Tag Archives: insulin

Anti-vaxxers in Free Fall

I read a news story in which a man is dying of Covid-19 in the hospital.  He is asked whether he regrets not getting vaccinated and rallies enough to reply, “No, I don’t believe in the vaccine.”  So what then does he believe in?  Systemic viral infection, suffering, and death?  If you don’t believe in vaccination, you don’t believe in modern medicine in toto.  You don’t believe in bacteriology, virology, cellular biology, microbiology, or immunology.  What then is left to prevent, diagnose, and treat disease?  Trump-ish medievalism, mysticism, shamanism, divine intervention?

A study by researchers at Harvard’s Brigham and Women’s Hospital used natural language processing to comb through 5,307 electronic patient records of adult type 2 diabetics living in Massachusetts and followed by their primary care physicians between 2000 and 2014.  They found that 43% (2,267) of patients refused to begin insulin therapy when their doctors recommended it.  Further, diabetics who declined the recommendation not only had higher blood sugar levels than those who began insulin, but had greater difficulty achieving glycemic control later on.[1]  So what do the insulin-declining diabetics believe in?  Chronic heart and kidney disease, blindness, and amputation – the all but inevitable sequelae of poorly managed diabetes?

The problem, really an epistemological problem, is that such people apparently have no beliefs at all – unless one imputes to them belief in disease, suffering, and death, and in the case of Covid vaccine resisters, the prerogative to inflict them on others.  This is not tantamount to a scientifically specious belief system that unintentionally infects others.  During the Yellow Fever epidemic that left Philadelphia in ruins in 1793, Dr. Benjamin Rush, highly acclaimed throughout the newborn nation, set about his curative missions by draining his patients, in successive bleedings, of up to four pints of blood while simultaneously purging them (i.e., causing them to vomit) with copious doses of toxic mercury.

Rush’s “Great Purge,” adopted by his followers, added hundreds, perhaps thousands, to the death toll in Philadelphia alone.  But at least Rush’s “system” derived from a belief system.  He did in fact  find a theoretical rationale for his regimen in an essay by the Virginia physician and mapmaker John Mitchell.  Describing yellow fever in Virginia in 1741, Mitchell noted that in yellow fever the “abdominal viscera were filled with blood, and must be cleaned out by immediate evacuation.”[2]   Bleeding, of course, was conventional treatment for all manner of disease in 1793, so Mitchell’s recommendation came as no surprise. Taken in conjunction with the system of mercuric purges employed by Dr. Thomas Young during the Revolutionary War, Rush had all the grounding he required for a ruinously misguided campaign that greatly extended recovery time of those it did not kill.  But, yes, he had his theory, and he believed in it.

In the early 19th century, Napoleon, sweeping through Europe, conquers the north Italian province of Bolzano, which in 1807 he incorporated into Bavaria. Two years later, when the Bavarian government mandates smallpox vaccination for all residents, the newly absorbed Italians launch an armed revolt, partly because they believed vaccination would inject Protestantism into their Catholic veins.[3]

All right, it is a nonsensical belief, even in 1809, but it is still a belief of sorts.  It is epistemically flawed, because it fails to stipulate what exactly makes a substance inherently Protestant in nature; nor does it posit a mechanism of transmission whereby a Protestant essence seeps into liquid smallpox vaccine in the first place.  In the realm of ethics, it suggests that the possibility of death pales alongside the certainty of spiritual contamination by a fluid that, however neutral in life-saving potency, is injected by a Protestant hand.

Only slightly less ridiculous to modern ears is the mid-19th-century belief that general anesthesia via ether or chloroform, introduced by James Young Simpson in 1847, must be withheld from women giving birth.  The reason?  Genesis 3.16 enjoins women to bring forth new life in suffering.  Forget that the belief is espoused solely by certain men of the cloth and male physicians,[4] and was based on a highly questionable rendering of the biblical Hebrew.  Forget as well that, for Christians, Christ’s death redeemed humankind, relieving women of the need to relive the primal curse.  Bear in mind further that the alleged curse would also forbid, inter alia, use of forceps, caesarian operations, and embryotomy.  A woman with a contracted pelvis would die undelivered because she is guilty of the sin over which she has no control – that of having a contracted pelvis.[5]

In a secular nation guided by a constitution that asserts everyone’s right to pursue happiness in his or her own pain-free terms, we see the primal curse as archaic misogynist drivel, no less absurd than belief that the Bible, through some preternatural time warp, forbids vaccination.  But, hey, it’s a free country, and if a mid-19th-century or early-21st-century man chooses to believe that anesthesia permits men to escape pain whenever possible but women only in male-sanctioned circumstances, so be it.  It is a belief.

Now it’s 1878, and the worst yellow fever epidemic in American history is sweeping across the lower Mississippi Valley, taking lives and destroying commerce in New Orleans, Memphis and surrounding cities and towns to which refugees are streaming.  Koch’s monograph on the bacteriology of sepsis (wound infection) was published that very  year, and neither his work nor that of Lister is universally accepted in the American south.  Nor would its precepts have counted for much in the face of a viral (not bacterial) invader carried up the Mississippi from Havana.

What can city boards of health do in the face of massive viral infection, suffering, and death?  Beyond imposing stringent new sanitary measures, they can quarantine ships arriving in their harbors until all infected crew members have either died or been removed and isolated.  This will prevent the newly infected from infecting others and crippling cities still further – assuming, that is, a belief system in which yellow fever is contagious and spread from person to person.

But in 1878 Memphis, where by September the epidemic is claiming 200 lives a day, this “modern” belief is widely contested among the city’s physicians.  Some are contagionists, who believe that disease is caused by invisible entities that are transmissible.  But others, greater in number, favor the long-held theory that infectious disease results from “miasma” or bad air – air rendered toxic by decaying plant and animal matter in the soil.  If you believe miasma causes disease, then you’re hard-pressed to understand how quarantining ships laden with sick people will do anything to control the epidemic.

This was precisely the position of the 32 Memphis physicians who defeated the city council’s plan to institute a quarantine and set up a quarantine station.  Quarantine is pointless in the face of bad air.  The city’s only recourse, so held the 32, was to alter the “epidemic constitution” of the atmosphere by inundating it with smoke.  Canon blasts and blazing barrels of tar up and down city streets – that’s the ticket to altering the atmospheric conditions that create infectious disease.[6]

The miasmic theory of disease retained a medical following throughout the 1870s, after which it disappeared in the wake of bacteriology.  But in Memphis in 1878, bad air was still a credible theory in which physicians could plausibly believe.  And this matter of reasonable belief – reasonable for a particular time and place – takes us back to the hospitalized Covid patient of 2021 who, with virtually his last breath, defends his decision to remain unvaccinated because he doesn’t believe in the vaccine.  What is the knowledge base that sustains his disbelief?  There isn’t any.  He has no beliefs, informed or otherwise, about bacteriology, virology, cellular biology, or immunology.  At best, he has decided to accept what someone equally belief-less has told him about Covid vaccination, whether personally, in print, or over the internet.

It is no different among the 43% of Massachusetts diabetics who, a century after Banting’s and Best’s miraculous discovery, declined insulin therapy when their doctors recommended it.  Their disbelief is actually a nonbelief because it is groundless.  For some, perhaps, the refusal falls back on a psychological inability to accept that one is diabetic enough to warrant insulin.  They resist the perceived stigma of being insulin-dependent diabetics.[7]  Here at least the grounds of refusal are intelligible and remediable.  An insulin phobia does not sustain real-world belief; it is an impediment to such belief in relation to diabetes and insulin, illness and long-term health, lesser and greater life expectancy.

Back in the present, I read another news story in which two unvaccinated hospital nurses explain to a journalist that they have refused Covid vaccination because the vaccines’ effectiveness is based on “junk data.”  Really?  Here there is the glimmering of a belief system, since scientific data can be more or less robust, more or less supportive of one or another course of action.

But what exactly makes Covid vaccine data worthless, i.e., junk?  And how have these two nurses acquired the expertise in epidemiology, population statistics, and data analysis to pass judgment on data deemed credible and persuasive by scientists at Pfizer, Moderna, Johnson & Johnson, the CDC, and the WHO?  And how, pray tell, have they gained access to these data?  Like all opponents of vaccine science, they pontificate out of ignorance, as if the mere act of an utterance confers truth-value to what is being uttered.  It’s an extreme example of asserting as fact what remains to be demonstrated (argument petitio principii), the legacy of an ex-president who elevated pathological lying to a political art form.

Even the nurses pale alongside the anti-vax protester who is pictured in a news photo holding a sign that reads, “Vaccines Kill.”[8]  Whom do they kill and under what circumstances?  Does he mean all vaccines are deadly and kill people all the time, or just certain vaccines, such as the Covid  vaccine?   But what does it matter?  The sign holder doesn’t know anything about any vaccines.  Does he really believe that everything we know about the history of vaccine science from the time of Jenner is bogus, and that children who once died from smallpox, cholera, yellow fever, diphtheria, pertussis, typhoid, typhus, tetanus, and polio are still dying in droves, now from the vaccines they receive to protect them from these infectious diseases during the earliest years of life?  Is the demographic fact that, owing to vaccination and other public health measures, life expectancy in the U.S. has increased from 47 in 1900 to 77 in 2021 also based on junk data?  In my essay, Anti- vaccinationism, American Style, I provide statistics on the total elimination in the U.S. of smallpox and diphtheria, and virtual elimination of polio.  Were my claims also based on junk data?  If so, I’d appreciate being directed to the data that belie these facts and demonstrate that, in point of fact, vaccines kill.

Maybe the man with the sign has an acquaintance who got sick from what he believed to be a vaccine?  Perhaps someone on his internet chat group heard of someone else who became ill, or allegedly died, after receiving a vaccine.  Of course, death can follow vaccination without being caused by it.  Do we then assume that the man with the sign and like-minded protesters are well-versed in the difference between causation and correlation in scientific explanation?

We know that for a tiny number of individuals aspirin kills.[9]   So why doesn’t the man hold up a sign that reads, “Aspirin Kills.”  Here at least, he would be calling attention to a scientific fact that people with GI conditions should be aware of.    We know that sugary drinks have been linked to 25,000 deaths in the U.S. each year.  Why not a sign, “Soda Kills”?  It would at least be based on science.  He chooses not to proclaim the lethality of aspirin or soda because he cares no more about aspirin- or soda-related deaths than Covid-related deaths.  If he did, then, like the two nurses with their junk data and the Covid patient announcing disbelief in Covid vaccination on his deathbed, he would have to anchor his belief in consensually accepted scientific facts – a belief that someone, anyone, might find believable.

He is no different than other American anti-vaxxers I read about in the paper. They are the epistemological Luddites of our time, intent on wrecking the scientific machinery of disease prevention, despite profound ignorance of vaccine science and its impact on human affairs since the late 18th century.  Indeed, they see no need to posit grounds of belief of any kind, since their anger – at Covid, at Big Government, at Big Science, at Big Medicine, at Big Experts – fills the epistemic void.  It fuels what they offer in place of the science of disease prevention:  the machinery of misinformation that is their stock in trade.

And therein is the source of their impotence.  They have fallen into an anti-knowledge black hole, and struggle to fashion an existence out of anger that – to push the anti-matter trope a little further – repels rational thought.  Their contrarian charge is small solace for the heightened risks of diseases, suffering, and death they incur, and, far less conscionably, impose on the rest of us.

______________________

[1] N. Hosomura, S. Malmasi, et al., “Decline of Insulin Therapy and Delays in Insulin Initiation in People with Uncontrolled Diabetes Melitus,” Diabetic Med., 34:1599-1602, 2017.

[2] J. M. Powell, Bring Out Your Dead:  The Great Plague of Yellow Fever in Philadelphian in 1793 (Phila: Univ. of Pennsylvania Press, 1949), 76-78.

[3] My thanks to my friend Marty Meyers for bringing to my attention this event of 1809, as reported by Emma Bubola,In Italy’s Alps, Traditional Medicine Flourishes, as Does Covid,” New York Times, December 16, 2021.

[4] With reason, wrote Elizabeth Cady Stanton in The Woman’s Bible (1895), “The Bible and the Church have been the greatest stumbling blocks in the way of women’s emancipation.”

[5] For a fulller examination of the 19th-century debate on the use of general anesthesia during childbirth, see Judith Walzer Leavitt Brought to Bed: Childbearing in America, 1750-1950 (NY:  OUP, 1986), ch. 5.

[6] On the measures taken to combat the epidemic in Memphis, including the rift between contagionists and noncontagionists physicians, see John H. Ellis, Yellow Fever and Public Health in the New South (Lexington: Univ. Press of Kentucky, 1992), ch. 3.

[7] A. Hussein, A. Mostafa, et al., “The Perceived Barriers to Insulin Therapy among Type 2 Diabetic Patients,” African Health Sciences, 19:1638-1646, 2019.

[8] Now, sadly, we have gone from hand-written “Vaccines Kill” signs to highway billboards, e.g., https://www.kxxv.com/hometown/mclennan-county/a-new-billboard-in-west-claims-vaccines-kill.

[9] Patients prescribed aspirin before developing a GI bleed or perforation are prominent among those killed by aspirin.  See A. Lanas, M. A. Perez-Aisa, et al., “A Nationwide Study of Mortality Associated with Hospital Admission and Those Associated with Nonsteroidal Antiinflammatory Drug Use,” Am. J.  Gastroenterol., 100:1685-1693, 2005; S. Straube, M. R. Trainer, et al., “Mortality with Upper Gastrointestinal Bleeding and Perforation,” BMC Gastroenterol., 8: 41, 2009.

The Costs of Medical Progress

When historians of medicine introduce students to the transformation of acute, life-threatening, often terminal illness into long-term, manageable, chronic illness – a major aspect of 20th-century medicine – they immediately turn to diabetes.  There is Diabetes B.I. (diabetes before insulin) and diabetes in the Common Era, i.e., Diabetes A.I. (diabetes after insulin).  Before Frederick Banting, who knew next to nothing about the complex pathophysiology of diabetes, isolated insulin in his Toronto laboratory in 1922, juvenile diabetes was a death sentence; its young victims were consigned to starvation diets and early deaths.  Now, in the Common Era, young diabetics grow into mature diabetics and type II diabetics live to become old diabetics.  Life-long management of what has become a chronic disease will take them through a dizzying array of testing supplies, meters, pumps, and short- and long-term insulins.  It will also put them at risk for the onerous sequelae of long-term diabetes:  kidney failure, neuropathy, retinopathy, and amputation of lower extremities.  Of course all the associated conditions of adult diabetes can be managed more or less well, with their own technologically driven treatments (e.g., hemodialysis for kidney failure) and long-term medications.

The chronicity of diabetes is both a blessing and curse.  Chris Feudtner, the author of the outstanding study of its transformation, characterizes it as a “cyclical transmuted disease” that no longer has a stable “natural” history. “Defying any simple synopsis,” he writes, “the metamorphosis of diabetes wrought by insulin, like a Greek myth of rebirth turned ironic and macabre, has led patients to fates both blessed and baleful.”[1]  He simply means that what he terms the “miraculous therapy” of insulin only prolongs life at the expense of serious long-term problems that did not exist, that could not exist, before the availability of insulin.  So depending on the patient, insulin signifies a partial victory or a foredoomed victory, but even in the best of cases, to borrow the title of Feudtner’s book, a victory that is “bittersweet.”

It is the same story whenever new technologies and new medications override an otherwise grim prognosis.  Beginning in the early 1930s, we put polio patients (many of whom were kids) with paralyzed intercostal muscles of the diaphragm into the newly invented Iron Lung.[2]  The machine’s electrically driven blowers created negative pressure inside the tank that made the kids breathe.  They could relax and stop struggling for air, though they required intensive, around-the-clock nursing care.[3]  Many survived but spent months or years, occasionally even lifetimes, in Iron Lungs.  Most regained enough lung capacity to leave their steel tombs (or were they nurturing wombs?) and graduated to a panoply of mechanical polio aids: wheelchairs, braces, and crutches galore.  An industry of rehab facilities (like FDR’s fabled Warm Springs Resort in Georgia) sprouted up to help patients regain as much function as possible.

Beginning in 1941, the National Foundation for Infantile Paralysis (NFIP), founded by FDR and his friend Basil O’Connor in 1937, footed the bill for the manufacture of Iron Lungs and then distributed them via regional centers to communities where they were needed.   The Lungs, it turned out, were foundation-affordable devices, and it was unseemly, even Un-American, to worry about the cost of hospitalization and nursing care for the predominantly young, middle-class white patients who temporarily resided in them, still less about the costs of post-Iron Lung mechanical appliances and rehab personnel that helped get them back on their feet.[4]  To be sure, African American polio victims were unwelcome at tony resort-like facilities like Warm Springs, but the NFIP, awash in largesse, made a grant of $161,350 to Tuskegee Institute’s Hospital so that it could build and equip its own 35-bed “infantile paralysis center for Negroes.”[5]

Things got financially dicey for the NFIP only when Iron Lung success stories, disseminated through print media, led to overuse.  Parents read the stories and implored doctors to give their stricken children the benefit of this life-saving invention – even when their children had a form of polio (usually bulbar polio) in the face of which the mechanical marvel was useless.  And what pediatrician, moved by the desperation of loving parents beholding a child gasping for breath, would deny them the small peace afforded by use of the machine and the around-the-clock nursing care it entailed?

The cost of medical progress is rarely the cost of this or that technology for this or that disease.  No, the cost corresponds to cascading “chronicities” that pull multiple technologies and treatment regimens into one gigantic flow.  We see this development clearly in the development and refinement of hemodialysis for kidney failure.  Dialysis machines only became life-extenders in 1960, when Belding Scribner, working at the University of Washington Medical School, perfected the design of a surgically implanted Teflon cannula and  shunt through which the machine’s tubing could be attached, week after week, month after month, year after year.  But throughout the 60s, dialysis machines were in such short supply that treatment had to be rationed:  Local medical societies and medical centers formed “Who Shall Live” committees to decide who would receive dialysis and who not.  Public uproar followed, fanned by the newly formed National Association of Patients on Hemodialysis, most of whose members, be it noted, were white, educated, professional men.

In 1972, Congress responded to the pressure and decided to fund all treatment for end-stage renal disease (ESRD) through Section 2991 of the Social Security Act.  Dialysis, after all, was envisioned as long-term treatment for only a handful of appropriate patients, and in 1973 only 10,000 people received the treatment at a government cost of $229 million.  But things did not go as planned.  In 1990, the 10,000 had grown to 150,000 and their treatment cost the government $3 billion.  And in 2011, the 150,000 had grown to 400,000 people and drained the Social Security Fund of $20 billion.

What happened?  Medical progress happened.  Dialysis technology was not static; it was refined and became available to sicker, more debilitated patients who encompassed an ever-broadening socioeconomic swath of the population with ESRD.  Improved cardiac care, drawing on its own innovative technologies, enabled cardiac patients to live long enough to go into kidney failure and receive dialysis.  Ditto for diabetes, where improved long-term management extended the diabetic lifespan to the stage of kidney failure and dialysis.  The result:  Dialysis became mainstream and its costs  spiraled onward and upward.  A second booster engine propelled dialysis-related healthcare costs still higher, as ESRD patients now lived long enough to become cardiac patients and/or insulin-dependent diabetics, with the costs attendant to managing those chronic conditions.

With the shift to chronic disease, the historian Charles Rosenberg has observed, “we no longer die of old age but of a chronic disease that has been managed for years or decades and runs its course.”[6] To which I add a critical proviso:  Chronic disease rarely runs its course in glorious pathophysiological isolation.  All but inevitably, it pulls other chronic diseases into the running.  Newly emergent chronic disease is collateral damage attendant to chronic disease long-established and well-managed.  Chronicities cluster; discrete treatment technologies leach together; medication needs multiply.

This claim does not minimize the inordinate impact – physical, emotional, and financial – of a single disease.  Look at AIDS/HIV, a “single” entity that brings into its orbit all the derivative illnesses associated with “wasting disease.”  But the larger historical dynamic is at work even with AIDS.  If you live with the retrovirus, you are at much greater risk of contracting TB, since the very immune cells destroyed by the virus enable the body to fight the TB bacterium.  So we behold a resurgence of TB, especially in developing nations, because of HIV infection.[7]  And because AIDS/HIV is increasingly a chronic condition, we need to treat disproportionate numbers of HIV-infected patients for TB.  They have become AIDS/HIV patients and TB patients.  Worldwide, TB is the leading cause of death among persons with HIV infection.

Here in microcosm is one aspect of our health care crisis.  Viewed historically, it is a crisis of success that corresponds to a superabundance of long-term multi-disease management tools and ever-increasing clinical skill in devising and implementing complicated multidrug regimens.  We cannot escape the crisis brought on by these developments, nor should we want to.  The crisis, after all, is the financial result of a century and a half of life-extending medical progress.  We cannot go backwards.  How then do we go forward?  The key rests in the qualifier one aspect.  American health care is organismic; it is  a huge octopus with specialized tentacles that simultaneously sustain and toxify different levels of the system.  To remediate the financial crisis we must range across these levels in search of more radical systemic solutions.


[1]C. Feudtner, Bittersweet: Diabetes, Insulin, and the Transformation of Illness (Chapel Hill: University of North Carolina Press, 2003), p. 36.

[2] My remarks on the development and impact of the Iron Lung and homodialysis, respectively, lean on D. J. Rothman, Beginnings Count: The Technological Imperative in American Health Care (NY: Oxford University Press, 1997). For an unsettling account of the historical circumstances and market forces that have undermined the promise of dialysis in America, see Robin Fields, “’God help you. You’re on dialysis’,” The Atlantic, 306:82-92, December, 2010. The article is online at   http://www.theatlantic.com/magazine/archive/2010/12/-8220-god-help-you-you-39-re-on-dialysis-8221/8308/.

[3] L. M. Dunphy, “’The Steel Cocoon’: Tales of the Nurses and Patients of the Iron Lung, 1929-1955,” Nursing History Review, 9:3-33, 2001.

[4] D. J. Wilson, “Braces, Wheelchairs, and Iron Lungs: The Paralyzed Body and the Machinery of Rehabilitation in the Polio Epidemics,” Journal of Medical Humanities, 26:173-190, 2005.

[5] See S. E. Mawdsley, “’Dancing on Eggs’: Charles H. Bynum, Racial Politics, and the National Foundation for Infantile Paralysis, 1938-1954,” Bull. Hist. Med., 84:217-247, 2010.

[6] C. Rosenberg, “The Art of Medicine: Managed Fear,” Lancet, 373:802-803, 2009.  Quoted at p. 803.

[7] F. Ryan, The Forgotten Plague: How the Battle Against Tuberculosis was Won and Lost  (Boston:  Little, Brown, 1992), pp. 395-398, 401, 417.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.