Sanitation and clean water prove to be effective alternatives
DRUG BUST by Alan Cassels
• The people’s briefing note on prescription drugs
“Vaccines saved more Canadian lives over the past 50 years than any other medical intervention.” That’s the bold headline on an advertisement for BIOTECanada and the 16 members of its Vaccine Industry Committee, made up of “global leaders in vaccine research and innovation,” from the country’s biggest pharmaceutical companies.
These are vaccine marketers so they have a stake in keeping aloft the notion that investments in vaccine research are important so we can continue to get needed vaccines to improve the health of Canadians. They tell us “Canadian innovation is driving the discovery of new vaccines that will transform the future of public health in Canada.”
Is it true that vaccines have “saved more lives” than any medical intervention? How vital are they in allowing us to live longer and healthier lives? When describing advances in vaccine research BIOTECanada singles out two particular vaccines: One to reduce the risk of cervical cancer (the HPV vaccine) and the other to reduce the risk of gastroenteritis (the rotavirus vaccine), which is responsible for a lot of diarrhea and death in the developing world.
Six years ago, the British Medical Journal ran a contest asking readers to vote for what they thought was the most important public health advance in the last 150 years. Vaccines appeared on the ‘top 15 list’ and the editorial proposing its inclusion cited polio, whooping cough and measles as three major diseases that have all been tamed by vaccine programs. Yet the advance people voted as #1, however, was not a medical innovation at all: it was toilets. Which is to say, advances in sanitation and the role of clean water in human health topped the list.
The biotech industry is not alone in claiming vaccines have been a major tool in the prevention of many deadly illnesses. Public health officials seem eternally eager to urge all parents to get onboard with the full suite of recommended childhood vaccines for all our children, as well as carrying out somewhat unsavoury mandatory flu programs for health workers.
In his book, Fooling Ourselves on the Fundamental Value of Vaccines, Australian author Greg Beattie lays out a very interesting case, mostly using graphs, which will make many people wonder if the value of vaccine programs has been exaggerated. His book closely examines the timing of vaccine programs, compared to changes in death rates due to a range of vaccine-preventable diseases such as measles, mumps and rubella. He says that the major drops in those deaths predated vaccine programs, sometimes by a lot. So something else was happening that caused a dramatic drop in deaths due to these diseases 40 to 50 years ago, before these vaccines were routinely given to children. What could it have been? You guessed it – improvements in sanitation, nutrition and general medical improvements (better diagnosis, etc). Did vaccines help? Maybe. But if they did, Beattie would argue it wasn’t by much.
Diarrhea is still considered a major killer of children under five in the developing world and vaccines tackling the rotavirus that sometimes causes it have been developed. Diarrheal deaths have been reduced markedly over the last 20 years, but there are still about half a million children every year around the world who die from dehydration and diarrhea, mostly in the developing world. Yet the US Centre for Disease Control estimates only about 20 to 60 children die in the US each year from complications due to rotavirus.
But when you try to tease out the effects of vaccines like that for rotavirus, they are hard to find. Why? Because the major reductions in diarrhea are due to better sanitation, use of oral-rehydration therapies (we have much better knowledge now on treating severe diarrhea) as well as growing knowledge around keeping potable water free from contaminants. Again, we come back to the major lifesaving actions of basic public health (and mostly sanitation-related) interventions.
According to the National Vaccine Information Centre in the US, by age three, most kids have had a case of rotavirus and by getting it the child will develop immunity for life. Many people don’t know that the vaccines that work against rotavirus also come with a somewhat checkered past; one was withdrawn back in 1999 after the CDC found the vaccine was linked to an increase in cases of intussusception (a type of bowel obstruction that can be fatal). In 2007, the US FDA issued a public health alert on a different rotavirus vaccine (intussusception again) and in 2010 the FDA issued another warning about a rotavirus vaccine that had become infected with a lethal strain of pig virus. Remember; this vaccine is for a ‘disease’ that is largely treatable, has very few deaths associated with it and involves huge costs in trying to immunize entire generations of children.
While brilliant Canadian research might be trying to develop better types of vaccines against the rotavirus, it seems to me you’d get a lot more public health impact if you made sure people washed their hands and tried to keep their drinking water clean and allowed natural immunity to develop. This vaccine seems a bit of a stretch in trying to be the poster-child for more investments in vaccine research.
Which brings me to the second example of stunning medical innovation, mentioned by BIOTECanada, which concerns the very controversial HPV vaccine. There are currently two vaccines on the market to immunize against the virus linked to cervical cancer. We have relatively low rates of cervical cancer deaths in Canada and an already effective screening program (the Pap smear) to prevent that disease, but what about in developing countries?
For several years now, a large HPV vaccine trial has been the subject of headlines in India, cited by one activist as a “clear case of child abuse” and a “violation of fundamental human rights.” She was referring to a trial in 2010 where more than 23,000 girls aged 10 to14 were given the HPV vaccine in a manner that activists asserted was “tantamount to using Indians as guinea pigs.” The main issues were the misleading information given to parents about the vaccine and the lack of proper monitoring of adverse effects and vaccine effectiveness.
You might put all that aside and ask, “But isn’t it important to study the vaccine in India and help prevent so many women dying every year of cervical cancer?” One of the big problems is, of course, the cost and whether or not there are even proper ways to measure the effectiveness of a vaccine program. Allyson Pollock, a researcher from the UK, told the British Medical Journal that an HPV vaccine program in India “seems totally irrational,” citing statistics showing that cervical cancer in India has already dropped dramatically, going from 42.3 per 100,000 women in 1983 to 22.3 per 100,000 women in 2005. That’s still a huge death rate, but something good must have been happening which predated the HPV vaccine, to have created such a huge reduction in cervical cancer deaths.
Currently, low-cost surveillance methods (such as the Pap smear) are effective and probably need to be more widely available in India. And given the many unknowns around the effectiveness and duration of protection offered by the HPV vaccine, it doesn’t seem to make much sense to be pushing poor women into HPV vaccine programs.
But back to the glowing promotional material put out by groups like BIOTECanada extolling the virtues of vaccine research. Do we need better vaccines? Maybe we do, but if the rotavirus and HPV vaccines are the best they can come up with, I would hope the investors are asking some hard questions about whether those companies are being somewhat disingenuous in wrapping up their research with so much hype.
Those who want to invest in improving the lives of people in this world might want to rethink the value of their investments. They might want to invest in toilets.
Alan Cassels is a pharmaceutical policy researcher at the University of Victoria and the author of several books, including ABCs of Disease Mongering: An Epidemic in 26 Letters. www.alancassels.com