US: The politics of immunization in public health.

[Guest guest]

Here are excerpts from a piece that tells you why they REALLY vaccinate

sometimes. I'll be getting the whole thing by mail from New Zealand (not on

the next except for abstract - colleague typed this up)

Here's what they really think of us . This ought to make you quite ill

I found this a fascinating insight into the minds of medical people, albeit

in 1989

" .. " We have to do it for political reasons. If anything happened, we'd be

dead. " A worst case scenario often leads to an intervention, since waiting

for more evidence of a need for intervention is perceived as a gamble that

provokes anxiety. "

TO SAVE THEIR YOU KNOW WHATS!

" one physician stated, " If we don't do it, somebody's going to cause a hell

of a lot of trouble. they're just going to raise a lot of hell, and its

easier to shoot'em and get 'em off your back. "

" Shots may also be given to prevent panic. Disease control staff often

express the view that doing something, in this case administering an

immunization, will prevent widespread public panic. In these cases the

perceived function of the immunization is not to prevent infection, but to

avert an inappropriate social response. "

http://www.ncbi.nlm.nih.gov/entrez/...7 & dopt=Abstract

Soc Sci Med 1989;28(8):843-9

The politics of immunization in public health.

McCombie SC.

Annenberg School of Communications, University of Pennsylvania,

Philadelphia 19104.

The role of socio-political and psychological factors in the decision to

immunize is explored using data collected in a county health department in

the United States. Decisions regarding the administration of post-exposure

immunizations for hepatitis A and rabies are described, and a tendency

toward unnecessary use noted. At times these interventions function more to

reduce the anxiety of a patient or clinician than they do to prevent an

infection. These findings may have implications for analyses of clinical

decision making that involve other types of interventions.

__________________________________________

" I want to describe a variety of ways in which social and psychological

factors enter into the decision to immunise in the hope that this will

suggest further research. I will use the phrase " shoot'em or you're dead'

to characterize situation in which uncertainty, socio-political and/or

psychological factors combine in a decision to immunize, even though the

immunization is not considered to be necessary for medical or

epidemiological reasons. "

" ...When someone is diagnosed as having hepatitis (A), panic and fear of

contagiou among those who perceive themselves as being exposed is not

uncommon. the extent of perceived exposure is oftne much larger than the

real exposure and includes friends casual acquaintances, work contacts, and

event the contacts of those who are perceived to be exposed. A wide-spread

misconception in American society is that hepatitis is highly contagious,

and this contributes to the panic and breoad definition of who is at risk

on the part of lay-people. Private physicians sometimes reinforce the

misconceptions of the public, and have been quoted as saying " Everyone who

has been around you needs a shot. "

(there is then a discussion about a group who call the H D, because they

***don't*** want to have the shot...so we'll leave them - they are only

discussed once, as some sort of strange anomaly amongst the hysterical

majority)

" Some insist that hepatitis is much more highly contagious than the health

department admits. Others say that they want to have the shot anyway, 'just

to be on the safe side'. A small number of people become angry, and

threaten to sue or take other action against the health department. This is

a situation in which the phrase 'shoot 'em or you're dead' may be used by

the department workers. ...Thus the shot is given to humor the patient. "

then they talk about situation where they say the vacine isn't necessary

but the person keeps complaining and threatens to call the media:

" one physician stated, " If we don't do it, somebody's going to cause a hell

of a lot of trouble. they're just going to raise a lot of hell, and its

easier to shoot'em and get 'em off your back. "

" ...the fear of hypothetical complications and the desire to intervene may

outweigh the knowledge that no risk of disease transmission exists. "

" Shots may also be given to prevent panic. Disease control staff often

express the view that doing something, in this case administering an

immunization, will prevent widespread public panic. In these cases the

perceived function of the immunization is not to prevent infection, but to

avert an inappropriate social response. A physician writing on the

prevention of hepatitis illustrates this point:

" " the problem with index cases in schools or businesses is usually more

psychological and political than scientific. concerned and often hysterical

teachers, students, employees, and lawyers for employers often demand that

health departments provide IG for contacts ranging far beyond the intimate

contacts of the index case.... " "

" another factor that influences a decision to administer an immunization is

the clinicians need to intervene even when the intervention is not likely

to have any beneficial effect. One of the physicians ...referred to the

concern that a small chance always exists that the individual requesting

the shot will develop hepatitis. He said " They teach you that in medical

school, when in doubt, do something. " He added, " if it's not too expensive. "

More discussion of shoot em or you are dead concepts and then about a case

in a restaurant where the case didn't meet criteria, and the diagnosis

hadn't even been made, but everyone was jabbed:

" .. " We have to do it for political reasons. If anything happened, we'd be

dead. " A worst case scenario often leads to an intervention, since waiting

for more evidence of a need for intervention is perceived as a gamble that

provokes anxiety. "

A whole lot more discussion of other similar events... then:

" these events suggests that medical personnel perceive immunizations as

placebos that may have a beneficial psychological action, in addition to

creating immunity to a specific disease agent....the general feeling among

physicians who recommend it seems to be " Well, it can't hurt. " This

attitude implies that it may help and perhaps both patient and physician

derive a psychological benefit when some form of treatment is provided.

Surveys indicate that the use of tetanus vaccine in the treatment of animal

bits is extremely common ...the use of tetanus vaccine in these situation

can result in a false sense of security and lead to a reducation in efforts

to locate a biting animal. "

Under " discussion " more 'shoot 'em or you're dead' discussion...

" the tendency toward over-immunization described here can be explained as

the application of the medical decision rule to preventive medicine.

According to Friedson, " the health professional typically assumes that it

is better to impute disease than to deny it and risk overlooking it. " the

consequences of the decision rule are unnecessary surgery and

overprescribing, which are most likely to occur when the patient is in

distress but signs and symptoms are ambiguous, and a treatment is available

that is not absolutely contraindicated. Both of these conditions apply to a

person who believes he has been exposed to a communication disease... "

Three major motivations for the use of placebos by physicians are described.

" As a gift, a placebo is given becaue the physician believes it will reduce

the patient's anxiety and thus his suffering. A physician may also use a

placebo as a challenge, to prove to himself that the patients complaints do

not derive from objectively defined disease and are all in his head.

Finally, placebos are used as a ransom in order to deal with demanding

patients. "

the article describes " pure placebos " as having no pharmacological activity

and impure placebos have pharmacological activity and include vaccines, and

the use of antibiotics for colds, and says:

" The use of an impure placebo may reduce the clinician's guilt about

deceiving a patient, and may help the clinician convince himself that he is

not using a placebo. Post exposure immunization for (contacts of) hepatitis

A and rabies are impure placebos...an injection of ISG may be both a gift

and a ransom. As a gift is symbolizes a successful patient-provider

encounter and communicates concern for the patient. As a ransom it gets the

patient off your back. However, rabies immunization given to a patient with

suspected pseudo-rabies may be viewed as a challenge since immunization

does not cure rabies once symptoms begin to develop. "

an example of using antibiotics as a placebo and its rationalisation:

" I think the patient has the flu, but I am going to give him broad specturm

antibiotics until his blood cultures come back negative. It is better to be

safe, and after all, it won't hurt to give him antibiotics, and besides,

***I won't have to worry***(this was in italics) about gram negative

septicemia. "

Discussions about physicians anxiety... " Nagging doubts and long term

anxiety (of the physician) are prevented by administering the questionable

interventions. "

" Often the impetus behind such activities is political or public pressure,

rather than a rational decision that the measures are necessary to control

disease. "

" CONCLUSION

" The administration of an immunisation may be undertaken for a variety of

reasons in addition to the prevention of the specific infection for which

they are appropriate. Immunizations are sometimes given to reduce patient

of clinician anxiety, prevent public panic or psychosomatic illness, reduce

the likelihood of malpractice litigation, and fulfill the clinicians' need

to intervene. In many parts of the world, and for various reasons,

immunization are not being administered to those who might benefit from

their use. At the same time, some immunizations are given when they are not

really needed and will have no tangible benefit in terms of disease

control. The popularity of injections in many areas of the world is related

to unnecessary use and may have iatrogenic effects...To facilitiate the

rational and equitable use of immunizations on a worldwide basis, studies

should be done on clinicians' perceptions and use of immunizations "

--------------------------------------------------------

Sheri Nakken, R.N., MA

Vaccination Information & Choice Network, Nevada City CA & UK

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