Friday, January 30, 2015

Are We at War? The Vaccination vs. Anti-Vaccination Situation
In light of the current measles outbreak, I'd like to take a moment to reflect on the tremendously divided nature of the vaccine debate (or lack of debate) that exists in our country. It feels eerily similar to the Red vs. Blue State divide that has plagued us now for several decades. In both conflicts, there exists such fear, such misinformation, such geographic isolationism, such supreme sensitivity, and such a lack of communication that we simply stand opposed to one another without any productive conversation. I'm afraid that if we never come together to talk about these things, we'll make no progress.

 And, like many, I'd really like to see progress.

Let me out myself first: I am pro-vaccine. I come to the table with a very strong opinion that vaccination is a good thing. My son is uber-vaccinated-- because we have traveled extensively since he was an infant, he had early vaccines for measles and hepatitis A and is even vaccinated against yellow fever and typhoid. Just this week, he had his kindergarten boosters. I always get the annual flu vaccine, and though I am not convinced the data on pregnant women getting a whooping cough vaccine in the third trimester is that robust, I pulled up my sleeve and ceded to vaccination just last month-- trusting that the risk is minimal. I'm a public health enthusiast.

All this being said, I work intimately with hundreds of families who believe otherwise-- and I don't only work with them, I love them and care for them, and counsel them.

As a family doctor caring for a population who chooses overwhelmingly to make alternative vaccine choices, I often find myself in the uncomfortable place where the two worlds collide. And while I consider myself a  vaccine believer, I also find myself intensely offended by the denigrating tone so many take with people who choose to make the choice NOT to vaccinate. Perhaps it's because I know them personally. And I know that they want what we all want-- what's best for our children. It's just what's "best" may not be so black and white for some as those of us believers want to believe.

I also know that berating parents for the decisions they are making for their children is unlikely to change their minds.

After all, what was your response the last time you were berated?  Did you say, Hey thanks for calling me uneducated and stupid and ignorant. You are soooo right, let me reverse my entire decision-making process and go with yours?

Doubt it.

Vaccinators (of which I consider myself one) are those I will call "vaccine believers". That doesn't necessarily mean we believe in God, Santa Claus, or the Republican Party. In fact, a large proportion  is made up of  liberals and skeptics: academics, journalists, returned Peace Corps Volunteers, scientists, and scholarly folk. But vaccinators are a mixed bag: we also include immigrants, the urban poor, and others who either aren't empowered enough to question authority or those who have personally experienced vaccine-preventable disease. Most believers have never read a book or a study about the safety of vaccines-- even the scholarly subset. They don't need to. They take the recommended schedule (available here), follow it like a road map, and trust in the integrity of the institution of medicine and the wisdom of their predecessors. Both instill in them a steadfast trust in the value of vaccines. Perhaps most importantly, believers are descendants of vaccinators. Their perception of risk is reinforced by the community in which they live and by stories of vaccine-preventable illness.They may have traveled to a country where they have seen victims of polio or meningitis. They may be from one of those countries. Or maybe not. They don't harbor suspicion about the morality of governmental recommendations-- in fact, they trust and embrace both the integrity of science and the righteousness of health policy-makers. They do question the morality of people who choose to put communities at risk for their own personal interest.

Anti-vaccinators are those I will call "vaccine atheists".  Again, this designation has nothing to do with religion-- in fact one of the largest outbreaks of measles prior to our current one involved an enclave of orthodox Jews in New York who were choosing not to vaccinate based on religious teachings (see report here). I'm just borrowing recognizable terminology. Where I live, most anti-vaccinators are not particularly religious, though many would call themselves "spiritual". Like believers, atheists are a mixed bag: some are quite educated, others are not. For a range of reasons-- I'm not always sure why-- they do not fear the diseases that vaccines are targeted to prevent. They don't believe in the inherent value of immunization-- and they believe that the potential risks of said vaccines are more likely and more dangerous than the diseases themselves. Just like believers, most vaccine atheists have not extensively read books or studies about the safety of vaccines. They, too, don't really need to. They know vaccines carry risks, and they choose not to chance those risks. Their perception of risk is reinforced by the community in which they live and by isolated reports of horrible outcomes after vaccination. Some specifically fear autism, but for most, the theoretically risks are much more complex. Importantly, most are descendants of non-vaccinators. They look at the CDC recommendations and scoff at the ridiculous number of immunizations recommended. They know that there is always uncertainty in any medical intervention, they wonder what the actual risk is for their child, and they question both the science and the moral integrity of those making official recommendations.


So, you see, there might be more similarities between the two groups than we might have previously guessed. We are all products of our upbringings. Neither side has read much. Neither can quote validated data. We both dig in our heels and hold our positions. And thus we quickly forget that we share some commonalities-- namely we live on the same planet and maybe even next door to each other, and we should be TALKING to each other.

Here's what I propose we talk about:

1) Fear
Vaccinators fear vaccine-preventable disease. They do not want measles, influenza, meningitis, or polio to be running around our country (and our world) infecting vulnerable children or frail adults. They do not want to return to a place where people die or are disabled from vaccine-preventable illness. Vaccinators also fear that decisions of others not to vaccinate put their children at risk. I get it.
Anti-vaccinators fear side effects, preservatives, chemicals, and immune loads. They fear the unknown. And they fear these more than the risk of illnesses that most have never seen. They do not want to expose their children unnecessarily to toxins that may put them at risk. Vaccinators may dismiss these fears-- citing examples of millions of children who have received such toxins without untoward side effects-- but in so doing, they neglect to validate that science is terribly imperfect, that in fact, scientists have frequently historically reversed themselves on interventions once deemed safe and necessary.

Let's talk about what scares us, why it scares us, and see if we can find some common ground. Let's talk about why some are afraid of the diseases and others of the vaccines. Let's see if we can reasonably sort out what we should be afraid of. . .and which fears we can probably set aside.

2) Misinformation
This is the trickiest for me-- as a scientist, doctor, and general book nerd, I love reading the data. My patients will tell you that a most common phrase out of my mouth starts with, "Studies have shown. . .". followed up by some really cool meaningful information that helps back up my recommendation.
And yet, as I have tried to find good information for my patients on the topic of vaccine safety, I have been terribly unimpressed-- by both sides of the topic. Most of the educational materials the CDC publishes is watered down, does not directly address my patients' specific concerns, and basically ends with "trust us". Now, I do trust the CDC, but not everyone does, and I can understand why. The CDC material often feels dismissive and, frankly, a little bit lacking. That being said, I find that most of the anti-vaccine material is inflationary and based in paranoia and fear rather than compiling what limited information is available. I have ordered at least half a dozen books to read on the topic and been thoroughly unimpressed by most of them.  For my vaccine skeptical families, I find myself recommending "The Vaccine Book" by Dr. Sears, which is imperfect but seems the best marriage of the two-- if you have other recommendations, please do let me know.

Let's talk about where you get your information. I'm curious. Can you please share resources you have found helpful? What about some that are unhelpful? Who do you trust? Why? Why not? What makes information trustworthy? What makes it untrustworthy? How much weight does anecdote carry in your decision making? What about a large population study? What can I do as your fellow human to make information feel more helpful?

3) Geographic isolationism
Just like red versus blue, carnivore versus herbivore, and God versus not-God,  we humans tend to surround ourselves with people who have similar thinking and similar modus operandi. Research shows that differences in vaccine uptake are extremely geographical, which literally means that our neighbors reinforce whatever set of beliefs we tend already to have. When we geographically isolate ourselves, we conveniently reinforce our own beliefs (right or wrong) and protect ourselves from intelligent conversation that might challenge those beliefs. And in this way, we don't encourage ourselves (or our counterparts) to develop intelligible and meaningful responses to real and important questions. For example, why are some people so scared of preservatives in vaccines and others aren't? Why are some people so scared of vaccine-preventable illness and others aren't? Why might someone you love and respect make a totally different decision about something you find morally reprehensible? Shouldn't we know the answers to these most basic questions? . To get answers, though, we have to ask. And to ask, we have to not only come into contact with but also feel safe in the company of those who might think differently than us.

Let's reach across the aisle and be curious (and I mean non-judgey curiously curious) and cross over the line every once in awhile. We might be surprised to find ourselves more educated because of it-- being curious with my patients has certainly led me to read more and understand more what people are afraid of. And my patients being curious about my thoughts has hopefully helped them make informed decisions.

4) Sensitivity
Even in my own social circles, I have found the topic of vaccine choices to be off limits in mixed company-- other than in my exam room where I have some say over what conversations are cultivated. Living in Sonoma County, I am well aware that I am often in mixed vaccine company, and as a mother, I wouldn't touch the topic with a ten foot pole. Immunization in my town is right up there with super stigmatizing topics: how much money your family makes and whether you do crazy things in your bedroom. Rather than friends and family being a safe venue for intelligent conversation, I find that people are so sensitive about their choices (in both directions), that we're afraid to ask. In fact, I was out for coffee with a doctor friend just this week, and he casually inquired about another doctor friend's vaccination views. He knew my perspective and felt safe asking me about me, but had never discussed the issue with her, knowing it could get sensitive fast. This returns me to the important notion that we are so influenced by what is happening in our community, so that even people I might consider vocal vaccinators find themselves silenced. I am supremely aware that I may isolate and offend my patients if I simply try to bulldoze them with personal opinions-- I believe it is my duty as a physician to be sensitive to their vulnerabilities and present the topic in a loving and respectful manner-- even (or maybe especially) when I disagree.

Can we lower our own sensitivity about decisions we make for our families and temper our defensiveness so that we might have meaningful conversations on the topic? What might those conversations look like in a non-judgmental space? Might we find some more middle ground?

5) Lack of communication
Communication, of course, involves all of the above issues already mentioned and so much more. And while I personally feel strongly that my own children be fully vaccinated for their well-being as well as the well-being of our community, I am utterly turned off by the general blasting of non-vaccinators. It simply will not work to scare or judge or berate parents into making different choices. It won't work. This is not a war. This is not really about me versus you. This is an opportunity to engage in meaningful conversation about true risks of real disease and true risks and benefits of vaccine, true fears and true needs of parents to do what is right for their child AND for public health and feel comfortable doing so.

Do me a favor, and cool your jets. Ask someone you know and love but that you assume has a different opinion than you on the vaccine matter to share their reasoning. Listen. Discuss. And then share yours. Then listen some more. You might be surprised about what may come out of such a conversation. You might learn something, you might teach something, and we may all be grateful for the step forward.

Thursday, January 29, 2015

Itchy butt, itchy butt please go away.

For those of you who've never had an itchy butt, the concept behind this post may seem funny (as my mother would say, both a little "funny ha ha" and little "funny odd"). But for those of us who have ever suffered from an itchy butt, this is no joke.

Itchy butt is disconcerting, anxiety-producing, and downright miserable.

It is one of those super embarrassing topics-- one of those oh-no-my-doctor-has-her-hand-on-the-doorknob-do-I-really-want-to-mention-this-topics, hanging right up there with discussions about the quality of one's sex life, underarm odor, and nose-picking. It's not something people like to talk about, even with their most intimate partners. It makes people feel dirty, anxious, desperate, undesirable, isolated, even crazy.  But estimates are that somewhere between 1% and 5% of the population suffer from itchy butt. So if you're lucky enough to never have suffered, say your prayers that you don't become the next victim.

I've seen young men certain they have a sexually transmitted disease, old women sure they have cancer, little kids (whose parents, having spent time googling, certain their child has pin worms, which sometimes they do) and everyone in between. It's thought that men outnumber women four to one, with the highest occurrence in the 40-50 year age range, but still common in people ages 30-70.

And-- big personal revelation-- I've suffered myself. It's wretched.

Itchy butt in doctor's speak is termed Pruritis Ani. Pruritis means itchiness; ani is an obvious reference to the anus, the anatomical structure that is the exit door for your bowel movements (or, as is my four-year-old's favorite word, poop). Yes, we have an actual medical term for it-- proof that it's prevalent enough to merit it's own diagnosis.

There are two types of itchy butt: primary/idiopathic (i.e. we have NO idea what causes it) and secondary (i.e. caused by something else). Somewhere between 25-75% of cases are secondary. That's a pretty big range-- a stat that basically means we can find an actual cause in only about half of cases. In the other half, who knows what started it?! An uncertainty leading to more feelings of insanity. That's why so many people have the experience of going to their provider to be seen, finally getting the nerve up to say something, and then feeling let down by the lack of answers. Too often, there are no answers to be had. Sorry.

The most common and obvious cause of itchy butt are hemorrhoids (swollen, inflamed veins in your anal region) and anal fissures (basically scrapes or little cuts in the anus that just have a hard time healing because, well, we all use our anus quite frequently). Hemorrhoids are caused by increased pressure down in your bottom. They are super duper common and often happen when people are constipated, have chronic diarrhea, are pregnant, or overweight. About 50% of the population will have a hemorrhoid by age 50. Ugh. Fissures are pretty common too-- you have an especially big poop or an especially hard one, it causes a little abrasion, and it takes awhile for that to heal.

Other less common causes of itchy butt include:
Skin stuff: allergic dermatitis (e.g. eczema or an allergic reaction to soap, lotion, lubricant, toilet paper) , psoriasis, seborrhea (cradle cap of the bottom), squamous cell cancer
Infectious stuff: fungus (e.g. yeast), parasites (pin worms are common, especially in kids)
Some medications: examples include tetracycline, colchcine, quinidine, local anesthetics, and neomycin
Some systemic illnesses: diabetes, lymphoma, obstructive jaundice, thyroid dysfunction, leukemia, chronic renal failure, and aplastic anemia
Foods: perhaps tomatoes, chocolate, citric fruits, spices, coffee (including both caffeinated and decaffeinated), tea, cola, beer, milk and other dairy products
Psych: anxiety, agitation, and stress
Other: fecal incontinence, excessive humidity, the use of soap, excess scrubbing of the anus, chronic diarrhea, and menopause.

Lots of reasons, many of which may apply to you. But, remember, HALF the time, there is no reason to be found.

Here's where itchy butt gets frustrating.

There is something about itchy butt that predisposes people to a vicious itch-scratch cycle in a very innervated area. Yes, our anus is super well innervated. And the combination of that cycle and the insane number of nerve endings down there, often leads to an intolerable impulse to scratch the perianal area. Again and again.The urge is classically worse after bowel movement, worse at night right before going to sleep, and sometimes even worse in the middle of the night.

This often leads to literally clawing the skin. Even for the most controlled human being, the urge to scratch can be tremendous, and even a little extra rub-dab-- with a wet wipe, a cream, a salve. And those very wipes and salves may be part of the problem.

Wet wipes, for example, which may seem to get you cleaner than toilet paper, contain preservatives that are commonly known to cause/worsen contact dermatitis. That means you use a wet wipe thinking it will make your itchy butt better, and it may only be making the problem worse. For these reason, it's reasonable to avoid all wet wipes (even those that claim to be gentle, unscented, etc).

Desperation also leads people to try all different kinds of products, natural and unnatural-- including hydrocortisone, witch hazel, calendula, lotions of a wide variety, Chinese herbs, Benadryl cream, cool water, hot water, comfry leaf, ice cubs. You name it, someone's tried it. Yes, even capsaicin (that's the stuff in chili powder that makes your tongue tingle). And, fortunately, in some cases, SOME of this stuff helps. But I'm here to tell you that, unfortunately, in most cases, most of these things just cause more skin irritation, give you further excuse to rub things on (furthering the itch-scratch cycle) and don't lead to ultimate relief.

The solution MAY be simpler than you would have thought.

Here's my prescription for itchy butt--  ridiculously simple, but often simple is the best!

First, if you are truly worried you might have a hemorrhoid, an STD or some other lesion down there, please go see your primary care provider. Let someone else take a look. If she sees something, she'll treat it.  And maybe you will get better. And try not to be embarrassed. If you've already done that and heard the disappointing, "It looks pretty darned normal back here, nothing to worry about",  please don't despair. It's not all in your head. It's real, it's itchy, but it's treatable. Go for simple.

1) First, STOP scratching! (So much easier said than done). Do anything in your power to stop scratching: cut your fingernails, wear gloves, wear tight pants, wear three pair of underwear, meditate. Anything that works to keep your hands away from those pesky little nerve endings. Break the cycle.

2) Next, stop putting any products down there, including soap when bathing, anti-itch creams, herbs, etc. Most topical formulations are probably contributing to irritating your skin, and you need to give the skin a chance to heal. Plus, any time you put something down there, it's an excuse to give a little scratch. And then you are back at it again.

3) Stop using wet wipes. I know, counter-intuitive, but trust me.

4) Get yourself a squirt bottle or spray bottle or some sort of other water container, and each time you either feel the urge to itch OR have a bowel movement, use water AND only WATER to clean yourself.

5) Resist the urge even to use toilet paper (it's just too tempting to give a little extra rub while your down there, and that little rub is part of the problem). It's not a matter of getting yourself cleaner-- even if you are convinced it's so.

6) If you are unbearably itchy, always go back to the cool water. Squirt, spray or sit in it. Do not rub it on.

No prescription is ever 100% effective, but I can offer you some hope. It really does work! And you can move on from focusing your crazy frenetic anxious all-consuming energy on your anus to somewhere more productive. 

Additional resources: