What's the best way to incentivize immunizations?

Vaccination saves lives.

Yet, resistance to immunization has become entrenched in some sociodemographic strata. Wealthy, educated liberals who care about organic food and "natural" products among them. 

Under-immunization of school-aged children in turn has led to outbreaks of measles and other transmissible infections, and contributes to  thousands of preventable influenza deaths in children each year. 

It's not enough to tout the benefits of vaccines, and then stand back with syringe in hand. Potential vaccines want to know vaccines are safe, and hear misconceptions about the low risks of vaccines. A seminal article by my Dartmouth colleague Brendan Nyhan showed that trying to disabuse vaccine skeptics of their misconception too may fail. 

Many states and countries are piloting various incentive programs designed to enhance immunization rates without engaging in potentially polarizing debate. From making immunizations mandatory to attend school to linking welfare benefits to vaccine receipt and even straight up cash incentives, lots of experiments are happening. Some of them even work.

Check out this great article by Susan Scutti of CNN and its accompanying video. I was proud to be quoted in it.

Let Opioid Users Inject in Hospitals

It is a new world in health care as America grapples with an epidemic of opioid drug abuse. The Centers for Disease Control and Prevention reported that opioid overdoses killed over 28,000 people nationwide in 2014, more than ever before.

From heart-valve infections to drug overdoses, the casualties of this epidemic wash up in our hospitals. It has changed my hospital service significantly. Almost every day, we try to save a young person dying from infectious complications of injection drug use.

Addicted patients usually bond with their providers over the shared goal of healing. Yet these interactions, which often bridge divides of class, culture and personal psychology, can break down. When addicted patients inject drugs in the hospital, doctors and nurses can find themselves cast in the role of disciplinarians, even jailers.

Confining patients to their rooms, restricting their activities and posting guards is expensive. It may also compromise a patient’s well-being: Ambivalent providers may visit less often, educate patients less avidly and spend less time devising the best treatments.

The worst effect of confining addicted patients in the hospital may be the damage to the patient-provider bond. 

To read more, including my proposal to let opioid users inject in the hospital, check out my new op-ed at The New York Times. 

Also, check out my new 8-minute radio spot about the topic at for Word of Mouth by Virginia Prescott at NHPR. It was also a trip to appear on Sirius XM's widely-syndicated Michael Smerconish show, although a recording has not been archived. The controversy the post created was nicely covered in Concord's Union Leader.

Vaccines just aren't as easy to discover as they used to be

Edward Jenner had it easy. Swab some cowpox in 1796, scratch the nastiness into the arm of a little kid (see below), and, PRESTO, instant immortality. 

Vaccine success after vaccine success followed. Measles, mumps, rubella, polio... one after another global scourge quaked before the mighty pipettes of vaccine researchers.

I admit, the stalwarts who discovered those vaccines did more than transfer cow-pus to an un-consented minor research subject prior to doing a victory lap around the farm. Rather, they earned their laurels by working hard, and by being brilliant.

But ease wrought hubris, and as deadly viral menaces fell in succession, you could forgive one noted twentieth century sage, US Surgeon General William Stewart (pictured below), for saying, "It’s time to close the books on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease."

Whoops!

These early triumphs gave way to a long, hard slog. Vaccines against HIV, tuberculosis, herpes, staphylococci, and hepatitis C, among others, have proven far more elusive. Amid small successes, and spectacular failures, we have discovered an uncomfortable fact: we don't really know what makes a good vaccine tick. 

This week I was glad to contribute both heat and noise to the mix. In an op-ed in the Health Affairs blog, I write about the dangers of dogmatism and the lessons learned on the road to a new HIV vaccine. And, we also published preclinical data this week on a new scalable version of our tuberculosis vaccine. Data from our Phase 1 trial of the same vaccine should come out soon!

Who knows if all this will lead to glory. Probably not! Either way, it's been a pleasure to try. 

Lessons learned from a beatbox heart

Jimmy’s mother cries in the corner. She holds her hands up and open, the way you might receive a baby.  Or, the way you indicate helplessness when your baby is now addicted to heroin and shivering in a hospital bed.

Jimmy’s heart is failing.  Antibiotics alone will fail him.  Soon a surgeon will open Jimmy’s chest, cut out his heart valve, and sew in a new one.  I say this as gently as I can.

Standing with a medical student beside me, I try to teach about the physical exam. About compassion. About how to respond when a young man who hasn't opened his eyes for minutes suddenly does, and says something frightening. 

Check out my new essay at ReflectMedEd for more.

World AIDS Day 2016

As World AIDS Day approaches on Thursday, there is so much to be thankful for, and so much work yet undone.

People with HIV on effective treatment live as long as those without HIV, and almost never transmit HIV to their seronegative partners. Pre-exposure prophylaxis (PrEP) is safe and it works, and through it and other means of prevention we are slowing the epidemic, bit by bit. This fall a new vaccine aiming to build on the RV144 success story began testing in South Africa.

Despite those massive successes, 2 million more people are newly infected with HIV every year. Less than half of the world's HIV-positive population can access HIV therapy. In the United States, only 30 percent of people with HIV achieve the goal of full virological suppression on medications. A substantial fraction of people living with HIV don't know they are infected, and stigma is still a problem for people with HIV.

HIV is the defining health threat of our day. We have made real progress, but we cannot be complacent. It was a honor to discuss these issues and more for NHPR's Exchange radio show.

Wait for it

At 94, my patient V. was funny and flirtatious.  Her French accent made even the name of her life-threatening fungal infection sound poetic.

“DEE-seminated HEESTO-plasmo-sees,” she said, “Oaf the skin.”

I smiled.

I also admitted her to the hospital because our treatments were not working.  

What I did next, though, surprised both of us. To read more, check out my new article at the great blog Reflective MedEd.

Pervasive HPV myths that keep us from preventing cancer

Human papillomavirus causes hundreds of thousands of cases of cancer each year, yet the uptake of safe vaccines to prevent those cancers has been mindbogglingly slow.

I was glad to be quoted in a Reader's Digest story called "10 Myths About HPV That Could Seriously Damage Your Health."

Opioid contracts can backfire on patients

The US Senate recently passed legislation designed to address the nation’s opioid addiction epidemic, and President Obama is expected to sign it into law. Among other things, the bill promotes the use of opioid contracts. These are written agreements between doctors and patients about the conditions for prescribing opioids long term for chronic pain.

This is great news. It could also harm patients. My patient, Cindy was a perfect example.

To hear what happened, read my new article at The Boston Globe's new publication STAT.

Giving patients what they want, even if the doctor doesn't have the time

Doctors struggle to find the time to have in-depth conversations with their patients. Patients, in turn, don't share their end-of-life preferences with their doctors, which leaves them vulnerable to getting more aggressive care than they want. It also wastes a huge amount of money. 

In my new article, I confess a time I contributed to this problem, and point to a really exciting new solution. Harvard researchers, conducting a huge study across the state of Hawaii, have now proven a new way patients can get their wishes respected even if their doctor doesn't have as much time as they want. Online videos about end of life decisions. The videos are outstanding, and proven to work. Plus - bonus! - they saved the system money. 

It's win-win. Check it out!

Will legislators defuse the ticking time bomb of dirty needle use?

For years, Indiana had slowly dismantled its public health system, and needle exchange programs lacked both funding and legal safeguards. Then an HIV outbreak exploded into public view, and Republican Governor Mike Pence had to do some fancy footwork to undo the damage done. He allowed needle exchange programs to operate and provided some long overdue prevention funding. In the meantime, dozens of young Indianans were infected with hepatitis C and HIV. It was a sad case of politics overturning science and common sense.

Now, New Hampshire and other states are in the same boat: politically-minded legislators bloviate about punitive anti-drug stances while the opiate epidemic rages. Complications of injection drug use are on the rise, and it's only a matter of time before a new HIV outbreak comes to town. Needle exchange programs, proven over and again to prevent infections and thus to save lives, languish in the legal shadows.

Fortunately, new legislation is being considered to change help catch New Hampshire up to the 21st Century, and maybe save some lives in the process. I was proud to be quoted here about this overdue change.