toss my used syringe into a gigantic red sharps box, on top of hundreds of other spent doses. There we are, thrown together, as we were in line.

I think of all the death and suffering among gay men that the organized, friendly health professionals at San Francisco General Hospital must have seen since the first days of the AIDS epidemic. In some ways this is just another response to a health crisis, offered generously and efficiently, without judgment, and mustering the greatest resources they are capable of providing.

I walk out of the vaccine facility with a lightness in my step, knowing that I am one of the lucky ones. There are still vaccines available today, just as there had been when my friend texted me a few hours earlier. I text other friends to tell them to come down here, and see other men doing the same. We are in this together—men who are still in many ways outsiders to mainstream American sexual culture, who have achieved a certain level of liberation in our celebration of the joy and intimacy of sex, and who, if we are lucky, have good friends who reach out in a time of crisis and tell us to get our ass down here right away.

The post I Stood in Line for the Monkeypox Vaccine. All Around Me Were Echoes of Other Epidemics appeared first on Zócalo Public Square.

Instead, Gonzales is among California’s most vaccinated places. In this Salinas Valley town of 9,000, where fewer than 10 percent of adults have a college degree, 98 percent of eligible residents have received at least one dose.

Readers of this column know that Gonzales is often an outlier of excellence among California communities. But in this case, it’s part of a larger, unexpected success story around vaccination in two of the state’s agricultural areas—the Salinas and Imperial Valleys. Their stories hold lessons that go beyond the pandemic.

The city of Salinas, the de facto capital of the lettuce-growing valley, also boasts a vaccination rate above 90 percent, well above the statewide average and the vaccination rate on the whiter, wealthier Monterey Peninsula. Meanwhile, Imperial County, along the U.S.–Mexico border, is the most vaccinated place in the southern part of the state, as CalMatters first noted. Imperial boasts an 86 percent vaccination rate (at least one dose)— 10 points higher than L.A., Orange and San Diego counties, and 20-plus points higher than San Bernardino and Riverside counties.

The contrast is even more dramatic when you compare heavily vaccinated Salinas and Imperial with the slow-to-vaccinate rural regions—the San Joaquin Valley and the North State—that have seen coronavirus surges paralyze local health systems this fall. Some counties in those regions—including Kings in the San Joaquin, and Lassen and Modoc in the far northeast—have vaccination rates below 50 percent. And perhaps most intriguingly, both the Imperial and Salinas valleys have large populations of younger Latinos working in agriculture and essential industries—the very demographic other parts of the state are struggling to vaccinate.

So, what explains the success of these two valleys, 500 miles apart?

The answers start with vegetables.

The Salinas and Imperial Valleys are California’s two great lettuce lands, leading producers of green vegetables, from spinach to broccoli. As such, they share networks of companies, mechanics, and workers who operate in the Salinas Valley through summer and fall, and the Imperial Valley (and neighboring Yuma, Arizona) in winter. It’s not uncommon to find agricultural workers with residences in both places.

Some of these same workers were among the hardest hit by the first wave of COVID-19 last spring, with 2020 infection rates as much as three times higher than California’s general population. The state was slow to require protective equipment, and testing was unavailable at first. But, after the early months of the pandemic, agricultural networks in the two valleys rallied in a big way.

Tight collaboration among entities that can be at odds—growers, labor groups, local governments, community advocates, and health clinics—was crucial. In the Salinas Valley, the Grower Shipper Association, an agricultural industry group, and Clinica de Salud, a community health clinic, shared an award for their joint efforts to protect workers. Together, they provided workers with personal protective equipment and quarantine housing, and, in 2021, they helped organize mass vaccination campaigns in the fields and at well-known sites like the Salinas Sports Complex. While the growers offered time off and transportation for vaccination, the clinics provided the doctors and nurses to do the jabs.

The Salinas Valley collaborators obtained their own supply of vaccines directly from the federal government, bypassing the state government. The vaccination collaborations also benefited from pre-pandemic organizing campaigns around farmworker health (particularly related to pesticide use) and the 2020 census count.

On the southern end of the lettuce network, county health officials worked with another industry group (the Imperial Valley Vegetable Growers Association), providers (including El Centro Regional Medical Center), and community nonprofits to get people vaccinated in even the smallest settlements of the sprawling valley. They provided transportation to get workers and far-flung residents to mass clinics at malls. And they brought vaccinations to the border, since many Imperial workers must cross to their jobs.

Participants in these efforts say the aggressive early spread of COVID in the community meant there was little vaccine resistance—too many people knew how deadly the virus was. Some also see the vaccination success as a by-product of increases in the county’s health infrastructure in the 10 years since the establishment of Obamacare.

But vaccination, for all the public conversation about national or statewide rates, is a profoundly local function. And Gonzales, which won a major national award for community health before the pandemic, provides a good example of how to do it.

Community health workers were central to the approach. Gonzales managed to hire two in 2020. Then in January 2021, by joining a program called VIDA that brought in county and philanthropic support, the city hired four more, for a total of six.

These community health workers went door to door, and into apartment buildings, schools and businesses, to build relationships with residents. They brought free food boxes, from three local food pantries that the city set up early in the pandemic, to quarantined residents. They also became certified COVID-19 testers. This helped them reach vaccine holdouts, who, after testing negative for COVID-19, were quickly registered for vaccine appointments.

The city’s vaccination campaign has been relentless—with many organizations partnering to host over 20 mass vaccination clinics since February at the high school, the small and independent Gonzales RX Pharmacy, and the local Catholic church. To make sure there were always enough people in town who could give shots, the city had five Gonzales firefighters certified in administering COVID-19 vaccines. In addition to these personnel, nursing students from nearby Hartnell Community College and pharmacy staff also handled inoculations.

“It’s very hard for people to say no, with the accessibility and ease of the process,” Carmen Gil, Gonzales’ director of community engagement, told me.

And therein may lie the prescription for ending this pandemic, even in the most stubborn locations. When so many different people and institutions in a place are working together to get you vaccinated, it doesn’t matter who you are or how small or rural your community is—resistance is futile.

The post Why California’s Lettuce Lands Are Unlikely Vaccination Leaders appeared first on Zócalo Public Square.

Beginning in 1966, Henderson led a global effort based at the World Health Organization (WHO) to accelerate smallpox vaccinations. In an extraordinary campaign that required vaccinating people in the poorest and most remote areas of the world (and detailed in his book Smallpox: The Death of a Disease), the disease vanished, with the last known naturally transmitted case of smallpox occurring in 1977.

Ever since, we have made great strides in the global control of infectious diseases, and even progress towards disease eradication, but frequently the endgame has been disrupted by an unexpected turn of events. In a recent book, I estimated that most of the world’s poverty-related neglected diseases are paradoxically found in the G20 nations. There are at least a half dozen diseases for which disease elimination or eradication would be feasible were it not for war or national turmoil, political malaise, or a growing anti-vaccine movement.

Some of the most dramatic examples of game-changing disruptions in disease control have been noted for human parasitic and tropical infections. During much of the 20th century, tremendous strides were made in the elimination of the highly lethal Gambian form of African sleeping sickness (human African trypanosomiasis or “HAT”) through a combination of case detection and treatment and tsetse fly control. Many of the methods used to wipe out sleeping sickness were developed by Dr. Eugene Jamot, a French physician working in Cameroon who pioneered the use of portable and movable treatment teams during the early 20th century.

By the 1960s, Gambian HAT was near elimination in many African nations. But when hostilities and civil and international conflicts broke out in Angola, Democratic Republic of Congo, Sudan, and elsewhere, public health control was interrupted, so that by the 1990s the incidence of HAT had returned to pre-Jamot era levels. More recently, as tensions have eased and mass treatment and tsetse control efforts have been reinstated, we have seen a 73 percent reduction in deaths from HAT between 1990 and 2010. With only about 10,000 cases of HAT remaining, we may still yet see the global elimination of this deadly disease.

War, conflict, and political instability also have halted or interrupted other global efforts to eliminate or eradicate parasitic diseases. Breakdowns in health systems in Venezuela are resulting in resurgences of malaria and Chagas disease. Public health disruptions from the ISIS occupation of Syria and Iraq have allowed the number of cases of cutaneous leishmaniasis, a disease transmitted by sandflies and often associated with a disfiguring ulcer on the face, to skyrocket and spread into neighboring countries. The only good news is that although wars in the Sudan almost derailed global guinea worm eradication efforts led by the Carter Center, the Centers for Disease Control, and WHO, through the perseverance of these organizations, this disease may soon become only the second disease ever eradicated .

Next to war and political instability, probably the next most corrosive factor thwarting public health gains against infectious disease is simple absence of political will. During the 1950s and ‘60s, under the auspices of the Pan American Health Organization, an ambitious effort to control yellow fever and dengue resulted in the eradication of the Aedes aegypti mosquito in more than a dozen Latin American and Caribbean countries. But lapses in mosquito control efforts and other factors allowed Aedes aegypti to reestablish, resulting in the reintroduction of dengue into the region during the 1980s. Now yellow fever has returned to Brazil, where it could gain access to Aedes mosquito populations and threaten urban centers.

Perhaps the most disheartening examples of infectious disease control going off the rails are instances in which there are deliberate attempts to block vaccination efforts. Today, the transmission of polio has been halted everywhere except in Afghanistan and Pakistan (and before that northern Nigeria) due in part to concerted efforts by religious extremist groups to kidnap or assassinate vaccine workers.

And now in the United States and Europe we have anti-vaccine groups who allege links between vaccines and autism, despite massive scientific data showing conclusively there are no links or even any plausibility for vaccines causing autism.

A particular concern is the resurgence of measles, because it is one of the most contagious of all the vaccine-preventable diseases and often is the first to re-emerge following a decline in vaccine rates. But really any one of the major childhood illnesses targeted for vaccination could re-appear. Measles was eradicated in the United States in 2000. However, it returned to California in 2015, and now the state of Texas is especially vulnerable because tens of thousands of children are not being vaccinated for non-medical exemptions. Globally, between 1990 and 2010 there has been an 80 percent decline in measles deaths and for the first time the number of young children who die of measles globally has dropped below 100,000. However, there are concerns that an American-led anti-vaccine movement could now derail this achievement and possibly even lead to a reversal of sustainable and global goals for health and poverty reduction.

We need a concerted effort by global leaders to close current gaps and explore final steps to eliminate our great plagues. To do so will require international cooperation by the WHO member states, especially the 20 wealthiest economies comprising the G20 nations. Taking on the considerable political and social hurdles will become one of the great international challenges in freeing populations from the tyranny of epidemics or pandemics.

The post To End Infectious Disease, We Must Cure Our Societal Ills appeared first on Zócalo Public Square.

Most Americans today have no concept of the terror generated by polio throughout the first half of the 20th century. During epidemics, newspapers and magazines displayed adorable children struggling to walk in braces or entombed in iron lungs, but the disease mostly fell off the national radar after it was eliminated from the country in 1979. In the past few years, however, polio has begun creeping back into headlines, for two opposite reasons. On the one hand, thanks to the Global Polio Eradication Initiative, the world is closer than ever to wiping out the virus completely; widespread vaccination efforts reduced the number of cases to 414 in 2014, mostly in Pakistan and Afghanistan. On the other hand, because of recent anti-vaccination trends, it’s not unreasonable to worry that a resurgence of polio might afflict Americans again.

The person responsible for easing our minds over the past half century was Jonas Salk, a physician-scientist who was born in a New York tenement and driven by a passion to aid mankind. During the 1952 outbreak, with funds from the March of Dimes, he rushed to develop the earliest vaccine for polio that used a killed, or “inactivated,” form of the virus. In that, he met resistance from more-senior scientists who believed that only a vaccine made from a live virus could provide lifelong protection.

The public was desperate for a vaccine, yet Salk was afraid these scientists would try to derail his efforts. Objections from one even prompted the famed newscaster Walter Winchell to warn his radio audience not to take the vaccine, because “it may be a killer.” So Salk initially made and tested his vaccine in secret. Thankfully, his promising preliminary results led to the March of Dimes launching the biggest clinical trial in the history of medicine. Beginning on April 26, 1954, with a six-year-old named Randy Kerr from McLean, Virginia, the trial eventually involved 1.5 million children, and had remarkable results: Salk’s vaccine was 80 to 90 percent effective in preventing paralytic polio. It was mass-produced and distributed around the country, and by the end of the decade, it had reduced the incidence of paralytic polio in the United States by 90 percent.

When the success of the vaccine trial was first announced, the public crowned Jonas Salk a national hero. He experienced a celebrity accorded few scientists in the history of medicine. Yet his rebuke by the scientific community had only just begun. As heads of states around the world rushed to honor him, scientists—the one group whose adulation he craved—remained ominously silent. Basil O’Connor, director of the National Foundation for Infantile Paralysis/March of Dimes, said they acted as if Salk had committed a felony. They accused Salk of failing to give proper credit to other researchers whose work had laid the foundation for his own. Salk in fact had tried to give them credit. But the media had made him the icon for polio, ignoring other scientists’ contributions. This set the stage for difficulties throughout Salk’s career wherein politics in and beyond the scientific community seemed to override good science.

Jonas Salk in his laboratory, 1954.

In 1961, a public health decision was made to replace Salk’s vaccine with one developed by a virologist who constantly tried to discredit him, Albert Sabin. Sabin’s oral vaccine, made with a live virus, was cheaper and more convenient, but also much riskier; it actually caused polio in some cases. Salk worked throughout the rest of his life trying to reverse the decision—a sole warrior in a fight against what he considered entirely a politically-driven change. (In 1999, four years after his death, the Sabin vaccine was replaced with a new version of Salk’s vaccine, which is still used today.)

Salk also campaigned vigorously for mandatory vaccination, putting the health of the public foremost. He went as far as calling the immunization of all the world’s children a “moral commitment.” Thanks to his efforts—along with those of other researchers—we’re able to enjoy our summers without the fear of a crippling disease.

America now has been polio free for more than 35 years, and children are supposed to be vaccinated when they are babies. We’ve reached the point, however, where it seems many people can’t believe an epidemic could really occur. Some parents refuse vaccination, arguing that a healthy lifestyle is enough to protect their children from potentially lethal infections. But studies have shown that the introduction of sanitation actually enhances the circulation of poliovirus, because babies are no longer exposed to the virus in the very small amounts that used to produce lifelong immunity. Poliovirus can spread relentlessly once it gets a foothold in an unvaccinated community.

Such was the case shortly after Salk’s vaccine was released in 1955. Massachusetts closed its vaccination program because a manufacturing error led to some contaminated shots. Even though the mishap was quickly corrected, the state did not reopen its program. That summer, Massachusetts suffered one of its largest epidemics. Four thousand people contracted polio, and 1,700 were paralyzed—mostly children.

Does the public want to repeat history? I think Jonas Salk would plead with them to learn lessons from our past. Californians did with the recent measles outbreak, which affected more than 130 people, the majority of whom were unvaccinated. This helped spur the state to join Mississippi and West Virginia by mandating childhood vaccination, despite an outcry from several groups. Now if only 47 other states would follow suit.

The post Vaccinations Have Always Been Controversial in America appeared first on Zócalo Public Square.

Between January 1988 and December 1990, Southern California saw 12,434 cases of measles. Los Angeles County was the first to report its problem in what became a statewide epidemic where 75 people died after developing complications such as pneumonia and encephalitis. In two of those three years, the federal Centers for Disease Control identified Los Angeles as the site of the largest outbreaks in the nation. How could we have forgotten so quickly how terrible measles can be?

At the time, I worked as an epidemiology analyst in the Los Angeles County Health Department’s Acute Communicable Disease Control (ACDC) unit. Back then, the unit was a modest group of about 20 people—among them physicians, nurses, epidemiologists, and support staff—that kept track of diseases such as influenza, meningitis, and the vaccine-preventable diseases, all of which by law must be reported to health departments. We also investigated outbreaks, and kept abreast of trends in world health.

When I started at ACDC in 1987, measles was low on the radar. It hadn’t been a scourge since the early 1960s, when an estimated 90 percent of Americans had been infected by age 15. A national campaign to vaccinate children followed. By the mid 1980s, there were less than two cases per 100,000 persons.

How did our outbreaks begin? In retrospect, 1987 may have been a harbinger of the epidemic; the number of cases of measles reported in the county that year jumped from 40 to 126. Then, by June 1988, the virus found a particularly vulnerable population—young children in low-income communities, who had very low vaccination rates. It’s not clear exactly why these kids didn’t keep up with their shots and why the pattern changed from previous years when high school and college students made up most of the cases. But whenever a highly contagious disease like measles finds a niche in an unvaccinated population, there is going to be an outbreak.

By early 1989, an epidemic was truly underway. In early 1990, I was brought in from the field office where I worked to help the county’s immunization program—which had a staff even smaller than the ACDC’s—handle the onslaught of cases. Reports of measles cases quickly stacked up on all our desks. As soon as we put down the phone, we got another call. I remember one of my colleagues, Dr. Lorraine Chun, who was out in the field investigating deaths among unvaccinated children and speaking with families, remarking that she had never seen anything so sad.

As the epidemic progressed, we recognized that the established vaccination protocol had slipped, and we had lost the progress made in previous decades. Trying to reverse the epidemic would take more than just vaccines, but we had none of the data and tools that epidemiologists use today to expedite their work (like the Internet, GPS, email, and cell phones). We waged the battle with pagers, fax machines, and stand-alone personal computers that we shared.

Soon, there were so many cases that investigating each one and following up on the possible contacts of the infected became impossible. We had to take stronger action in the community. All schools and child care centers were required to identify unimmunized kids and tell parents that those children had to stay home. Special clinics were set up near schools to vaccinate kids at risk. At colleges that had measles outbreaks, more than 11,500 students and staff were immunized—in both voluntary and mandatory programs. Medical staff at jails, prisons, and juvenile halls throughout California immunized at least 46,000 people. L.A. County alone distributed over 600,000 doses of vaccine.

Educational campaigns in Spanish, Hmong, Samoan, and other languages urging parents to vaccinate their children were disbursed through the media, churches, English-as-a-second-language classes, and mailings. And in an important change, authorities decided—based on the number of toddlers who became infected—to lower the age for receiving the first dose of measles vaccine from 15 to 12 months of age. Since the vaccine is slightly less effective when given at that younger age, public health officials also began recommending that children receive a second dose between ages 4 and 6. This schedule is maintained to this day.

Even with the intense effort and over $30.9 million spent statewide, the epidemic lasted for three years. It wasn’t until 1995 that the L.A. Times declared victory, noting that “rates of measles, mumps and other diseases that can be prevented by vaccines dropped to a ‘historic low’ in Los Angeles County.” By 1997, the incidence rate in the U.S. as a whole was less than 1 per 100,000. In 2000, measles was declared to be eradicated in the United States—making us the envy of the world where measles remained the eighth-leading cause of death. Though I no longer worked at ACDC by that time, I hoped that the terrible toll exacted by measles during the 1988 to 1990 epidemic had sufficiently spurred us into permanent vigilance.

Why then, less than 20 years later, do 113 countries have higher rates of immunization than we do? Why are we currently facing measles again?

Perhaps we are victims of our own success. The outbreaks that produce mass vaccination campaigns seem to fade from memory after a few decades, and the virus surges back again.

I must confess that the late ‘80s outbreak of measles has faded from even my memory. Even though I spent every workday for nearly two years engaged in addressing the epidemic, I have to wrack my brain to recall details.

We need to find ways to remember better. It should not take having a family member die from measles-induced encephalitis to brand in our minds the effect this virus can have. Public health agencies continue to devote money and time to delivering messages on vaccination, but they are useless unless everyone takes them to heart. Back in the unit, we used to talk about the difficulty of reaching that last group of people reluctant to vaccinate. Our saying: “90 percent of the budget goes to reaching the last one percent.”

Instead of using the tools that all the science-based, peer reviewed research says will prevent epidemics of disease and save lives, a segment of our population chooses to play a dangerous game by not vaccinating. They fear the odds of an adverse event from the vaccine are greater than those of a severe outcome from acquiring the disease itself.

I have been telling everyone I can about the danger of stepping backward into a hole we have previously fallen into. The question is, how can we get people to listen?

The post I Was on the Front Line of L.A.’s Last Measles Outbreak appeared first on Zócalo Public Square.

She and her husband, only three years beyond college, had bought their first house. A solid redbrick and clapboard Cape Cod, it sat on a leafy street named for a character out of a Longfellow poem. In its driveway glistened a new sedan, silver-gray with a burgundy roof and whitewalls, a gift from her father, a Ford dealer.

And under its dormers that last day of August 1954 slept her three children: A sunny toddler with platinum blonde hair and a weak stomach sphincter, known around the house, mostly affectionately, as Miss Urp. A 3-year-old bruiser with a devilish twinkle in his eye, whom the neighbor nicknamed Meatball. Then there was the eldest, a lithe towhead with quick feet and an even quicker tongue—him they called Motormouth. He was set in a week’s time to walk the two blocks down the hill and start first grade at Nakoma Elementary School.

Everything was the way she liked it, under control.

(The prior sentence, the careful reader knows, is a signal, the gun hung on the wall in the first act, which must go off in the second. And it will—in the case of my mother’s story, in a way unknown to today’s parents facing decisions about whether to vaccinate their children.)

In the middle of that night, Lois was roused by sounds from the boys’ bedroom. Tucked under the shed roof at the back of the house, the room was stuffy with the heat of late summer. The older boy, who shared a bed with his little brother and a ratty blue bear, lay feverish and whimpering. Her husband carried the boy to the bathroom. He was too weak to stand and use the toilet.

The next day they drove him to the hospital for a spinal tap. The spinal fluid was cloudy. “During the past three or four days almost complete paralysis of both lower extremities and left upper extremity and trunk musculature has developed,” his doctor would write in the medical record on September 4.

Lois Mace Paul, 28, had come very far, very fast from a Depression-era childhood in a small Iowa town—husband, house, kids so well behaved that strangers would stop by the table in restaurants to compliment her. But now she was also the mother of a boy with polio. He lay in an isolation unit, afraid and confused, unable to sit or roll over. She could only stand in the doorway, swathed in a surgical gown and mask, forbidden to hold or comfort him for fear of spreading the virus.

We can safely assume these events counted as life-changing for Lois. After 10 days in isolation, the boy was put on a children’s ward, where he would remain for 130 days, “for institution of hot packs and passive stretching exercises and later institution of active exercises,” according to his medical record. Every afternoon at 2, Lois traveled the three miles to the hospital to sit with the boy. She would read to him as he ate the sandwich—always peanut butter on white bread—that she smuggled past the nurses; her boy wasn’t keen on hospital food. Her husband took the night shift, arriving at 7 to launch Pooh and Christopher Robin on their next “expotition.”

Even judged by the standard of today’s families balancing work and parenthood, the logistical challenges were daunting. Meals to make, clothes to wash and hang, diapers to change. Schedule babysitters for every afternoon. Change clothes and put on makeup—a respectable woman didn’t go downtown in jeans and without a face. Find a way to get back and forth; there was only the one car. Make dinner so her husband could get back to the hospital on time. Bathe and put the little ones to bed on her own. How much time or energy could there have been for coffee or cocktails with friends, or for nights out with her husband?

And it didn’t end there. When the boy was finally sent home, he had to be carried up and down stairs. Over the next decade there would be braces and crutches that he was always expensively outgrowing. And as he grew and his unbalanced muscles twisted his frame, Lois and her husband would sit eight times in a surgical waiting room while Dr. Wixson used chisel, hammer, wire, and staples to straighten the boy’s back and legs. Not until the boy himself waited outside an operating room as his own infant child underwent orthopedic surgery could he imagine how fear had shadowed Lois’ life.

Imagination is about all we have to tell us what those events meant to Lois emotionally. She didn’t talk much about feelings.

The boy’s only hint came one afternoon, about the time of his sixth birthday. A high school running back had injured his neck in a game and had been brought into the ward the night before, his limbs numb. As Lois and the boy looked on, a doctor and nurses, after some probing, helped the player sit, swing his legs off the bed, and, to the delight of staff and parents, stand again. Seeing what pleased adults, the boy turned to Lois. “I’m going to do that soon,” he said. She didn’t reply, but tears streamed down her face.

We know she grieved. Lois shared the bad news in a letter to her best college friend, who had joined the Iowa diaspora to Los Angeles. It read like a funeral notice. “Oh, my beautiful little boy,” she wrote in ending. Lois confided to her favorite aunt that she feared the boy would die.

Why didn’t Lois vaccinate me? Because she had not been given that choice. I had fallen ill 224 days before the announcement, on April 12, 1955, that the field trials of the Salk polio vaccine were a success.

As she lay in bed that night, digesting the news that had been shouted out across the country over radio, television, and public address systems in workplaces and schools, Lois had a choice to make. Because kicking inside her was the boy she had conceived in her grief the previous fall.

Today’s parents make those choices knowing much more than she did about the effectiveness and safety of the vaccines offered to their children. They can rely on decades of experience and scientific research.

Lois faced only scientific uncertainty. The Salk vaccine was new. It had been only 60 to 70 percent effective in the trial but had been deemed safe. Some of the world’s top polio researchers weren’t so sure. They had publicly opposed the trial, thought the vaccine the wrong approach, maybe even dangerous. Their fears materialized within weeks. Cutter Laboratories in Berkeley shipped vaccine contaminated with live virus. More than 200 children and family members were paralyzed, and 11 died. The vaccination campaign was briefly suspended.

But from her own experience, Lois Mace knew things that today’s parents, thanks to vaccines, have never had to learn—need never learn—about pain and grief and loss of control. As soon as she could, she took all her children to get the shots, and went back again after the Cutter fiasco.

She could not be certain it was the best choice for them. She knew, to her very bones, that it was the right choice for her.

The post My Mother Couldn’t Choose Whether to Vaccinate Me for Polio appeared first on Zócalo Public Square.

California’s measles outbreak has touched off a debate about how to reduce the number of parents who choose—in defiance of all credible public health information—not to vaccinate their children. So far, the debate has focused on tightening California laws that make it easy for parents to obtain exemptions from school vaccination requirements. Newly introduced state legislation would eliminate the “Personal Belief Exemption” that thousands of anti-vaccine parents have used.

I’d be more than happy to see this proposal become law. But the politics of reducing parental choice are fraught, and there are limits to the law’s ability to compel good parenting. There’s also a hard cultural fact: few things are more fundamentally Californian than the freedom to believe whatever pseudo-religious or pseudo-scientific nonsense you choose. So, one way or another, it’s likely that parents will still find ways to avoid vaccinating their children, despite the risks to both their own kids and their communities.

A tougher, smarter way of dealing with anti-vaccine parents would be to target not their choice—but the secrecy that surrounds that choice.

Under today’s privacy laws, public schools and health authorities must protect the identity of parents who choose not to vaccinate. That’s wrong for many reasons. First, the secrecy effectively forces public employees, whose first duty should be to the public’s safety, to be enablers of those who threaten that safety. Second, parents who endanger the community’s health don’t deserve official protection. And third, the confidentiality of such exemptions makes it harder for those families who vaccinate their children to protect themselves.

People deserve privacy in their private spheres. But a parent who won’t vaccinate is not making a private health decision: She is making a public health decision that profoundly affects others.

So let’s treat the exemption she obtains as the public act it is. Every single exemption request should be reviewed in a public meeting and approved by a public body (like a city council or school board). And if the exemption is approved, basic information—the parent’s name, address, and the vaccinations declined—should be available on the Internet via a publicly maintained registry.

The virtues of disclosure are clear. Having your family’s name published as a potential hazard to public health would be a strong disincentive to obtaining an exemption for all but the most committed (i.e., delusional) anti-vaxxers. And the rest of us would be able to identify our unvaccinated neighbors, and our children’s unvaccinated schoolmates. This would be especially helpful to pregnant women, and the parents and caregivers of children who are either too young to be vaccinated (the first measles, mumps, and rubella vaccine isn’t given until after a baby’s first birthday) or have serious diseases like cancer (as in the case of the Marin County six year old recovering from leukemia) that compromise immune systems and preclude vaccination.

In effect, the question of how to handle unvaccinated children and their parents would move from the realm of school administrators to the community at large. And the community level is where the question is best addressed, since we encounter the unvaccinated not only at school but also in parks, churches, and stores.

There is some risk of community and personal conflict in this shift, to be sure, and anti-harassment laws would have to be strictly enforced. But there would also be potential for the kind of conversations necessary to change minds and get more children vaccinated.

Those who have studied the question of how to convince people to vaccinate report that the voices of distant authorities—public health departments, governors, even President Obama—aren’t particularly effective, given deep public distrust of institutions. People you know—neighbors, friends, co-workers—make better emissaries to the unvaccinated. But you can only be an emissary to unvaccinated neighbors or friends if you know they are unvaccinated.

The recent legislation acknowledges this need for conversation with a proposed requirement that all parents be notified of the vaccination rates at their kids’ schools. But that doesn’t go far enough. Indeed, it might create additional anxiety by instigating guessing games and speculation, without triggering the desirable peer pressure of true disclosure.

Some committed opponents of vaccines may howl about their identities being made public or about the exposure of their children, but such objections are easily turned back against them. If you believe you have the absolute power to make whatever decision you want for your children, why would you deny me the right to do the same, including the right to decide whether my children should be going on play dates to the homes of people who have recklessly opted out of modernity?

That response may sound harsh and insufficiently sensitive to privacy. But for better and for worse, it fits the obligations of 21st century childrearing. As a parent myself, I’m repeatedly reminded—by doctors, nurses, public officials, schools, and the dozens of legal waivers that daily life requires me to sign—that I am required to know everything I can about my kids. I’m supposed to know where they are at all times, and to monitor every minute of exercise and each spoonful of sugar. I’m supposed to find out everything I can about the kids they hang out with, and I’m supposed to monitor all their online movements. It’s no coincidence that most successful public service announcement series in America, now celebrating its 25th anniversary, is NBC’s “The More You Know.”

There are other good ideas out there for putting pressure on parents who don’t vaccinate. You could hand out stickers or buttons to all vaccinated schoolchildren—creating a social pressure on those who don’t. Laws could permit insurers to raise the premiums of those who don’t vaccinate (right now, insurers can only set rates based on age, geography, and tobacco use). A new tort could be created to permit people who incur medical and other costs because of an outbreak to sue and recover damages from the unvaccinated. I particularly like a proposal from Dorit Rubinstein Reiss, a law professor at UC Hastings, to charge a significant fee for vaccine exemptions to cover the costs of an outbreak.

This issue is personal. My own children are still little, and it will be a few more years before all three are old enough to have had all their vaccinations. Media outlets have recently compiled data on the number of vaccination exemptions in California schools, and it bothers me that, of the 95 kids who attend kindergarten with my oldest son at our local public school, three are unvaccinated because their parents have obtained Personal Belief Exemptions.

I should have the right to know who those families are. And I look forward to the day when I can engage them in a conversation about what our families owe each other.

The post If You Don’t Give Your Kids Shots, At Least Give Me Your Address appeared first on Zócalo Public Square.

As a doctor of internal medicine, I would like nothing better than to tell this medical assistant to get a flu shot or stay away, but I have no such authority. Nor does my healthcare organization, which employs this medical assistant. Healthcare workers are protected by union contracts, and unless the state of California overrides a given provision, the contract determines what employers can demand. As things stand, if you want a healthy nurse, you have to keep your fingers crossed.

To understand this absurd situation, it’s necessary to understand something about the public policy involved. For years, the official recommendation from the Centers for Disease Control has been that at least 90 percent of healthcare workers get flu vaccinations. Ninety percent is the magic threshold for what’s called “herd immunity.” If you have a herd of 100 animals and 90 of them are immune to a contagious disease, then that disease will be unable to establish a stronghold within the herd.

In other words, if 90 percent of healthcare workers were to get inoculated—leaving room for up to 10 percent of their colleagues to refuse based on known allergies or a past adverse reaction—then our hospitals and doctor’s offices would be safe. Currently, however, only 64 percent of healthcare workers in California get the influenza vaccine. Even a devastating and well-publicized H1N1 pandemic in 2009 didn’t prompt the implementation of all possible precautions.

For that reason, last February, California state legislators wrote up a bill to do something about it. The bill, Senate Bill 1318, would require healthcare facilities to meet a 90-percent flu vaccination rate among their workers by 2015. Of course, in order to meet a requirement like that, employers must be able to force—or at least strongly incentivize—their employees to get the vaccine. To that end, the original version of SB 1318 contained a mandate that all unvaccinated healthcare workers wear a mask for the duration of the influenza season, from October through April, while in patient care areas. That way, no healthcare worker would be forced to get the vaccine, but the price to pay would be the inconvenience of wearing a mask.

Along the way, however, legislators experienced a last-minute loss of nerve, so they removed the mask provision, fearing it to be a landmine of personal rights violations. Instead came a general requirement that all healthcare facilities meet the 90-percent worker vaccination mark by 2015. As for how facilities would enforce that measure absent any teeth, that question was left unresolved.

In any case, SB 1318 made it to the desk of Governor Jerry Brown, getting California a little closer to doing away with a needless health hazard. But Brown vetoed it on September 30 of this year. The California Nurses Association, a powerful labor union, had objected to the measure, alleging it was “divisive and could lead to future discrimination issues in the workplace.” (The alternative of letting unvaccinated employees wear a mask seven months out of the year had been struck down by the union months earlier.)

For now, the only hope for doing something about the problem can be found at the local level. In California’s public health system, the public health departments of individual counties are governed by physician “health officers,” the local equivalent of the surgeon general. These doctors have oversight of all communicable disease control within their jurisdiction, and they technically have the power to quarantine a city and even to throw infectious citizens in jail. Of course, no one is expecting them to do anything like that. But odds are good that more and more physician health officers will institute their own influenza mask mandate—or find some other way to motivate workers to get the shot.

As Dr. Bob Hartmann, health officer of Amador County, recently told me, “If the legislature is going to continue to wimp out, we as health officers need to mandate.” Hartmann ordered masks for unvaccinated workers in October 2011, and Amador County has already seen its hospital vaccination rate soar to 89 percent. “Hospital CEOs were begging me to do it,” Hartmann said. “It made their job easier when I gave the order, so they didn’t have to. And really, it’s my responsibility as the Health Officer of this county to step up to the plate.”

Is such use of power unprecedented or, as some healthcare workers allege, unconstitutional? Actually, no. For years most hospitals in the United States have required employees to receive vaccinations against measles, mumps, rubella, and Hepatitis B as a condition of employment. Adding influenza shots to that mix hardly seems dramatic, especially considering that more people die from influenza each year than of all those other diseases combined.

To be sure, measures like the mask mandate have prompted skeptics to object on scientific grounds. They point to a study by the CDC in 2008 that concluded that viruses such as influenza can survive for hours on surfaces, that they can be spread by surface-to-hand or hand-to-hand contact, and that masking creates a false sense of protection for employees and patients. But the study did not show that masks make things worse—and, more important, if the effect of a mask mandate is that more healthcare workers get vaccinated, then the mandate surely serves its purpose.

Of course, all of these fights revolve around a more fundamental—and age-old—debate over where to draw the line between protecting the rights of the public and the rights of the individual. Should our government have the power to mandate a vaccine? Or do individual rights take precedent? But that debate seems awfully arcane when a potentially infected healthcare worker is coughing on my AIDS patient. They have a right to work in a different profession if they like, but no healthcare worker has a right to infect—and possibly kill—my patients.

The post You Have the Right To Be Sick—But Not On My Patients appeared first on Zócalo Public Square.