Despite a legacy of scientific misconduct,and the usual complexities of conducting science across cultural differences, people in countries across the world volunteer for vaccine studies.
Why? What motivates them? What are their fears?
Medical anthropologist Sienna Craig, I and our esteemed colleagues recently investigated. Check out our new paper, here in BMC Public Health.
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.
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.
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.
Midway through her sophomore year of high school, my patient told her parents that she had missed two periods and was worried she might be pregnant.
Stunned to learn that she was sexually active, her parents took her to the pediatrician, who had another surprise: She wasn’t pregnant but she did have H.I.V.
To learn more - including how my patient could have been protected from late H.I.V. diagnosis by a cool mobile app - check out my new post up at The New York Times. Many thanks to support from Dartmouth Public Voices Fellowship, a chapter of the Op-ed Project.
Ebola is on the run: the number of cases dipped below ten a week recently, and a few days ago investigators announced in the prestigious journal The Lancet that a new Ebola vaccine was “100% effective.”
In response, global health authorities are starting to sound a little giddy. “We believe that the world is on the verge of an efficacious Ebola vaccine,” said Marie Paule Kieny, the World Health Organization’s assistant director-general for health systems and innovation (and a senior author on the paper). “It could be a game changer.”
She’s right: this is wonderful news, and a great testament to human ingenuity. A genetically engineered hybrid of the benign vesicular stomatitis virus and the Zaire strain of Ebola, together called rVSV-ZEBOV, was tested in a multi-site clinical trial conducted amid a massive aid response in Guinea, one of the poorest countries in Africa. The scientific and logistical acrobatics required to pull this off boggle the mind.
Yet, for three reasons, we cannot know if the vaccine really worked, or how well.
To read more, check out my new post over at The Conversation.
The AIDS activist Larry Kramer once said,
AIDS was allowed to happen. It is a plague that need not have happened. It is a plague that could have been contained from the very beginning.
The past 10 years we have witnessed innumerable incredible advances in HIV science and HIV treatment, but Mr. Kramer's words still ring true. We could have done more to stop it, and we still leave a lot of the work left undone.
This is particularly poignant since new challenges have now joined the old scourges of poverty and stigma and the wily habits of a historically pernicious virus.
These new challenges include what one of my patients called the "Peter Pan Syndrome" and an uptick in injection drug use in many areas of the United States. The Peter Pan Syndrome is when patients told they did not have long to live at the beginning of the HIV epidemic now grapple with the accelerated effects of aging, a phase of life they never thought they would face. Additional challenges include complacency in youth who didn't grow up losing friends from HIV, and donor fatigue, and the short-term thinking of budget-conscious legislators who cut funding to HIV prevention programs that save lives.
These and other modern realities of the 2015 HIV epidemic are on full display in a new article in the Concord Monitor in which I was proud to be quoted, including:
The most pernicious myth in the HIV epidemic today is that people infected with HIV contracted the virus because they are somehow different – that in some way people with HIV deserved to get infected. This is hard-hearted and ill-informed, but I understand how the finger-pointing can be a defense mechanism against fear. The truth is, we are all vulnerable to this wily virus, and the only way we will win against HIV is to band together in compassion.
Twenty years from now will we look back and say we learned from our early mistakes, or will we rue the mistakes we made again and again?
Thirty years ago today, on March 2, 1985, the Food and Drug Administration approved a new HIV test. It was the result of nine months of round-the-clock labor by dozens of scientists. Immediately adopted by the American Red Cross and other institutions, the blood test marked the beginning of a new era in HIV medicine.
Since then, so much has changed. Check out my new post at The Conversation to learn more.
I was honored to have my thoughts included with those of luminaries like Anthony Fauci of the NIH in The Atlantic's year-end review of lessons learned from the 2014 Ebola epidemic. Click here to read the whole article by Julie Beck.
The first time I did CPR, coagulated blood spurted onto my new white coat from a wound in the patient’s chest. Another time a patient’s urine soaked through the knees of my pants as I knelt at his side.
Even in the best of conditions, cardiopulmonary resuscitation (CPR) is a spit-smeared, bloody business that can expose health care workers to all kinds of body fluids. Like all health care workers, I put on gloves and a game face and accept such things as part of patient care.
The 2014 Ebola outbreak changes all that. It is much more dangerous for clinicians to resuscitate patients with Ebola. As a result, should we skip CPR altogether? Bioethicist Joseph Fins of the Weill Medical College of Cornell University recently suggested we should.
I disagree. See my rebuttal at Health Affairs. What do you think?
Tim Lahey, MD MMSc
An HIV doc and clinical ethicist, I write about medicine, ethics, and HIV here and in The Atlantic, Scientific American, TheBody.com, Health Affairs blog, The Conversation and The New York Times.
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