Thoughts on the New Shingles Vaccine

For the last two decades, our practice has observed what appears to be a marked increase in the number of cases of shingles.  Not only has this condition apparently become more common, it would also seem to be affecting younger people than in the past.  Of course, clinical impressions do not always accurately reflect the broader national picture.  In this case, however, data from the National Institutes of Health confirm that the number of patients experiencing acute episodes of herpes zoster has dramatically risen as much as 50% in just three decades.

Some medical authorities have attempted to explain the explosion in herpes zoster cases with the theory that our success in vaccinating against chickenpox in children has, ironically, resulted in more cases of shingles in adults.  Like the popular hypothesis that the thimerosal in vaccines causes autism, however, the current studies have found no clear correlation between changes in vaccination protocols or formulation that correlate with changes in the prevalence of disease.  To date, no other compelling theory has been offered to explain the increase.

For British pharmaceutical giant GlaxoSmithKline, however, the present shingles epidemic is less of a mystery than it is a lucrative opportunity.  At the cost of $280 for the two requisite injections, GSK is salivating at the estimate that Shingrix will bring in over $1 billion dollars in revenue by 2022.  The vaccine, a blend of antigen derived from hamster ovaries, fats from salmonella, and herbal extract from soap tree bark, has performed well in clinical trials.  The adverse affects of muscle pain, fatigue, and headache in about half of vaccine recipients notwithstanding, Shingrix not only reduces the risk of getting shingles but also prevents the chronic pain of post-herpetic neuralgia. 

But, rewinding a bit, what of the elephant in the room?  While the manufacturer of Shingrix stands to benefit from the failure of medical scientists to identify a clear cause for the increase in the number of shingle cases, it may turn out to be critical for our public health and wellness to get to the bottom of this conundrum.  There are several important questions to ask.  For example, does the recent success of shingles indicate a widespread decline in the immunity of older Americans?  If a lack of immunity is to blame, then what factors are impairing our bodily defenses?  Or perhaps the problem lies not so much in our immune systems failing to keep the herpes virus in check as it does in as of yet unknown factors catalyzing the dormant pathogen. 

Unfortunately, the new vaccine threatens to lull both the public and healthcare workers into a false sense of complacency.  Disease, as uncomfortable and frightening as it may be, often has a silver lining: illness can be a tap on the shoulder - or slap in the face - from mother nature encouraging us to examine our lifestyles and devise better ways to live.  These "wake up calls" not only help us to make healthier personal choices but can also act as a referendum on societal trends.  Driven by the motivation of enormous profits, however, humanity today seems more inclined to hit the snooze button than learn a valuable lesson.  We do so at our own peril.



Two Different Standards for Diabetes Testing

At the beginning of this year, the American College of Physicians issued revised guidelines for the drug management of type 2 diabetes.  Central to their recommendations is a target A1C of between 7% and 8% for most patients.  Conversely, for the past several years, the American Diabetes Association has set a goal of an A1C below 7%.  The ACP and the ADA are both influential healthcare authorities whose directives impact the way we practice medicine in America today.

While the discrepancy has led to a robust discussion among physicians, patients are more likely to just end up confused.  How can two authoritative sources disagree on the basic standard for optimal blood glucose levels for those with type 2 diabetes?  Of course, as Dr Shubrook from Touro University argues, there is consensus that diabetes care needs to be tailored to the needs of individuals patients.  Recognizing the value of personalized care, the disparity between the two guidelines can be understood as being representative of a broad spectrum of possibilities that allow physicians to make case-by-case decisions.

It is even more important, however, to grasp that the numerical findings from lab testing are, ultimately, numbers on a page, subject to both a margin of error and different perspectives regarding their relevance.  Disagreements among healthcare professionals are not unique to the interpretation of A1C results but also impact our understanding of cholesterol numbers, blood pressures, and PSA testing.  The use of the PSA test, in fact, has even drawn the sharp criticism of Richard Ablin, the scientist who first identified prostate-specific antigen.

Returning to the subject of blood glucose, it is generally accepted that lower blood sugars are preferable over chronic hyperglycemia, so one wonders why the American Diabetes Association would set a higher average target A1C.  There are two possible answers to this question.  First, according to research, hospitalizations and fatalities in elderly patients treated for elevated blood glucose are, in fact, more often caused by hypoglycemia than hyperglycemia.  Furthermore, other studies have demonstrated that many of the diabetic drugs generate at least one common adverse effect.  Adding to a patient's drug regimen is, therefore, likely to result in additional health issues which also require treatment, trapping doctors and patients in a vicious cycle.

This dilemma for conventional care is actually an opportunity for  AOM (acupuncture and Oriental medicine).  As a Western medical condition, the treatment of diabetes is outside of the scope of acupuncture and Chinese medicine care, but, backed by 2,500 years of success in helping those suffering from diabetes to enjoy a better quality of life, AOM is not dependent on our modern diagnoses or testing to be effective.  The key to getting a good outcome is relying on the unique methodology of traditional Chinese medicine that facilitates authentically personal care.

The process begins with identifying the main complaint and all of the presenting patterns for each patient.  By focusing on the chief complaint, the Chinese medical practitioner sets a pragmatic goal to quickly make a difference in the patient's quality of life, while addressing all of the patterns provides holistic, individualized care to promote long-term wellness.  Although the explicit reduction of blood sugar levels is unrelated to the traditional treatment goals of Chinese medicine, patients who receive Chinese medical care typically report significant improvements in their daily blood glucose readings and A1C levels.

As the number of individuals with type 2 diabetes continues to rise, we need to use all of the resources at our disposable to ensure that patients live the healthiest and longest lives possible.  This means not only availing ourselves of the newest Western treatment options but also employing traditional medicine where appropriate.  When it comes to the epidemic of type 2 diabetes, we just cannot afford to discriminate against useful treatments that can deliver the personal, effective treatment that patients need.

A Larger Perspective on American Healthcare

Both from the perspective of doctors and their patients, it may not be apparent why the United States needs to be on a different trajectory for healthcare.  For those of us who have lived or traveled abroad in the developing world, we have seen the inadequacy of healthcare services firsthand and feel fortunate to have state-of-the-art medical resources at home.  Not only is exceptional medical treatment available to American patients, it is also true that we boast some of the best medical schools and medical technology in the world.  For many healthcare workers outside of the U.S., it is often a dream to be able to study medicine and hone their skills on American soil.

Personal experience with socialized medicine and universal healthcare models may also make us feel lucky to have the system we do.  Excessive government control of medical services can lead both to fewer choices as well as lower quality of healthcare due to a lack of competition. Complacency and stagnation may threaten the quality of medical care we receive almost as much as insufficient resources and poverty.

As Americans, we realize that exceptional healthcare is available to us, but we also recognize that many people struggle to afford their insurance premiums.  In my practice, I have often heard the stories of patients who are unable to retire as they cannot afford health insurance without any employer subsidies.  For many, the cost of insurance seems to be the only real healthcare crisis, and we have all heard and read about Americans whose premiums went up, not down, with the Affordable Care Act.  For those individuals, Obamacare did exactly the opposite of what was promised, so, although the high cost of insurance is unequivocally a problem, the ACA legislation does not feel like the correct fix.

The issue, however, only becomes clear when we step back and look at the big picture, viewing American healthcare from a public health point-of-view.  Back in 1970, most developed nations, the U.S. included, spent between 5% and 7% of their national Gross Domestic Product on healthcare.  Talking about the percentage of GDP needed for healthcare is helpful as it not distorted by the effects of inflation.  Today, the total cost to provide healthcare to our European counterparts has risen to approximately 10% of GDP, but here in the U.S., depending on the source of your statistics, we spend a whopping 17.2% of our GDP for medical care.

17.2% of GDP is a massive expenditure of resources just to stay well.  Imagine if a pioneer in the American West had to devote 17% of his or her resources towards managing illness:  it would be all but impossible to survive.  The amount of money necessary to sustain American health is a great personal burden, but, with government subsidizing well over half of the costs, it is also a devastating social strain.  If our healthcare costs can rise 50% faster than costs in countries like France and Germany in just 35 years, imagine what we will face in decades to come.

Of course, we would like to think that our investment in health--roughly three to four times per capita compared to other nations--pays off with better health and longer life.  In reality, the U.S. ranks poorly in many key indicators.  When it comes to arguably the most important statistic, life expectancy, Americans live shorter lives than people in about 30 other countries.  Perhaps even more shocking, there are many places with far lower rates of infant mortality. 

So there you have it:  Americans pay more than anyone in world for healthcare that, despite its potential for excellence, does not actually provide care comparable with most other developed nations.  In a nutshell, this is the core argument for healthcare reform.  Viewed from this angle, American healthcare has to change. 

The solutions are out there.  It is easy to see which countries today are the most successful at delivering the best possible medical care for the least amount of money.  Undeniably, the Spanish, the Israelis, and, perhaps most of all, the Japanese, top the charts as providing their citizens with the greatest wellness and longevity for the least amount of money.  If you were Japanese, you would be likely to live about 4 years longer than the average American and for about one-third of the cost.

The future of the Affordable Care Act is uncertain.  In its short history, it became obvious that the ACA suffered from deficiencies, and few Americans prefer government mandates if there are alternatives.  Nevertheless, Obamacare is inspired by the most successful healthcare models in the world, those which deliver medical services to as many people as possible without an untenable financial burden on individuals or society.  If the ACA is repealed, let us hope that lawmakers keep their eyes on the big picture and recognize that a future where 25% or more of our national resources are committed to keeping us healthy and alive is simply not sustainable.  Without a major overhaul of the healthcare system, Americans are headed either towards a future where healthcare becomes a luxury or keeping Americans alive bankrupts the nation.