Jeneen Interlandi

<h1>(Editorial Observer): Peter Hotez is no stranger to vitriol. An outspoken proponent of vaccines in a state with one of the most vocal anti-vaccine lobbies in the country, Hotez, dean of the National School of Tropical Medicine at the Baylor College of Medicine in Texas, has been harassed at lectures, threatened online and blamed for his daughter’s autism.</h1>

In early May, he took to Twitter to lament a report from the Texas health department showing a 14% increase in the number of parents seeking vaccine exemptions in the state. In response, state Rep. Jonathan Stickland accused Hotez of being in the drug industry’s pocket and referred to his science as self-serving “sorcery.”

“It’s one thing to have emotional parents or angry activists coming after you,” Hotez says. “It’s really quite another to get it from elected officials.”

Attacks on scientists who defend vaccines are nothing new. In the late 1990s and early 2000s, Paul Offit, a vaccine expert at the Children’s Hospital of Philadelphia, received so many credible death threats resulting from his pro-vaccine advocacy that the FBI assigned him a bodyguard.

But the public health stakes are higher today. The percentage of unvaccinated children has quadrupled since 2001, vaccine-preventable diseases like measles are creeping back as a result, and mistrust in science — the fuel powering this crisis — has migrated from the fringes to the center of American life. The denigration of individual scientists is a chilling aspect of that mistrust; experts say it skews public discourse by scaring vaccine proponents into silence.

So far, the assaults on Hotez’s work and character have been more off base than threatening. The diseases he studies afflict the poorest of the poor; they spread in places where bare feet routinely mingle with open sewage and where people have only contaminated water to drink and bathe in. His work has produced results — in the past decade or so, he has managed to nudge vaccines for several such diseases, including hookworm, into Phase 2 clinical trials. But this is not exactly cash-cow science.

“I haven’t even paid off my mortgage,” Hotez says. “They keep saying that I’m making all this money off my work, and my wife keeps saying, ‘If only!’”

The undermining of one of humanity’s greatest public health triumphs has many causes — not just mistrust of science, but also political opportunism, cultural amnesia and social media’s ability to bring together like minds and to grant even the most wildly inaccurate premises an aura of truth.

But to reverse the current trend, the mistrust in science and medicine will have to be repaired.

That will not be easy, especially when some of that mistrust is propagated by elected officials. President Donald Trump, for instance, spent years consulting with prominent anti-vaxxers and suggesting that he believes vaccines cause autism.

The president did eventually reverse his position on the issue, telling reporters that parents need to “get the shots” for their children — a welcome change. The more officials who make clear to uncertain parents that vaccines are safe, lifesaving and crucial to public health, the better. Beyond that, political leaders can address the current crisis by increasing funding for health departments that are best positioned to combat rampant misinformation, and by passing laws to make it harder for parents to skip crucial shots.

It’s not hard to guess what will happen if no such steps are taken. The number of measles infections in the United States this year is already more than double what it was in all of 2018, and that count could easily double again in 2020.

Last year, Hotez and his colleagues pinpointed 15 locations across the country where measles would most likely re-emerge. At least seven of those areas have already seen an outbreak.

Such predictive power may sound like sorcery to some. But it’s science, plain and simple.

This article originally appeared in <a href="https://www.nytimes.com/2019/06/02/opinion/vaccines-peter-hotez.html" target="_blank">The New York Times</a>.

In early May, he took to Twitter to lament a report from the Texas health department showing a 14% increase in the number of parents seeking vaccine exemptions in the state.

When defending vaccines gets ugly

Renelsa Caudill, a Washington, D.C.-area cardiac nurse, remembers being forced to pull a cardiac patient out of the CT scanner before the procedure was complete. The woman had suffered a heart attack earlier that year and was having chest pains. The doctor wanted the scan to help him decide if she needed a potentially risky catheterization, but the woman’s insurance, inexplicably, had refused to cover the test.

Melissa Johnson-Camacho, an oncology nurse in Northern California, remembers a mother who had to ration the special bags that were helping to keep her daughter’s lungs clear. The bags were supposed to be changed every day, so that the daughter did not drown in her own fluids, but they cost $550 each.

And Karla Diederich, also from California, remembers saying a final goodbye to her friend and fellow intensive care nurse Nelly Yap in their hospital’s parking lot. Yap was dying of metastatic cancer. She was scheduled for another round of chemotherapy, but the hospital had changed owners while she was on sick leave and she had lost her job — and insurance — as a result. “Nelly spent most of her life taking care of other people,” Diederich says. “And when she needed that care herself, it was not there.”

The women say that their professional experiences have led them to an inescapable conclusion: The motives of gargantuan for-profit health care industries — hospitals, pharmaceuticals, insurance — are incompatible with those of health care itself. They argue that a single-payer system, run by the federal government and available to all U.S. residents regardless of income or employment status, is the only way to fully eliminate the obstacles that routinely prevent doctors and nurses from doing their jobs.

Several proposals now working their way through Congress would aim to create just such a system. The nurses’ support for such proposals — the union has endorsed a bill put forth by Rep. Pramila Jayapal of Washington — is somewhat surprising, because the zero-sum nature of American health policy tends to place them on the losing end of any major system overhaul. The money it will take to provide many more services to many more patients will have to come from somewhere, the thinking goes. And the paychecks of doctors and nurses are a likely source.

That calculus has not deterred the nurses.

Perhaps that’s because they see so much time and money wasted by the bureaucracy of the current system. By most estimates, the administrative costs of American health care surpass those of any other developed nation. Or maybe it’s because of the innumerable avoidable medical crises they constantly find themselves confronting. Patients go into heart failure because they can’t afford blood pressure medication, or gamble with their diabetes for want of insulin, then turn up in the hospital needing care that’s far more expensive than any preventive measure would have been.

Or maybe they just know that a steady job with decent health benefits does not exempt anyone from the arbitrary agonies of our current system. Johnson-Camacho recalls having to discharge a patient without essential chemotherapy — not because the patient was uninsured but because his insurer refused to cover the drug that had been prescribed. “I had just finished explaining to him how important it was to take this medication faithfully,” she says. “I told him, ‘Every day you skip it is a day that the cancer has to potentially spread.’ And then we had to send him home without it.”

Johnson-Camacho says another patient — a young man with a treatable form of cancer — was so overwhelmed by the cost of his care, and so terrified of burdening his family with that cost, that he told her he was planning to kill himself.

Anyone who has been to a hospital or seen a family member grapple with illness has at least one story like this. Nurses, who encounter the system daily for years or decades, have hundreds, and they know better than most how brutally such stories can end. “It’s barbaric,” Diederich says. “Crucial medical decisions are being made by businessmen whose primary goal is to make a profit. Not by medical professionals who are trying to treat their patients.”

The next remaking of American health care is still a long way off. Recent congressional hearings and a report from the Congressional Budget Office have helped to clarify the long roster of questions that lawmakers will have to address if they are serious about any of the many bills now circulating. But concrete answers to those questions have yet to materialize, and in the meantime, American patients are ambivalent. Polling suggests that a majority now support the idea of universal health care, but many are still wary of the trade-offs such an overhaul would require.

Proponents who want to persuade those skeptics would do well to have nurses make the case. “People say they are scared to have the government take control of their health care,” Diederich says. “But they should be scared of the people who are in control now.”

This article originally appeared in <a id="b8fdc540-6693-4b35-bb35-2ac5613f6be3" href="https://www.nytimes.com/2019/05/27/opinion/nurses-medicare-for-all-health-insurance.html">The New York Times</a>.

Nurses see everyday need for 'Medicare for All'

(Editorial Observer): The experiences that have turned the members of National Nurses United, the nation’s largest union for nurses, into vocal advocates for a universal, government-run health care system are numerous and horrific.

<h1>I was 15 when I started smoking, and so were most of my friends. We smoked to rebel against our parents but also to identify with them — of course they smoked, even as they told us not to. We smoked because it was feminine and sexy, and also masculine and tough. Because celebrities did it, and they looked cool. Because the prissy kids didn’t do it, and we weren’t them. Because cigarettes were both forbidden and easy to get: 10 quarters in a cigarette vending machine, which you could still find in most pizza joints and doughnut shops in suburban New Jersey in the early 1990s.</h1>

All of that — the appeal, the access, the illicitness of cigarettes — was by design. By the time my friends and I were born, cigarette makers had stitched their products into the fabric of our culture so thoroughly that not even a century’s worth of research tying those products to an array of slow, painful deaths was enough to deter many of us.

Tobacco companies made cigarettes a diet tool and a matter of high fashion. They made smoking a feminist act. They didn’t just assure the public that it was safe to smoke; they used doctors to push their brands. And the more they came to understand their own product, the more they advertised cigarettes to the young. Most people who don’t start smoking by the end of adolescence never will. The cigarette makers knew that. They used cartoon camels, pictures of Santa Claus and larger-than-life cowboys in their ads.

It helped that their key ingredient was highly addictive. It also helped that they were willing to lie. When concerns emerged about nicotine dependence, cancer and heart disease, they kept regulators at bay by playing up scientific uncertainty. Then they bought off scientists and disguised corporate propaganda as independent research. By the time their deceptions were exposed, a new generation of smokers — promising billions of dollars in industry revenue — was hooked.

In the late 1990s, Big Tobacco was finally brought to account for its practices, and a string of public health policies were put in place that over the past three decades have all but eliminated the scourge of teen smoking. But many of us who became tobacco consumers at 13, 14, 15 remain so at 39, 40, 41. And in recent years, we have watched history repeat itself.

The tobacco industry is pushing a new kind of smoking device — the e-cig or vape pen — that it says is far healthier than traditional cigarettes: no tobacco, no tar, just nicotine and flavored vapor. These devices, the industry says, will finally help us adult smokers quit or curb our habit. But here’s the rub: E-cigs have brought smoking back into vogue for teenagers. As a result, the cost of this new cure may be another generation exposed to the same addiction we are still fighting.

Tobacco remains the leading cause of preventable death in the United States. Smoking kills some 480,000 people a year — more than AIDS, car accidents, illegal drugs and suicide combined — and costs $170 billion in annual health care expenditures, according to the Centers for Disease Control and Prevention. E-cig makers say, and some health experts believe, that e-cigs could help lower these terrible numbers, because they contain far fewer toxins than traditional tobacco cigarettes. The thinking goes that if all current smokers switched to these devices, the burden of disease and death could be dramatically cut.

Few have been more captivated by this argument than Scott Gottlieb, departing commissioner of the Food and Drug Administration, the federal agency responsible for regulating tobacco and nicotine products.

Since he assumed his role at the agency two years ago, Gottlieb has tried to strike a balance between encouraging adult smokers to switch to e-cigs and keeping the devices away from minors. Children and teenagers face disproportionate risk from smoking, in part because nicotine is known to harm the developing brain. In 2016, the FDA prohibited the sale of e-cigs to minors, and issued a string of new regulatory requirements for vaping devices. Then, under Gottlieb’s tenure, the agency extended the deadline for meeting those requirements by several years, while also announcing plans to curb the nicotine content of regular cigarettes.

That plan backfired last year, when teen vaping reached epidemic proportions. Gottlieb has since tried to put the industry in check by, among other things, forcing e-cig makers to devise plans for keeping their products away from kids and issuing thousands of warning letters to retailers caught selling nicotine products to minors.

E-cig makers have responded to that pressure with a bait-and-switch that would make their Big Tobacco predecessors proud.

Juul, the company most responsible for the surge in teen vaping, scrubbed its Facebook and Instagram accounts and agreed to dramatically restrict sales of its most youth-friendly flavors, like mango, crème and fruit. But the company also received a $12.8 billion minority investment in December from tobacco giant Altria, a move that will allow Juul products to be displayed alongside regular cigarettes in the nation’s brick and mortar retail outlets. For its part, Altria volunteered to withdraw all its flavored-pod products from the market until the youth vaping epidemic was resolved. Gottlieb and others say the Juul combination with Altria severely undercuts that promise.

Gottlieb’s boldest anti-smoking efforts, which include reducing nicotine levels and banning menthol flavors in traditional cigarettes, are still in the planning stages. It’s unclear whether his successor will shepherd them into policy.

In the meantime, according to Reuters, a slew of Juul copycats are making their way into convenience stores in defiance of an FDA rule banning the sale of new e-cig products after August 2016. Juul is promoting itself as a health-conscious company, even as it develops new, potentially more addictive vaping products. And Philip Morris International has created a nonprofit — the Foundation for a Smoke-Free World — through which it has tried to partner with the World Health Organization. The foundation’s stated goal is to reduce the global health burden of cigarette use. But according to tobacco industry watchdogs, leaked PMI documents suggest that its true aim is to promote the company’s own vaping products.

None of this should come as a surprise. The tobacco industry was built around a product that is inherently dangerous and unhealthy. And it has a long history of duplicity.

There are still many unanswered efficacy and safety questions about e-cigs. It’s unclear how well they work as a smoking cessation tool. And while they are almost certainly safer than regular cigarettes, they are not necessarily safe. Health officials know next to nothing about the flavorings or about other chemicals generated by the heating of e-liquids. They also don’t know how many teenagers who start using e-cigs will move on to tobacco products.

In the absence of such information, some e-cig proponents have fallen back on a trope from the previous tobacco wars: Smoking should be a matter of personal choice and personal responsibility. That argument is not entirely wrong. Nicotine and tobacco are, after all, legal substances, and if e-cigs do prove safer than regular cigarettes, adult smokers should be encouraged to switch.

But the next FDA commissioner would be wise to carry out the work that Gottlieb started — to keep all nicotine products from reaching underage users. I take full responsibility for choosing to smoke. But I wish that someone would have made it harder for 15-year-old me to do so. I hope the powers that be will do at least that much for the teenagers of today.

This article originally appeared in <a id="24604a8c-2fdb-40f3-8644-871d805b4508" href="https://www.nytimes.com/2019/03/08/opinion/editorials/vaping-ecigarettes-nicotine-safe.html">The New York Times</a>.

All of that — the appeal, the access, the illicitness of cigarettes — was by design.

Vaping is big tobacco's bait and switch

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Jeneen Interlandi

Articles written by the author

When defending vaccines gets ugly

Nurses see everyday need for 'Medicare for All'

Vaping is big tobacco's bait and switch