Article Referenced in Loop Article Part 7

Measles --- United States, January--May 20, 2011

Weekly

May 27, 2011 / 60(20);666-668

On May 24, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr).

Measles is a highly contagious, acute viral illness that can lead to serious complications and death. Endemic or sustained measles transmission has not occurred in the United States since the late 1990s, despite continued importations (1). During 2001--2008, a median of 56 (range: 37--140) measles cases were reported to CDC annually (2); during the first 19 weeks of 2011, 118 cases of measles were reported, the highest number reported for this period since 1996. Of the 118 cases, 105 (89%) were associated with importation from other countries, including 46 importations (34 among U.S. residents traveling abroad and 12 among foreign visitors). Among those 46 cases, 40 (87%) were importations from the World Health Organization (WHO) European and South-East Asia regions. Of the 118, 105 (89%) patients were unvaccinated. Forty-seven (40%) patients were hospitalized and nine had pneumonia. The increased number of measles importations into the United States this year underscores the importance of vaccination to prevent measles and its complications.

Measles cases are reported by state health departments to CDC, and confirmed cases are reported via the National Notifiable Disease Surveillance System (NNDSS) using standard case definitions (3). Cases are considered internationally imported if at least some of the exposure period (7--21 days before rash onset) occurred outside the United States and rash occurred within 21 days of entry into the United States, with no known exposure to measles in the United States during that time. Import-associated cases include 1) internationally imported cases; 2) cases that are related epidemiologically to imported cases; and 3) imported virus cases for which an epidemiologic link has not been identified but the viral genotype detected suggests recent importation.* Laboratory confirmation of measles is made by detection in serum of measles-specific immunoglobulin M antibodies, isolation of measles virus, or detection of measles virus RNA by nucleic acid amplification in an appropriate clinical specimen (e.g., nasopharyngeal/oropharyngeal swabs, nasal aspirates, throat washes, or urine). For this report, persons with reported unknown or undocumented vaccination status are considered unvaccinated. An outbreak of measles is defined as a chain of transmission with three or more confirmed cases.

During January 1--May 20, 2011, a total of 118 cases were reported from 23 states and New York City (Figure 1), the highest reported number for the same period since 1996 (Figure 2). Patients ranged in age from 3 months to 68 years; 18 (15%) were aged <12 months, 24 (20%) were aged 1--4 years, 23 (19%) were aged 5--19 years, and 53 (45%) were aged ≥20 years. Measles was laboratory-confirmed in 105 (89%) cases, and measles virus RNA was detected in 52 (44%) cases. Among the 118 cases, 105 (89%) were import-associated, of which 46 (44%) were importations from at least 15 countries (Table), 49 (47%) were import-linked, and 10 (10%) were imported virus cases. The source of 13 cases not import-associated could not be determined. Among the 46 imported cases, most were among persons who acquired the disease in the WHO European Region (20) or South-East Asia Region (20), and 34 (74%) occurred in U.S. residents traveling abroad.

Of the 118 cases, 47 (40%) resulted in hospitalization. Nine patients had pneumonia, but none had encephalitis and none died. All but one hospitalized patient were unvaccinated. The vaccinated patient reported having received 1 dose of measles-containing vaccine and was hospitalized for observation only. Hospitalization rates were highest among infants and children aged <5 years (52%), but rates also were high among children and adults aged ≥5 years (33%).

Unvaccinated persons accounted for 105 (89%) of the 118 cases. Among the 45 U.S. residents aged 12 months−19 years who acquired measles, 39 (87%) were unvaccinated, including 24 whose parents claimed a religious or personal exemption and eight who missed opportunities for vaccination. Among the 42 U.S. residents aged ≥20 years who acquired measles, 35 (83%) were unvaccinated, including six who declined vaccination because of philosophical objections to vaccination. Of the 33 U.S. residents who were vaccine-eligible and had traveled abroad, 30 were unvaccinated and one had received only 1 of the 2 recommended doses.

Nine outbreaks accounted for 58 (49%) of the 118 cases. The median outbreak size was four cases (range: 3--21). In six outbreaks, the index case acquired measles abroad; the source of the other three outbreaks could not be determined. Transmission occurred in households, child care centers, shelters, schools, emergency departments, and at a large community event. The largest outbreak occurred among 21 persons in a Minnesota population in which many children were unvaccinated because of parental concerns about the safety of measles, mumps, and rubella (MMR) vaccine. That outbreak resulted in exposure to many persons and infection of at least seven infants too young to receive MMR vaccine (4).

Reported by

Div of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Huong McLean, hmclean@cdc.gov, 404-639-7714.

Editorial Note

As a result of high vaccination coverage, measles elimination (i.e., the absence of endemic transmission) was achieved in the United States in the late 1990s (1) and likely in the rest of the Americas since the early 2000s (5). However, as long as measles remains endemic in the rest of the world, importations into the Western Hemisphere will continue.

The unusually large number of importations into the United States in the first 19 weeks of 2011 is related to recent increases in measles in countries visited by U.S. travelers. The most frequent sources of importation in 2011 were countries in the WHO European Region, which has accounted for the majority of measles importations in the United States since 2005 (2), and the South-East Asia Region. This year, 33 countries in the WHO European Region have reported an increase in measles. France, the source of most of the importations from the European Region, is experiencing a large outbreak, with approximately 10,000 cases reported during the first 4 months of 2011, including 12 cases of encephalitis, a complication that often results in permanent neurologic sequelae, 360 cases of severe measles pneumonia, and six measles-related deaths (6).

Measles can be severe and is highly infectious; following exposure, up to 90% of susceptible persons develop measles. Measles can lead to life-threatening complications. During 1989--1991, a resurgence of measles in the United States resulted in >100 deaths among >55,000 cases reported, reminding U.S. residents of the potential severity of measles, even in the era of modern medical care (7). In the years that followed, the United States witnessed the return of subacute sclerosing panencephalitis among U.S. children, a rare, fatal neurologic complication of measles that had all but disappeared after measles vaccine was introduced in the 1960s (8).

Children and adults who remain unvaccinated and develop measles also put others in their community at risk. For infants too young for routine vaccination (age <12 months) and persons with medical conditions that contraindicate measles immunization, the risk for measles complications is particularly high. These persons depend on high MMR vaccination coverage among those around them to protect them from exposure. In the United States this year, infants aged <12 months accounted for 15% of cases and 15% of hospitalizations. In Europe in recent years, measles has been fatal for several children and adolescents, including some who could not be vaccinated because they were immune compromised.

Rapid control efforts by state and local public health agencies, which are both time intensive and costly, have been a key factor in limiting the size of outbreaks and preventing the spread of measles into communities with increased numbers of unvaccinated persons. Nonetheless, maintenance of high 2-dose MMR vaccination coverage is the most critical factor for sustaining elimination. For measles, even a small decrease in coverage can increase the risk for large outbreaks and endemic transmission, as occurred in the United Kingdom in the past decade (9).

Because of ongoing importations of measles to the United States, health-care providers should suspect measles in persons with a febrile rash illness and clinically compatible symptoms (e.g., cough, coryza, and/or conjunctivitis) who have recently traveled abroad or have had contact with travelers. Providers should isolate and report suspected measles cases immediately to their local health department and obtain specimens for measles testing, including viral specimens for confirmation and genotyping.

MMR vaccine is safe and highly effective in preventing measles and its complications. MMR vaccine is recommended routinely for all children at age 12--15 months, with a second dose at age 4--6 years. For adults with no evidence of immunity to measles,^† 1 dose of MMR vaccine is recommended unless the adult is in a high-risk group (i.e., health care personnel, international travelers, or students at post-high school educational institutions), in which case, 2 doses of MMR vaccine are recommended. Measles is endemic in many countries, and exposures might occur in airports and in countries of travel. All travelers aged ≥6 months are eligible to receive MMR vaccine and should be vaccinated before travel (10). Maintaining high immunization rates with MMR vaccine is the cornerstone of outbreak prevention.

Acknowledgments

The findings in this report are based, in part, on contributions by Mary McCauley and Paul Chenoweth, National Center for Immunization and Respiratory Diseases, CDC.

References

1. Katz SL, Hinman AR. Summary and conclusions: measles elimination meeting, 16--17 March 2000. J Infect Dis 2004;189(Suppl 1):S43--7.
2. Parker Fiebelkorn A, Redd SB, Gallagher K, et al. Measles in the United States during the postelimination era. J Infect Dis 2010;202:1520--8.
3. CDC. Manual for the surveillance of vaccine-preventable diseases. 4th ed. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://www.cdc.gov/vaccines/pubs/surv-manual/default.htm. Accessed May 20, 2011.

1. CDC. Measles outbreak---Hennepin County, Minnesota, February--March 2011. MMWR 2011;60:421.

1. World Health Organization. Global elimination of measles---report by the Secretariate, 16 April 2009. Available at http://apps.who.int/gb/ebwha/pdf_files/EB125/B125_4-en.pdf . Accessed May 20, 2011.
2. Institut de Veille Sanitaire. Epidémie de rougeole en France; Actualisation des données au 20 mai 2011. Available at http://www.invs.sante.fr/surveillance/rougeole/Point_rougeole_200511.pdf . Accessed May 23, 2011.
3. Gindler J, Tinker S, Markowitz L, et al. Acute measles mortality in the United States, 1987--2002. J Infect Dis 2004;189(Suppl 1):S69--77.
4. Bellini WJ, Rota JS, Lowe LE, et al. Subacute sclerosing panencephalitis: more cases of this fatal disease are prevented by measles immunization than was previously recognized. J Infect Dis 2005;192:1686--93.
5. Editorial team. Measles once again endemic in the United Kingdom. Eurosurveillance 2008;13. Available at http://www.eurosurveillance.org/viewarticle.aspx?articleId=18919. Accessed May 20, 2011.

1. Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L. Measles, mumps, and rubella--vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47(No. RR-8).

* Additional information is available at http://www.cdc.gov/osels/ph_surveillance/nndss/casedef/measles_2010.htm.

^† Documented receipt of 2 doses of live measles virus-containing vaccine, laboratory evidence of immunity, documentation of physician-diagnosed measles, or birth before 1957.

What is already known on this topic?

Measles, mumps, and rubella (MMR) vaccine is highly effective in preventing measles and its complications. Sustained measles transmission was eliminated from the United States in the late 1990s, but the disease remains common in many countries globally, and cases of measles are imported into the United States regularly.

What is added by this report?

During the first 19 weeks of 2011, 118 cases of measles were reported in the United States, the highest number for the same period in any year since 1996, and hospitalization rates were high (40%). Importations accounted for 46 (40%) cases, including 34 (74%) cases among U.S. residents who had recently traveled abroad, among 105 import-associated cases.

What are the implications for public health practice?

High 2-dose MMR vaccine coverage is critical for decreasing the risk for reestablishment of endemic measles transmission after importation of measles into the United States. Before any international travel, infants aged 6--11 months should receive 1 dose of MMR vaccine and persons aged ≥12 months should receive 2 doses of MMR vaccine at least 28 days apart or have other evidence of immunity to measles.

FIGURE 1. Distribution and origin of reported measles cases (N = 118) --- United States, January 1--May 20, 2011

Alternate Text: The figure above shows the distribution and origin of reported measles cases (N = 118) in the United States during January 1-May 20, 2011.

FIGURE 2. Cumulative number of measles cases reported, by month of rash onset --- United States, 2001--2011

Alternate Text: The figure above shows the cumulative number of measles cases reported, by month of rash onset, in the United States during 2001-2011. During January 1-May 20, 2011, a total of 118 cases were reported, the highest number reported for the same period since 1996.

TABLE. Countries where measles was acquired, by World Health Organization (WHO) region --- United States, January--May 20, 2011
WHO region	No. of cases	Country	No. of cases
African	2	Kenya	1
		Nigeria	1
Eastern Mediterranean	2	Pakistan	1
		Jordan	1
European	20	France	11
		France/United Kingdom	1*
		France/Italy/Spain/Germany	1*
		Italy	1
		Poland	1
		Romania	1
		Spain	1
		United Kingdom	3
Americas	1	Dominican Republic	1†
South-East Asia	20	India	14
		Indonesia	1
		Philippines	4
		Philippines/Vietnam/Singapore/Malaysia	1*
Western Pacific	1	China	1
* Patient had visited more than one country where measles are endemic during the incubation period, and exposure could have occurred in any of the countries listed. † Although the patient acquired measles in the Dominican Republic, the likely source of infection was a French tourist with measles who stayed in an adjacent room at the same resort at the same time as the patient. The genotype identified in this patient was D4, a genotype commonly circulating in France.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

A Community Conversation - Part 8

A Community Conversation About Health and Responsibility: Vaccines and Beyond

Part 8:  Finding the 3rd Option

There’s something about two clear options that humans find appealing.  We write stories about good and evil with heroes to cheer for and villains to boo!  We go to sports events where one side must win.  Even in a debate, where the participants are bringing up really good points, we declare a winner and a loser.  Our legal system.  Enough said.  

It goes on.  Right and wrong.  Black and white.  Left and right.  Liberal and conservative.  Pro-vaccine and anti-vaccine.  Rich and poor.  All or nothing.  Us and them.  

These are examples of polarization.  And, a polarized world view is like looking at our planet and only seeing the north and south poles, while ignoring everything from Greenland to New Zealand.  With this approach, we are left with two options which both seem cold, hard, and lacking in diversity.

Fortunately, there are choices beyond penguins versus polar bears!  There is always a 3rd option to every situation, and many times a 4th, 5th and 99th...if we are willing to look for it.  

So, what gets in the way?  How do we find ourselves so split?  There are many forces which push us towards polarization.  

First let’s talk about the types of polarization that are deliberate manipulation.  There’s the Straw Man fallacy, in which someone exaggerates or misrepresents someone else’s argument in order to make it easier to defeat them.  We see this all the time in politics.  There’s also the philosophy of “just pick the lesser of two evils,” also frequently seen in politics.  There’s also the use of trigger words such as “conspiracy theorist,” as a way to discount and shut down an opponent.  None of these manipulative tactics have anything to do with finding the best solution, respecting the other person, or even having a real conversation.  They’re all about winning.

Such manipulation is designed to prevent you from questioning why you can’t have a third option.  The polar bears and the penguins like feeling important.  But what about bananas?  And kangaroos?  And all the other interesting stuff in the middle? 

Of course, not all polarization is deliberate.  Sometimes we spend so much time talking to polar bears and penguins that we genuinely forget about the tropics.  For example, when March Twisdale was interviewed for a Beachcomber article about her participation in the film, Everybody’s Business, the reporter assumed that anyone involved in the film must hold a polarized view.  Without asking, it was reported that March Twisdale & her husband had not vaccinated their children.  Apparently, anyone involved in medical choice advocacy must be “anti-vaccine.”  In fact, March has high regard for the role of vaccines in healthcare and her children are vaccinated against tetanus, polio, measles, mumps, rubella, and diphtheria.  

Polarization is also incredibly contagious.  As we become more polarized, we perceive more polarization in others.  With each issue that we see in a polarized way, it increases the chances we will approach the next issue in a polarized way as well.  Polarization breeds polarization, as we feel the need to defend ourselves from “the other side.”  Parent-child transmission of polarization is also quite common.  Perhaps we need a vaccine against polarization? 

It’s time to back up and see the bigger picture.

First, let’s acknowledge why polarization is so seductive.  Our emotional state can impact how we approach a problem.  For example, when we are under stress, we seek the comfort of joining the “winning side.”  When we are frightened, we want the safety of a “right answer.”  When we are tired, we want the simplicity of a “quick and easy answer.”  When we are insecure, we want to know that we are part of a group of “like-minded people.”

It takes time to deeply explore and evaluate an issue.  It takes even more time to explore possible solutions.  And sometimes it can feel like this effort is a luxury we cannot afford.

But finding the third option is worth the effort.  Non-polarized attitudes allow us to see all the options and come up with creative solutions that better meet everyone’s highest needs.  Polarized “solutions” may be quick and easy, but they tend to be inherently destructive.  In the long run, it is worth investing the time to find true solutions.

But how can we find it, if no one is talking about it?  What are the habits that help us find non-polarized solutions?

Let’s start with humility.  I don’t know everything and neither do you.  So let’s share our knowledge and work together.

Self-knowledge matters.  Why do you believe what you believe?  What’s behind that?  And what’s behind that?  Check your assumptions.

Ask genuine questions.  Encourage others to share their core assumptions and world view.  They might surprise you.

Seek the future.  We can’t progress without constantly challenging ourselves to learn something better.  Progress takes time, effort, imagination, and a few mistakes.  But there is nothing more depressing than deciding that we are at the pinnacle of human evolution and it’s all downhill from here.  There is still much to learn.

Long story short - if you’re looking at any issue in a polarized way, consider inviting your fellow penguins or polar bears to go on a trip to the equatorial regions of the world and learn something new while you’re there!

“A Community Conversation About Health and Responsibility: Vaccines and Beyond” is an ongoing series written by two close friends with a passion for improving community cohesion and building respectful relationships in a diverse world.  This article was co-created by Karen Crisalli Winter and March Twisdale.  BLOG:  Vaccinesandbeyond.blogspot.com   Email:  KarenandMarch@rocketmail.com  

A Community Conversation - Part 7

A Community Conversation About Health and Responsibility: Vaccines and Beyond

Part 7:  Keeping Things In Perspective 

Fall is upon us. The school year has begun. Once again, we are subjected to a constant series of public health messages and editorials claiming that making an informed choice about your health care is immoral and selfish. If you want to be a good person, these sources claim, you must follow directions.

Okay, it usually isn't phrased that way. It's usually phrased as “the threat of vaccine refusers” or “the danger of vaccine free-riders.”  But the core message is still the same: the right to medical choice endangers public safety.  This message is tiresome, it's polarizing, and it's false. But it's also pretty pervasive. So, with a deep sigh, we address this issue again.

As is frequently quoted in alarmist articles, Washington state has one of the nation's highest vaccine exemption rates: 4.5%. Is this a problem? Maybe not. The Pacific Northwest also has an unusually high rate of autoimmune diseases, some of which are a medical contraindication for certain vaccines. We also have an unusually high level of education and access to health care. The relatively high vaccine exemption rates may be a healthy indication of well-informed parents making careful decisions for their unusually vulnerable children.

Perspective is important.  How is it that 95.5% vaccination rates could be considered a cause for alarm?  After all, it indicates that we are successfully providing vaccines to all children, even those living in severe poverty.  Given the state of our overall health care system, this is quite an accomplishment.  

But what about those exemptors?  Can't they cause devastating epidemics of measles that endanger us all?

Sigh. No.

First, unvaccinated children do not compromise the immunity of children around them. Kids who are immune to measles will not lose that immunity by playing with children who are not immune to measles. Being unvaccinated is not contagious. If your vaccination worked and provided you with immunity, you are safe from infection.

To see evidence of this, look carefully at the statistics on all the recent US measles outbreaks. Measles is a highly contagious disease, yet all the outbreaks are small and localized. This pattern is revealed in a CDC document analyzing 9 outbreaks of measles in 2011, with a total of 118 cases. The median size of the outbreak was 4. The largest outbreak was 21. Everyone made a full recovery. This is not a devastating outbreak of disease. This is strong herd immunity.  (For a link to the full document, see our blog.)

What about the babies? Well, one outbreak in Washington was started by a baby too young to be vaccinated. The baby traveled to a nation where measles is endemic, then returned home and shared measles with an unvaccinated child. All subsequent infections in that outbreak were unvaccinated children and teens who had accepted the risk of measles when they declined the vaccine. And once again, everyone made a full recovery. Even the baby who started the whole thing.

The current approach to measles vaccination is working, including the part where people are allowed to refuse. The simple fact is that people want safe and effective vaccines. There is no coercion required. Greater than 95% of our state’s population will happily and willingly choose any vaccine that is safe, effective, and offers a genuine health benefit. That is plenty to achieve herd immunity against measles...because the vaccine has a very high efficacy rate and longevity of protection.

Which brings us to pertussis.  If herd immunity is working well for measles, why do we have epidemics of pertussis?  After all, the vaccination rates are fairly similar.

The unfortunate reality is, the measles vaccine has an efficacy rate of over 98% and offers lifelong immunity.  The pertussis vaccine has an efficacy rate of only 60-70% and wears off in 3-5 years.  Because of these differences in the vaccine, we have achieved herd immunity for measles.  We have not achieved herd immunity for pertussis...and we will never do so with the current vaccine. 

Medical choice doesn’t endanger public safety.  In truth, medical choice protects us all.  When a safe, effective, appropriate vaccine is available, most parents choose it for themselves and their children.  If significant percentages of people are refusing a vaccine, there's a reason. Perhaps the vaccine isn't very effective. Perhaps the complication rate is too high. Perhaps the rising rates of allergies have made certain vaccines contraindicated for too many people.

The important concept here is that when we accept a poor vaccine, vaccine manufacturers have no financial incentive to improve it. If everyone finds it acceptable, why should they waste their money making it better? When large numbers of people start refusing a vaccine, there's suddenly a profit motive to put forth better research and offer a better vaccine.

Coercing people into vaccinating does not improve the safety or efficacy of vaccines. It doesn't make concerns go away. If anything, coercion heightens anxiety and suspicion and feeds into conspiracy theories. Name-calling just distracts from the real questions about safety and efficacy.

We deserve access to safe, effective vaccines. We deserve the right to decline vaccines that do not meet our standards for safety and efficacy. How can we work together to make that happen?

Have ideas?  Suggestions?  Please visit our blog, and share your comments.  Also, we invite all readers to review Part #3, Individual Power in Community Health Dynamics.  As we start another school year, it is important to remember the many tools available which empower us to protect our own health and the health of others.

“A Community Conversation About Health and Responsibility: Vaccines and Beyond” is an ongoing series written by two close friends with a passion for improving community cohesion and building respectful relationships in a diverse world.  This article was co-created by Karen Crisalli Winter and March Twisdale.   BLOG:  Vaccinesandbeyond.blogspot.com   Email:  KarenandMarch@rocketmail.com

Part 6: What is Choice? (Part 2 of 2)

A Community Conversation About Health and Responsibility: Vaccines and Beyond

Part 6:  What is choice?  (2nd Half)

In the last article, we discussed the reality that there are powerful forces that set the “menu” from which individuals may then make choices.  This isn't necessarily a bad thing, because the human brain can only tolerate so many options before getting overwhelmed.  Our overall goal is the nebulous and elusive concept of “enough choice.”

The first three powerful forces that intersect to control our health care choices are: 

1. Government and Law

2. Official Recommendations

3.  Religion

Note:  Missed last month’s article in The Loop?  

Check it out on our blog:  vaccinesandbeyond.blogspot.com

Now let's get into the fourth major force at play...

4.  Money

The Golden Rule; those with the gold, make the rules.  While we may wish it wasn't so, no group force can sidestep this one.  Money matters in ways both obvious and surprising.  For example, the United States is one of only two nations to allow direct to consumer (DTC) advertising of pharmaceuticals.  Does this empower patients to take control of their own health care?  Or does it allow savvy advertisers to take advantage of vulnerable people?  Profit motives drive health care towards wealthy urban areas and away from poor or rural areas.  This tends to leave certain areas with too much choice (ie: which brand of CAT scanner do you prefer?) and other areas with too little (ie: a 200 mile drive to get a CAT scan).  And, of course, we’re all well-familiar with the complexities, confusions, and frustrations swirling around the issue of insurance!  Keep in mind that personal wealth is not always a liberating force.  A local CAT scan in a rural area cannot be purchased at any price, because the machine just isn’t there.  Conversely, Michael Jackson would most likely be alive today if he had lacked the wealth to buy dangerous, inappropriate health care.  Although, Michael Jackson also might be alive today if it weren’t for...

5.  Social Pressure

Pressure from neighbors, family, schools, and society strongly impacts our health care decisions.  How many of us have used powerful painkillers or stimulants in order to stay on a job despite injury or sleep deprivation?  Social pressure takes many forms.  Organized protest events, such as the ones in front of Planned Parenthood, are often more about social pressure than politics.  When a co-worker is praised for working 16 hour days, it can start to feel...unsafe...to go home at a reasonable hour and get a decent night's sleep.  Or how about the way sports writers idolize athletes who play through an injury?  Or the smile of approval (or scowl of disapproval) from a doctor?  Whatever form it takes, social ostracism generally makes the non-mainstream choice painful, while social affirmation encourages compliance with the norm.  At its best, social pressure can prevent us from making serious mistakes, especially when that social pressure is applied through direct conversations with open-minded and supportive people who have our best interests at heart.  At its worst, social pressure can become a form of community bullying or intimidation.  Both the best and worst aspects of social pressure can happen in groups of any size, from an entire nation to a single friendship.

For a moment, let’s look at a local example of how all five of these forces are intersecting around the Franciscan Health System’s absorption of the Vashon Health Clinic.  As voters and citizens, we have participated in the process which led to the current menu of legal medical procedures, rights, and freedoms.  As islanders, we sought cooperation with the government (tax dollars), and Grannie’s Attic was created to help with ongoing funding.  Even the decision to partner with Highline was driven by economics.  Then, as Highline faced tough economic times, some form of official recommendations were sought and received, leading Highline to consider a merger with the Catholic Franciscan Health System.  This merger was born of economic need and has brought with it both a blend of economic support for ongoing services and religious-based limitations of available medical procedures and freedoms.  In response, we see social pressure in the form of community meetings, articles in the local papers, letters to the editor, invitations to consider the Catholic viewpoint, and activism as concerned islanders begin to search for a different, 3rd option.  That option, of course, will also be impacted by all five of the major menu-setting forces.  And so it goes.

The five forces of law, official recommendations, religion, money, and social pressure all work together to set our health care menu.  Now, let’s review their unique strengths and weaknesses.

Law is often slow and clumsy.  It is the only force that can apply criminal sanctions, although religions can excommunicate you.  However, it is also the only force that offers a guaranteed opportunity and clear process to

challenge an existing decision.

Official recommendations can change rapidly, but this agility also makes them vulnerable to trends, poor research, and short-term thinking.

Religion can offer genuine concern for the large picture of human society, but it can be almost impossible to challenge a religious doctrine successfully.  In addition, personal religious beliefs of equal value can occur in absolute opposition to each other.

Money can open many possibilities, but self-interest and greed is ever- present.  Once set in place, changing the flow of money can be extremely difficult.

Social pressure can be the most flexible and individualized force, but its nebulous nature makes challenges difficult.  Pushing back against social pressure can feel like fighting clouds; you can't get a grip on them, they won't go away, and then they suddenly clear up for no apparent reason.

As with all of life, diversity is strength.  It will not serve us well to live with a medical menu that is set only by law, or official recommendations, or religion, or money, or social pressure.  We need a balance.  And when that balance is disrupted, we need to push back until balance is restored.

“A Community Conversation About Health and Responsibility: Vaccines and Beyond” is an ongoing series written by two close friends with a passion for improving community cohesion and building respectful relationships in a diverse world.  This article was co-created by Karen Crisalli Winter and March Twisdale.   BLOG:  Vaccinesandbeyond.blogspot.com   Email:  KarenandMarch@rocketmail.com

Part 6: What is Choice (Part 1 of 2)

A Community Conversation About Health and Responsibility: Vaccines and Beyond

Part 6:  What is choice?

Society is, by definition, a collaboration.  Like all group environments, there is a give and take of rights, responsibilities, and choices.  This is true whether we’re talking about a family, a town, a board, or a hospital.  This is also true whether you live in a democracy, a theocracy, or a tyranny.  In all systems, there are forces that "set the menu” from which individuals can then make a choice.

Despite the rhetoric to the contrary, limitations can be a good thing.  The human brain can only tolerate so many options before getting overwhelmed.  When overwhelmed, our ability to choose well goes down dramatically...a known fact that is sometimes used against us in aggressive and unscrupulous marketing strategies.  At other times, however, a plethora of choices is valuable.  For example, few people need every single brand of detergent to be offered at their local store.  Even fewer wish to spend hours in the soap aisle carefully weighing the advantages and disadvantages of each product.  On the other hand, people with severe skin allergies might be very interested in a wide selection of detergents; as they hope to find one that won’t give them a rash! 

In general, a collaborative society seeks to meet the needs of the community and the individual by setting a menu of options that is not too narrow and not too broad.  Most of us, consciously or unconsciously, believe that the best way to ensure “enough choice” would be to have someone like ourselves be in the “menu selecting” position of power.   However, when the menu is set by people whose values differ significantly from our own, we tend to express considerable outrage!  This leads to a great deal of amusing and ironic hypocrisy from all points on the political compass.

When speaking about public health, there are a variety of forces that overlap, conflict, combine, and collaborate to create the menu of health care choices available to individuals.  In this article and the next, we'll look at five of the most powerful group forces at play, and our access as citizens to these arenas of power.

1.  Law & Government

Our society decided long ago that legal oversight of choice is desirable.  However, where to draw the line is often a contentious question, leading to spirited debates.  This is further complicated by the fact that our government was designed to spread “menu control” around, with the federal, state, county, and local layers of governance each having limited, intersecting, and sometimes conflicting powers.  For example, the civil rights movement, marijuana legalization, and the recognition of gay marriage are all interesting areas of tension between state governance and federal governance.

When it comes to our access as citizens, some laws are passed with great fanfare, others are passed very quietly.  But, all laws in this culture are documented and there are established methods for individuals to work toward altering them.  However, just because a choice is legal does not mean it is available.  There are many other forces that limit availability like....

2. Official recommendations

Various governmental and professional groups make official recommendations.  These groups are obligated to follow the law and their recommendations are documented.  However, there is often no clear path to challenge recommendations, even though they may limit medical choice just as effectively as law.

Consider the 2008 recommendation by the American College of Obstetricians and Gynecologists (ACOG) on the subject of vaginal birth after cesarean (VBAC).  The 2008 recommendation stated that a VBAC should only be attempted if a surgical team was “immediately available."  This recommendation led to many resource-limited small or rural hospitals refusing to permit VBAC due to lack of an "immediately available" surgical team.  Thousands of women were forced into expensive and potentially dangerous surgeries they did not need and did not want.

Now, consider the education of your family doctor.  The Accreditation Council for Graduate Medical Education (ACGME) is a private professional organization responsible for the accreditation of 9,000+ residency programs.  Residency programs currently include training in all forms of legal birth control.  However, accreditation requirements are reviewed every seven years, and that review is happening now!  Will the requirement for training in birth control be weakened or eliminated entirely?  The Catholic Ethical and Religious Directives expressly forbid contraceptives, leaving 30-50% of US hospitals unable to offer a “full education” residency program due to restrictions from...

3.  Religion

The separation of church and state both protects our secular society from becoming a theocracy and allows religious groups to follow their faith with autonomy from popular opinion.  This autonomy even allows religious groups to defy certain laws with relative impunity.   A church can refuse interracial marriage, so long as it is willing to forego the tax benefits of being in compliance with federal civil rights law.  The “sanctuary movement” of the 1980's consisted of churches openly defying immigration laws to provide sanctuary for Central American refugees fleeing civil war.  Religious exemptions from vaccination laws are respected in nearly all states.

This independence gives religion unique power when setting the public health “menu.”  Historically, a variety of religious groups have sought to expand, restrict, or modify the health care menu.  One strategy is religiously-based political action.  Another strategy is social pressure, which we'll discuss later.  Yet another strategy is the ownership of medical facilities, which are then obligated to follow the religious values of the sponsoring religious organization. 

Religiously controlled health care mostly becomes problematic when a single religious group controls such a large percentage of medical facilities that it begins to function as a monopoly.  Monopolies of all kinds interfere with individual choice, thus the various legal restrictions upon them.  A religious monopoly upon a vital service like health care has some very serious implications.  The carefully crafted checks and balances of our political system do not apply to religious organizations, leaving the individual very few medical or religious rights that can be defended.  Thus a religious monopoly can endanger both our health care and our religious freedom.

So why would anyone accept a religious monopoly on health care?  In general, it’s all about....

4. Money

Which is what we'll start talking about next article.  See you then!

“A Community Conversation About Health and Responsibility: Vaccines and Beyond” is an ongoing series written by two close friends with a passion for improving community cohesion and building respectful relationships in a diverse world.  This article was co-created by Karen Crisalli Winter and March Twisdale.   BLOG:  Vaccinesandbeyond.blogspot.com   Email:  KarenandMarch@rocketmail.com

A Community Conversation - Part 5

A Community Conversation About Health and Responsibility: Vaccines and Beyond

Part 5:  What is Science?   

The term “science” is widely misunderstood by most people.  “Science” does not mean lab coats and test tubes.  It does not mean dissecting frogs and reading textbooks.  It does not mean advanced degrees and multi-million dollar labs.

Science is simply a set of rules for organizing thoughts and information.  If these rules are applied correctly, errors in thinking become obvious.  This gives you a chance to adjust your thinking to more accurately reflect reality.  Science also scales well.  It works at the individual level.  It works at the community level.  It works at the global level.

Let's give a more specific example.  Suppose that you read some books on foraging and decide that dandelion greens sound delicious.  You are out in your yard one day, eating a sandwich, and spot a dandelion green.  You put it in your sandwich and take a bite.  After chewing for a bit, you make a decision as to whether dandelion greens are, in fact, delicious.  Then you tell your friends.

That's science....let me explain why.

You did some background research which indicated that dandelions could be easily identified, were not toxic, and might taste good.  You developed a testable hypothesis that stated “Raw dandelion greens in my sandwich might be tasty to me.”  You did a controlled experiment (sandwich with dandelion green vs. sandwich without dandelion green).  You analyzed your data and drew a conclusion.  Then you communicated your results.

Incidentally, I have done this experiment.  I have concluded that raw dandelion greens taste bad.  To me, that is.  I have no scientific data for other people.  Except my children.  They think raw dandelion greens taste bad too. 

Another backyard scientist might point out that the taste of dandelion greens changes dramatically with the seasons.  I would then have to concede that my hypothesis had left out important data.  I would modify my conclusion to read “dandelion greens taste bad to me in the summer.”  I might do another experiment in January.  Or I might decide I was no longer interested in this particular scientific experiment and move on to hypotheses regarding different cookie ingredients.

Like many things, science is defined by the rules.  So is baseball.  Baseball is baseball as long as you follow the rules of baseball.  Baseball does not require hot dogs, giant stadiums, fireworks, and million-dollar player contracts.  It's still real baseball if you're playing on a dirt field with no spectators.  Baseball is baseball.  Science is science.

The rules of science are not that complex and it doesn't take a lot of education to apply them.  Small children can learn to do high-quality science.

However, even simple rules can get broken, forgotten or misunderstood.  This is why baseball has umpires.  This is why any good game handbook has two sections: the basics of the game and the nuances of how to deal with specific and unusual situations.

Science is much the same, with one critical difference: there's no single umpire.  Instead, there are many umpires.  Other scientists serve as umpires for the most complex aspects of specific scientific studies.  But there is another group of people who hold some responsibility to act as umpires for science.

Us.  You and me.  Yes, we all have a right and responsibility to ask questions about science and call foul if we see some serious rules violation.

Imagine you were at a baseball game in a big stadium and watched a player skip first and second bases completely.  Instead, the player just ran out to third base and ran back to home.  The umpire declared it a home run.  Do you suppose that everyone would just nod politely and cheer?  Not likely!  The stadium would ring with shouts of outrage...probably from fans of both teams!

Of course, not everyone is a fan of baseball.  You may not know or care about the rules of baseball.  So why should you know and care about the rules of science?

First of all, doing basic science at home can make your life better.  Science enables you to test what will work best for you in your life and to recognize what will not work well.  Does the more expensive product work better than the cheaper product?  Do you actually need any product at all?  Do an experiment and find out!  This kind of experimentation can save you thousands of dollars.  What forms of discipline are most effective with your children?  Do some experiments and find out!  Setting up genuine experiments and honestly examining the data can save you countless hours of stress and grief. 

Obviously, certain areas are not suitable for home science.  Subsistence farmers cannot do a lot of experimenting, because a crop failure would mean starvation.  Hobby gardeners can do experimentation, since they can always buy food at the grocery store if their crop fails.  Any real experiment may confirm or disprove a hypothesis.  If the results of a disproved hypothesis would be catastrophic, leave the science to people with a greater tolerance for risk.  Tasting a dandelion to see if you like it is a completely reasonable scientific experiment.  Tasting a random plant to see if it is poisonous may be scientific, but it's also a bad idea.

But why should you care about professional science?  For one, professional scientists can sometimes do the experiments that are too risky or too expensive for home scientists.  They can also work with much larger sets of data and come up with results that can be applied to a wider range of situations.

More significantly, you should care about professional science because it affects your life.  Unlike professional baseball, scientific claims are being used every day to influence and even control your choices.  Science is used to justify laws and guide health care.  Scientific claims can be found in nearly every newspaper, often with instructions on how to modify your life based on those scientific claims.  Science is used to claim both truth and morality.  Whether you like it or not, science is a significant force in your life.

Learn the basic rules of science and apply them in your life.  If you see someone making a scientific claim, do your due diligence as an umpire.  Pseudoscience is philosophy dressed up in a costume to look like science.  Don't be fooled.  Bad science is science that has (intentionally or accidentally) broken some of the basic rules of science.  Don't be fooled.  Bad reporting is a newspaper article that takes a real scientific study and simplifies or distorts it beyond all recognition.  Don't be fooled.  See our blog for more information on recognizing pseudoscience, bad science, and bad science reporting.

Real, high quality science is a powerful tool.  Don't let the charlatans and counterfeiters deceive you.  Do your due diligence as both a citizen scientist and as an umpire.  You deserve real science.  Don't settle for less.

“A Community Conversation About Health and Responsibility: Vaccines and Beyond” is an ongoing series written by two close friends with a passion for improving community cohesion and building respectful relationships in a diverse world.  This article was co-created by Karen Crisalli Winter and March Twisdale.   BLOG:  Vaccinesandbeyond.blogspot.com   Email:  KarenandMarch@rocketmail.com