Experiences of a Pediatrician with the Swine Flu

H1N1 Swine Flu Vaccine

Spring of 2009, when news of the H1N1 swine flu began to hit the media, I contacted our local health department and the CDC, to “get the facts” and prepare our office for the onslaught of questions that parents of my patients would naturally have. We have seen this all before.

Here in my busy general pediatric practice, each time there is a news story about a case of lyme disease or meningitis, we get swamped with phone calls and emergency visits from concerned and panicking parents. With the flu it always seems to be a crisis.

Each year I watch how the 24 hour news media kindles the fires of panic about the flu. There is invariably a tragic story that comes out sometime in November or December about a child dying somewhere in the country and suddenly everyone is demanding flu vaccine and/or their own personal supply of Tamiflu. This is a very human response. It’s a kind of reality check that wakes us into action. And we are all easy victims to the panic of “breaking news”. Fear, though, can fuel all kinds of rash decisions. Naturally, when something like this occurs, people look to their doctor to be a voice of reason.

This year was a particularly extreme version of that scenario. Perhaps it stems from the persistent underlying stress we’re all feeling about the economy, or the fact that around here the weather’s been a bit bizarre (it’s been raining pretty much every day since April) but when people heard about a “new” virus that could reach the level of “pandemic”, they were just about at a break point of panic. Trying to remain a calm source of guidance to my patients has been a daunting task when we are faced with unknowns and misinformation. Here is a list of the contradictory information that concerns us all as we prepare for next autumn.

  • The statistics on severity of the disease are completely skewed because the number of cases collected by the department of health reflects only people who ended up in the hospital and there were millions of cases of people who had relatively mild unreported cases of the flu, though the press never reported this. In-office testing for Flu misses at least 50% of the cases.
  • Each year the seasonal flu vaccine provides only partial or no coverage for influenza strains not included in that vaccine. We’re being told that the ‘seasonal’ flu vaccine this year will NOT cover the new swine flu, which, they say is why we need a swine flu vaccine. The reason for fearing the swine flu and mandating a swine flu vaccine stems from the projected (but as yet unknown) mutations that may occur in the coming year however there is no evidence that the new vaccine will protect us from those mutations since it is being created based only on this past years H1N1 virus. (the vaccine has not as yet been fully tested here in the states.)
  • The swine flu this year was a relatively mild illness, and while it is important to recognize that every flu can cause death, the mortality rate for this particular “new flu” was actually quite low, based on corrected statistics. This exposure might actually provide the millions of people who had the swine flu this year some protection next year if it does not mutate. (indeed there is the distinct possibility that they may have partial protection even if it does mutate though it’s too early to tell!). The irresponsible overuse of Tamiflu and other antiviral drugs as “preventive” treatments only serves to encourage mutations and mounting resistance, making us more vulnerable.
  • The 24 hour news media will continue to create fear and stress in the general population because it’s good for business. Stress itself depresses our immunity and may actually make us more susceptible to the flu! When people’s judgment is jaded by fear, they will demand any antiviral treatment whether it is warranted or not.

This is the doctor’s dilemma for anyone working on the ‘front line’ of health care, particularly in a crisis where fear is fueling the debate.  Is medicine to be about policy-making or fostering individual relationships? Is it political or personal?  Can one sustain both in the midst of a crisis?

A wise man once said, “At the doctor’s gate, many sick people wait.” People are not looking just for mandates and policies when they’re sick. What they seek is a trustworthy companion when the fear of illness knocks at their door.  While decisions in emergencies typically require protocols, it is the wise clinician that sees beyond statistics to the ‘whole’ patient with calm attentiveness.  We must be careful not to get caught treating data at the expense of people. Trust can only be generated when the standards of care that a doctor follows do not constrain the connections he makes with those who have come for help.  This is what I call real “participatory medicine”.

The legal pressures on physicians reach far beyond legislation however.  “Standards of Care” tend to preserve the status quo and do not encourage ‘thinking outside the box’. This can greatly limit our creativity in finding solutions to the problem at hand. But what’s more worrisome is how they tend to undermine the personal trust we’ve developed with our patients. This can be very dangerous in a crisis.

Can we envision a standard of care that is not grounded in fear but rather in the mutual respect and trust between physician and patient?  Standards of care were meant to be rational guidelines, not tools to measure liability and yet that is exactly what they have become. Indeed this is why so many physicians are afraid to use alternative therapies in their practice. This merely creates a rather generic impersonal medical assessment though.  In an acute emergency like the flu, what we need (and what most of us want) is a personalized medicine that addresses the different affinities, strengths and weaknesses, of each individual.  A medicine that recognizes the amazing resilience of our immune system, embracing it as a kind of bridge to the outside world rather than a wall needing constant fortification.

The viral “xenophobia” we’re seeing now runs counter to the way we actually exist in nature. Our immune system is much more like a brain open for learning, being shaped by our environment than a military tank.  Perhaps it’s time we start looking at ways to make it more resilient rather than more resistant.  As I watch how “well” the children in my practice recovered from this past flu, the discussion with parents naturally turns to what lessons we’ve learned and what we can use from this in the coming year. This kind of dialogue seems personal and reasonable.  Ultimately that is what each family desires.

This is compassionate medicine. And it is rewarding to both patient and physician.


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