Warning: this post has a long, boring prologue. Proceed at your own risk.
I am an expert in the prevention and treatment of adult diseases. That’s what I do from well before the sun rises until well after it sets every day of every week. To become an expert and retain this status is not a simple task. After college I completed four years of medical school, three years of residency in my specialty, and chose to become “board-certified”. There are doctors who are not board certified in their specialties, and there’s nothing nefarious about that—all that is required to practice medicine is a valid license from the state. But my hospital doesn’t allow physicians on staff if they are not board certified, recognizing that this status means something. There is no good reason to eschew board certification. To fail the boards repeatedly betrays a lack of basic competency, given that most doctors are actually good test takers, otherwise they’d never have made it so far.
Historically, once one was board certified in internal medicine, the certification was for life. Several years ago this changed, with older doctors being grandfathered into permanent certification, and all new internists being required to re-certify every decade. Since medicine is an ever-changing field, my license required fifty hours of continuing medical education yearly. In addition to that, I’m now two years away from my re-certification, which requires more continuing education. The American Board of Internal Medicine suggests spreading re-certification over a two year period. I’ve started doing the required learning modules and they are hard. Depending on the field, each question takes me about twenty minutes of research just to make a reasonable guess at the answer. Most of the modules are knowledge-based, but I’m required to do at least one that helps me review my practices. I could, for example, review a few dozen charts of hypertensive patients to see how well I am managing them, and come up with a plan to improve my practices. After all of this, I may sit for my board exam.
All this is simply to serve as a bit of background—when I talk about medicine, I’m not pulling it out of my ass. Some doctors, though…
Which brings us back to the Huffington Post, that web-repository of quackery. The latest abomination is from Dr. Frank Lipman, a self-proclaimed expert in preventative health care. I emphasize self-proclaimed because he doesn’t seem to understand much about the subject. Doctors must be able to think independently. They must be able to look at the data, look at the recommendations of others, and apply these to individual patients. While one patient might “by the book” require a particular type of medication, you may know that this particular patient won’t do as well for one reason or another. But one cannot ignore evidence.
Lipman starts out with the predictable but clearly false claim that he is not “anti-vaccine” (instead being pro-vaccine safety and freedom of choice, setting up the false dichotomy implying that the rest of us are against safety, freedom, and presumably the American way). He then goes on to forcefully, in bold typeface, declare that most of his patients should not get the swine flu vaccine (I can hear Rebecca Watson’s voice in my head doing the voiceover of the capslock—good lulz). A generous person might take this information and think, “Gee, perhaps he has a geriatric practice so that most of his patients don’t fall within the current evidence-based recommendations.” That would be stretching generosity to the breaking point. He goes on to discuss why he anti-vaccine (in this case). But let’s talk a bit about flu and about prevention from, you know, an expert.
Let’s start with what swine flu is and is not. Every year, influenza sweeps across the world, affecting the US most strongly in the winter months. It causes at least 35-40 thousand excess deaths every year, and even more hospitalizations and lost days of work and school—and all that is in a “typical” year. In typical years, flu is most brutal on the very old, very young, and chronically ill. Swine flu follows a different pattern. It isn’t any less virulent or deadly than seasonal flu, but attacks a much greater number of people, especially those who don’t usually suffer much during a typical flu season. It also has refused to confine itself to the normal flu season, having simmered all through the summer. Vaccination helps prevent illness, hospitalization, and death due to influenza, so each year we formulate a vaccine based on the current circulating strains. To what extent vaccination is beneficial is an open area of investigation, but that it helps is clear.
Vaccination is an important tool in prevention of morbidity and mortality. Prevention is generally discussed as being primary or secondary. Primary prevention is the prevention of disease as you might typically think of it. If you can prevent someone from developing diabetes, polio, or heart disease, that is primary prevention. Once someone has a particular disease, preventing further episodes is secondary prevention. If my patient has coronary artery disease (say, having had a heart attack in the past), I can I practice secondary prevention by treating them with certain medications and with good health habits that reduce the risk of further heart attacks. There is another category—tertiary prevention—which usually refers to preventing a disease which complicates another. Diabetics are prone to heart disease, and there are ways to prevent heart disease in diabetics.
So let’s see what our “expert” in prevention says about flu shots.
1) At this stage, for the most part the swine flu seems benign.
Over a million people in the US have already come down with swine
flu, many of them without even knowing that they had it. The vast
majority of people who get the swine flu recover after a week or so of
high fever, aches, and respiratory distress. It’s not pleasant, but
except in rare circumstances, it is not fatal. Most people who’ve been
infected by swine flu think so little of it, they believe they just had
a really bad cold or a regular flu. So unless the swine flu evolves to
a much more virulent form, there’s no need for mass vaccination.
Given what we know about the flu, this is foolish. Yes, swine flu is about equally as virulent as the usual flu—that is, it causes a great deal of excess significant illness and death. What threshold does Dr. Lipman, as a prevention expert, recommend for preventing a preventable disease? Is there a certain prevalence threshold? A certain virulence threshold? Apparently, his recommendation is based on his “feeling” that it is “rarely fatal” and “relatively mild”.
2) We don’t know if the vaccine will be effective.
Vaccines are only useful against the specific viral strain that was
available at the time of their manufacture. But influenza viruses
mutate quickly, and as the WHO has already said, the real concern with
H1N1 swine flu is that it will combine with seasonal flu in the Fall,
creating a new strain that will of course be immune to all available
That reasoning is, in a word, stupid. The reason we need a new vaccine every year is that the flu changes. The reason we know which strains to vaccinate against is through careful public health surveillance. We do this fairly successfully most years. This year there is a seasonal flu vaccine based on the current strains, and a separate swine flu vaccine based on the fact that swine flu is still circulating widely. It has been tested as safe and effective, and is developed and produced just as all previous flu vaccines. To take the nihilistic view that because the flu mutates we should ignore decades of evidence and experience and just give up is the height of arrogant ignorance.
3) We don’t know if the vaccine is safe.
The FDA has authorized an expedited approval process for the swine flu vaccine but we don’t know yet if it is safe. Even GlaxoSmithKline, one of the vaccine manufacturers has said, “The
total population studied in clinical trials will be limited, due to the
need to provide the vaccine to governments as quickly as possible.
Additional studies will therefore be required and conducted after the
vaccine is made available.“
In other words, the only thing that is safe, is to say that no one
knows. Since it’s never been used before and they have not had time to
conduct any sufficient human testing, by getting vaccinated you are
being a human guinea pigs.
That is simply untrue. This vaccine has been developed and produced just as previous vaccines have, and there is no reason to think that it is any more or less safe. To take this particular paranoid view is to ignore the science and the evidence.
His next point is either completely ignorant or sinister: vaccine manufacturers are insulated from liability, therefore they have no incentive not to hurt you. The reason vaccine manufacturers receive immunity is so they will still be able to provide this not-very-profitable service. Anti-vaccine cultists would sue the vaccine makers into oblivion, or clog the courts trying. Instead we have a rational surveillance program. Since significant vaccine-related side effects are vanishingly rare, it is only on mass release that rarer ones may become apparent, therefore we have a system for monitoring vaccine safety. Thankfully, serious side effects of flu vaccine are not distinguishable from the baseline incidence of these problems, and are rarer than serious flu-related illness.
The evidence shows that the most effective primary prevention of influenza is vaccination. Still, it’s rather more invasive than, say, dietary changes. Is there any evidence for other primary prevention strategies? The answer is essentially, “no”. Lipman gives a heap of worthless advice about “phytonutrients”, vitamin D, and exercise, some of which is plausible but not supported by evidence, and some of which is implausible enough to be laughable.
When you read the comments to a post like this, you can see that some will never be persuaded by evidence or science—they hold fixed-false beliefs which people like Lipman feed. His self-declared status as an expert in prevention is irresponsible. He makes no evidence-based recommendations, and many that are downright dangerous. He illustrates one of the fundamental contradictions in the alternative medicine movement: the claim to be pro-prevention but actions that completely belie the claim. It would be sad if it weren’t dangerous and irresponsible.