Thursday, December 10, 2009
dosing Prevention and Management of Vitamin D Deficiency in Children: Part I: Vitamin D Requirements: New Recommendations
Prevention and Management of Vitamin D Deficiency in Children: Part I: Vitamin D Requirements: New Recommendations
- Mechanism of Action
- Current Standards for Vitamin D Intake
- Vitamin D Status in Infants and Children
- New Recommendations
- Patients at Increased Risk
An extensive review on vitamin D deficiency in children, with new recommendations for supplementation, was published in the August 2008 issue of Pediatrics by Misra and colleagues on behalf of the Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. This paper provides an excellent resource for pediatric health care providers on topics ranging from biomarkers of vitamin D deficiency to dietary sources and dosing of vitamin D products.
Based on a review of the literature, the group recommended that serum 25 (OH)D levels be maintained at least above 20 ng/mL and that daily supplementation with 400 International Units (10 mcg) of vitamin D be initiated within days of birth for all breastfed infants and in formula-fed infants and children who do not ingest at least 1 L of vitamin D-fortified milk each day. Premature infants, dark-skinned children, and children who live at higher latitudes may require larger doses of vitamin D, up to 800 International Units (20 mcg) per day. Supplementation for vitamin D insufficient or deficient children should be dosed according to the chart below:
Patient Age Dose (International Units/day) < 1 month 1,000 1–12 months 1,000 to 5,000 > 12 months > 5,000
In addition to their recommendations, the authors also highlighted the need for additional studies to determine if higher levels of 25 (OH)D (> 32 ng/mL) should be considered, as well as to determine the appropriate balance of the benefits and risks of sunlight exposure.
In November 2008, the American Academy of Pediatrics (AAP) released a guidance paper on the prevention of rickets and vitamin D deficiency in infants, children, and adolescents. This new report replaces their 2003 statement which recommended a daily intake of 200 International Units. As in the Lawson Wilkins Society article, the 2008 AAP statement recommends that the daily vitamin D intake for all pediatric patients be increased to 400 International Units (10 mcg), with a goal 25 (OH)D level of at least 20 ng/mL. The AAP statement also recommends that breastfed infants receive a vitamin D supplement at a dose of 400 International Units/day beginning shortly after birth and continuing until they are weaned and consuming at least 1 L of vitamin D-fortified formula or milk per day.
Daily supplementation is also recommended for older children and adolescents who do not consume at least 400 International Units of vitamin D with their usual diet. The AAP guidelines were based on studies documenting the safety of vitamin D at this higher dose as well as new evidence suggesting a possible role for vitamin D in preventing cancer, cardiovascular disease, and diabetes.
Many parents who light up are aware of the dangers of secondhand smoke; they blow it out the window or smoke at home only when the kids are not there. But people rarely account for what is left behind after a cigarette has been extinguished. When smoke dissipates, it does not just disappear. Compounds are left over that settle on walls, furniture and clothes, or become part of house dust. Call it "thirdhand smoke," which is what a team of researchers trying to raise awareness of the dangers of smoking named it in January.
The study, published in the journal Pediatrics, surveyed 1,500 smokers and nonsmokers about the hazards of secondhand and thirdhand smoke and found that 84 percent of smokers believe secondhand smoke is dangerous to children, while only 43 percent think thirdhand smoke is harmful. But the compounds in thirdhand smoke can be ingested or absorbed through the skin, and some give off gases as they deteriorate, says Jonathan Winickoff, an associate professor of pediatrics at Massachusetts General Hospital, who led the research. Many are carcinogenic. "The more you smoke in these locations, the more microlayers of these toxins build up," Winickoff says.PHOTO ILLUSTRATION BY REINHARD HUNGER
SET DESIGN BY SARAH ILLENBERGER Enlarge
Winickoff is analyzing data on children who live in apartments and encounter thirdhand smoke only from other units in their buildings. He expects to publish his results early next year. LIA MILLER
Correlations in Marriage Patterns
Some state-level patterns of marriage and divorce correlate3 with the overall socioeconomic characteristics and political behavior in those states. This does not mean that one pattern causes the other to happen, only that both tend to be true in the same place.
A state's education levels, for example, tend to be associated with the median age at marriage and the multiple-marriage patterns of its residents. In states with high shares of college-educated adults, men and women marry at older ages, a finding supported by other research indicating that highly educated individuals marry later in life. In states with low shares of college-educated adults, adults are more likely than average to marry three or more times. In states with low income levels, men are more likely than average to have been married three or more times.
For this analysis, correlation also was tested between a state's marriage or divorce statistics and the share of its 2008 presidential election vote that went Democratic. States with high shares of Democratic votes tended to have lower shares of currently married residents, lower shares of adults married at least three times and low rates of marriages within the previous year. Residents of states with high shares of Democratic votes tend to marry at older ages than residents of states with low shares of Democratic votes.
This analysis did not find a strong correlation between divorce statistics -- either a state's share of divorced adults or its rate of divorce within the previous year -- and socioeconomic indicators (income and education) or 2008 presidential election patterns. There was a strong correlation, however, between young age at first marriage for women and a high divorce rate for women within the previous 12 months.
Correlation also was tested to see whether a state's religiosity was associated with marriage and divorce patterns. Religiosity was expressed as the proportion of a state's residents who said in response to a survey that religion was "very important" in their life.4 However, this analysis did not find a strong association between a state's religiosity and its marriage or divorce patterns.
Explore marriage and divorce patterns and see how your state measures up using interactive maps at pewsocialtrends.org.
Wednesday, December 9, 2009
Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform | Health Care Reform 2009
Diane R. Rittenhouse, M.D., M.P.H., Stephen M. Shortell, Ph.D., M.P.H., M.B.A., and Elliott S. Fisher, M.D., M.P.H.
With discussions about U.S. health care reform focused heavily on insurance reforms, relatively little attention has been paid to the delivery-system reforms that will be required to improve the quality and coordination of health care and slow the growth of spending. The “patient-centered medical home” (PCMH) and the “accountable care organization” (ACO) are two widely discussed models for delivery-system reform that take complementary approaches to achieving these goals. The PCMH model emphasizes the creation of a strong primary care foundation for the health care system, and the ACO model emphasizes the alignment of incentives and accountability for providers across the continuum of care. With support from the Commonwealth Fund, we recently met with other leaders involved in the development of these models to clarify their key elements and identify ways of ensuring that such reforms are mutually reinforcing.
The PCMH model builds on substantial evidence demonstrating that greater emphasis on primary care can result in higher-quality care at lower cost. The model combines the core tenets of primary care (first-contact care that is continuous, comprehensive, and coordinated across the care continuum) with 21st-century practice innovations such as the use of electronic information systems, population-based management of chronic illness, and continuous quality improvement. One important cornerstone of this model is a focus on meeting the needs and preferences of patients; another is payment reform that improves reimbursement to primary care practices and rewards high performance. The model is widely endorsed by purchasers, payers, physicians, and patient-advocacy groups, and multipayer medical home demonstration projects are under way throughout the country.
The challenges to implementation of the PCMH model include two issues that lie beyond the direct control of the primary care practice.1 First, although the model calls for primary care practices to take responsibility for providing, coordinating, and integrating care across the health care continuum, it provides no direct incentives to other providers to work collaboratively with primary care providers in achieving these goals and optimizing health outcomes. Second, although evidence suggests that increased investment in primary care can result in savings from several types of reductions — for example, inappropriate use of tests and procedures, emergency department utilization, and hospitalizations for conditions that could be treated in an outpatient setting — most primary care practices do not have financial arrangements that allow them to share in these savings. The effect on total costs of implementing the PCMH model alone could be limited, because primary care physicians have little direct leverage over other providers in the care continuum, and under the largely fee-for-service payment system it is unlikely that other providers will respond to reductions in the number of referrals or admissions by allowing their incomes to fall. These limitations could be addressed most readily if the model were implemented in the context of a larger entity such as an ACO.2
An ACO is a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population. Multiple forms of ACOs are possible, including large integrated delivery systems, physician–hospital organizations, multispecialty practice groups with or without hospital ownership, independent practice associations, and virtual interdependent networks of physician practices.3 ACOs could receive fee-for-service payment and share in any cost savings achieved relative to a risk-adjusted projected spending target for their patient population; alternatively, payment could be partially or fully capitated, with risks and gains both being shared by all providers. Performance measurement to evaluate the quality of care and to prevent potential overuse (in fee-for-service organizations) and underuse (in capitated ones) is a cornerstone of the model. Some evidence suggests that more fully integrated ACOs provide higher-quality, more efficient care than smaller, more loosely organized ones.4 Challenges to the implementation of the ACO model include the need for strong leadership to address the cultural, legal, and resource-related barriers to creating new provider organizations in many communities.5
Regardless of the organizational structure, an ACO will not succeed without a strong foundation of high-performance primary care. The current shortage of primary care capacity and the outdated infrastructure of most primary care practices could limit the successful implementation of ACOs; conversely, investment in the PCMH model could accelerate the development of high-performing ACOs. The fact that the ACO model does not explicitly require support for primary care has led to considerable concern that ACOs dominated by hospitals or specialists would not adequately invest in primary care — or that hospitals and specialists would garner a disproportionate share of any savings. Because it is widely recognized that increased investment in primary care is needed to slow the overall rate of growth in spending, finding a way to ensure adequate support for primary care will be critical to the design and implementation of ACOs.
As both models move through pilot programs toward implementation, we have identified several strategies for ensuring that they are mutually reinforcing. First, accreditation and certification processes should be aligned. The National Committee on Quality Assurance (NCQA) has a voluntary PCMH recognition program that has been used in many of the early medical home initiatives. There is ongoing debate about the best criteria for recognizing a practice as meeting the standards of a PCMH, and the NCQA is seeking input on this topic from stakeholders. No ACO accreditation or certification process has yet been developed, but when one is, it will be critical to include criteria that ensure sufficient primary care capacity for the patient population and to closely align the standards with those of PCMH recognition.
Second, because successful implementation and evaluation of both models will require measurement of performance, a common set of primary care performance measures should be developed; these should be consistent with the domains outlined in the Commonwealth Fund’s “2020 Vision of Patient-Centered Primary Care” (e.g., timely access to care, coordination of care, and engagement of patients) and endorsed by the National Quality Forum. Performance measurement for determining the amount of shared savings or other financial incentives for ACOs must weight primary care measures heavily rather than focus narrowly on metrics related to hospital care.
Third, the payment mechanisms used must align the incentives of the two models to increase accountability for total costs across the continuum of care while ensuring that a sufficient investment is made in primary care capacity. In Medicare and other demonstration projects, incentives should be aligned so that primary care practices could benefit financially from simultaneous participation in both PCMH and ACO pilots. Because transforming primary care in accordance with the medical home model requires considerable resources, incentives for both quality and savings should emphasize high levels of primary care performance to ensure that ACOs provide adequate support to their primary care providers to enable them to attain and sustain the essential capabilities of a PCMH.
These two approaches are synergistic models of delivery-system reform that, together, promise to redirect the U.S. delivery system toward reduced cost growth and improved quality. ACOs will require a strong primary care core to succeed and, in turn, can provide essential delivery-system infrastructure beyond the primary care practice to ensure the full realization of the PCMH model. Ongoing evaluation of both models, preferably in combination and in diverse settings, is essential. Demonstrations should be designed as pilot tests that can be continued if successful, modified as necessary, and (when successful) implemented broadly, with continued adaptation. Finally, one of the most important elements of federal health care reform will be expanding the capacity of federal agencies, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, to implement, support, and evaluate these promising delivery-system reforms.
Drs. Shortell and Fisher report receiving consulting fees from Kaiser Permanente; Dr. Shortell also reports receiving advisory fees from Centene. No other potential conflict of interest relevant to this article was reported.
From the Department of Family and Community Medicine, University of California, San Francisco, San Francisco (D.R.R.); the School of Public Health, University of California, Berkeley (S.M.S.); and the Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Medical School, Lebanon, NH (E.S.F.). The authors participated in the meeting along with Melinda Abrams, M.S., Michael S. Barr, M.D., M.B.A., Robert Berenson, M.D., Karen Davis, Ph.D., Kevin Grumbach, M.D., David Meyers, M.D., Hoangmai Pham, M.D., M.P.H., Robert L. Phillips, Jr., M.D., M.S.P.H., and Dana Gelb Safran, Sc.D. The consensus that emerged from the discussion and that is summarized in this article should not be taken to be the perspective of any specific individual or organization.
This article (10.1056/NEJMp0909327) was published on October 28, 2009, at NEJM.org.
Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA 2009;301:2038-2040. [Free Full Text] Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med 2008;359:1202-1205. [Free Full Text] Shortell SM, Casalino LP. Health care reform requires accountable care systems. JAMA 2008;300:95-97. [Free Full Text] Tollen L. Physician organization in relation to quality and efficiency of care: a synthesis of recent literature. New York: The Commonwealth Fund, April 2008. McKethan A, McClellan M. Moving from volume-driven medicine toward accountable care. Health Affairs Blog. August 20, 2009. (Accessed October 26, 2009, at http://healthaffairs.org/blog/2009/08/20/moving-from-volume-driven-medicine-toward-accountable-care.)
Tagged as: Primary Care
Flu During Pregnancy May Increase Risk Of Schizophrenia In Certain Offspring; influenza type B seems to be more implicated.
Flu During Pregnancy May Increase Risk Of Schizophrenia In Certain Offspring
ScienceDaily (June 11, 2009) — When mothers become infected with influenza during their pregnancy, it may increase the risk for schizophrenia in their offspring. Influenza is a very common virus and so there has been substantial concern about this association. A new study in the June 15th issue of Biological Psychiatry suggests that the observed association depends upon a pre-existing vulnerability in the fetus.
Specifically, Dr. Lauren Ellman and colleagues determined that fetal exposure to influenza leads to cognitive problems at age 7 among children who later develop a psychotic disorder in adulthood, but fetal exposure to influenza does not lead to cognitive problems among children who do not later develop a psychotic disorder. It is important to note that these results were dependent upon the type of influenza, with this association present only after fetal exposure to influenza B as opposed to influenza A.
This research was conducted as part of the Collaborative Perinatal Project, which followed pregnant women and their offspring in the 1950’s and 60’s, collecting blood throughout pregnancies for later analyses. A series of cognitive assessments were conducted with the children of study participants and then psychotic diagnoses were determined in adulthood.
The findings from this study suggest that a genetic and/or an additional environmental factor associated with psychosis likely is necessary for the fetal brain to be vulnerable to the effects of influenza, given that decreases in cognitive performance were only observed in influenza-exposed children who developed a psychotic disorder in adulthood.
“The good news is that most fetuses exposed to influenza virus while in the womb will not go on to develop schizophrenia. The bad news is that the prior association between influenza infection and later development of psychotic disorders was supported,” comments John Krystal, M.D., the editor of Biological Psychiatry.
This finding has the potential to influence efforts to develop prevention, early intervention and treatment strategies, such as taking steps to maintain careful hygiene and, if clinically appropriate, administration of the influenza vaccination to reduce infection among women prior to pregnancy. Dr. Krystal notes, “It also raises an important unanswered question: How does influenza virus affect the vulnerable developing brain and how can we prevent or reverse the consequence of fetal influenza infection in vulnerable individuals before they develop schizophrenia?” More research is needed to elicit answers to these vital issues.
interesting paradigm of how viral diseases can affect gene expression and manifest in psychiatric disease 30 years later.
Exposure To Influenza During Pregnancy May Increase Risk Of Schizophrenia In Offspring
ScienceDaily (Aug. 3, 2004) — NEW YORK, NY (August 2, 2004)– A new study published today in the JAMA publication, Archives of General Psychiatry, indicates that prenatal exposure to influenza may increase the risk for development of schizophrenia years later. The study, which evaluated archived sera from pregnant women who participated in a large birth cohort called the Child Health and Development Study (CHDS) from 1959–1966, was conducted by researchers at the New York State Psychiatric Institute and the Mailman School of Public Health at Columbia University, in collaboration with the Kaiser Permanente Medical Care Plan, Northern California Region and the Public Health Institute, Berkeley, California.
Today's findings are part of a larger team study known as the Prenatal Determinants of Schizophrenia (PDS), which examines prenatal infection, nutrition, chemical exposure, paternal age, and a range of other prenatal factors that influence schizophrenia risk.
The study has shown for the first time that serologically documented prenatal exposure to influenza is associated with schizophrenia. The risk of schizophrenia was increased threefold when influenza occurred during the first half of pregnancy; however when influenza occurred during the second half of pregnancy, no increased risk was observed.
"It is an exciting time for research that combines serologic documentation of infectious diseases during pregnancy, long-term follow-up, and careful assessments for schizophrenia and other disease outcomes," said Alan Brown, MD, lead author and associate professor of clinical psychiatry and epidemiology at the New York State Psychiatric Institute and Mailman School of Public Health. "Because the individuals whom we are studying have only recently passed through the age of risk for schizophrenia, it has become possible only in the last few years to analyze archived prenatal serum specimens in order to address the question of whether schizophrenia is related to prenatal risk factors such as viruses, as well as nutritional factors and toxins, during pregnancy." The 40-year study of the CHDS was made possible by ongoing support from the National Institute of Child Health and Development.
"These findings represent the strongest evidence thus far that prenatal exposure to influenza plays a role in schizophrenia," said Ezra Susser, MD, DrPH, senior investigator of the PDS study, chair of the Department of Epidemiology at the Mailman School of Public Health and head of Epidemiology of Brain Disorders at the New York State Psychiatric Institute. "Although the findings may ultimately have implications for prevention, we strongly caution against making any public health policy recommendations until these links have been confirmed through further study."
The PDS, initiated by Dr. Susser together with Dr. Brown and Dr. Catherine Schaefer of Kaiser Permanente Division of Research, included a nested case-control study of the CHDS birth cohort, which was recruited from 1959-1967, and was followed up for psychiatric disorders 30-38 years later. During that time period, the CHDS, under the direction of Jacob Yerushalmy, University of California, Berkeley, recruited nearly every pregnant woman who received obstetric care from Kaiser Permanente in Alameda County, California. All of the children born were automatically enrolled in Kaiser Permanente. The PDS study cohort consisted of the sub-sample of 12,094 live births who were members of Kaiser Permanente from January 1, 1981 through December 31, 1997.
Dr. Brown and colleagues from the PDS team measured influenza antibody in archived serum samples derived from the blood of 64 pregnant women whose offspring later developed adult schizophrenia and from a comparison group of 125 pregnant women whose offspring did not develop schizophrenia. They found an association between the presence of elevated influenza antibody levels and schizophrenia in the adult offspring suggesting that prenatal exposure to influenza may increase the vulnerability for schizophrenia.
This study was funded by the National Institute of Mental Health, the National Alliance for Research on Schizophrenia and Depression, and the Lieber Center for Schizophrenia Research.
The PDS research is part of a number of "life course studies" being overseen by Dr. Susser at the Mailman School. In addition to the CHDS study, Dr. Susser and his team are looking at large birth cohorts from the U.S., Israel and Norway to observe the pathogenesis of chronic and acute diseases and their links to prenatal and postnatal exposure to environmental factors such as viruses and toxins.
The Long-Term Evidence for Vaccines | Print Article | Newsweek.com Prelude to backlash against backlash?
The Long-Term Evidence for VaccinesVaccination does more than protect against flu. Study after study shows that keeping children safe from viruses has long-lasting, positive health benefits.
By Laurie Garrett and Dana March | Newsweek Web Exclusive
Dec 7, 2009
With some reports saying that the worst of the H1N1 outbreak may have already come and gone this flu season in North America but not worldwide, parents who decided to sit out vaccinations for their children may feel validated. But not only is that strategy risky, it's uninformed, and ignores a larger truth about the benefit of vaccines. Throughout North America and Europe, an anti-vaccination movement has steadily grown over the past two decades, and was recently jet-propelled amid anxiety over immunizing pregnant women and children against the H1N1 "swine flu." The greatest fall-off in child vaccination, and the strongest proponents of various theoretical dangers associated with vaccines, are all rooted in wealthy, mostly Caucasian communities, located in the rich world. At a time when billions of people living in poorer countries are clamoring for equitable access to life-sparing drugs and vaccines for their families, the college-educated classes of the United States and other rich countries are saying "no thanks," even accusing their governments of "forcing" them to give "poison" to their children.
Will the children of these naysaying parents of the rich world turn to Mom and Dad 30 years from now and say, "Thanks for not getting me immunized. Thanks especially for saying no to the flu vaccine?"
If a woman is exposed to influenza while pregnant, or if an unvaccinated child gets the flu in his or her first year of life, the baby's developing brain may be severely damaged by the virus. Analysis of medical records of Americans who were born in the late '50s and early '60s shows that having the mother catch the flu while pregnant increased the chance her child would later develop schizophrenia. It's not a trivial difference: the children of moms who had flu midway during their pregnancies were as much as eight times more likely to become schizophrenic.
Overall, prenatal and infant exposure to influenza is strongly associated with cognitive failures. Babies are born with brains and immune systems that are still developing, and will not be hard-wired and strong until their second year of life. Scientists are increasingly discovering links between viral infections during those precious times, and psychiatric problems ranging from lifelong depression to acute learning deficits. In utero or infancy infection with chickenpox doubles the risk of cerebral palsy, according to Australian researchers. Having rubella during pregnancy increases by 80 percent the chances of severe birth defects in that mother's child, including small brains and hearts, blindness, deafness, and severe learning deficits.
Children who contract measles, chickenpox, or whooping cough can develop encephalitis or meningitis—infections of the central nervous system—which can cause epilepsy, brain damage, and death. Parents cannot protect their children's brains against everything, but the basic battery of vaccines can block the bulk of these viral insults. And the good news is that the still-developing immune system of babies and infants is ripe for the vaccine-induced programming that can confer decades—in some cases, lifelong—protection.
Other vaccine-preventable diseases—measles, rubella, mumps, chickenpox, and whooping cough—can damage the optic nerves and hearing of fetuses and newborns. The effect in these cases is immediate and obvious. In the pre-vaccine era in the United States, a thousand kids lost their hearing every year due to measles infection, five out of every 10,000 children who contracted mumps suffered permanent deafness, and 10 percent of child deafness was due to rubella (a.k.a. German measles).
And today, in countries with spotty child-immunization achievements—including the United Kingdom—viral infection in utero or in infancy accounts for 10 to 25 percent of child deafness.
Influenza in utero or in the first year of a child's life is a major cause of adult cardiovascular disease—heart attacks and strokes. People who suffered influenza during the Great Pandemic of 1918–19 were 20 percent more likely to develop heart disease as adults. To put that in perspective, having a "bad cholesterol count" of more than 240mg confers a 20 percent elevated risk of heart attacks, according to the American Heart Association.
Dr. Marietta Vázquez studied 350 mothers and infants from birth to 12 months of age who were hospitalized at Yale-New Haven Hospital over nine flu seasons (2000–2009). The babies of flu-vaccinated moms were larger, healthier, and, 85 percent of the time, fully protected against influenza. Similar findings have recently been reported out of Bangladesh, where the babies of vaccinated moms averaged a half pound larger than their unprotected peers and were less likely to be born prematurely.
The good news is that five decades of global child-vaccination programs have dramatically reduced infant and child mortality rates, and improved life expectancies in most of the world. In September, UNICEF reported that for the first time since WWII the number of children dying in the world annually fell below 10 million in 2008, largely due to child immunization. Vaccines, UNICEF says, are saving 2.5 million kids from dying every single year.
But outbreaks of vaccine-preventable diseases are surfacing wherever clusters of people either decline immunization, or are denied it by virtue of population poverty. The unimmunized few are a threat to all, as they may harbor viruses and pass them onto others whose vaccine-induced immunity is waning due to HIV, cancer, or simply the passing of time. Conversely, failing to be immunized in childhood renders young adults vulnerable to infectious diseases that they may not encounter until they go off to college or travel outside of their home regions.
A cursory search of outbreak reports over the last 13 months demonstrates that measles, mumps, diphtheria, whooping cough, polio, and typhoid fever are surfacing now in all sorts of settings, from jet planes to college dormitories, from Dutch religious sects to villages of Caribbean islands. Some of these outbreaks are tiny, involving no more than a cluster of individuals. But over the last year, several outbreaks have reached epidemic levels.
The United Kingdom has more such outbreaks than any other wealthy country, and that comes as no surprise as Dr. Andrew Wakefield—a key proponent of the theory that additives in vaccines cause autism—started his anti-immunization career in the U.K., in 1998 publishing now thoroughly refuted "evidence" of an autism link. Wakefield is now the subject of a hearing conducted by the U.K.'s General Medical Council for alleged medical misconduct. The discovery that he was secretly funded by personal-injury lawyers that sued vaccine makers has further fueled inquiries. Still, Wakefield's ideas continue to resonate in the UK, to the dismay of the country's pediatricians. Today, 20 percent of U.K. children enter primary school without having completed their full schedule of basic vaccinations— 40 percent, in some parts of the country—according to the Department of Health.
For those fighting disease on the global stage, the H1N1 pandemic has brought into stark relief a puzzling, difficult dichotomy. In the wealthy world, where individuals have the luxury of demanding 100 percent safety, the balance between individual and population rights has shifted so far toward individualism that it is nearly impossible for public-health authorities to persuade people to accept even one in 1 billion risks on behalf of society as a whole. (The exception is the U.S. armed forces, where duty to country includes an obligation to accept full vaccination.) But the very tools of protection that many individuals in the rich world are rejecting—especially the H1N1 vaccine—are completely unavailable to more than half the population of the world. Some 24 million children last year had no access to basic vaccines, says UNICEF, and at least 4 billion people cannot get flu vaccines right now.
For the poor and emerging-market countries, this inequity in access to life-sparing public-health tools is viewed as not only grossly unfair, but as a sign of the arrogant hypocrisy of the wealthy world. The rich countries demand that the planet's poor make sacrifices to slow down epidemics—such as slaying their chickens to stop bird flu, or losing tourist dollars by publicly acknowledging outbreaks within their borders—but offer little in return, including access to precious vaccines.
Yes, the proper adjective is "precious": miracles of science that, combined with smallpox immunization, saved more lives during the 20th century than were lost in all the wars, all the genocides, and all the epidemics of that hundred years. When a baby in an African village dies of measles, or a schoolchild in China succumbs to typhoid fever, none can question how precious that lost life was, or how vital a difference a vaccine could have made.
GARRETT is a Pulitzer Prizewinning writer and senior fellow for global health at the Council on Foreign Relations. MARCH is a doctoral candidate at the Mailman School of Public Health at Columbia University, specializing in life course, social, and psychiatric epidemiology.
Find this article at http://www.newsweek.com/id/226097