Our team is specialized in tracking signatures of infrastructure strain and collapse of societal protection mechanisms. It is ironic that, while we have often had a focus on countries other than the US, we are seeing indication of strain and collapse in basic public health measures in our own country.
Recent examples include Texas, where they have had a recent outbreak of measles as well as now-recent reports of whooping cough transmission not seen in 50 years. The epidemic of whooping cough in Washington State, once considered a "crown jewel" of our nation's public health, is now considered a state of public health compromise.
What do we mean by "public health collapse"? It is a failure to provide appropriate safeguards against preventable, serious disease. However, this failure is not one of public health officials but largely of vaccine refusal by parents. Yes, there is the issue of waning immunity that promoted updated recommendations by CDC regarding pertussis vaccination. However the elephant in the room remains a problem that we have seen repeatedly in the forecast and warning environment: that humans need visible reminders of the morbidity and mortality of these diseases. If enough time goes by without a visible reminder that 1) these diseases exist, 2) they cause serious disease, and 3) they can kill, then you have social resistance to protective countermeasures.
There are multiple factors contributing to this crisis (not in any particular order):
- The "infectiousness" of ideas. We have seen thoroughly unqualified and untrained individuals make claims regarding vaccines being tied to autism, vaccine preservatives tied to mercury toxicity, and "too many" vaccines given at the same time tied to serious medical consequences in children. Thanks to the Internet, these false ideas have spread "virally" and infected not just your average parent, but physicians. We have seen many colleagues in medical fields outside of family medicine and pediatrics (who are on the front line of vaccine promotion) continue to express opinions in support of the abovementioned false associations. It might be suggested to these colleagues that they should be held liable for promoting these blatantly disproved and false claims to their patients, to possibly include report to their state board of medicine. It might be suggested to those parents who heed such advise they would be in good legal position to sue a physician should their child be harmed by not vaccinating. It might be suggested community officials should be empowered to prosecute if an individual in the center of a social network promotes vaccine refusal, and a large outbreak of vaccine-preventable disease is the result. A cost analysis of the recent measles outbreak in Newark, Texas might be considered and the leaders of the megachurch who promoted vaccine refusal could be asked to pay for the response cost.
- The continued rise of Jenny McCarthy is another example of our inability to enforce accountability. Most of my colleagues believe that any parent who places their trust in such individuals over trained professionals deserve the outcomes. ... But the outcomes include the death of an innocent child who is not able to make such informed decisions. This swings the light of accountability on the responsible parents if a child is harmed by their decisions.
- Practicing physicians are in a "damned if you do" / "damned if you don't" situation. There is rarely a week or month that goes by without a parent who informs the front line physician that they do not believe in vaccination. This is despite the gentle reminder the disease in question is serious and may kill their child or another child in their community. Often these parents quote the Internet, or a local herbalist, accupuncturist, or chiropractor as their most trusted source of information. As an added insult to injury, we have seen physicians sued by parents who initially refused vaccination for their child... a child who later died from the disease in question. We have seen inadequate legal protection for physicians caught in this situation.
- Ours is a culture of independence and individuality. The social unity we once saw post-World War II has eroded to the point of disunity when it comes to "without a second thought" mindfulness of our fellow neighbor and the community we live in. Many of the parents who refuse vaccination are counting on their neighbors to vaccinate their children so there is enough herd immunity to protect their own unvaccinated child. Those of the "Golden Generation" did not have such attitudes and placed greater trust in the medical and public health community. It is unfortunate that trust has eroded so dramatically.
- The ongoing collapse of the US healthcare system (some say restructuring) has contributed many tales of physicians being arrested for running "pill mills" and Medicare fraud schemes. Add to that the unseemly display of wealth where patients see a physician (usually a surgeon) pull up into the hospital garage with a high-end Porsche virtually guarantees erosion of trust... nevermind other unbelievable stories of malpractice committed by our mostly highly trained colleagues. Many physicians are now left demoralized and looking for a quick way out of clinical medicine with decreasing numbers of new physicians to backfill their positions.
- Then we have the "nature abhors a vacuum" phenomenon, where we are seeing midlevel providers fill the gaps left by fleeing physicians. Some of these midlevel providers such as nurse practitioners have gained legal authorization to practice medicine without physician oversight. We routinely see problems with misdiagnosis and failure to promote proper preventive medicine such as the recommendation of Tdap for pregnant mothers. Some physicians have referred to this phenomenon as the "dumbing down" of medicine and "you get what you pay for". Yet the vacuum needs to be filled...
- As far as public health goes, it has been unable to keep up with a rapidly overpopulated America. They simply do not have the resources, manpower, or mindpower to keep up. For both overworked clinicians and public health officials we see a "hunker down" mentality of being barely able to keep up with the daily work load (which has increased dramatically in clinical medicine thanks to EHR and ICD-10 implementation). The outcome means we see increased resistance to change and innovation alongside frank burnout.
- Meanwhile, our population density continues to increase unabated alongside increasing connectedness with the rest of the world, courtesy of the ever-expanding global air traffic grid.
A bleak picture indeed. Why do we care about this issue as operational biosurveillance professionals? Forecast and warning is completely dependent on appropriate interfacing with a society able to process and use the information, which includes the promotion of effective countermeasures such as vaccination. We have directly observed progress at the community level in using forecasts that are dynamically updated to drive health risk awareness and vaccination. While this process was done in collaboration with community physicians and public health officials, execution of forecast and warning dissemination was completely independent of existing public health and medical channels. This concept exploits the already well known phenomenon of nearly half of Americans consult the Internet for health information.
We, as operational biosurveillance professionals, find a common challenge with public health and clinical medicine in combatting the vaccine refusal movement. This is ironic given the many fights we have had over the years dealing with a public health and medical community highly resistant to change. Effective deployment of an operational forecast and warning capability for disease threats is predicated on access to countermeasures. We embrace the concept that "national security begins and ends at home", where every citizen contributes to community resilience in the face of a health threat. Part of that contribution is promoting effective herd immunity through vaccination. Here we acknowledge that naturally occurring infectious disease can at times pose a national security issue.
So what does the future hold for the US? We anticipate future outbreaks and epidemics of measles, mumps, and pertussis and preventable, needless deaths of children as a result. Further, we expect to see the following:
- Introductions of polio (however little person-person transmission inside the US thanks to effective water/sanitation). We note this has occurred in the past, typically among migrant religious vaccine-refuser populations. These introductions will create anxiety among physicians and public health officials due to worry about lapses in community herd immunity.
- Resurgence of Haemophilus influenza type B transmission. This is a dangerous pathogen that causes menigitis, epiglottitis, and sepsis in children.
- Resurgence of invasive pneumococcal infection in children.
- Resurgence of rotavirus
- Resurgence of rubella
- ... With the possibility of seeing case reports of tetanus and diphtheria in unvaccinated children
The abovementioned expected resurgence will most likely appear in fits and starts as did measles, mumps, and pertussis. Media exposure will generate limited public debate, but is likely to fizzle out without social action until enough of these occurrences have hit a "critical mass" prompting social outcry. The problem will be whether any of these events generate enough of a geotemporal intensity of morbidity and mortality to truly drive social action to reverse the vaccine refuser movement.