Wednesday, September 21, 2011

Michelle Bachmann's Assault on Public Health (Art Caplan)

Michele, My Warning Bell about Vaccine Fear-Mongering
Public Health
Arthur Caplan, 09/20/2011

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Greg Kaebnick, the editor of the Hastings Center Report (and, full disclosure, a former student of mine!) kindly invited me to offer some comments on my decision to publicly challenge Congresswoman and presidential candidate Michele Bachmann’s comments on the safety of the HPV vaccine. I am happy to do so. It lets me tell a story that might be of interest to the bioethics community and to offer a few comments about my own thinking about the public work in which some bioethicists engage.
Yesterday, Bachmann abandoned her claim that the vaccine was dangerous, saying she was only repeating a story she had been told. Of course, rumor-mongering is hardly a defense. Moreover, she has apparently decided to make an antivaccination stance a key part of her campaign to dislodge Texas Governor Rick Perry from his position as the GOP’s leading presidential candidate.
In running against vaccines, Bachmann is willing to dissemble and lie about vaccine safety to try and score political points. She is also apparently willing to sacrifice the lives of young women in the U.S. and around the world to cancer, as well as others who may die of whooping cough or flu to her political ambition by impugning the safety and efficacy of vaccines and vaccine mandates. This stance should not only disqualify her from selection as the GOP candidate for any national office, but it should also lead her Minnesota constituents to think about whether she belongs in Congress at all.

The HPV flap to date

 On Tuesday, September 13, the day after the GOP presidential candidates debate, Bachmann claimed on various media outlets that the HPV vaccine was dangerous and could cause “mental retardation”. Bachman told Matt Lauer on the “Today” show that she had met a woman who said her daughter had “suffered mental retardation from the vaccine.” She went on to say that the HPV vaccine has "very dangerous consequences" and that it puts "little children's lives at risk."
The whole off-the-wall discussion during the debate about Perry’s push to promote the HPV vaccine through an executive order had me angry. Bachmann’s fear-mongering about vaccine safety to gain an edge on Perry pushed me over the edge. Within hours, I wrote an impassioned column trying to get the facts straight. I posted it on my Facebook page and tweeted it as well. The column got some attention, and I got a number of requests for radio and print interviews about it on Tuesday.
On Wednesday I happened to see a Facebook post by my friend and former colleague at the University of Minnesota, Steve Miles. He, too, was angry about Bachmann’s lies about vaccine safety and had posted this item: “I am offering $1,000 for the name and medical records release of the person who Michele Bachmann says became mentally retarded as a consequence of the HPV. Please share this message.”
The American Academy of Pediatrics also issued a strong statement, and a few commentators and fact-checking items in the newspapers noted that her remarks were not true. Still, I worried that the stench of fear was going to linger around vaccines yet again, and I decided I should take on Bachmann’s untruths, too. I did not want Bachmann to give more fuel to anti-vaccinators or to risk the lives of children whose parents might not get them vaccinated because of fears she was continuing to stoke.
Although I thought Steve’s $1,000 wager would get some attention, I thought we needed to up the ante. We needed a gimmick to debunk the Bachmann blarney. So I tweeted and e-mailed my own challenge: If Bachmann could produce a person within a week who had been made “retarded” by the HPV vaccine, and if that claim could be verified by three doctors that she and I agreed upon, then I would give $10,000 of my own money to a charity of her choice. If not, she would give $10,000 dollars to a charity of my choosing.
I repeated the challenge on the radio interviews I had that Thursday morning and said the clock had started ticking. Pretty soon, my phone was ringing and e-mails were coming in from journalists. Steve let me know he did not agree with the terms of my challenge but that he was on board with me and would add his $1,000 dollars to it. So there was an $11,000 throwdown.
During interviews that Thursday, I pointed out again and again that there was no evidence at all that the HPV vaccine caused “retardation,” that the CDC/VAERS Web site had never received any such report, that there had been no report I knew of in any other country in the world of any such side-effect despite more than 35 million doses administered, and that it was reprehensible that the same sort of fear-mongering that was causing infants to die of pertussis, flu, rotavirus, measles, and polio around the world was being offered up about HPV vaccine by a serious contender for the presidency of the United States.
I then received a request for an interview on “Anderson Cooper 360” on CNN about my challenge. The power of TV in American culture is still impressive. After the Anderson Cooper interview, the issue of Bachmann’s vaccine fear-mongering became national news, splashed all over the print, radio, and Internet. Bachmann was being held accountable, and lying about vaccine safety was costing her. By Saturday she had dropped in the polls.
Her campaign has not responded to Steve or me. An NPR reporter told me that her press person said she would not respond because she had not received “a letter” from me challenging her views about the HPV vaccine. That response is absurd on its face.

On taking a public stand

Part of the reason I was angry about Bachmann’s comments is that I have been working on vaccine ethics long enough to be acutely aware of the harm caused by vaccine misinformation. In 2004, I had been asked by a Pennsylvania official for help in determining how best to allocate the then-scarce supply of flu vaccine. I told him I did not know anything about vaccines, but that I was sure some bioethicists were working in this area. It turned out that I could not find any to recommend.
I began wondering why that was, since vaccines are the single most effective medical intervention ever mounted against disease, with at least one major scourge of humanity, smallpox, eliminated due to vaccines and another, polio (which I had as a child), close to eradication. Long story short, I ended up launching a project at Penn on vaccine ethics and a related project, which I run with the able help of Jason Schwartz.  I signed up for a course on how to make vaccines; sat in on lectures on vaccine issues; and met Paul Offit, of our Children’s Hospital and department of pediatrics, who had been waging a one-man war against anti-vaccination propaganda for years. I got deeply involved in the subject and wound up publishing quite a bit on vaccines in general and on HPV vaccine in particular.
Having been involved in a highly visible way in other situations where politicians, zealots, or advocates have tried to advance misinformation in the name of a political or medical goal – including the Terri Schiavo case, the battle over federal funding of embryonic stem cell research, the claim that a Belgian man had “woken up from a 23-year coma” to use facilitated communication to reveal the horror of his experience, and crackpot offers of cures with untested adult stem cell therapies, among others – I knew a few things about the importance of speaking up, the need to have scholarship in place to back up one’s comments, and the price that often has to be paid for doing so.
The need to speak from an ethical perspective in public forums and outlets about inaccurate, misleading, or outright false claims about bioethical issues should be self-evident. While it is important to publish one’s views in the peer-reviewed literature and to share them in the seminar room, it is equally important for those who have the skills and the facility to communicate with broader audiences to do so. Like economics, political science, climate science, agriculture, and engineering, bioethics is not a purely theoretical field. To do what nearly all of those in the field claim it seeks to do – advance patient interests, enhance the prospect for justice for the least well-off, correct abuses of patient and subject rights – some in the field must engage in policy and public dialogue. At the same time, of course, if one is going to speak up, then it is important either to have published on the matter or to have mastered the relevant subject area at least to the point where one is comfortable teaching and lecturing about it.
The danger in advancing civic debate and public understanding is that your own peers will not know your scholarly work on a topic and will see any highly visible public activity as self-promotional pandering – or at best as popularizing, although that is little better on the academic scale of value. The duty to get involved surely overwhelms the price.
It is also true that entering the public arena means interaction with the media. Time and again, I have seen my comments distorted, misstated, or simply misused, even by highly respected journalists. It has already happened in the HPV vaccine story. The Internet only makes matters worse, given its immense power of repetition.
I think my decision to call out Michelle Bachmann on her comments about vaccine safety and vaccine mandates with my $10,000 challenge was the right one. I believe it is having the effect I intended. The lack of evidence behind nearly all of the claims of vaccine dangers and risks remains in the news. There may even be a better understanding of what is involved in creating different types of vaccine mandates. And women and men in America may be more willing to get their children vaccinated against a disease that kills and maims thousands and to support efforts to get the HPV vaccine to poor women worldwide to prevent many of the hundreds of thousands of deaths that occur every year from cervical cancer.
If vaccination is going to be a key part of the winnowing process of those who want to be president, then the framing of that debate has been reset in a much more positive mode.
Arthur Caplan is the Emanuel & Robert Hart Director of the Center for Bioethics and Sidney D. Caplan Professor of Medical Ethics at the University of Pennsylvania, and a Hastings Center Fellow. Follow him on Twitter @ArthurCaplan.
Caplan’s references and writings on vaccines:
Boom and bust-have we learned what we need to from the flu vaccine shortage?” Johns Hopkins Advanced Studies in Medicine, 2005: 522-3.
“Off the grid: Vaccinations among home-schooled children,” The Journal of Law, Medicine & Ethics, 35, 3, 2007: 471-77. (with D Khalili).
“Lessons from the failure of human papillomavirus vaccine state requirements”, Clinical Pharmacology and Therapeutics, 82, December, 2007: 760-3, (with JL Schwartz, RR Faden and J Sugarman).
“Leveraging Genetic Resources or Moral Blackmail? – Indonesia and Avian Flu Virus Sample Sharing,” American Journal of Bioethics, 7, 11, 2007: 1-2 (with DR Curry).
“Ethics” in: S. Plotkin, W. Orenstein and P. Offit, eds., Vaccines, 5th ed., 2008: 1677-1684 (with JL Schwartz).
“Genital warts: mountains or molehills?” The Lancet Infectious Diseases, 8, 5, 2008; 277-8 (with SC Hull).
“A proposed ethical framework for vaccine mandates: Competing values and the case of HPV”, Kennedy Institute of Ethics Journal, 18,2, 2008: 111-124. (with RI Field).
“Is Disease eradication unethical?” The Lancet, 373, 2009: 2192-3.
“Disease eradication –  a response,” The Lancet, 374, 2009: 1144 (letter).
“The case for vaccinating boys against HPV,” Public Health Genomics, 12, 2009:362-7 (with S Hull).
“Unlicensed Pandemic a (H1N1) Vaccines: Explicit ethical rules of the road are needed in public health emergencies,” The Lancet, 2009: 375, 2010 444-45.
“Physician attitudes toward influenza immunization and vaccine mandates,” Vaccine, 28, 2010: 2517-22 (with J Desante and A Behrman, F Shofer).
“Influenza vaccination of healthcare personnel,” Infection Control and Hospital Epidemiology, 31, 2010: 987-995 (with TR Talbot, H. Babcock, D Cotton, LL Maragakis, GA Poland, DJ Weber).
“Clinical trials of drugs and vaccines in poor nations -- ethical challenges and ethical solutions,” Clinical Pharmacology and Therapeutics, 88, 5, 2010: 583-4.
“Health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital” Vaccine, 29, 9, 2011: 1762-9 (with K Feemster, S Coffin, P Offit, C Feudtner and M. Smith).
“Vaccination: facts alone do not policy make,” Health Affairs, 30, June 2011: 1205-8.
“Ethics of vaccination programs,” Current Opinion in Virology, 1, 2011: 1-5. (with Jason Schwartz).
“Time to mandate influenza vaccination in healthcare workers,” The Lancet, 378, 2011: 310-311.
“Vaccination refusal: ethics, individual rights and the common good,” Primary Care Clinics Office Practice, 2011, in press. (with Jason L Schwartz)
Posted by Susan Gilbert at 09/20/2011 11:36:03 AM |

Monday, September 19, 2011

Too Many Tasks (Marin IJ)

I’m sitting down to write on an important topic. I should check my email. Right, where was I? An important topic for students, parents, professionals, and, well, just about everyone. Who’s texting me? Oh shoot; I need to finish that Amazon order. I forgot to call the plumber. And the dog needs to go out. Did I feed my daughter’s Brazilian water frog? I should check my email. Wait, focus. Important topic. Interesting topic. And it’s critical that everyone understand the limitations and risks associated with it. I really should check my email. Multi...must check email! …Tasking.
Like many people in our digitalized and sensory-loaded world, I’m a fervent multi-tasker. Email, bills, scheduling, patient-care, child-care, pet-care, Twitter-care, fantasy sports; I can do it all. And I can do it all at the same time! At least so I thought. Just checked my email for the fourth time this paragraph. My wife wants to know if we can go to a school fundraiser tonight. My boss is trying to schedule a tennis match. I wonder which QBs are available on the cbsportsline waiver wire? Expedia has a new fare alert for me. $299 bucks to fly to Omaha! Sweet. Contrary to the ethos I’ve prided myself on, in a world of information overload, constant data processing can actually “smog,” “asphyxiate,” and starve away productive time. In fact, multi-tasking may threaten efficiency more than aid it. 
Skeptical? Well, stay with me here (your stock portfolio and Facebook newsfeed can wait), and consider evidence from cognitive testing. Researchers looking at individuals performing two or more tasks at once have found that, quite consistently, people complete tasks faster if they do them serially (one, then the other) rather than in parallel (start one, start the other, back to the first, and so on). In fact, loss of efficiency has been estimated to be around half-a-second per task switch and up to twice the sum of the time needed to complete two tasks in order. So, for example, if it takes me two minutes to check and respond to my email and three minutes to order a new mattress online, it would take me up to ten minutes to do the two tasks “at the same time” (switching back and forth between tasks with a delay with each switch). But if I did the tasks serially (i.e. focusing on one task and completing it before moving on to the next), the two tasks should take me only five minutes.
Now, as we all know, multi-tasking is more or less a fact of life. Most of us are forced to multi-task some or all of the time, both at work and at home. A busy shift in the Emergency Department (ED) is an excellent example of this, and one that I’m quite familiar with. I spend my days talking with patients, performing physical exams, entering orders, documenting, calling consultants, communicating with nursing and other personnel, performing procedures, making referrals, all while trying not to neglect an important task like prescribing the correct medication. Studies of ED physicians demonstrate that their tasks will be interrupted four to fourteen times per hour, or every four minutes or so. An observational study of nurses reported that ED nurses (at work) multitask 34% of the time. Each and every single one of the interruptions that ED providers experience could have disastrous consequences. (This is why we have developed safety mechanisms like timeouts and checklists.)
But of course, some multi-tasking is unavoidable. Our patients surely appreciate that we break away from a routine task, like charting, to tackle another more critical task, such as providing acute resuscitation. And, keep in mind that some “multitasking” is not harmful. For some people, listening to music while driving or studying is not really multi-tasking at all but rather a multi-sensory approach to a task. This habit may or may not affect efficiency and performance. People are (according to cognitive studies) able to train themselves to block out distractions when performing an assignment. Note that I say “distractions” and not tasks. Tasks, especially ones that require working memory - very short term memory designed to aid in completion of short term tasks - will be more efficiently completed in order and cannot be blocked out as part of a multisensory approach. Working memory is ephemeral and highly sensitive to interruptions. We all experience this as those “I lost my train of thought” moments.
Can you minimize brain stalls and achieve a healthy level of multi-tasking? Maybe, but first you have to set aside dedicated time to think, focus, and plan. Creativity benefits from focus and people who have planned or rehearsed tasks beforehand are less likely to suffer delays. Here’s another tip: try to resist over-dosing on jolts of satisfaction (“dopamine squirts”) associated with compulsive behavior – like checking email every 2.4 minutes. And when possible, finish what you started  - NOW – rather than deferring it to the “later” bucket. Working memory is temporary and what may seem unforgettable right now is actually quite forgettable in 15 minutes. Finally, experiment with focus adjuncts – meditation or paying attention to your breathing may help, as might noise-erasing headphones (which, my wife lovingly has dubbed “wife- and kid-erasers”). Of course, a lot of the modern world cannot be easily “noise-erased,” but if you make an effort to slow down, especially with important endeavors, your reward, ultimately, will be higher efficiency and fewer mistakes.
Well, phew, I’ve made it through this task. Hope you did too. How many unread emails do I have? That frog must be absolutely starving. Now, if you’ll excuse me, I’ve got a few other things to do…

Work Does Not Have to Hurt (Marin IJ)

This Labor Day, as we honor workers, let us also celebrate workplace safety. Well, perhaps workplace safety is not so much something we celebrate, as it is something we should expect. And if you consider where we’ve come from, remarkable progress has truly been made. Over one hundred years ago, Upton Sinclair’s novel The Jungle depicted the truly awful working conditions of the early 20th century Chicago meatpacking industry. For example, consider the job of “beef-boner”…”Your hands are slippery, and your knife is slippery, and you are toiling like mad, when somebody happens to speak to you, or you strike a bone. Then your hand slips up on the blade, and there is a fearful gash. And that would not be so bad, only for the deadly contagion. The cut may heal, but you never can tell.” Grimy and grim. And workplace danger was not restricted to beef boners – in year 1913 alone, the Bureau of Labor Statistics (BLS) documented 23,000 industrial deaths among a workforce of 38 million, equivalent to a rate of 61 deaths per 100,000 workers. And there were likely thousands more that went un-documented. Even thirty years ago, in the 1980s, after vast improvements in working conditions and safety, over 7000 people a year died on the job.

Last week, the BLS released the data for 2010, reporting 4,547 fatal work injuries, a rate nearly twenty fold improved from 1913. Of the year 2010 deaths, 1,766 were transportation related, 808 from assaults (including self-inflicted), 732 from being struck by an object, 635 from falls, 409 from toxic exposures and 187 from fires and explosions. Occupation-wise, the greatest magnitude of deaths was seen in transportation/material moving (1,115) and construction/mining industries (760). A somewhat surprising third were management occupations (533) – including 29 (no longer) top executives.

So nowadays, as you can see, workplace deaths are rare enough that they are fastidiously tracked – in fact you can find a description of specific events on the OSHA website (this, by the way, is only recommended for Faces of Death aficionados). Cleary, further improvements in work safety are possible but nonetheless, non-fatal injuries on the job are a problem of much greater frequency. According to 2009 BLS data, there were over 3.2 million workplace injuries or illness reported in the private sector alone. These include 195,150 back injuries and 212,760 falls. Ouch. In all, days-away-from-work approached one million in 2009 (this was actually an 11% decrease from 2008). As one might expect, high risk professions include those with significant lifting/physicality requirements – such as patrol officers, nursing aides, orderlies and attendants, delivery truck drivers, construction laborers, and janitors and cleaners.

No profession, however, is immune from on the job injuries. Even pillow softness testers must suffer some risk– although it is not immediately evident to me what this might be. Hazards exist in the offices and hallways around us. To help keep you safe in these environments, I canvassed the web ( and Dr. Scott Levy, Chief of Occupational Medicine at San Rafael Kaiser, for some safety tips.

1) Boot the boxes…
And other clutter out of the hallway and walkways. Tripping over your own box of files would not only be embarrassing, it could also be quite painful.

2) Don’t carry anything higher than your eye level or read while walking.
Can’t see where you are going? Carrying a heavy load? Not noticing Wobbly Wanda and her cup of very hot tea. Ruh-oh.

3) Don’t run unless someone’s life is at stake.
Stieg Larsson, author of The Girl with the Dragon Tattoo, died prematurely because the elevator was broken and he ran seven flights of steps to make a meeting on time. His heart couldn’t take the stress of always being in a rush. Can yours?

4) Look before you sit.
Seems simple, but a chair is not always that clear of a target to hit – especially if you’re distracted. A bruised bum or a bum back could be your penance for poor sitting technique.

5) Think Ergonomically
A properly designed (ergonomic) workstation can help minimize work place injuries. This fact becomes quite obvious when people with very different proportions attempt to use the same workspace.

6) Something’s in the air around here
Besides hazards that lead to musculoskeletal injuries, consider other sources of injury. Strong scented colognes and perfumes can easily aggravate allergies and trigger asthma attacks.

7) Wellness is not for Wussies.
Consider starting or joining a workplace wellness program.  There's a lot of evidence that having a healthier workforce will lead to fewer injuries.

8) Light Matters
Don't overlook the importance and relevance of your office lighting. Traditional fluorescent light bulbs flicker very rapidly and can lead to increased fatigue – not to mention irritability.

9) Control the Urge to Multi-Task
This is a tough one – and I’m as guilty as the next over-stimulated employee. More on this another time, but just know that serious multi-tasking does not help you to be more effective, in fact it can be quite detrimental. You are much more likely to forget something important (such as driving on the right side of the road) if your mind is flipping back and forth between two activities.

In sum, advises Dr. Levy…“Although office injuries will never drop to zero despite our best efforts, there are ways to minimize the numbers.  Developing an ongoing program where office hazards are continually monitored will lead to improved staff morale in addition to the obvious benefit of an overall safer workplace.”

Indeed, work does not have to hurt.