The Medicine

If you work in a public hospital, you know that winter will bring overflowing wards, staff shortages and incessant phone calls from the infection-control unit until you finally front up for your flu shot. The program is designed to protect us from infecting our patients. I’m ashamed to admit it but I avoided getting the vax my intern year. I’d overheard my senior registrar refuse. She backed away from the roaming flu-vax nurse, saying she had a cold and was worried she’d develop Guillain-Barré syndrome (GBS) were she vaccinated. I was more scared of GBS (sort of like polio) than of the flu, so I spent that winter dodging the vaxxers. Had I bothered to actually check the risk of GBS I’d have discovered it to be vanishingly rare, and more often a complication of actual flu. But it’s funny how easily a scary rumour or half-understood belief can overwhelm logic, science and common sense. I once shared an office with a specialist who was a hard-nosed positivist about all medical matters except for his refusal to vaccinate his children or eat food heated in a microwave oven, and his belief that a particular pot plant he kept on the filing cabinet was absorbing our computers’ harmful electromagnetic radiation. When it comes to self-protection it seems the human animal is particularly vulnerable to magical thinking. We had a bad flu season this year. The wards were full of people with Influenza A rasping, “But I had my flu shot!” It wasn’t because this year’s strain was especially virulent. It was mainly because this year’s vaccine didn’t provide good cover for the main strain of Influenza A that ended up in circulation: a type (H3) that’s hard to grow in labs, more inclined to “antigenic drift”, more likely to affect the old and the very young. Determining which three or four strains to include in each year’s vax is a work of prediction that requires a massive global effort. It’s tricky, because the circulating strains frequently change. The final viral contenders are chosen at the biannual World Health Organization meetings where scientists from all over the world share data collected from what is a continual, global surveillance of circulating influenza strains. The strains to be included in Australia’s 2018 vaccine, for example, were determined in September this year – because it takes about six months for licensed pharmaceutical companies to make the vaccine from prediction to syringe. The influenza vaccine is made inside fertilised chicken eggs. (Hundreds of millions of eggs are used each year.) The eggs are infected with the flu virus, incubated for a few days until (much like crowded trains in winter) they’re fit to burst with virions (virus particles). The fluid inside the eggs is then sucked out, the virus is rendered inactive, then the viral antigen is extracted and put into syringes. When we’re injected, our immune system produces antibodies to the viral antigens so that if we’re hit by that particular strain of flu we can annihilate it before it turns us into a bed-bound wreck. In a normal year there’ll be a 50% success rate, which – all things considered – is pretty good. I thought all this collaboration was a straight-out global good news story when I first heard about it. I imagined a bunch of colleagues huddled in a warm WHO room, sharing notes, predicting influenza patterns, and keeping their eyes on viral strains in ducks and pigs that might leap into humans at a moment’s notice and lead to global pandemics. A pandemic (or global outbreak of an infectious disease) occurs when a virus that our immune systems have never encountered starts to circulate. There have been influenza pandemics every few decades for the last 450 years. The Spanish flu of 1918–19 infected a third of the world’s population and killed tens of millions of people. Protecting the world from catastrophe requires everyone involved to use the kind of social skills taught in kindergarten: cooperation, veracity, a willingness to share. But even kids know that our capacity to act in these ways may be hampered by things like hunger, fear, poverty, or the promise of stacks and stacks of cash. Globally we have the capacity to produce a few hundred million influenza vaccines each year and a population of 7.5 billion. If there’s a need for a pandemic-preventing vaccine, who gets the protection? The last time WHO actually declared an influenza pandemic was in response to the 2009 Influenza A (H1N1), or “swine flu”, outbreak. Thankfully, the virus turned out to be far less virulent than was at first feared. However, WHO’s declaration triggered a mass automatic and pre-contracted buy-up of vaccines and antiviral drugs by (the wealthier) governments worldwide, costing many billions of public health dollars. It was later revealed that some of the experts advising WHO received funding from the pharmaceutical companies that benefited from the decision (those who manufactured the vaccines and anti-viral treatments). Further, the efficacy of antiviral treatment drugs had been overstated in the drug-company trials and – unlike vaccines – are of uncertain benefit in a pandemic situation. WHO recently removed the main one (oseltamivir, aka Tamiflu) from the list of essential medicines, but not before it generated sales of US$18 billion for Roche (half of which came from government stockpiling). That profit-seekers will attempt to infect and misdirect the actions of our governments and international organisations is well established. (Think of coal and tobacco, for example.) In matters of global significance, the conflicts of interest that can arise from industry infiltration, partnerships or “market-based-solutions” – whether declared or not – could be disastrous. Vigilance is essential, because when it comes to public health, the belief that big business would voluntarily forsake profit to save us is, like the pretty plant on the filing cabinet, just magical thinking.