The Medicine

The Monthly (Australia) - - NEWS - by Karen Hitch­cock

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.

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