When Children Die

Like many other people from Ottawa, I have been very much affected over many years by the courage of Jonathan Pitre, who passed away on Wednesday evening. He was 17 years old and suffered from epidermolysis bullosa. There have been tributes for Jonathan from so many, including hockey players and civic leaders and journalists, as well as Moms and Dads and all the rest of us. One of the most moving tributes came from the journalist, Andrew Duffy, who has followed Jonathan’s story over many years.

Hard upon this story came the news of an accident in Saskatchewan that resulted in the death of 15 members of the Humboldt Broncos of the Saskatchewan Junior Hockey League. Most who died were under 20.

When I read through the tributes to Jonathan Pitre and his mother, or those for the Humboldt Broncos and their families, I feel so grateful that I have never had to cope with such a difficult event in my life. I wanted to write about this, but I wanted not to focus on advice on how to manage such tragedies.

I’ll give some references, in case some readers were hoping for advice. This is a great article from The Guardian considering one woman’s experience with the death of her child. I found that this article really helped me to contemplate how to be a comfort to someone facing this tragedy. I also found this article addressing what not to say to a parent whose child has died very helpful. The only guidance I would add to this list is: Be extra cautious about social media – it can catch people unawares, causing additional, unnecessary hurt.

I learned all I ever need to know about what it would be like for a child to die from the two women in my life from whom I have loved the most: my mother and my daughter.

My mother had two children who died very young. My oldest brother died of influenza in 1955 at age 2. This was 18 years before the World Health Organization first introduced flu vaccine recommendations for general use. A second brother died in 1956 of RhD hemolytic disease of the newborn. This is a condition that occurs when a mother who has an Rh negative blood type develops antibodies after being exposed to her child’s Rh positive blood during pregnancy. These antibodies may affect Rh positive children in subsequent pregnancies. The antibodies can cause severe illness, including death. In 1968, anti-RhD immune globulin (Rhogam) was introduced. By injecting inject mothers who were Rh negative with Rhogam, RhD hemolytic disease could be prevented. My brothers died too young to benefit from these medical discoveries.

As a child, and even as an adult, I could never completely understand my mother’s ongoing sadness over my brothers. However, in the hour after my daughter’s birth, having held her for not more than twenty minutes, I understood what every new parent also quickly understands: I could not bear it if I lost this child. I ceased to wonder about my mother’s sadness. I no longer wonder at any parent’s sadness. I know I would be inconsolable if I lost any of my children and that is what Jonathan’s mother and the families of Humboldt are going through today. Are we not all with them in spirit?

I also have one piece of advice that I can give. It is contained in this blog I wrote for The Scientific Parent. Sadly, it is one of the most popular blogs I have ever written. It provides advice on how to help children cope with difficult news. The Scientific Parent used the blog so much that they developed a graphic to go with it. I would like nothing more than for its circulation to end, but more realistically, I am glad if it is helpful.

Get the Flu Shot – Promote World Peace

Tomorrow, nursing staff in the Youth Program at the Royal will offer the flu vaccine to inpatients. This is the kind of public health work that nurses often do, education and prevention, and they are very good at this work. But, inevitably, from time to time, they will have to present the science that vaccines work and I have pulled together my approach to flu vaccine advocacy.

I prefer the World Health Organization website information which includes an article that lists the proven benefits of vaccines, including all the scientific references. Let me present the abbreviated version I’m going to use if anyone asks me tomorrow why I think they should use vaccines.

I remind my patients (and anyone who’ll listen, really) that there are four different categories of vaccine-related benefits: diseases are controlled; the unvaccinated population is protected; related diseases, even cancer, can be prevented; and there are other societal benefits as well, such as economic growth, promoting equity and even peace. These benefits are all proven in studies and the WHO website lists those studies for the skeptical.

To present a compelling argument regarding disease control, I am going to keep handy the picture below of the statue erected at World Health Organization Headquarters when smallpox was eradicated. Smallpox was declared eradicated in 1979, almost forty years ago. This took an international effort and even countries that couldn’t get along for other reasons got along to eradicate small pox. They are now working to eradicate polio, with a timeline to complete this by 2018 – next year. This will be a historical event of great importance, again the result of a level of international cooperation that is now rare.

I am going to emphasize that vaccination against certain infections can prevent other diseases, including cancer. Prevention of chronic liver infection with the Hepatitis B vaccine can prevent liver cancer and even now, barely 10 years after the introduction of the HPV vaccine, scientists are measuring the decrease in incidence of cervical cancers caused by serotypes 16 and 18.

Finally, I am going to speak about all the societal benefits. I am going to begin by summarizing the savings. It is well-established that public health measures save $7 for every $1 spent, but vaccines are sometimes even more economical. Some studies are now available that show that $10 can be saved for every $1 spent fully vaccinating very young children.

As for equity, the burden of the diseases that vaccines can prevent is borne mostly by the disadvantaged. When this burden is lifted through vaccination, these groups are more likely to flourish.

As for peace, the United Nations Children’s Emergency Fund (UNICEF) has medicated at least 7 cease fires during civil conflict that were related to vaccines. Even people in conflict can resolve some differences so that disease can be prevented.
Being vaccinated is one of the few things a person can do for the greater good and know that they are being effective.

I hope that my young patients will be convinced with this science of the value of vaccines, but I will still thank them just for listening to my public health service announcement. I have also made cookies that look like viruses (sort of) for the vaccination celebration. Vaccines deserve celebrating, I’ll tell them.

Get the flu shot. Have a cookie. Promote peace.

Loss Leader

IMG_0499flu2 IMG_0498fluThe two pictures attached to this article were provided to my husband when he picked up a prescription this week. They are the Pharmacy’s questionnaire for people wishing to get a flu shot and the “informed consent” that they must sign in order to be inoculated. Now my husband wasn’t there for a flu shot so it is interesting that they just happen to be giving out this paperwork. Do you think this is a public service? I took it as more of a flyer, letting people know who’ve been advised to get the flu shot that they can get it “free” at the pharmacy, a little chore they can get done while they’re getting their prescription or picking up shampoo. In fact, having heard how convenient it is to do this at the pharmacy, many people may actually decide to get their flu shot there. I am pretty cynical about the motivation of pharmacists to provide this service and so I see these documents as “flyers” advertising a “loss leader”.

Contrast this with the experience should the patient happen to have visited their family doctor for the flu shot, which I did. My family doctor asked me many of the questions on the “Flu Vaccine Questionnaire” and outlined some of the new aspects of this year’s vaccine, but he took the fact that I was there seeking this service as my informed consent and certainly didn’t ask me to sign a waiver. I don’t think it’s an error on his part. I believe that this reflects that he provides and coordinates all of my health care. When I signed up for his practice, that was our agreement that he would direct my primary care and I would get my care from him.

I believe that what my family doctor does is very similar to what every family doctor does. The pharmacist is clearly required to complete – or have you complete – a number of documents. Pharmacists don’t keep a detailed medical record such as your family doctor is required to keep that already outlines all of the medical history contained in the questionnaire. Your family doctor will also have details of any past blood work, your most recent physical and likely more medical information about you than you ever dreamed there could be. More importantly, your family doctor will understand what all of this information means to a degree that your pharmacist does not. That is the benefit of a medical education, an understanding of health and disease in all its complexities. That is why whenever a pharmacist (or any allied health professional) wants to begin to perform “simple” medical acts to save the system money and resources, I become suspicious.

A pharmacy is a big business. I do not believe that there are very many, if any, pharmacies left in my community that are not franchised. I felt more comfortable when the pharmacist was the owner and “operator” of a pharmacy. I have no difficulty with businesses working to make a profit – I think they ought to make a profit – but I don’t like false advertising. I don’t think that the main reason pharmacies provide vaccinations is to provide a service. I think the convenience is a “loss leader” for more profitable enterprises. I’d prefer that the focus of the person providing my flu shot was my health care. That’s what patient-centred means to me.

Vaccines and Vaccination: How history can inform science

The anti-vaccine movement fascinates me. The proof that vaccines prevent debilitating and often mortal illnesses is so well-established and so widely accepted by the scientific community that I just cannot understand how people examining this evidence honestly can fail to see its veracity. However, in every decision not to get the flu vaccine personally, in every decision not to have one’s child vaccinated, we see people carefully considering and rejecting a proven measure to prevent serious illness in themselves or a loved one. I have no doubt that it is the publicity that the anti-vaccine movement has received that has influenced these people. Their influence is so powerful that it even affects healthcare providers. In this report, a well-known Canadian infectious disease specialist recommends against mandatory flu shots because the legal challenges against this challenge “may not be winnable”: http://www.theglobeandmail.com/life/health-and-fitness/health/conditions/doctor-stirs-debate-over-mandatory-flu-shots/article10322395/. This article from the United Kingdom last summer outlined that the majority of doctors and nurses “declined” the flu shot the previous winter:  http://www.independent.co.uk/life-style/health-and-families/health-news/health-officials-very-disappointed-that-most-doctors-and-nurses-declined-flu-vaccinations-last-winter-8662483.html

In the first case, it is evident that anti-vaccine ideology has become so mainstream that that the case for mandatory vaccination in a group at high risk for influenza, a serious illness and health workers do know this, is not “winnable” in a legal challenge. Have we all forgotten SARS? Even in Toronto? Toronto, Canada’s largest city, well-equipped, well-resourced, was brought to its knees by SARS. I guess we all assume an influenza epidemic could never be as bad as SARS. The second article is also telling. The article does consider that there may be logistical difficulties to being vaccinated against the flu but both of the hospitals I work in bend over backwards to make it easy to get the vaccination.

As I began my research for the series of blogs I intend to write this summer about vaccines and vaccines, I found this timeline of the history of vaccines from the College of Physicians of Philadelphia: http://www.historyofvaccines.org/content/timelines/all. Each entry has short articles associated with it and, while it naturally focuses on the American and Philadelphian situation, it is a complete detailing of the development of the scientific theories regarding infectious disease and the use of vaccines to prevent disease. The timeline shows us that the benefits of inoculation were understood in China before 1000 CE and, in a letter from the Emperor K’ang to his descendents, we read the following:

“The courage which I summoned up to insist on its practice (inoculation) has saved the lives and health of millions of men. This is an extremely important thing, of which I am very proud.”

We also learn from the timeline that George Washington had the troops of the Continental Army vaccinated against smallpox in 1777. The proof of the efficacy of vaccines is so clear from this history prepared by the doctors of Philadelphia, as is the stark reality of the devastation and personal suffering caused by the diseases they prevented. Today, not only has smallpox been prevented, it has been eradicated – thanks to smallpox vaccination. Vaccination is arguably one of the greatest medical success stories and yet even doctors do not routinely get their flu shot.

Perhaps not enough history is taught in medicine. I hope more doctors than those in Philadelphia will pause to look at timeline developed by the College of Physicians of Philadelphia and take a moment to reflect on the history of vaccines and the diseases they prevent. Otherwise the words of George Santayana may be a medicine’s fate:

“Those who cannot learn from history are doomed to repeat it.”