HIV and ID Observations

My ID colleague Dr. Adam Ratner, Chief of Pediatric ID at NYU Medical Center, just published an insightful and remarkably timely book called Booster Shots:  The Urgent Lessons of Measles and the Uncertain Future of Children’s Health.

Chapter Six is entitled “Making Nothing Happen,” and it starts off with this especially profound paragraph:

Prevention can be a tough business. A pediatrician talks to a parent about choking hazards or sleep positions or bike helmets, but she never gets to know which specific children that advice has helped. You can’t see prevention unless you broaden your view, looking at populations over time. Getting rid of leaded gasoline decreases childhood lead poisoning; changing recommendations about infant sleep positions lowers the risk of sudden infant death syndrome. But you don’t get to know which kids benefited — who would have not worn that helmet and had the bike accident, tipped over that unsecured television stand, died of SIDS… Vaccines are one of our best tools for prevention. They are amazing inventions that prevent serious diseases so kids can get on with their lives. But you never really know exactly who they helped. Vaccines are masters in making nothing happen.

I emphasized the last sentence, because it is the opposite of this “nothing” that happened to that poor child in Texas — who by not receiving their recommended measles vaccine, missed the opportunity for “nothing” and now is tragically dead.

And some of the responses to this case, including from the very person charged with running our Department of Health and Human Services, reveal significant weaknesses in understanding both the medical significance of the case, and, just as damningly, the human heart — how we feel when reading about a childhood death. These comments clearly aim to downplay the importance of this outbreak in general, and the death of this child in particular, so I’ll follow them with corrections:

• “It’s not unusual.”  In fact, the last measles death in the United States occurred in 2015, in an adult. So it’s the opposite of “not unusual.”
• “Outbreaks happen all the time.” This is the largest outbreak in Texas in more than 30 years. Measles was eradicated in this country in 2000, with sporadic cases happening only from international exposures. The drop in measles vaccination rates in some regions since then has led to some large local outbreaks — including this one in New York City which motivated Adam to write his book.
• “Those hospitalized are mainly there for quarantine.” Not according to the chief medical officer at the hospital, Dr. Laura Johnson, who said “We don’t hospitalize patients for quarantine purposes.”
• “Everyone I know had measles growing up, including me, and we all turned out fine.” That’s because with nearly universal infection, the denominator was huge. But before the vaccine became available in 1963, 400 to 500 people died of measles each year, most of them children. There’s your numerator.
• “It’s just one death out of 124 cases, while 1 in 36 kids has autism.” The measles vaccine does not cause autism. The original paper was based on fraudulent data, and later retracted; multiple other population-based studies have found no relationship.
• “If everyone else gets the vaccine, why should I have to worry about it for my child?” This isn’t so much a lack of medical knowledge problem, but a selfishness problem. Take a look at yourself in the mirror.

Let me turn now to why pediatric deaths and illness weigh so heavily in the minds of all healthcare providers and public health officials. It’s a lesson I’ve learned first-hand by being married to a pediatrician, watching my wife consumed with worry when a single patient in her practice is seriously ill. It’s captured well in this quote from Dr. Burton Grebin:

The death of a child is the single most traumatic event in medicine. To lose a child is to lose a piece of yourself.

This is why medical students, interns, and residents have so much closer supervision in pediatric teaching hospitals than in general hospitals. Why surgeons have to train an extra-long time to become pediatric specialists. Why pediatric practices field calls 24/7 from worried parents (especially first-time parents) about every little thing. (But some aren’t so little.) And it’s why the loss of a child is considered one of the most traumatic experiences an adult can have.

This is not ageism; this is human nature — who we are. And if the raw emotions don’t resonate, here’s some simple math:  Let’s say this death in Texas was a 10-year-old child; the death robbed this person of approximately 70 years of life, of being part of and building a family, of contributing to our society. And it’s not just deaths that the measles vaccine prevents. A case of encephalitis with residual neurologic deficits could lead to decades of disability, with extraordinary individual and societal costs.

So let’s remember that lifesaving childhood vaccines are indeed “masters in making nothing happen.” In this case, nothing sure beats the alternative.

The views and opinions expressed in this blog do not represent those of NEJM Journal Watch, NEJM Group, or the Massachusetts Medical Society.