Minnesota Medicine

Published monthly by the Minnesota Medical Association
February 2002/Volume 85

Giving Vaccines a Boost

Family physician-turned-publisher Deborah Wexler, M.D., has found a way to better equip providers on the vaccination frontlines. 

By Renee Whisnant

The pictures and stories are heartbreaking. A newborn baby whose cheeks, neck, and chest are covered with dark red, pus-filled sores—varicella. A woman’s distended abdomen, encased in thick, dark blue veins—liver cancer caused by hepatitis B. A young child, whose body is bent severely backwards, wrenched unnaturally—tetanus. These pictures, found on the Web site of the Immunization Action Coalition (IAC), show the horror of diseases that are preventable through immunization.

It’s the possibility of preventing these diseases that drives Deborah Wexler, M.D., founder and executive director of the IAC. She and her staff have turned a small, grassroots organization into an information clearinghouse that helps hundreds of thousands of health care professionals better immunize their patients. The information published by the IAC ranges from immunization schedules for young children, to practical vaccine management guidelines for clinics, to accounts of people whose lives have been affected by vaccine-preventable diseases. Although unpleasant, the stories and their accompanying photos are one way that the IAC reminds health care providers—along with an often misinformed public—that no one can be complacent when it comes to vaccinations.

“I don’t think people realize how horrible these diseases can be,” says Wexler. “So few people have seen a death from varicella or a child being permanently disabled from a complication of varicella. They don’t know how awful it is, or what a tragedy it is for a family.”

Discovering Her Direction

It took Wexler a while to find her way to immunization advocacy—but once she did, it became completely consuming.

Growing up in St. Louis Park, Wexler wasn’t sure what she wanted to do in life. Her journey of self-discovery took her to California in the late sixties, where she attended the University of California, Riverside, and later transferred to Berkeley. She left California after her third year of college, still unclear about her future. “I knew that when I got out of college I’d need to have a job, so I applied to the nursing school at the U of M,” says Wexler. While taking the nursing prerequisites, Wexler rediscovered that she excelled in science courses. “My aunt told me, ‘Debbie, why are you in nursing when you should go to medical school and be a doctor?’” Wexler tried premed classes, which conflicted with her nursing courses, so she had to make a choice. She decided to follow her aunt’s advice.

Wexler majored in biology, going to school off and on and working in various jobs, including a ward secretary position on the men’s surgical ward at the old Minneapolis General Hospital. While she was an undergraduate she also organized the founding of the Wedge Community Co-op, a cooperative grocery store in Minneapolis. She eventually graduated from the University of Minnesota with an undergraduate degree in 1975 and a medical degree in 1982. 

As a resident through the University of Wisconsin Madison’s Department of Family Medicine and Practice, Wexler trained at the Family Medicine Clinic in Eau Claire. She became interested in hepatitis prevention as she treated refugees from Southeast Asia, where there is a high rate of hepatitis B infection. “I became known as the doctor who knew the most about hepatitis B in the residency program,” Wexler says. She developed a clinic wide tracking system to make sure that Southeast Asian refugees were vaccinated against hepatitis B or followed for liver disease.

In 1988, Wexler began working at the West Side Community Health Center (now West Side Health Services) in St. Paul and again saw refugees regularly. The clinic participated in a project with the St. Paul Public Health Department and St. Paul’s Women, Infants, and Children program in which Wexler, a nurse, and interpreters went to public housing projects to vaccinate children. “Not only were these kids not getting vaccinated against hepatitis B, but they weren’t getting MMRs, DTPs. They weren’t getting vaccinated. Their parents were not familiar with and had not been taught about the importance of immunization.” 

Realizing that the vaccination needs of Twin Cities children, especially Southeast Asian children, needed more attention, Wexler and other public health and health care professionals formed the Hepatitis B Coalition. The group sent out letters to doctors who treated high-risk patients, went to Hmong New Year celebrations to talk to people about the importance of vaccines, and gave presentations at housing projects. The coalition hired one part-time employee to work out of a corner of the St. Paul Public Health Department offices.

After three measles deaths in St. Paul in 1990, the Hepatitis B Coalition decided to broaden its educational role and address all immunizations and vaccine- preventable diseases. Thus was born the Immunization Action Coalition, with the Hepatitis B Coalition remaining intact as a program of the IAC. 

Neal Holtan, M.D., M.P.H., medical director of the Minnesota Institute of Public Health and a member of the IAC advisory board, remembers Wexler when she started the Hepatitis B Coalition. “She convinced us all, one at a time, to help her,” he says. “She had a tough job on her hands, getting this idea going. People were thinking ‘Well, it’s just too difficult, we probably are doing enough.’” At the time, there were debates about vaccines and about which vaccines should be given to children at what ages. There were conflicting views within the scientific and medical communities as well. “She had trouble on all fronts, but she’s just incredible. I have huge respect for her,” Holtan says.

Wexler’s biggest challenge initially was funding. In 1994, lacking financial support, the organization closed for a few months. “I didn’t know about fundraising,” says Wexler. “Learning to ask for donations is tough and being OK with asking pharmaceutical companies for support was a challenge eight years ago. I’ve come to terms with the fact that their support helps make our work possible. There aren’t strings attached, and they value our work.”

With improved fundraising has come tremendous growth. The first Hepatitis B Coalition mailing went out to 40 health professionals; the IAC now reaches more than 400,000 people twice a year. The IAC has grown from one employee to five full-time and two part-time employees, with several consultants who assist in grant writing, Web site upkeep, and design. These days, the IAC has a $1 million budget, with half of its funds coming from the CDC, $100,000 from donations, and the rest from pharmaceutical companies. 

“Our goal is to give health professionals tools to help them do a better job on the frontlines,” Wexler says. “Vaccines are lifesaving, and while it takes time to administer the shots, care for the patients, and do the paperwork, it’s a basic foundation of preventing disease.”

A Force of Nature

It’s not only funding that allows the IAC to realize its goals; Wexler’s lively presence also plays a part. “She’s a force of nature,” says Holtan. “She is very energetic and has visions for what needs to happen to improve people’s health.”

At the IAC, Wexler is in constant motion. Her waist-long necklace of large colored stones and her dangling rectangular earrings sway as she zips about the office, greeting people as they enter the hallway that the IAC offices occupy in the Liberty State Bank building in St.Paul. When Wexler reaches for the phone, the call could be from the CDC, a physician in Turkey, or a University of Minnesota student whose mother in Cambodia has contracted hepatitis B. 

Working on one of the IAC’s main publications, Vaccinate Adults, which is mailed to 160,000 providers, Wexler zooms toward the industrial-sized copy machine down the hall, past a wall filled to the ceiling with small mailbox-like slots, holding dozens of brochures, information sheets, and videos. The hall is filled with bundles of the IAC’s 28-page newsletter, Needle Tips, ready to be mailed out to the 230,000 health professionals who receive the mailing twice a year. The newsletter includes the most current national immunization recommendations, vaccination schedules, screening questionnaires, educational charts and articles for providers, and catalogs of resources. Wexler explains that providers need help in keeping current with the ever-changing field of immunization, especially with new national recommendations being released every couple of months and vaccine shortage information constantly being updated.

The IAC works closely with the CDC staff, who review material and reply to questions the IAC collects from health professionals. The answers are printed in an “Ask the Experts” column that appears in both Vaccinate Adults and Needle Tips. The CDC also provides Vaccine Information Statements (VIS), federal documents that are translated into 26 languages. “There’s no other place in the world that you can get all these VISs in one place,” says Wexler. 

The organization doesn’t only publish printed material. The IAC also distributes a weekly electronic newsletter, and all of the IAC information is available on the Web site, www.immunize.org, which is visited more than 5,000 times a day. Many of the materials are translated into 27 languages.

And the information is available for free, although donations, of course, are welcome. “Our interest isn’t in making money on the sales of these items, our goal is to have well-informed health professionals,” says Wexler.

Combating Misinformation 

At her computer, Wexler clicks to a link on the coalition’s Web site that is visited by the general public as well as by doctors and nurses. “Unprotected People” is a collection of stories that help bring the reality of vaccine-preventable disease to light. One tells the story of a three-month-old baby who died from hepatitis B. Although her mother had tested positive for the disease, someone mistakenly entered that she was negative on her medical records, and the baby did not receive the hepatitis B immunization at birth. This death could have been avoided had the baby been immunized before leaving the hospital.

Wexler has also seen children die when their parents are persuaded against immunization by a small, vocal group of people who make up the anti-vaccine movement. “They get the attention of the media, and we have to spend a lot of time countering their misinformation,” says Wexler, who says the movement is fraught with pseudoscience.

“Preventing an illness is a difference that can’t be measured,” says Holtan. “To see the difference, go back 100 years, or 120 years. See the mortality from these so-called harmless childhood diseases.”

It’s not only the public that needs educating. Wexler can’t believe how few health professionals get vaccines themselves, particularly flu shots. “I was so shocked that only 34 percent of M.D.s and R.N.s get vaccinated annually,” she says. “They think they don’t get sick, but you can have a mild case of the flu and spread the disease to somebody and make them really sick.” She would like to see more adults in general get their immunizations, especially those in high-risk groups. “Fifty-four percent of people 65 and over have a pneumococcal vaccine once in their lifetime,” Wexler says. “It’s still way too low—why isn’t it 90 percent? It’s a national problem.” She says that gains are being made in vaccinating children; now more work needs to be done to ensure that adults have the correct vaccinations, too.

The Work’s Rewards

Wexler’s family has played a part in the coalition—her children have helped illustrate IAC publications (see drawings accompanying this article), and her husband, Michael, keeps up the domestic front so that Wexler can give the IAC her full attention. Turning to a page in Needle Tips, Wexler points out the cartoons that her children have been contributing for years. “My kids think it’s cool,” says Wexler, “although they’d like me to be home more.” When she does have time to relax, Wexler loves having her husband read to her while she knits. She hesitates, then admits that she also enjoys watching action films with her sons.

Wexler’s work is made easier by the constant support of her husband, who is a stay-at-home parent, a homeschool teacher, an editor and publisher of a literary magazine, and a poet. “He’s a gem,” Wexler says. “He supports what I do tremendously. When I have to leave home and go away for trips, he takes care of everything at home.”

Such support allows Wexler to throw considerable energy into her work, which has provided her with much satisfaction. The organization has received public recognition—the CDC’s Partners in Public Health Award in 1997 was given for the IAC’s work in achieving high levels of routine hepatitis B immunization. But the less-public rewards—the e-mails and thank-yous the organization receives daily for providing critical information about immunization—are equally important to Wexler. And every time IAC newsletters are headed to the printer, Wexler says, she feels a sense of accomplishment. 

“I love what I do.”

Renee Whisnant is a staff writer for the MMA.