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Smallpox Vaccine


In late January, New York City will receive 15,000 doses of smallpox vaccine to begin voluntary vaccination of health care workers as part of President Bush's homeland security initiative.

If vaccination of health care workers goes well, other "first responders" like police and firefighters will then be vaccinated, and the shot will be made available in 2004 to members of the general public who want it.

But the vaccination campaign raises many questions. How safe is smallpox vaccination? Do people over 34, who were vaccinated as children, still have protection or do they require booster shots? Should the general public seek vaccination? And how likely it is anyway that smallpox will be used as a biological weapon?

The last question is critical for answering the first. If the chances of an attack are exceedingly low, the risks of vaccination almost certainly outweigh the benefits. The currently existing vaccine, which is basically a variant of the first vaccine ever developed (by Edward Jenner, in 1796, is the most dangerous vaccine still in use. It kills 1-2 people per million and causes life-threatening illness in about 14-52 people per million, according to the federal Centers for Disease Control.

The vaccine uses a live virus, vaccinia, which is a relative of the cowpox virus that Jenner first observed to protect milkmaids from developing the far more deadly smallpox. Most of today's vaccinations use dead or inactivated viruses, so they are far less likely to have serious side effects. Because smallpox vaccination uses a live virus, however, people who are vaccinated can actually infect others with it-- if people who have not been exposed previously touch the vaccination site or otherwise come in contact with fluids from it.

About 1 in 1000 vaccinated people will have a serious, but not life-threatening response, such as a rash which spreads from the vaccination site. Sore arms and fever were common in recent tests of the vaccine conducted to aid the government's decision on widespread vaccination. The tests compared full dose vaccine to diluted versions. This research needed to be conducted because without dilution, there isn't enough existing vaccine to protect the population.

Out of nearly 700 young adults (mainly college students) who volunteered to take the shot, over one third stayed home from school or work for a day and about nine percent developed fevers. Fourteen percent developed rashes which spread beyond the vaccination site. All strengths of the vaccine were effective in this test. There were no deaths.

Today's population, however, is at higher risk from the vaccine than populations that were vaccinated earlier. For example, people with HIV could become seriously ill if they were vaccinated or exposed to virus from vaccinated people. Other people at high risk include people with any form of immune suppression (transplant patients, people on steroids for auto-immune disorders), pregnant women, people with certain skin diseases such as eczema or atopic dermatitis and those who are allergic to certain antibiotics which are contained in the vaccine. Researchers estimate that about 15 percent of the population currently has at least one of these risk factors.

Andrew Stern, the president of the SEIU (the largest national health care workers's union), released a statement in December saying, "The Administration and Congress have protected the wealth of the drug companies who make the vaccine, but not the health of hospital workers and the public. President Bush's smallpox plan will put thousands of Americans at unnecessary risk." SEIU Local 1199 will hold a forum in late January to plan the local union's reponse to the city's vaccination efforts and discuss whether they will recommend vaccination, which is voluntary, to their members.

"We want to make sure all possible risks are weighed, for health care workers, hospital patients and their families," said Dieter Metzger, a spokesperson for the union. Amongst 1199's concerns are the lack of provisions for time off for those who have bad reactions to the vaccine, protection from spread of vaccinia to vulnerable workers and patients, and protection from discrimination for workers who choose not to be vaccinated.

So how dangerous is smallpox itself?. In the past, it killed about one-third of those who were infected. Now, experts think mortality would be lower because many smallpox deaths resulted from bacterial infections which often develop on the "pox" (Note, graphic image) or sores, which cover the bodies of victims. Antibiotics can now easily treat such infections. Also, people can be vaccinated to avoid illness within three to four days of exposure, leaving a window of time for rapid vaccination in event of a terror attack.

And while there is currently no treatment approved for smallpox, a new antiviral drug, cidofovir, has been found to be effective in culture and in mice. Researchers are testing an oral form of this drug; an injectable version is already approved for treatment of a common opportunistic infection of the eyes seen in people with AIDS, called CMV retinitis.

Further, everyone over 34 has been vaccinated at least once. A review of smallpox cases in Europe and Canada in the 20th century found that 52 percent of unvaccinated people died, but only 1.4 percent of cases were fatal for people vaccinated within 10 years and the mortality rate for those vaccinated from 20-50 years prior was 11 percent. A more recent study also suggests on-going protection, showing a strong immune response by cultured cells in people vaccinated between 6 and 35 years ago. Researchers are not sure how generalizable these studies are but the World Health Organization's smallpox fact sheet suggests at least some protection.

The last cases of smallpox to hit New York occurred in 1947. At that time, a businessman visiting from Mexico became ill with the disease and infected 12 other people. Two of them died -- but the city prevented further spread of the illness by vaccinating 6 million people in one month.

Complications from the vaccine killed six people, ironically, more than the disease did.

A country which is at possibly the highest risk for terrorism in the world, Israel, has already vaccinated 17,000 of its soldiers, police and health care workers and plans to vaccinate more. So far, there have been only two serious negative reactions and no deaths. But on Christmas day 2002, Israel announced that it would not vaccinate its entire population, declaring the risk of a smallpox attack to be low.

When the risk of disease is so hard to determine, deciding on use of a risky vaccine is extremely difficult. People over 34 tend to wonder what the big deal is, and why something that all of us received as kids is now seen as so dangerous as to make even clinical trials on children unethical (a recent plan to test the diluted vaccine was stopped by critics). The issue is context. Smallpox was a real threat until 1977, when the World Health Organization declared that it was eradicated. A 30-50 percent chance of death is certainly a greater risk than a 1-2 in a million risk.

It took enormous effort by thousands of dedicated doctors, scientists, public health workers, nurses and others around the world to eradicate the smallpox virus, which had long been one of humanity's greatest foes. Smallpox is believed to have killed more people than any other infectious disease, claiming 300 million lives in the 20th century alone.

Communists, capitalists and others across boundaries worked together to ensure the end of the virus, which was then stored only in two sites by the U.S. and the former Soviet Union. Stolen virus from the former Soviet facility, which was less than secure as Soviet rule ended, is believed to be the source for any virus potentially obtained by terrorists.

Unleashing such a threat after such an effort can only be seen as an attack on civilization itself. Let's hope it doesn't happen and that the risk from the vaccine is the greater. But unfortunately, right now, we just don't know.

Maia Szalavitz is author, with Dr. Joseph Volpicelli, of "Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems." She writes frequently on health, science and public policy for the New York Times, New York Magazine, the Village Voice, and other publications. 

The Brooklyn Mental Health Court


"A young fellow in his third year of college had a psychotic break," Judge Matthew D'Emic recounts. The man began hearing voices, which spoke to him through the TV and the radio and convinced him that he was Jesus Christ reborn. He began to act increasingly strange and distant -- and was soon arrested for grabbing a woman's purse. His claims about being the savior irritated his fellow inmates at Riker's Island, and he was brutally beaten while awaiting the disposition of his case.

Typically, in New York City, people such as this man, whom the judge did not name, are at the start of an alternating cycle between incarceration and homelessness in which their underlying mental illness is never adequately addressed. Of the inmates on Riker's Island, as many as 20 percent have a severe mental illness -- and of those who were on psychiatric disability before their arrest, nearly half had been homeless the night before, according to the Urban Justice Center. Around 3,000 severely mentally ill people are incarcerated at Riker's Island on any given day, making it in effect the city's largest psychiatric hospital.

But a new court which began operating in October in Brooklyn hopes to start to change that. The college student whose story D'Emic told is one of the first case to be referred to him.

"He had never been in trouble before," says D'Emic, who has now seen him in court for several months. His father attended his court appearances. "At first, I could see this terrible look on his father's face, like ÔWhat happened?'" says D'Emic. "Now he comes and says that his son is back to his old self." He has re-enrolled in college and is under psychiatric care.

If he completes his period in care under court supervision satisfactorily, the student's case will be dismissed and he will not have a criminal record. The Brooklyn Mental Health Court focuses on serious non-violent crimes committed by the mentally ill. Participants are referred by the District Attorney's office or by other judges. Some violent crimes like burglary can be considered on a case-by-case basis. However, the District Attorney has to approve all participants.

But while these courts sound like a great solution to the problem of the criminalization of the mentally ill, many advocates for those with serious psychiatric problems are skeptical.

Even Judge D'Emic admits that the courts alone can't solve a critical underlying problem, which is a severe shortage of services and residences for those with mental illness. "I do see that there is a problem with not enough services being available," he says, even though only about 30 defendants have already been through his court.

"[These courts] don't do anything to fix the community mental health system, which is in complete shambles in most of the country and that certainly includes New York City," says Heather Barr, staff attorney at the Mental Health Project of the Urban Justice Center.

"I feel like this is more of a band-aid approach," adds Susan Saler, Director of Services for the National Alliance of the Mentally Ill's New York Metro Chapter, though both support measures in general to keep the mentally ill out of the justice system. Both advocates say that if community services were adequately funded and regulated, however, many of the mentally ill would not get arrested in the first place.

A more positive reaction is expressed by Dr. John Goldkamp, a professor of criminal justice at Temple University, and a leading authority on both drug courts and mental health courts. "I think that [these courts] bring an important focus to a long-neglected area," he says. "Good mental health courts are going to play a very important role." Goldkamp says there are now about 20 mental health courts across the country, with others about to be launched. He says that their goal primarily is to keep the mentally ill out of prison

Judge D'Emic is quite clear about that. Using short stays in jail to punish non-compliance with treatment poses a real problem with the seriously mentally ill, that it may not pose with other offenders in alternative sentencing courts.

"Drug treatment courts have the option of putting defendants in jail for a few days for non-compliance," he says. "If I do that, the person could decompensate, he might not get his medications and then I'm worse off than I was before."

As a result, D'Emic must use rewards like fewer court appearances, praise and even lectures to try to motivate those before him. Jail is a last resort. It is not used as a motivator, but simply to protect the public if a defendant becomes dangerous.

Part of the impetus for creating the court, in fact, was the failure of drug courts to help those who were both addicted and mentally ill. Because they were often unable to comply with treatment -- and because many drug treatment centers are not set up to treat serious mental illness -- the addicts with mental illness frequently wound up back in prison.

Since about 50 percent of the severely mentally ill have drug problems and about 50 percent of addicts have additional mental illnesses of varying severity, this is a large group of people who often have contact with the criminal justice system.

Goldkamp says that just as drug courts were started in part because the drug treatment system was failing to help, the same is true of mental health courts. "Thank goodness for the judges who want to face this problem of mental health, just like others wanted to deal with substance abuse. There are all kinds of issues that make this even more complicated and difficult. [These courts] are only there because of the failure of other social service delivery systems," he says.

But many advocates for the mentally ill feel that spending money on mental health courts reduces the pool of money available to improve community treatment. Goldkamp doesn't think this is necessarily so; he says that drug treatment providers initially opposed drug courts using the same reasoning but that the special courts can push providers to offer better and more cost-effective services if they are set up properly.

The New York State Office of Mental Health is spending $465,000 on this court and on training judges to expand it. There will be an outside evaluation once the court has been in operation for six months.

Only time will tell whether these courts will be successful in New YorkÑbut there is no doubt that change is needed. On any given day, there are about 8,000 seriously mentally ill people in New York state's prisons and jails -- and roughly 10,000 seriously mentally ill homeless people on the city's streets.

Maia Szalavitz is author, with Dr. Joseph Volpicelli, of "Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems." She writes frequently on health, science and public policy for the New York Times, New York Magazine, the Village Voice, and other publications.

Artists And Health Insurance


The nation's looming health care crisis -- 40 million without health insurance, insurance premiums rising, and benefits being reduced -- has made headlines of late. The most startling news is that, in the midst of a recession, health care costs are expected to rise between 13 and 16 percent in the next year. Like many New Yorkers, artists are already beginning to experience changes in their access to health insurance and care.

By some estimates, four of every 10 artists lack health insurance, compared with 14 percent of the total population. This is not because artists are unemployed, however. Like the vast majority of the uninsured, artists tend to lack insurance because they work for employers who do not offer health care; the sporadic, project-based nature of the working artist's career is a major hurdle to health insurance. This is not news to the many actors, musicians, painters, and dancers who keep the day job as much for the benefits as for the steady check.

Complicating this factor, according to a new report from the Future of Music Coalition, is the fact that artists are often considered by insurance companies to be a "risky" population. Whether because of their long hours, frequent travel, repetitive stress disorders, and such job hazards, or because, as the coalition's report suggests, because of an anti-arts bias based on the "hypothesized decadence of art culture," the reality is that it is hard for artists to get access to coverage on their own, even if they could afford the high premiums charged for individuals. In 2002, premiums for the major individual health plans serving New York ranged from $400 to $500 per month for individuals and well over $1000 per month for families.

Major arts unions like the Writer's Guild of America, American Federation of Television and Radio Artists, the American Federation of Musicians, and the American Society of Composers, Authors, and Publishers form a safety net for many artists by offering subsidized group health coverage. However, unions are now feeling the same pressures that are causing employers to pass on more of the costs of health insurance to their employees. (In a Commonwealth Fund/Health Research and Educational Trust survey published last month, the majority of New York State employers said that they plan to pass on more of the costs of health insurance to their employees next year.)

The Screen Actor's Guild has already announced that, starting in January, they will begin to charge enrollees a monthly premium for the first time, either $50 or $65. The benefit plan will also become less generous, charging higher deductibles and copayments and covering fewer services. The change that will affect the most members is that eligibility requirements will be substantially tightened. In 2003, actors will have to earn $20,000 to qualify for one plan or earn $9000 or work 61 days to qualify for another. These changes, the union trustees say, are absolutely necessary to prevent health costs from eating through its assets within the next two years. In May of this year, the guild extended Rule One, which requires that producers dedicate 13.8 percent of actors' salaries for health and pension plans, to all productions worldwide in another effort to shore up the health plan's funding.

Health care is a more pressing issue now because of rising costs, but the arts community has long been advocating for improvements to access to health care for artists. The explosion of HIV/AIDS in the arts community in the 1980s galvanized many to fight for better health care for the dying; now Broadway Cares/Equity Fights AIDS helps those living with the virus. In the mid-1990s, New York-based Actors' Fund won a grant from the National Endowment for the Arts to mount the Artists' Health Insurance Resource Center, a central clearinghouse that educates artists about health insurance options. The online database provides information about group health plans, federal and state public programs, options for the self-employed, and advice on how to get and keep insurance. According to James Brown of the Actors' Fund, the recently redesigned website gets about 650 individual users a day, half of which live in New York City.

Since 2000, the Actors' Fund has also been running the Physician Volunteers for the Arts, which serves the uninsured and underinsured members of the performing arts community. Free clinics staffed by volunteer physicians provide basic health services and referrals for specialized treatment.

Assemblyman Richard Brodsky is sponsoring a bill in the state legislature that would pay for 50 percent of the COBRA premium for up to six months for eligible members of the entertainment industry. COBRA, or the Consolidated Omnibus Budget Reconciliation Act, guarantees employees leaving employer-sponsored coverage the right to buy into that coverage for up to 18 months. While the law provides continuity of care, its premiums -- around $350 for individuals and more than $1000 for families in New York in 2002 -- prove out of reach for many, particularly for those who have recently lost their jobs. Brodsky's bill would subsidize 50 percent of COBRA coverage to qualifying members of the entertainment industry (e.g., screenwriters, actors, musicians, dancers) for up to six months.

Such measures, while crucial, may only be damage control. Increasing problems with access to and continuity of care in the arts community are one more sign that major legislative reform to the health care system is needed.

Martha Hostetter writes for American Theatre magazine.



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