Posts Tagged ‘TB’

Vaccines, quarantines, and compulsion in supporting the public health

February 9, 2015  |  General  |  2 Comments

I posted a version this one last year, but the recent outbreak of measles has once again ignited the debate of just what the government has the right to do or not do in compelling individual actions in support of public health. This is an old question, and it’s worth considering it in historical context.

One aspect of the endless vaccine debate is the aspect of coercion some parents feel about requiring children to be vaccinated before they can go to school. The government mandates vaccination. But this isn’t really an absolute requirement. Although all 50 states ostensibly require vaccination, all but 2  (Mississippi and West Virginia) allow parents to opt out for religious reasons, and 19 states allow this for philosophical reasons. (See here for a list.) Still, in general vaccines are required unless the child has a medical reason not to get them, such as having a problem with the immune system. Is this an unprecedented use of state power? I don’t think it is.

In fact, historically there have been many examples of the government inserting itself into healthcare decisions of individuals and families in order to protect the public health. Some of these go back many years. Quarantine, for example, goes back to medieval times, centuries before the germs were discovered. It has since 1944 been a power of the federal government; federal agents may detain and send for medical examination persons entering the country suspected of carrying one of a list of communicable diseases. Quarantine has also been used by local and state governments, particularly in the pre-antibiotic era. Diphtheria is a good example, as you can see from the photograph above. Quarantine can be abused, and has in fact been abused in the past for discrimination against certain minority groups. A brief paper from the American Bar Association details some of those instances here. The paper even suggests that it should be abolished for these reasons. But the practice is a very old one.

Of course the government mandates many things for the protection of public health. Milk is pasteurized (although there are raw milk enthusiasts who object), water is purified, and dirty restaurants can be closed. Like quarantine, these measures restrict our personal freedom a little, but what about government-mandated medical treatment? That sounds a bit more like the situation with compulsory vaccination of children. As it happens, there are more recent examples of compulsory treatment, particularly involving tuberculosis.

A couple of decades ago I was involved in a case of a woman with active tuberculosis who refused to take treatment for it. Worse, her particular strain of TB was one highly resistant to many antibiotics, so if that spread it would represent a real public health emergency. The district judge agreed. He confined the woman to the hospital against her will so she could be given anti-TB medications until she was not longer infectious to others. At the time I thought this was pretty unusual. When I looked into it, though, I found that there have been many instances of people with TB being confined against their will until they were no longer a threat to others. The ABA link above lists several examples of this.

So it’s clear to me there is a long tradition of the state restricting personal freedom in the service of protecting the public health. Like everything, of course, the devil is in the details. To me the guiding principle is that your right to swing your fist ends where my nose begins.

Vaccines, state power, and legally mandated medical care

Vaccines, state power, and legally mandated medical care

March 2, 2014  |  General  |  2 Comments

One aspect of the endless vaccine debate is the aspect of coercion some parents feel about requiring children to be vaccinated before they can go to school. The government mandates vaccination. But this isn’t really an absolute requirement. Although all 50 states ostensibly require vaccination, all but 2  (Mississippi and West Virginia) allow parents to opt out for religious reasons, and 19 states allow this for philosophical reasons. (See here for a list.) Still, in general vaccines are required unless the child has a medical reason not to get them, such as having a problem with the immune system. Is this an unprecedented use of state power?

In fact, historically there have been many examples of the government inserting itself into healthcare decisions of individuals and families in order to protect the public health. Some of these go back many years. Quarantine, for example, goes back to medieval times, centuries before the germs were discovered. It has since 1944 been a power of the federal government; federal agents may detain and send for medical examination persons entering the country suspected of carrying one of a list of communicable diseases. Quarantine has also been used by local and state governments, particularly in the pre-antibiotic era. Diphtheria is a good example, as you can see from the photograph above. Quarantine can be abused, and has in fact been abused in the past for discrimination against certain minority groups. A brief paper from the American Bar Association details some of those instances here. The paper even suggests that it should be abolished for these reasons. But the practice is a very old one.

Of course the government mandates many things for the protection of public health. Milk is pasteurized (although there are raw milk enthusiasts who object), water is purified, and dirty restaurants can be closed. Like quarantine, these measures restrict our personal freedom a little, but what about government-mandated medical treatment? That sounds a bit more like the situation with compulsory vaccination of children. As it happens, there are more recent examples of compulsory treatment, particularly involving tuberculosis.

A couple of decades ago I was involved in a case of a woman with active tuberculosis who refused to take treatment for it. Worse, her particular strain of TB was one highly resistant to many antibiotics, so if that spread it would represent a real public health emergency. The district judge agreed. He confined the woman to the hospital against her will so she could be given anti-TB medications until she was not longer infectious to others. At the time I thought this was pretty unusual. When I looked into it, though, I found that there have been many instances of people with TB being confined against their will until they were no longer a threat to others. The ABA link above lists several examples of this.

So it’s clear to me there is a long tradition of the state restricting personal freedom in the service of protecting the public health. Like everything, of course, the devil is in the details.

Remembering children victims of the “white plague”: tuberculosis

April 21, 2012  |  General

I recently ran across this incredible image, a painting by Edvard Munch. He called it “the sick child.” The artist painted from memory his younger sister, ill with tuberculosis.

It has taken only a couple of generations for Americans to forget one of the great killers of history — tuberculosis. Sixty years ago Rene and Jean Dubois  wrote a historical study of TB that still stands as a landmark study. It’s a fascinating book, written in 1952, just about the time we at last had effective antibiotic treatment for TB.

Tuberculosis was the most common cause of death during the nineteenth century, responsible for around a third of deaths. Think about that for a minute — a third of all deaths. Many, many of those dying were children. Adolescents and young adults were also common victims. I find Munch’s image of his sister, with her pallid eyes and hollow cheeks, to be much more haunting than the artist’s more famous images, such as the series collectively called “The Scream“. This one is the face of innocent suffering. TB killed her, as it did millions of other children.

Because of antibiotics tuberculosis no longer kills children in America. But the bacterium is a crafty one, devising ways to resist antibiotic action. We are really only one jump ahead of this ancient scourge.

You can find more specific information about TB here, and about its history here.

Whooping cough (pertussis) and civil rights

December 30, 2010  |  General  |  No Comments

I’ve written before about whooping cough, or pertussis, and its vaccine. It’s a potentially deadly illness for infants. There’s been quite a large epidemic of whooping cough over the past few months in California. In fact, it’s shaping up to be the largest epidemic in fifty years. Five infants have died as a result.

We have a vaccine for it, although it’s not an ideal one. For one thing, it can’t be given to the youngest of infants, those at most risk of dying from the disease. For another, the protection the vaccine gives wanes with age, requiring booster shots. The upshot is that those receiving the vaccine are getting it as much (or more) to protect others than to protect themselves. That raises the key question of to what extent it is our civic duty to get the vaccine, and give it to our children, to protect those very small, vulnerable infants who can’t get it yet. Freedom of choice collides with the public welfare.

Dr. Bill Schaffner, a distinguished infectious disease expert at Vanderbilt University, recently weighed on on the question of compulsory vaccination in this context. He writes:

“But here’s a reason [for refusing vaccine] that really makes me cringe — our society puts more value on personal choice than on protecting our fellow citizens. “Mandates” has become a dirty word. We don’t like mandating anything in this country. No, we’re not going to mandate and take away personal choice. But what choice did those five infants have? Does our thirst for individual freedom absolve us of our responsibility to protect them?”

There is precedent from the past for compelling people to do things for public health reasons. Old quarantine laws are one example. Of course making a sick person stay at home does not force them to get a particular treatment, such as a vaccination. There is a parallel, however, with tuberculosis treatment. There have been instances when courts have confined a person with active TB and forced them to receive treatment for it. Although this treated the person, the reason for the compulsory treatment was that it protected the community.

As a trained infectious disease specialist myself, I have do doubt that the vaccine, although not ideal, works. You will find people who disagree with that statement. What interests me the most on the issue is the question of civil rights: to what extent does the state have the right to compel its citizens to do something to protect the health of others? The answer, I think, is — it depends.