Thursday, June 30, 2011

Shaw's Paradox

The Sick Child [with TB] by Edvard Munch; from Wikipedia

File:George bernard shaw.jpg
George Bernard Shaw
 from Wikipedia
In 1906, there were no treatments for Tuberculosis [TB] except for isolation, fresh air, and a tuberculin inoculation. What if you were a doctor/scientist at this time, such as Sir Almroth Edward Wright, who knew how to inoculate more safely; you knew that lives could be saved this way, but you could take on only one more patient. Who do you save? Who is worthy of your discovery? That is The Doctor’s Dilemma [Sir Colenso Ridgeon’s dilemma, that is] in George Bernard Shaw’s play.

In the 1966 Tyrone Guthrie Theatre edition of The Doctor’s Dilemma, Shaw’s 1911 Preface on Doctors exposes his views—somewhat paradoxical views when read in 2011. Back in the early 1900’s, in England, there wasn’t a National Health Service. In addition, doctors were paid per smallpox vaccination, and under the Vaccination Act, it was compulsory. Shaw was very outspoken about this; he thought that smallpox severity was lessening, and that it would go away without intervention--the vaccine had nothing to do with the decrease in deaths. This is an interesting position from a man that supposedly held science in high regard.  In the play he takes recent scientific findings on opsonic theory and builds a smart exploit—of different kinds of people, of science in the wrong hands, of journalists who don’t understand science, of medical ethics, and places them before us. There is high regard for the science, but little for the people using it.

His 1911 preface exposes [in his view] bacteriology as a superstition, germ theory as farce, and likens vaccines to homeopathy [which he despised]. He also was against vivisection and despised all doctors [GPs and surgeons]. His science loving yet science denying views are his paradox. Of smallpox vaccination he says:
“…Such monstrosities as vaccinations are, as we have seen, founded, not on science, but on half-crowns. If the Vaccination Acts, instead of being wholly repealed as they are already half repealed, were strengthened by compelling every parent to have his child vaccinated by a public officer whose salary was completely independent of the number of vaccinations performed by him, and for whom there was plenty of alternative public health work waiting, vaccination would be dead in two years, as the vaccinator would not only not gain by it, but would lose credit through the depressing effects on the vital statistics of his district of the illness and deaths it causes, whilst it would take from him all the credit of that freedom from smallpox which is the result of good sanitary administration and vigilant prevention of infection…”
His preface, seen with a modern scientific eye, is nearly funny--until you realize that similar diatribes exist today. Perhaps with better understanding of the science of vaccinations today, he would have had a different opinion. 

Shaw’s answer to the dilemma is given by the preface: that doctors should be paid by the nation and paid bonuses when their individual district’s death rate decreases, and he offers this advice:
“Take the utmost care to get well born and well brought up. This means that your mother must have a good doctor. Be careful to go to a school where there is what they call a school clinic where your nutrition and teeth and eyesight and other matters of importance to you will be attended to. Be particularly careful to have all this done at the expense of the nation, as otherwise it will not be done at all, the chances being about 40 to one against your being able to pay for it directly yourself, even if you know how to set about it. Otherwise you will be what most people are at present:  an unsound citizen of an unsound nation, without sense enough to be ashamed or unhappy about it.”
He seems to have followed his own advice. He was 94 years old when he died following an accident in his garden…and it wasn’t an infection.

Millions of lives have been saved by vaccination. Shaw would have liked to have seen this [would he have seen this?] as well as the formation of the NHS in 1948.

The BCG vaccine [used to prevent TB, and used in countries with high rate of infection] became available in 1921.

For information about modern-day vaccines, visit either The CDC vaccine, the NHS vaccine, or WHO vaccine websites.

An early 1900 article in NYT about using opsonic theory to treat TB.

Saturday, June 11, 2011

When Soil Hits the Air

Photograph taken by tanakawho 2007; from Flikr
There are organisms that are indigenous to soil, and sometimes they get kicked up by Mother Nature into the air or water and enter humans, and sometimes they cause disease.

File:Mature sporangium of a Mucor sp. fungus.jpg
Mucormycosis Spore; Photograph from CDC
Sadly, at least three people have died from invasive mucormycosis [a fungal disease] in Joplin, MO, following the massive tornado in May.  Not all the information is available about how they contracted it, but skin trauma or inhalation are the most likely mechanisms.

Mucormycosis is very rare and epidemics are even more rare since it is not contagious.  It is mainly found in soil, from decomposing vegetation, so an event that would literally throw it up into the air could, and potentially has, lead to infections with the organism.

After the Northridge earthquake of 1994 there was an increased incidence of cases of valley fever or coccidiodomycosis.  This was due to the increased amount of fungal spores that entered the air and were inhaled.  Primarily the already immunocompromised became infected, but infection in immunocompetent people did result as well.

This past winter [for North Americans] Australia's Queensland state had an increase in melioidiosis [a bacterial infection] due to flooding.  Again, this organism is indigenous to their soil, and it was put where it ought not be.

A past epidemic of mucormycosis did not involved Mother Nature.  In the 1970's contaminated elastic bandages lead to cutaneous mucormycosis.  If not treated quickly with an intravenous antifungal [like amphotericin B] and surgical debridement, it can rapidly spread and cause more severe infection or death.

I truly hope that this is the last bad offering of Mother Nature to the people of Joplin, MO for a very long time. 

Wednesday, June 8, 2011

Not Quite Gone, Almost Forgotten

In 1980, the World Health Organization declared that smallpox had been eradicated.  Stores of this DNA virus remain in Russia and the United States, for research purposes, and in the case of a rogue sample being released.  Just recently, the World Health Assembly delayed the decision to eliminate the stores.

The last smallpox infection was seen in 1977, and many doctors today would only recognize it as constructed in medical text and history books.

I recently found these two illustrations by Megan Pearce, an incredibly talented artist.  They are from  her blog, but she has started a new website, so go here if you would like more information about her work.

A lot of older people would be able to describe the skin lesions of smallpox, and that the people who survived often had scars that remained. Many famous people survived it including George Washington, Andrew Jackson, Abraham Lincoln, and many of Henry VIII's relatives. They were the lucky ones--30% of the infected died, mainly due the more severe forms of the infection.  In a few of the ones who survived, blindness and limb deformities resulted.

Initially there was a prodrome of fever, headache, muscle ache, nausea, and back pain that lasted for up to 4 days.  Then lesions would erupt in the mouth, throat, and other parts of the gastrointestinal tract.  A few days later, a skin rash would appear, and lesions would develop on the face and spread all over the body.  Smallpox could take four forms: ordinary, modified, malignant, or hemorrhagic. The malignant and hemorrhagic forms were the most lethal.

Like the second man above, people who survived often felt as it they disappeared as their scars remained.  Stalin had smallpox as a child, and as a leader, had his photographs retouched to remove the scars--they were, like smallpox, not quite gone, but almost forgotten.

Friday, June 3, 2011

Blame it on Jenner

File:Variolation vial India.jpg
Smallpox Inoculation Powder 
from India; Photo from the CDC
Edward Jenner vaccinated his own children [except with cowpox, not smallpox] to test what centuries of peasants and village folk already knew—that inoculations saved lives.  Many people in rural areas of Greece, Arabia, North Africa, Persia, India, and China used smallpox scabs and pustules to inoculate themselves and their families.

Occasionally the procedure would backfire, and patients would get really sick, and some would die.  Jenner’s discovery of milkmaid’s immunity to smallpox [via exposure to cowpox], brought to his attention by another milkmaid, led him to the use of cowpox for a safer inoculation technique. 

File:Inoculation day 16.png
Smallpox versus cowpox innoculation;
From Wellcome Foundation

Dr. Jenner wasn't the first to 1774 Benjamin Jesty immunized himself and family with cowpox. Note that he lived a long life.

Copyright Sarah Smith and licensed for reuse under Creative Commons.

File:Edward Jenner2.jpg
Edward Jenner
But Jenner started it officially—vaccinations—and organized preventative medicine ensued.  If you’ve ever met a person who is antivaccine, blame it all on Jenner. Of course it wasn’t his fault antivaxxers organized, but his 1798 paper Inquiry into the causes and effects of the variole vaccinae lead to greater rates of inoculation, and inoculations done more safely

In England alone, between 1810 and 1820, smallpox deaths decreased by half. This “of the cow” entity given the moniker "vaccinae," became a cause of the Epidemiological Society of London, which lead to organized efforts to vaccinate and organized efforts to resist.

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In Paul Offit’s book Deadly Choices:  How the Antivaccine Movement Threatens Us All, a whole chapter, Past is Prologue, highlights how the after-effects of Jenner’s discovery lead the Epidemiological Society of London to organize and lobby government for better preventative health for its people.  They asked the English government to step in and require smallpox vaccination.

The English 1853 Bill to Further Extend and Make Compulsory the Practice of Vaccination meant well, but wasn’t enforced. Enforcement increased in 1867 with fines and imprisonment for those who didn’t get vaccinated or have their children vaccinated.  Herein lied the birth of the antivaccine movement. Richard Butler Gibbs started the Anti-Compulsory Vaccination League [ACVL] in 1866.  He and many others didn’t like being told what to do, and thought that the fines were so high as to cajole the poor to get vaccinated. 

The ACVL spread antivaccine propaganda with outright falsehoods about science and the goal of preventative medicine.  There was resistance in the Americas too, but globally, the vaccination rates were enough to eradicate smallpox.  The last infection was seen in 1977.
Photo of Antivaccine Postcard from StampCircut; sold for 4000 pounds
File:Revista da Semana.jpg
1904  Brazilian Antivaccine
poster from Wikipedia
Again, or still, there are people that use the same tactics, with the addition of the internet, to instill fear and misinformation about vaccination.  Some vaccine preventable diseases such as pertussis and measles are resurging again, thanks to the efforts of the antivaccine campaigns. These infections can spread and potentially mutate into greater problems than they currently are. That's Jenner's fault too, perhaps.

Other Links related to vaccination and smallpox:
For Fun:

Alien Smallpox Turkey by ~NickNP on deviantART

Wednesday, June 1, 2011

Two More Books Reviewed and What's Coming Up

There are two more books that have been reviewed [upper right corner of page].
  •  If you are interested in finding films to watch that bring up medical ethical dilemmas, I recommend The Picture of Health.
  • I continue to love Blood Work--will likely highlight some spots here in a later post.

Next post: Blame it on Jenner

Coming up:

George Bernard Shaw was suspicious of science and doctors [severe understatement] when he wrote The Doctor's Dilemma.

Malaria in the literature, maps, macroscopic views, and fairy tales too.

Is there any particular infectious disease you want to hear about?  Just let me know.
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