‘First, do no harm’

We grieve with the thousands of parents who have lost children to dengue. The disease is endemic in 100 countries where 50 percent of the population is at risk, and incidence in the Philippines spiked in 2010, later exceeding 200,000 cases and recording over 2,000 deaths in 2015, when it became the most seriously afflicted country in the West Pacific Region and the seventh worldwide.

The pain of loss must be sharper for parents who suspect that the use of the Dengvaxia vaccine might have caused their children’s death. That the vaccine might have saved hundreds of children from dying offers small consolation. Doctors who might have endorsed the vaccine must share these parents’ grief and regret, but training compels them to look at the bigger picture.

Medical and ethical norms place doctors who must make potentially life-and-death choices among imperfect options between two competing principles: the injunction “First, do no harm” and the warning, attributed to the 14th-century German theologian Johannes Eckhart, that “the price of inaction is far greater than the cost of making a mistake.” Vaccines are never 100-percent effective and often bring serious side effects. Doctors balance the potential harm from early use and the certain harm from delaying their deployment for further research.

After the purchase of the vaccine in January 2016, additional studies led the World Health Organization and its manufacturer, Sanofi Pasteur, to warn in March that its use may render those not previously infected by dengue vulnerable to a more severe attack of the disease. But the WHO acknowledged in April that the Philippine dengue vaccination initiative was “consistent with the recommendations by WHO experts’ group” and affirmed its continuing support.

The reflex, mutually reinforcing government-media response to the Dengvaxia issue did not focus on remedial measures for “vaccinees” to allay parents’ anxieties. It focused instead on the search for someone to blame and to punish for possible procurement violations, the subject of the House of Representatives’ inquiry in November, and for the deaths of children after vaccination.

Congressional hearings and media reporting on Dengvaxia would have benefited from a closer focus on the Department of Health’s “act-wait dilemma” and a sharper distinction between the judgment to use the vaccine and possible anomalies in its procurement. Without adverse findings against Dengvaxia, parties involved in its acquisition would still be liable if they had illegally profited from its purchase. But corruption, even if confirmed, would not negate the value of the vaccine and the need for its speedy deployment.

Persida Acosta, who heads the Public Attorney’s Office (PAO), and Sen. Dick Gordon are not doctors. PAO Forensic Laboratory Director Erwin Erfe is a doctor, but his career has not focused on wellness; he deals with the dead. None of them own the credentials to second-guess the judgment of medical experts on the vaccine’s benefits and risks. Their corruption concerns, as Rep. Lito Atienza suggested, would be better presented in court, if they have the evidence, rather than in contentious, confusing congressional hearings.

Over 800,000 children received the vaccine. About 40 vaccinee deaths have undergone investigation, 14 by University of the Philippines doctors and 26 by the PAO. Analysis could not determine that Dengvaxia caused any of these deaths, something that might comfort bereaved parents. Despite benefits from Dengvaxia use if administered under proper guidance, the DOH has suspended its use. The DOH has also reported a drop in enrollment in other safe and necessary immunization programs, prompting an unprecedented public statement from health professionals against allowing “hysteria to rule over logical and scientific judgment.”

Some media reporting has probably abetted the backlash against vaccination. Noli de Castro headlined his Kabayan Special Patrol coverage of the issue thus: “Disgrasya sa Dengvaxia: Batang hinihinalang namatay sa Dengvaxia, ‘pinageksperimentohan?’” (Dengvaxia Calamity: Child suspected of dying from Dengvaxia, subject of an “experiment?”)  The question mark in the fear-mongering headline does not excuse the malicious suggestion of the DOH practicing Nazi-type medical “experiments” on children.

Political leaders and media practitioners can do more damage to public health issues than individual doctors.  They must reflect on how their intervention may have contributed to the fears about immunization and their accountability for deaths that it could have prevented. They are equally subject to the command “First, do no harm.”

Edilberto C. de Jesus (edcdejesus@ gmail.com) is professor emeritus at the Asian Institute of Management.