public health dilemmas

I was sitting in my training for India today and a thought occurred to me.

The polio eradication project (STOP) works all over the world in developing countries and helps governments design and implement massive polio vaccination campaigns. In almost all the these vaccination campaigns, vaccinators go from house to house giving the vaccine to all children under 5 years old. (It's an oral vaccine and easy to give (pretty hard to mess up in reality), and you don't need any specialized training to give it.)

The oral polio vaccine is a fairly safe vaccine; the risk of complications are minimal, but there is a small (about 1 in 4 million) chance of the vaccine virus reverting to a dangerous virus type and causing disease (this is called Vaccine Associated Paralytic Polio, or VAPP). There are risks associated with any vaccine (or any medical procedure for that matter; although autism is not a risk with the MMR vaccine), and a 1 in 4 million risk is pretty darn low, especially in developing countries where the risk of polio disease from regular virus is much higher.

In the US we stopped giving the oral polio vaccine(OPV) a few years ago and replaced it with the injection polio vaccine(IPV) precisely because the risk of Vaccine Associated Paralytic Polio(VAPP) was higher than the risk of actually getting polio in the US. This makes sense. And using the OPV vaccine in the developing world makes sense as well (it's easier to give, it's cheaper and it works better, so if there is actually polio around, it's a better vaccine to use.)

But here's my issue. We don't actually tell any of the general public in the developing world that there are risks associated with the vaccines we're pushing. The reason being that 'it would do more harm than good.' People would be scared of getting the vaccine, would refuse it, and would substantially increase their risk of getting regular ol' polio. So, instead, we make the 'big brother' decision to just not tell people.

Can anyone see where I'm going with this? The phrase 'white man's burden' sound familiar?

The four basic principles of medical ethics:
Beneficence (do good)
Nonmaleficence (do no harm)
Autonomy (people have a right to assert control over their bodies and medical care)
Justice (medicine must be practiced equitably and without prejudice)

I don't know about you, but to me, this flies in the face of the last two.

The vaccine campaigns never force the vaccine or use outright coercion on vaccine refusers. But, this is still the patriarchal (and imperialistic) approach of making decisions for disempowered persons.

Sadly, this is a common approach in international health, and is quite common even in the United States, particularly among disempowered populations.

I have already committed to doing the stint in India this summer, however I think I will have to think carefully before I would consider doing another trip with STOP or taking a job with the international vaccine programs. I'm already on the top of the global hierarchy in many ways and exercise that power in ways I don't even realize. However, I hope that I can at least minimize the impact of that power in the arenas that I am conscious of.

Hmmm...the global AIDS program use a much more community and individual empowerment based approach. Maybe that will be my next stop.