This has been two weeks of particular craziness in health care, in which everyone, on all sides, did their level best at missing the boat.
First, our friends at CDC’s Advisory Committee on Immunization Practices went ahead and changed the recommendation for Hepatitis B vaccine for newborns, a crazy change if ever there was one. Here are the facts: giving the Hepatitis B vaccine has reduced the number of hepatitis B infections by something like 18,000 infections a year before age 10, which is a big deal, because kids who get infected at birth and in childhood are much more likely to develop liver cancer or cirrhosis and die young. There are no known deaths in newborns from Hepatitis B vaccination itself.
So what’s the beef? Some people worry that giving newborns the Hepatitis B vaccine might cause autoimmune diseases like rheumatoid arthritis or multiple sclerosis. Or might cause diabetes. Or might cause leukemia. Or SIDS. Though there is no evidence that any of that occurs.
Some people just don’t like the idea of newborns getting shots. (I don’t like that idea either.) These folks are thinking about the precautionary principle in public health, which says, don’t do something until it is proven safe. And they may also be remembering that old saw in statistics – absence of evidence is not evidence of absence, worrying that even though no one has proven that the Hepatitis B vaccine causes any problem, there still could be a problem that we aren’t seeing or haven’t seen yet. They also worry about profit driving our public health decision making — but given that the Hepatitis B vaccine costs about $12.00, evil pharma isn’t making it big on this one. They know that Hepatitis B is likely to be transmitted by infected mothers, but if mothers get themselves tested, they say, the risk is much reduced.
Only partly true! my public health colleagues point out. Babies and children can still get hepatitis B from household and other contacts, because the disease is still present in the population.
10-15 percent of new mothers are not tested before giving birth because they don’t have primary care and prenatal care. Public health folks think that means we should keep giving the shot to newborns because of those 10-15 percent, and also because of the people who are infected but don’t know it and might transmit the disease to kids. But wait, the opponents say. You want my low-risk kid to have a shot as a newborn because somebody else is high risk but didn’t get tested? I lead a very pure life. My kids don’t get exposed to people who might be high risk, who lead a very different lifestyle than my kids and I do. You want my newborn to get jabbed because there are high risk people walking around? Who my kid isn’t going to have contact with? My kid gets jabbed but gets very little benefit?
A pox (so to speak) on both their houses. There is no reason to change these recommendations now. We have an inexpensive vaccine with no known risks that works to save lives and prevent cancer. It works because there is too much Hepatitis B circulating in the population. So there is no reason to expose more kids to risk, because someone somewhere is worried about something.
The people who think their kids are at low risk because they themselves don’t do drugs or have multiple sexual partners are deluding themselves. You might be at lower risk but you aren’t at no risk. You live with other people, and all their friends and contacts. We live together or die together. Welcome to the human race. We are one people after all, whether we like it or not.
BUT my public health colleagues are also missing the boat. We need to vaccinate everyone because we don’t have a health care system in the US that provides primary care to everyone. Which means we can’t test all pregnant women. Which means there is risk to newborns. But we all, public health folks, politicians and the rest of us, should be working to build such a system. If everyone had primary care, we could test all pregnant women – and everyone else. And vaccinate everyone against Hepatitis B. And treat everyone who is infected. (Like HIV, Hepatitis B can be controlled but not always cured. Control with medications reduces the likelihood of disease transmission.) And then maybe, just maybe, we can eventually eliminate Hepatitis B in the population, so no one would need vaccination at all. (We’d also be able to eliminate HIV/AIDS, Hepatitis C and colon cancer, if we got everyone primary care.)
But we aren’t there yet, or even close. So changing this recommendation is likely to cost lives, not save them. Shame on Bobby for that.
There’s also craziness on the other side of the partisan coin. Bobby and his folks have $50 billion to give away to states at $100 million a year or more to each state for five years. This money comes through Rural Health Transformation Grants and was part of a political deal made with Senator Murkowski from Alaska to get her vote on Trump’s Big Beautiful Bill, so called. (I’m betting most of that money will be wasted, because it has no real focus.) Bobby and his buds are asking states to jump through various hoops to get the moolah. One of those hoops, for a piece of the money, is asking states to restrict SNAP aka food stamps, so they can only be spent on nutritious food. Spend nutrition money on nutritious food? Somehow Democrats are outraged, and shocked, shocked that Republicans could be so paternal as to tell people they have to spend public money on doing what it was designed to do. Say what?
Restricting SNAP so food stamps can only be used on nutritious food is a good idea. It’s long overdue. Kudos to those who are working to get this done. And shame on the Democrats who object to this common sense and overdue change.
You can find Michael Fine’s commentaries and short stories on https://michaelfinemd.substack.com/and on http://www.michaelfinemd.com