the vaccine war



Tom Delbanco, M.D.
April 29, 2010 11:09
Tom Delbanco M.D.A professor of medicine at Harvard Medical School and a primary care physician at Boston's Beth Israel Deaconess Medical Center, he also served as senior consultant for this program.

From the words flying back and forth, The Vaccine War has got more than a few people riled up. Infections, tragedies, and public health debates rarely lack controversy. But recall also that a few months ago the world was in uproar about Swine Flu. How bad would it be? How widespread? Would the vaccines work? When would they arrive? Who should get first crack at them ... the elderly, the young, pregnant women, health workers? Everyone was on edge, including us, the primary care doctors who'd help deliver the goods once they arrived.

I can't remember pundits asking a question that proved at least as important: Who'd say "yes" or "no" once my needle was ready? Turns out an awful lot of people refused the shot, and that wasn't limited to parents who believe vaccines mean trouble. It included more than a few health professionals. I have several in my practice: brilliant scientists, analytic thinkers, professors ... I asked them to explain their saying no, but most refused to give a reason.

I met with Norman Letvin, a famed vaccine scientist at my hospital who leads a large team of talented scientists working feverishly to prevent HIV infection. He startled me: A majority of his younger colleagues were avoiding flu shots despite his urgings and our hospital's fervent efforts to vaccinate its entire workforce. He smiled, looked frighteningly scholarly, and asked me why I thought this was happening.

First, I guessed fear of serious side effects, such as Guillain-Barre syndrome: enormously rare, but frightening as paralysis spreads (usually self-limited, with most recovering fully over time). Wrong. Next guess was lack of efficacy; his colleagues understood vaccines better than I ever could and didn't think this one would work. Wrong. I tried again: they thought the flu would be milder than most expected. No. What about quiet rebellion against authority's urgings? Wrong again. I gave up.

To paraphrase his highly scientific insight: "People are afraid of shots. Shots hurt. No one likes a shot!"

He may be right. Not only do parents (and clinicians) hate watching kids cry as the needle goes in, but I struggled and failed again recently to convince one of my long-term patients to switch to insulin injections. In his 50s, with more than 15 years of diabetes, a history of ineffective pills and unpleasant side effects, his blood sugars are much too high and his kidneys are becoming damaged. Yet he refuses shots that might both help him feel better now and turn things around long-term.

I'd love to hear Freud and Pavlov speculate about shots. Is the fear genetic (why are many terrified of snakes right from the start)? Is it conditioned by early childhood vaccinations? Deep down, are people afraid of crying? Are shots assaults? Do we believe the arm or buttock will hurt forever?

I suspect Norman may be right, but if so, why? What do you think?

posted april 27, 2010

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