Dengvaxia, fear, and (mis)trust

Finally, experts from the Philippine General Hospital have spoken about the alleged Dengvaxia-related deaths, helping adjudicate an issue that has been mired in controversy and infused with hysteria. Their preliminary findings indicate that out of the 14 deaths, three were caused by severe dengue — two of which may have been due to vaccine failure — and that further studies are required to ascertain whether Dengvaxia had anything to do with them.

The PGH panelists are reputable specialists, and while no panel should be beyond criticism, there is no reason to doubt their expertise or independence. Hopefully, they will come up with definitive findings soon, and that the political aspects of the case — that is, whether there was undue haste or influence in the acquisition of the vaccine — will be pursued with the same sobriety. (It is entirely plausible that we’re dealing with a good vaccine that was procured in a questionable manner. Or that we’re dealing with a questionable vaccine that was procured with good intentions. Both vaccine and procurement can be dubious, but we must not conflate the medical with the political.)

As in the beginning of this issue, one priority remains: reassuring the public that the children who were vaccinated are most likely safe; that everything is being done to get the facts straight; and that there are channels they can reach if the kids present with any symptoms (as should be the case in a functioning healthcare system). Other ways of preventing dengue should be aggressively pursued, especially since the vaccine, even if effective, covers less than 1 percent of the population.

Another priority is communicating the fact that vaccines in general remain safe and essential, failures and scandals notwithstanding. Reports that immunization rates for some diseases have decreased — on top of a preexisting downward trend — are not helped by the histrionics of Public Attorney’s Office chief Persida Acosta and the hyperbole of broadcaster Noli de Castro. Fear-mongering may not be their intent, but it is a very clear side effect.

Medical science is always caught in an uphill battle when it comes to communicating facts to the public, for a number of reasons. First, people always seek explanations, and would often make use of tangible incidents to explain otherwise inexplicable outcomes. Circumcision, for instance, is seen to make boys grow taller, even if it just so happens that the usual age for circumcision is also the time that growth spurts usually happen. “Correlation does not imply causation” is a key scientific tenet, but it’s also one of the hardest to explain.

There is also the challenge of dealing with large populations. Even if a certain drug just has a 0.01-percent risk of an adverse reaction, giving that drug to one million individuals would still lead to 100 individuals with the adverse reaction—not to mention unrelated deaths or illnesses that are inevitable in a large-enough cohort. Of course, these incidents are the ones that will be reported and magnified. The challenge for policymakers and communicators is to reconcile — and explain — the fact that public health is all about weighing risks and benefits, but at the individual level, a tragedy is a tragedy.

Finally, there is the problem of (mis)trust, and in this, the pharmaceutical industry and the medical profession have to own up to their shortcomings. Regardless of the merits of the case against Sanofi Pasteur, the Dengvaxia issue was easily turned into a scandal because it fits the narrative of big pharma whose main concern is profit—a resonant theme in a country where the prices of medicines are among the highest in the world, and where many doctors remain beholden to pharmaceutical companies.

We can see all these challenges today, as what I would call “medical populism” pits parents and experts, “DDS” and “dilawan,” and various physicians against each other. Beyond a resolution of the Dengvaxia controversy and its fallout, much work—and soul-searching—needs to be done if we are to effectively communicate health issues and restore public trust in the healthcare system.

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