Making the right choice

NARENDRA ARORA

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AS both a doctor and a public health professional, I am transfixed by one compelling question: Why are public health issues and debates so often limited to just doctors and those with abbreviations like MBBS, MD, MS or MPH added to their names? Does the ambit of health not extend to other areas of specialization and expertise?

Georges Clemenceau, Prime Minister of France in the early 20th century, once famously remarked, ‘War is too important to be left to the generals.’ Likewise, thought and ideation on public health, debates and discussions on available options, choices and technologies, fall not just in the domain of doctors, medical practitioners and public health specialists. They intersect various disciplines.

Take the whole business of medical research, of poring over literature, of hours and hours and years and years of study. What are its benefits? Is the cost-benefit ratio worth it? Wouldn’t empiricism be a better strategy? I am often asked these questions by friends and at social gatherings, and frankly they are not new. They have been around for hundreds of years and are a sub-stream of the history of healing.

The tackling of an illness is not a one-stop, one-shot affair – though it may often seem that way to the patient who takes a jab or pops a pill and begins to feel better within a few hours. Yet, this end process is the product of striving, of a constant, continual battle against disease where there have been successes and there have been failures – new treatments and drugs, and better treatments and drugs, and breakthroughs in preventive technologies.

The impact of this – the slow gains and dramatic successes, the setbacks and failures – is felt by not just researchers tucked away in a laboratory in the middle of the night, or reading under a dim light at four in the morning, it has a value in terms of lives, longevity and economics. As such, its effect is measured by demographers, economists, public policy framers, food security specialists, urban planners, and those working in a dozen other fields.

Vaccines are an example of just such a breakthrough technology. They constitute a major advance in humankind’s battle against disease. The eradication of smallpox and imminent defeat of polio are milestones in this ceaseless, relentless journey, one in which vaccines have proved an accelerative force. Whatever the critics may say, vaccines have made a difference to those at maximum risk of exposure and debilitation due to an individual disease.

Vaccines are not just a medical professional’s favoured device – his or her hobby horse as it were – but a genuine cross-cutting tool. That’s why the importance of vaccines has come to be recognized not just by doctors, but by a variety of stakeholders concerned with issues of social development. Vaccines are now a necessary imperative of the development process.

I began my career as a paediatrician and the need for vaccines for new-borns and little children was obviously a feature of my professional life. Today, I work at the interface of public policy and social good on the one side and public health on the other. Here too – or even more so – vaccines are essential to the conversation and to that interface.

 

Why? The answer is disarmingly simple, and not one related to complex issues of vaccine delivery systems and manufacture. It actually flows from a simple recognition that treatment is a more hazardous, unpredictable and imponderable-dependent phenomenon than prevention.

Take an everyday example from a paediatrician’s life. If he or she has to treat a case of pneumonia, success is contingent on a whole host of parameters, many of which are not in the paediatrician’s control. Will the mother take the child to the doctor at the right time? Will the paediatrician diagnose the problem correctly and begin the right course of treatment? Will the economic burden, family concerns and social or personal anxieties of the child’s mother and father allow them to complete the course of treatment optimally?

Here medical science begins to engage with social reality, and more dangerously, with game and probability theory. The paediatrician is soon out of his or her depth – the correct diagnosis and treatment is necessary for the child’s recovery, but may not be sufficient. This appears even more terrifying when one considers that pneumonia can be an eminently preventable or treatable situation.

What would happen though if the paediatrician were to consider the case of saving a child from measles or from diphtheria, pertussis (whooping cough) and tetanus – DPT, to use the familiar abbreviation? The measles and DPT vaccines are part of the regular course of immunization for children in India. When a doctor encounters a sick child, if he knows the child has undergone an immunization regimen, he can with a degree of high probability rule out measles or DPT. The process of vaccination is a planned activity, leaving nothing to chance and pre-empting any anxiety at a later stage. For a paediatrician, it changes the odds considerably in favour of the suffering child and her health and well-being.

 

When I offer this reasoning to friends, they nod sagely and comment that immunization rates will increase with education, that as literacy and schooling levels move up in our country so will awareness about health needs and, therefore, vaccines and vaccination. I have no real argument against this but would like to point out that there is no automaticity to the logic that perception of immunization needs and socio-education status are directly proportional.

I would like to explain this with an example. In a sense, the principal decision maker as to whether a child should be immunized or not is the mother. Recognition of the benefits of vaccination or a preventive health technology is easiest for a working mother, one who is not at home 24/7 to care for an ill child, and who detects an opportunity cost in not anticipating a health problem for the child.

If you consider the Indian labour market, working women are found in the upper echelons of society and in the poorest sections. The first segment comprises extremely educated women; the second segment comprises under-educated or even illiterate women for whom working and earning those extra few hundred rupees is crucial to supplementing the husband’s income, paying for a child’s schooling or additional set of clothes and so on.

In between there is a vast middle class – in which women may or may not be very educated, but many of whom are neither socially conditioned nor economically driven to pursuing careers and going out of the house to work. Tens of millions of such women see the domestic arena as their domain, and caring for unwell family members and nursing them to health as a legitimate, non-negotiable and immutable obligation.

Assessments that I have been part of have taught me that the third category is sometimes slower to accept the utility of immunization. As such, far from simply educational levels and college degrees, immunization decisions are driven by need based notions and an enlightened self-interest.

Many years ago, I read a book on Adam Smith and the evolution of classical liberal economic theory. It struck me then that there were impressive commonalities between how individuals and societies exercised economic choices – and how parents and families took immunization decisions.

 

Nevertheless, one would have to acknowledge that there is a strong and vociferous anti-vaccine lobby, both in the West and in countries such as India. I have little sympathy for it and believe its claims are rooted in a misguided interpretation of science. In a few countries, such groups have caused the reintroduction of vaccine preventable diseases with loud and shrill campaigns.

In the United States the government advises that by the age of six, children should be vaccinated against 14 diseases. A national survey published in October 2011 in the journal Pediatrics, found more than 10 per cent of parents rejected and deviated from the recommended schedule. In some cases they delayed shots and in others they ignored them altogether. This potentially put two million infants and young children at risk against diseases that were entirely preventable and could prove fatal.

As an aside, the fact that this is happening in the world’s richest nation, and involves parents who are likely to be wealthy and educated, only validates my contention that socio-economic status and enthusiasm for immunization don’t automatically travel in parallel. In many cases in India, for instance, there is a strong and genuine demand among poor parents for vaccines for their children. Unfortunately, the system comes in the way of these underprivileged families getting access to vaccines they need.

 

What is the history and basis of the anti-vaccine movement – fringe and small as it may be – in India? The introduction of the first six odd vaccines in India under the Expanded Programme on Immunization was not a problem. Murmurs started only in the 1980s with the first discussions on the need to introduce the measles vaccine. Advocates for the measles vaccine, some of them among India’s finest public health specialists, contented there was evidence of the impact and swift decline in cases and mortality in societies that had used the vaccine. They were challenged and disparaged, asked to produce evidence of the extent of the measles problem in India.

Today, 30 years on, the debate has been settled. We know the measles vaccine has been efficacious, that millions of children have been saved and that someday in the foreseeable future young Indians will cease to encounter measles at all. Sadly, the template of the argument back then – on whether the measles vaccine was necessary or not – is still with us.

The nub of the matter is this – for many diseases for which vaccines are available, authoritative epidemiological data is not available. However, empirical evidence and the experience of medical practitioners and public health professionals makes it clear that these diseases touch significant sections of the population and that the use of vaccines will make a difference. Should one wait for epidemiological data collection mechanisms in India to become world-class – which they are not at the moment – or should one make an intervention that will save lives? The dilemma boils down to that. To my mind, there is only one answer.

 

Take pneumonia. There are two bacterial vaccines directly useful against pneumonia – the Hib vaccine and the pneumococcus vaccine. (Admittedly the influenza, pertussis and measles vaccines also guard against pneumonia.) Hib vaccine use has proved very effective wherever it has been deployed. It has more or less eliminated meningitis – caused by the bacterial infection – in many countries.

Such infections are very prevalent in India. There are various estimates as to the extent, but the actual proportion is not known. Even so there is compelling indirect evidence. Pneumonia due to the pneumococcal infection is widespread in India and INCLEN itself has done studies related to this. That aside, almost half of pneumonia cases among children in India are caused by bacteria and the patient recovers after taking a course of antibiotics. By inference, we know there is a space and a need for vaccines.

That is why, when anti-vaccine constituencies say we don’t know the burden of disease of an individual organism, they are right only within a narrow prism. True, we only have modelling studies. Nevertheless, the indirect evidence is so strong that it only offers a stronger justification for studies that will help us make a reasoned and precise estimate of burden of disease for these two organisms. Merely opposing introduction of vaccines is running away from the real problem and not helping the cause of public health.

 

It is sometimes easy to forget that public health is at the end of the day a summation of the health of millions of individuals. No doubt we ask several legitimate questions: Can we estimate the actual benefit of a vaccine? What will be the quantum of lives saved? Will it save 200,000 lives a year or only 50,000? How will it help? What is the economic value it will add to GDP?

To a child who is in risk of contracting a vaccine-preventable disease, however, there numbers and guesstimates don’t matter. His or her parents will never ask: Will my child be in the 50,000 or the 200,000 or outside? Life is not a statistic.

Vaccines and their presence or absence have several ramifications that we don’t often consider. For instance, there is an impact on disease control beyond the specific infection vaccinated against. In the six weeks following measles, there is a four to six-fold greater risk of the child developing blood dysentery. This can kill children. However, if the measles vaccine has been given to the child, the organism is not able to invade, the measles outbreak does not happen and cannot weaken immunity – and the blood diarrhoea does not occur.

This was actually one of my earliest lessons on the collateral impact of immunization. Thirty years ago, in the early 1980s, I was part of a team that began an ORS programme in a poor community in Faridabad (Haryana), just South of Delhi. We encountered a considerable outbreak of blood diarrhoea, which children developed due to shigella. Looking for a long-term solution, we realized that measles vaccination coverage was poor in the community. We began a measles immunization campaign – and soon enough the results were there for all to see.

There are so many other examples. All infections can lead to malnutrition – the child doesn’t eat, the parents may have to make a choice between treatment and nutritious food as they lack the monetary means for both. Whatever the reason, the fact is nutrition suffers, and this is so common in socio-economic settings in which India’s poor live. If you prevent the entire episode of illness, are you not making a big change?

We have to get away from the mentality that vaccines simply prevent death. That is certainly true, but an equally important impact is in reduction of morbidity (burden of disease) and in diminishing of severity of disease (resulting in fewer cases of hospitalization).

 

Indeed, immunization and vaccination hold the key to how long we live, the work we do, and the quality of life we lead in more ways than is commonly imagined. Non-communicable diseases are a growing public health concern in not just developed countries but increasingly in the emerging economies of Asia, such as India and China as well. What role could vaccines play here, one may ask? NCDs are, after all, usually associated with sedentary lifestyles and changing eating habits, problems that are not quite vaccine preventable.

One could be surprised. A study in the United States pointed out recently that senior citizens given the influenza vaccine had a 20 per cent lower chance of being troubled by cardiovascular disease, and half the chance of mortality as compared to a person of the same age who had not taken his ‘flu shot’.

 

One of the critical and thorny components of the immunization debate is the phenomenon of AEFI: Adverse Events Following Immunization. There are people who use the occurrence of AEFI to disparage specific vaccines, if not the entire process of vaccination. Consider the situation. An otherwise normal child is injected with something (a vaccine) that is meant to prevent disease. Instead he becomes the hub of an adverse event, and perhaps dies. This is a potent weapon in the hands of vaccine opponents. Any statistical assumption about lives saved – 200,000 lives or 50,000 lives or whatever – is blown to bits by simply one child dying due to an AEFI.

Why do AEFI occur? Occasionally these are due to programme errors – such as some of the 30 or so deaths following measles vaccination in India in the past four years – or due to rare allergies that affect an individual child. Certainly, we need to provide for care for children who may suffer a rare allergic reaction following immunization and learn to anticipate these wherever feasible. Overall, however, we have to weigh the frequency of AEFI occurrence against the broader societal benefit.

Infant mortality in India is about 47 per 1,000 births. There are 25 million infants born in the country every year. This means a million children in the zero to one year age group die each year. This amounts to over 100 children dying every hour. Now do consider that an AEFI death is any death of a child within four weeks of being immunized. Given that 100 children below the age of one die every hour in India, it is very probable that many of the AEFI deaths are coincidental deaths – tragedies that would have occurred anyway.

This is not to discount cases of AEFI but only to place them in context. India needs a robust mechanism for surveillance of AEFI. All serious events of this type need to be assessed for causality. In the past four or five years, there have been major improvements in AEFI surveillance. Reporting has become more rigorous, and more cases are being recorded. This has also led to more AEFI cases and deaths being collated. It does not mean vaccination and immunization is becoming more deadly.

To draw an analogy, consider a police station that starts honest tabulation of First Information Reports (FIRs) in its precinct. It would appear that there has been a spurt in crimes. Actually, the number of crimes may be the same or may even have come down, but the FIRs are now reflecting a realistic picture.

Exactly the same phenomenon was noticed when polio surveillance of immunization related events was stepped up in 1997. There was a surge in cases for two or three years – reflecting honest reporting – then a plateau, followed by a decline. After a robust system is set in place, programme errors decline and AEFI occurrences become infrequent.

 

A healthy childhood would make it more probable that the youngest in this country have fewer handicaps to cope with when they reach adulthood, and so can contribute to the prosperity of their society. Immunization facilitates this journey.

However, there is no inevitability to this evolution. It can be helped – or hampered – by a set of choices taken or not taken, by investments made or not made, by public health systems scaled up or not scaled up, by vaccines embraced or not embraced. India is at the cusp of many such once-in-a-lifetime decisions. May it choose wisely.

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