By Kate Johnson – November 1, 2009
As a medical journalist in Montreal I’ve been fielding calls from friends and family in other parts of the country, asking my advice on whether they should get the H1N1 vaccine. While I am still waiting here, the decision is upon them.
I am not a doctor, I remind them. We’ve already heard our doctor’s advice, they say.
And yet they are still unsure. Why?
It has to do with trust.
Writing in the Vancouver Sun, Peter McKnight argues that the public’s 50/50 reaction to the vaccine dilemma is not about a shortage of facts, it’s that “they don’t believe the people who are providing them with the facts: scientists and public health officials.”
“We live in an era of distrust of authority, including scientific authority,” he continues.
So, why the distrust in medical authority?
Because a few high profile examples can do monumental damage.
I’ve written recently about the pharmaceutical industry’s skills when it comes to marketing.
BigPharma spends more on marketing than on science. The industry is an example of awesome marketing wizardry. The ethics of this are debatable, and too complex to deal with here. I’ve suggested that, as long as we’re aware, and accept that the industry is biased, we can still make informed choices.
But recent evidence suggests that doctors are not always aware of, or on guard against the influence of the pharmaceutical industry.
For example, they prescribed Paxil, and now there are some 600 lawsuits filed against the manufacturer GlaxoSmithKline claiming that the antidepressant causes birth defects. The first case resulted in a $2.5 million judgment against the company.
I’m not saying these doctors deliberately misled their patients. But perhaps they were misled by the marketers.
Another example is the HPV vaccine – targeting human papilloma virus, which can cause cervical cancer. Writing in the Journal of the American Medical Association , Dr. Charlotte Haug points out: “If the potential benefits are substantial, most individuals would be willing to accept the risks.”
She hints that perhaps the risks of the HPV vaccine may actually outweigh the benefits. Yet, the HPV vaccine is now widely recommended for teen girls and young women, after a massive marketing campaign earned GlaxoSmithKline the “brand of the year” for creating “a market out of thin air.”
The H1N1 pandemic is a pharmaceutical marketer’s jackpot. Think of it. Worldwide demand. Universal recommendations for vaccination. Fast-track approval with few questions asked. And a general public that has accepted uncertainty, because it is there – regardless of whether they get the shot or not.
Doctors are recommending the vaccine because other doctors are recommending it. Medical authorities like Health Canada are recommending it because the U.S. Centers for Disease Control and the World Health Organization are recommending it. But when asked personally if they will be getting vaccinated – many doctors say no. Surveys estimate this number could be anywhere from 30% to 60%.
In the end, the decision about the H1N1 vaccine comes down to weighing the risks and benefits, when we are not fully informed about either.
When it comes to scientific information, or gaps in it, society can handle that. “Medical knowledge is typically incomplete and ambiguous,” writes Dr. Haug.
But it’s when strong, unambiguous recommendations for the H1N1 vaccine fail to acknowledge such information gaps that the public’s trust can falter. That is when medicine starts to sound like marketing.
In this context, the “soft sell” tends to sound more convincing. “It’s entirely reasonable to be immunized,” write Dr. Richard Schabas and Dr. Neil Rau in the Globe and Mail. “It’s also reasonable to take a pass. The anticipated benefits from immunization are very small, and the risks are tiny.”
Given the scientific evidence that is currently available, I think I’m likely to get the H1N1 vaccine. But I do wonder about the subliminal influence of marketing.
“When weighing evidence about risks and benefits, it is also appropriate to ask who takes the risk, and who gets the benefit,” Dr. Haug continues. “Patients and the public logically expect that only medical and scientific evidence is put on the balance. If other matters weigh in, such as profit for a company or financial or professional gains for physicians or groups of physicians, the balance is easily skewed.”
There is no evidence of marketing the H1N1 vaccine, though that doesn’t mean it isn’t there. The bottom line is, we don’t know. Under other circumstances, most people would wait until they felt sufficiently informed before making their decision. But time is not on our side. For one thing, H1N1 is already here. For another thing, when the vaccine is offered in your area, it might be your only chance to get it.
My sister, who lives in Ontario, will get the vaccine this week, unsure, but pressured. Like me, she has asthma, and is considered high risk for H1N1 complications like pneumonia. As a Montreal resident, it looks like I still have several weeks to wait. As I field questions from loved ones who are already joining the line-up I find my growing confidence is based on trust. Trust that the medical authorities are aware of marketing pressures and that they are making informed, independent recommendations.
Kate Johnson's Medical Musings 
Say what? “There is no evidence of marketing the H1N1 vaccine, though that doesn’t mean it isn’t there.” Just turn on TV and it there is free advertising for big Pharma.
1.There is no evidence based science that H1N1 vaccine prevents serious complication/death from H1N1.
2. There is no evidence based science that H1N1 vaccine prevents infection with H1N1.
3. There is no evidence based science that H1N1 vaccine is safe for fetuses.
4. There has been NO safety data released by any of the manufacturers of the H1N1 vaccine
Re HPV- ” the rate of serious adverse events is greater than the incidence rate of cervical cancer.”
http://ahrcanum.wordpress.com/2009/10/28/gardasil-vaccine-doesnt-work-contains-tween-80/
It should not be a dilemma. You already know the answer to your question. NO.
Another thoughtful blog, Kate.
There are various issues at work here.
First, looking at everything rationally, should you get vaccinated or not? There probably isn’t one right answer to that, as it depends on the individual, their risk of getting flu, of getting serious complications from it, and whether they have contra-indications to the vaccine. It may even not be clear cut even then, as there is a certain element of personal preference about trading off the risks of minor, but likely, side effects of the vaccine against much more serious, but rare, complications of flu.
Another thing is that most people are not very good at assessing risk. To decide whether to have the flu vaccine, you need to understand the risks of having the vaccine and the risks of not having the vaccine. Minor side effects of the vaccine (flu-like symptoms) are pretty common, so there is an obvious risk to having the vaccine, and more to the point an immediate one, which most people find easy to assess.
The risks of not having the vaccine, however, are a lot less certain. Maybe you won’t get flu at all this year. Maybe you’ll get it and feel a bit ill for a couple of days and then you’ll be fine. Maybe you’ll get serious complications and die. Those kind of risks are hard for most people to process. I’m a statistician, and even I find it quite hard to make judgements about those sort of risks for my own situation (of course we’re in a particularly bad situation with H1N1 when it comes to assessing the risks, because we simply don’t yet have good enough data to be sure what they are).
So I think the trade off of immediate and obvious risks of having the vaccine versus the rather hard-to-assess risks of not having the vaccine would lead many people not to have the vaccine, even if it might be considered strictly rational for them to have it. Not that I’m saying that it would be rational for everyone to have the vaccine, of course, as stated above.
But all that assumes that you’re talking about people who are reasonably well-informed about the risks and benefits of the vaccine. There is a lot of misinformation out there, peddled by the vociferous ranks of anti-vaccination campaigners. There is nothing new about this. It’s been going on since the days of Jenner (there’s an interesting article about the history of anti-vaccinationists at http://www.bmj.com/cgi/content/extract/325/7361/430), and will probably go on for a while yet. It doesn’t take long when a vaccine is developed before the anti-vaccinationists come up with their crazy theories about some mythical harm that the vaccine has. I’m not sure what the favourite one is for the H1N1 vaccine, although something I’ve read on one internet forum is a theory that it increases the risk of getting flu. Some people will believe those crazy theories, and will therefore decide not to have the vaccine for their own reasons.
And then, of course, is the question of whether people trust their doctors. I’m not sure how things are in Canada at the moment, but here in the UK it’s probably fair to say that most people trust their doctors less than they used to. There are probably many reasons for this, but one reason that has been much discussed is the system by which GPs are paid according to hitting various targets. This creates an incentive to hit the targets, whether or not it’s clinically appropriate. My own GP has in the past advised me to have a cholesterol test, which I as a medical statistician know would be completely pointless, but by a strange coincidence one of the things they get paid for is the number of patients who get cholesterol tests. Vaccination is another thing that doctors get paid for, so many people quite reasonably feel that a doctor who advises vaccination may be acting in their own financial interests rather than the clinical interests of the patient.
In my view, this “payment by results” scheme was a huge mistake.
It was a no-brainer for me. My doctor had; I wanted it. The H1N1 vaccine is made the same way that ALL influenza vaccines are made; it just has a different strain…as do each year’s seasonal flu vaccines.
It comes down to understanding risk. Side effects from vaccines are rare and generally mild—-site soreness/redness. Serious adverse events are trivially rare. Deaths due to vaccines….I’d worry about getting hit by a piece of space junk before I’d worry about dying because of a vaccine.
I don’t especially enjoy getting the flu and short of being house-bound for several months, the vaccine is my best option to avoid H1N1. My chances of a serious illness or even death from infection with the H1N1 virus are pretty small BUT I’d still be a vector. Than again….I’m guessing that you already know what I think 🙂 Thanks for the comment on my blog post!