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FIRST OPINION
The Vaccine Hurdle
 If You Can't Trust
Your Doctor, Who Can You Trust?
July 21, 2002
By HERBERT J. KEATING, M.D,
Northeast Magazine
At this writing, the deranged microbiologist
who loosed anthrax on America has not been caught. If I were to lay
my hands on the guilty party, and if I were unshackled from my
profession's ethical bonds, I would mete out the proper justice; I
would make him inhale some of the spores, and be done with it.
Inadvertently, however, this terrorist may be responsible for
improving the public health system in this country. Suddenly, the
government - specifically, the Centers for Disease Control - is
looking seriously at the availability of vaccines for all kinds of
bioterrorism bugs, including anthrax.
But they have a serious obstacle to overcome: Many black Americans
simply don't trust the government to do right by them, medically.
Sophie M. is a patient of mine, and is a sweetheart. She is a
healthy, large woman with flawless skin and glossy, perfect nails.
Her visits are a delight, because she has a deep, fervent religious
faith that she shares generously.
Shortly after the anthrax case in Connecticut, I saw Sophie in my
office for a routine follow-up visit for her blood pressure, a
problem that runs in her family, as it does in many African-American
families.
As I pumped the cuff, she said, "I won't be surprised if it's
sky-high."
My stethoscope in my ears, I grunted in deaf, general commiseration
as I strained to hear her blood pressure.
"130 over 80," I announced, and pulled the stethoscope from my ears.
"That's OK. I want you to stay on the same dose of your medication."
I turned to write a note in her record.
"Things stressful at work?" I asked. I knew that Sophie worked at
the local post office.
"You best believe it, Doc," she said forcefully. "This anthrax
thing's got everybody nerved up."
"I can imagine," I said.
"Doc, should I take this anthrax vaccine they're offering to us?"
I deliberated a minute. The anthrax vaccine was a series of six
shots. The track record for safety seemed good, but six shots?
"I probably would," I answered. "Especially if there is another
outbreak of cases."
Sophie paused, thinking things over.
"If I take it, I'll probably be the only black person in the station
to," she answered. "You should see the forms and all to sign, just
to get the vaccine."
The patient paused, and then added, "One of the union leaders told
me that it might be like Tuskegee, and I shouldn't get the vaccine."
I groaned to myself.
"Tuskegee" was a shameful episode in our nation's public health
history. In 1932, a group of black men who had contracted syphilis
were recruited by the public health service, and followed in a
research project. Because there was no effective antibiotic
available to treat syphilis at that time, the researchers wanted to
see what would happen to the men as syphilis progressed: the
so-called "natural history" of syphilis. Amazingly, this group was
watched and analyzed and not treated for decades, even when
effective antibiotics were developed. Some developed severe
neurological problems, including a dementia like Alzheimer's.
"I don't think another Tuskegee will happen in America again," I
said. My voice sounded weak relative to the strength of my
conviction. I really did feel that way.
"Oh, I'm not so sure, Doctor," Sophie answered.
In its best light, the inexcusable behavior of the researchers
involved in this study may be explained by their misdirected zeal to
preserve the "science" of the original experiment. Their faulty
reasoning may have been that if they treated the patients with the
new antibiotics, how would they know what the variety and frequency
of outcomes would be of untreated disease?
In the worst light, they were guilty of seeing the Tuskegee patients
as experimental creatures, somehow subhuman.
"Well," I said gently, "I think the risk is low, no matter what.
There have not been new cases of anthrax since the old lady from
Connecticut. And she seems to have gotten it through the Jersey mail
system."
"Maybe I will ask my pastor," Sophie answered.
I felt slightly hurt and a little indignant. She trusted her pastor
more than me? What would he add? What medicine does he know?
In the late 1990s I attended an astonishing presentation about HIV
at the annual meeting of the American Public Health Association in
Indianapolis. A survey of black people in the southern United States
found that a majority thought that HIV was somehow "leaked" from a
government lab into the general population. Even more disturbing, a
sizeable minority of the surveyed people thought that HIV was a
white plot against black people.
I believe that some of these misperceptions derive from the "lesson"
of Tuskegee. Instead of seeing Tuskegee as a tragic mistake from a
dark period of American history, and not relevant to today, many
African-Americans take an alternative view, one propagated by people
interested in exploiting real or perceived racial divides for their
own interests.
This may make black Americans sick.
My first impulse was to say to Sophie, "Take the damn vaccine." But,
instead, I swallowed hard, and said, "Yes, maybe talk to your
pastor."
And left it at that.
Dr. Keating practices internal medicine and geriatrics and is
clinical professor of medicine at the University of Connecticut
School of Medicine. All patients' stories are real, but their
identities are concealed for confidentiality reasons.
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