PARENTING OPTIONS FOR INFERTILE COUPLES WITH SPINAL CORD INJURY

July 29th, 2011

Some men with spinal cord injury are not able to impregnate their partners because they are unable to produce viable sperm. But there are other options for having a family that you and your partner might want to explore.One possibility is artificial insemination with donor sperm. Sperm banks collect sperm samples from healthy anonymous donors. Use of donated sperm allows a couple to go through the experience of pregnancy together and to begin parenting the child from the moment it is born. For some couples, however, the “imbalance” of having a child genetically related to the mother but not the father is unacceptable and a reason not to pursue this option.A second possibility is adoption. The adoption procedure may involve extensive evaluation of you, your partner, and your home by the adoption agency, long waiting lists for an available child, and a series of evaluations and court proceedings before the adoption is legally finalized. Adoption agencies may have discriminatory attitudes toward parents with a disability, but your application to adopt a child cannot be refused solely on the basis of your disability. A private (non-agency) adoption is an alternative, but this can be extremely expensive and result in much disappointment if the birth mother decides not to relinquish the child.If you wish to adopt a child, consult with other adoptive parents who have disabilities and inquire at several adoption agencies to find one that is best suited to your needs. If you are willing to persevere, adoption can be a rewarding way to become a parent.Elliott looks back on the day his first wife announced her pregnancy as a turning point in his recovery. He recalls the surprise and happiness in finding out he could father a child, his wife’s enthusiasm, and a dawning sense of responsibility. For more than two years Elliott had been dependent on others. Now he would have to take care of someone else. At the age of twenty-two, he wasn’t “real hot” about having a child – until he found out he was going to have one! “The real point at which I knew I was trapped and there was no way out, and I didn’t want any way out, was when I saw her born. I was there in the delivery room. She had me wrapped around her little pinky from the day she was born!”After his divorce, Elliott lived alone for three years, rebuilding his self-confidence and independence, working, dating, getting his power wheelchair and van. Then he met the woman who would become his second wife, and they lived together for a few years before marrying.In this marriage, Elliott feels he is an equal partner. He sometimes asks his wife for assistance with particularly difficult or time-consuming tasks, but he functions independently for the most part. He has been steadily employed during their marriage, recently switching to a better job. His daughter, always a frequent visitor, moved in with them during high school and is now starting college. Elliott’s second wife has never had children. Now in her mid-thirties she and Elliott are thinking about having a child together.Elliott was fortunate in having substantial recovery of his sexual function and being able to father a child without medical intervention, gut his story also illustrates the interaction between physical and psychological factors in dating, developing romantic and sexual relationships, and being a responsible and loving parent. Elliott found that the road to becoming an attractive sexual partner and succeeding in a long-term relationship required self-confidence, some social risk-taking, a sense of humor, a relish for relationships, and responsibility for his own life.
*130/156/5*

ADOLESCENT ALCOHOL/SUBSTANCE ABUSE TREATMENT

July 16th, 2011

Once it has been determined that an adolescent needs treatment and the adolescent has agreed to treatment, it is important to proceed in a careful way. Because medical and psychiatric complications frequently accompany adolescent substance abuse, a thorough medical and psychiatric evaluation should precede or be an early part of any treatment plan. Treatment options include outpatient, residential, or hospital-based care and can involve individual, group, and family counseling, plus self-help groups such as AA or NA (Narcotics Anonymous). Halfway houses may also be helpful for adolescents who are not ready to return home from a hospital-based program, but who no longer need the structure of a hospital.There are very good alcohol/drug treatment programs for adolescents. There are those, on the other hand, which might most kindly be described as “nontraditional,” or those less concerned with therapeutics than with turning a profit. Don’t forget the standard questions before referring an adolescent to any program: “Does the program work?” “Is the program drug free?” “Is there a strong family component” “Is there a strong therapeutic component ” “Is there a strong educational component ” “Is the adolescent involved in treatment planning?” “Is there a peer component?” “Are there provisions for aftercare?” “What are the costs and risks of treatment, including both financial cost and time cost?” “What beliefs are instilled” “What are the staff credentials, including training, experience, licensure and certification?” “Is there a full range of services, including pediatric, psychiatric, educational, psychological, and alcohol counselors?” “Is there involvement with AA?” “How does the program feel when you visit it?” “Does the program evaluate itself?” “Is the program accredited?” “If so, by whom?”When referring an adolescent for treatment, it is important to remember that alcoholism is a chronic disease. Treatment does not end with discharge. The conceptual model to use is not that of an acute illness like appendicitis, where the offending tissue can be surgically removed and the problem will never recur. It is rather a chronic illness like asthma, or arthritis, where ongoing monitoring is always essential, and whereas some cases are mild and require only outpatient treatment, others may require hospitalization.*153\331\2*

DISEASES OF BOTH THE ARTERIES AND THE VEINS

July 1st, 2011

An uncommon problem with blood vessels is a malformation in which arteries and veins are directly connected, instead of being joined by capillaries. This can take two general forms: arteriovenous malformation, which is a congenital condition, and arteriovenous fistula, which is usually the result of trauma.Arteriovenous malformations are “tangles” of small arterial vessels that are intertwined with small veins. The blood from the arteries flows directly into the veins. These malformations can be present anywhere in the body and in any organ. The consequences of having an arteriovenous malformation depend on their location and size. A small one in the brain may produce more problems than a larger one in the liver, for example.A fistula can be thought of as a window or conduit that directly connects a large artery with a large vein. This might occur if a person receives a puncture wound that penetrates through an artery and vein that lie next to each other. Even after the healing process occurs, a connecting pathway between the two vessels may remain. Some blood from the artery may be diverted (shunted) directly into the vein before it goes to the capillaries. If a fistula (or arteriovenous malformation) is large, the blood flow through it may be very high. If so, the heart works excessively hard to keep up with the needs of the body.Some arteriovenous malformations can be fixed by blocking the artery from which they branch. This can occasionally be done by inserting a special small balloon or other material directly into the artery with a catheter.*215\252\8*

OTHER OPIOID ANALGESICS: METHADONE AND PETHIDINE

June 29th, 2011

Methadone is a synthetic opioid analgesic which is indicated for the treatment of severe pain in patients unable to take morphine. It is effective orally, rectally and by injection. Methadone is contraindicated (or should be used with great caution) in patients who are frail, elderly or confused and in those with significant hepatic or renal impairment, as the risk of toxicity is higher. The side effects of methadone are similar to morphine except that cumulative toxicity may occur, usually heralded by sedation and confusion.     Administration of methadone is complicated by the drug’s complex pharmacokinetics. After a single dose, the half-life is about 15 hours but the duration of action is only 4-6 hours. With continued therapy, the half-life increases to 2-3 days and it is usually necessary to reduce both the dose and frequency of administration.• Failure to reduce the frequency of administration after the first few days -will predispose to cumulative toxicity with sedation and narcosis.     Pethidine is a synthetic opioid drug used for the treatment of severe acute pain. It has a therapeutic ceiling related to CNS toxicity and should not be used in the management of chronic cancer-related pain.     Accumulation of norpethidine occurs in patients given high or frequent doses and those with significant renal impairment, causing CNS excitation with agitation, tremor, myoclonus and seizures. The myoclonus and seizures are unresponsive to naloxone and are treated with benzodiazepines and anticonvulsants.• Pethidine given in high dose or in the presence of renal impairment leads to CNS irritation and seizures and it should not be used for chronic cancer-related pain.*57\55\2*

IBS AND EVERYDAY POISONS: STOPPING SMOKING – GOING ‘COLD TURKEY’ OR CUTTING DOWN SLOWLY? & SMOKING AND CAFFEINE

June 16th, 2011

Going ‘Cold Turkey’ or Cutting Down Slowly?It is worth noting that if you cut down by any more than a third of the daily amount of cigarettes you could have a full-blown withdrawal syndrome even though you are still smoking. Maybe this is why total abstinence is usually encouraged. On the other hand if you could gradually cut down without lapsing when you had a night out or a bad day, and look after your diet and so on, it could make the final bid easier. It is to be hoped that you will take heart from these stories and remember at the time these people gave up they knew nothing about diet or supplements – you are going to find it much easier!Smoking and CaffeineThe British Medical Journal published some material which shows that caffeine metabolism slows down within days of giving up smoking. Smokers often tend to be quite heavy coffee drinkers, possibly because they metabolize caffeine faster. If they continue with the same amount after the caffeine metabolism slows down, their blood levels of caffeine may go up by 250 per cent. This can continue for several months after stopping smoking. It would seem sensible to change to decaffeinated coffee and even to cut down on that before stopping smoking. Caffeine poisoning could be a large part of the unpleasantness of withdrawal for some people.*44\326\8*

ASTHMA AND DOCTORS

June 6th, 2011

The relationship between a doctor and a patient is an important factor in the treatment of illness. Both the doctor and the patient share a responsibility in the management of asthma. Except for those living in sparsely populated rural areas, most people are able to choose their doctor, particularly their general practitioner.The GP is usually the primary care medical professional in the treatment and management of asthma. It is common for a GP to refer patients to a specialist for specific tests and further assessment, but it is normally the GP with whom the patient has the most contact.Choosing your GP is an important decision. If possible, it is best to have a doctor whom you respect and trust professionally as well as like personally. A mutually respectful and trusting relationship between a doctor and patient makes communication easier, helping the patient feel comfortable in discussing personal health problems and helping the doctor diagnose problems more readily.As the severity and symptoms of asthma can vary from person to person, it is important to have a doctor who is able to recognize and diagnose asthma, is cognizant and up to date with available medications, and who will spend the necessary time working out a management plan for each patient. A patient should also ask for an action plan that can be implemented in the event of an acute attack.Unfortunately the ideal is not always the reality. You may not live in an area where there are enough available doctors to choose from. This can be a particular problem for asthmatics living in rural communities. It is particularly important for such people to have a good management plan and know how to self-medicate.While asthma education for both doctors and patients is improving, asthma is still poorly treated in the community and the information given to patients by doctors is often inadequate and incomplete. This was certainly true for Sonia, 58, when she sought a new GP:I don’t have a car, so I went to the doctor nearest my home. I began to realize that he did not know much about asthma after he prescribed ten courses of antibiotics for my wheezing over a four-month period. I also had Ventolin, but my asthma got worse. Finally I went to the out-patients clinic at a hospital, saw a specialist and my treatment was changed. I am now on Becotide as well as Ventolin and am much better. The specialist advised me to get a peak flow meter and I use it twice a day to monitor my breathing. I also go back to the hospital for regular reviews. The specialist at the hospital said he has written to my GP, but so far I have not been back to see him. Now that I am feeling better, I feel more confident, so perhaps I can discuss my medication with the GP without feeling I am telling him what to do.There is still a serious communication gap between many doctors and their patients. This can be the fault of either. Doctors have a responsibility — but so do patients. Doctors are not trained communicators or educators and some have to deal with difficult and obtuse patients who don’t reveal all their symptoms, take their medication erratically and often take more notice of what unqualified people tell them than the advice given by their doctors. Most doctors have a few horror stories to tell about self-treatment.Many doctors do not appear to allow sufficient time to explain the disease and the management of asthma to the patient. A competent doctor should be able to give the patient and their family a thorough and realistic explanation of asthma and how to manage it effectively.The National Asthma Campaign has produced The Asthma Management Plan, a booklet which has been distributed to doctors and medical students. The publication provides doctors with:•An endorsed asthma management plan in a form that can be used both as a reference and as a teaching tool;•A consistent terminology for both doctor and patient to use;•Check points to help ensure comprehensive management. The National Asthma Campaign’s Management Plan provides a framework within which doctors and patients can work together. It engenders a new and better doctor/patient relationship and encourages patients to take more responsibility for their health and asthma management. Initiatives such as this booklet are addressing many of the perceived problems in asthma treatment and doctor/patient relationships.Most State Asthma Foundations offer a telephone service to help the public with questions and problems about asthma treatment, medication and management.QUESTIONS TO CONSIDER WHEN CHOOSING YOUR DOCTOR:Are you comfortable and at ease with your doctor, and can you discuss your health problems openly?Does your doctor respect your views and your confidentiality?Does your doctor adequately explain what is happening and what treatment to expect?4- Does your doctor spend enough time with you?Does your doctor prepare you for possible side effects of the prescribed medication?Do you feel that you are participating in your general health care and asthma management plan?Does your doctor show displeasure if you suggest a second opinion? (A patient has a right at all times to obtain a second opinion from another doctor regarding any aspect of health.)A visit to your doctor is often more productive if you write down all your questions and observations of symptoms beforehand.*46\148\2*

BACH FLOWER REMEDIES: A NEGATIVE CLEMATUS TYPE

May 22nd, 2011

A negative Clematus type does not live in the present. Whenever he comes across any problem in practical life, he does not face it nor seek its solution. He just slides himself into unrealistic and illusory notions of a bright future. If he undergoes any loss due to his unrealistic mode of living, he does not care; he is so sure of his vision’s bright future.He wants to live alone so that he can completely lose himself in his colourful fantasies.When he is alone with nothing to do, he cuts himself completely from the present, becomes inattentive and careless, does not see anything lying near him, looks away – a vacant distant look with eyes open but not seeing – awake but semi-conscious, sleepy, dreamy, yawning.If he falls ill, he dees not go to the doctor, and makes no effort to get well, because he feels he has nothing to do with the present. Lying in bed he transports his mind to his rosy dreamland, forgetting all physical ailments. For him there is no value of his present earthly existence, as he is not concerned with the present. He is a day-dreamer, absent minded and lives more in thoughts than in his actions. He has a poor memory as he is inattentive when he listens. He may cross you in the street without noticing you, as he is too pre-occupied with his own thoughts.His eyes and ears are more atuned to inward seeing and hearing than their common outward use, and this may adversely affect these organs, and result in street accidents. Sleepiness, drowsiness, inconsciousness, giddiness, dozing and falling asleep while talking or hstening to an important talk depict the negative Clematis State, as it indicates temporary loss of interest in the present. Anybody and everybody may at times find himself in the above state when his mind is so pre-occupied with his inner problems, joys or sorrows or thoughts of an impending important function, that his attention is withdrawn from the present. Clematis will bring him “down to earth”In the negative Clematis State the person does not attach any importance to his physical being. Naturally very little energy would be available at the physical level. Cold hands and feet and a feeling of emptiness in the head results in a weak memory, and inability to recollect details of a message.*92\308\8*

THE INFERTILITY PROBLEMS: THE FEMALE’S ROLE

May 15th, 2011

The female partner should be carefully checked to exclude any obvious reason for her apparent infertility. Often unusual findings bubble to the surface. We well remember one woman, married for nearly six years, who had failed to become pregnant. Close questioning revealed that the marriage had never been consummated. Her inherent fears of sexual intercourse, plus a strict religious upbringing combined to produce this sad suite of affairs. The woman was good-looking and attractive, mentally agile and held an important position working with senior executives. She had to use her brains every day, and was not lacking in common sense. But when it came to bedroom activity, her fears and phobias took over completely. Medical hypnotherapy, for nearly a year, managed to remove most of her subconscious phobias and enabled her to indulge in, and even enjoy, normal intercourse. When this took place, of course, she soon became pregnant. Her husband was the happiest man alive. He had stoically ploughed along for years, hoping for the best. Ultimately, the best of both worlds had finally arrived.A physical examination, with special emphasis on the pelvic organs of reproduction, is essential; then various forms of investigation may follow. It must be established that ovulation is taking place regularly. It is also imperative to discover if there is any block 10 a sperm’s reaching the egg, enabling conception, which takes place in the outer pan of the oviduct (the Fallopian lube).*46\45\4*

PELLAGRA

May 8th, 2011

It is several years now since I wrote my first book Stress and Nervous Disorders. I remember writing about a young lady who came to see me in one of my clinics in the South of England. The lady was upset and very tense as she had been diagnosed and classified as mentally unstable. Yet when I spoke to her, I felt doubtful about this conclusion and it soon became clear that she suffered from a condition called pellagra, which, by her own admission, made her impossible to live with. Pellagra is described as a chronic disease, caused by a deficiency of niacin in the diet, and characterised by skin eruptions and mental disorders. It is the label of mental illness that is most difficult to shake. I still see her occasionally, and there is little that reminds me of the person who, so many years ago, walked into my consulting rooms. This metamorphosis is largely due to the fact that she no longer suffers from pellagra. When I first interviewed her, she told me that she had been on a weight-reducing diet and that she had taken appetite-suppressing drugs. She had indeed managed to lose a considerable amount of weight and she also told me that she remembered feeling very clear in her mind. At no time did she ever consider the idea that she might be suffering from malnutrition. Although she thought that the diet and resulting weight loss had done her a lot of good, after a while the first signs appeared of her brain and nerve cells having suffered from lack of nutrition.As soon as I saw her I recognised her skin problem as pellagra and I told her that her only way to recover was to follow a healthy and balanced diet. I reassured her that if she kept to the instructions she need not worry about regaining any of the weight she had shed with such effort. In fact it was largely due to her weight loss that she had become deficient in the B Complex vitamins, and therefore I immediately prescribed vitamin B6 and vitamin C.It is not unusual for vitamin deficiencies to occur when diets become unbalanced and sometimes this is the case, even with carefully worked out slimming diets. In these cases I always introduce a diet rich in soya and rice, as these are valuable dietary supplements. With supplementary minerals such as potassium, chromium, selenium and the B vitamins, many deficiencies can be redressed. Once I had explained to this patient the basis of my diagnosis and resulting recommendations, she was as conscientious in following my dietary instructions as she had been when she wanted to lose weight. She soon noticed a remarkable improvement in the condition of her skin. Some Niacin and vitamin B3 gave her a little extra help and the end results took her by surprise.With a long-standing problem like pellagra, it is essential to rebuild the body. Once the diagnosis has been reached, some remedies or supplements can be introduced, including oil of evening primrose and additional vitamins, minerals and trace elements. Given today’s harassed and frantic lifestyle, the B vitamins are vital. They are particularly important for the health of nerves and the brain, and also for defence against infections. As man is not able to store B vitamins, we must ensure a ready supply in our diet. Moreover, B vitamins are water soluble and therefore easily lost in the cooking process. This information should be kept in mind when deciding on a vitamin supplement.Taking a vitamin B Complex supplement to correct vitamin deficiencies, will maintain the nerves and the nervous system in good order, release energy from our carbohydrate fuel, maintain the health of our digestive tract, repair and regenerate the circulatory system, assist the metabolic process of fats and proteins, and maintain healthy eyes, hair, skin and mucous membranes.Especially in the case of a pellagra condition, it is worth noting that after taking vitamin B3 or Niacin, if the vitamin is taken in its nicotinic acid form, a flushing or tingling sensation can sometimes be experienced. It is often also considered necessary to take vitamin B2 or Riboflavin which is one of the co-enzymes which enables us to utilise oxygen safely and effectively. It is involved in the conversion of protein, fats and sugar into energy. It is important for the eyes, skin, hair and nails, and for the repair and maintenance of soft tissue, such as the lips, tongue, and mucous membranes in the mouth (for example). Again this vitamin is water soluble and therefore not stored in large amounts and must be regularly provided in the diet. Since the richest food sources of Riboflavin include liver and yeast, vegetarians often choose to take a vitamin B2 supplement. Riboflavin naturally has a strong yellow colour and sometimes is the cause of highly-coloured urine, but it is harmless.If the skin has suffered for a long period of time from a pellagra condition, it is possible to introduce some remedies to help restore good health. Again, I feel that the natural herbal antibiotic, Echinaforce, is of great help. Another symptom of pellagra can be unpleasant gastro-intestinal complaints. In these cases the Centaurium (corn flower) remedy should be used and this can be easily combined with Echinaforce and the vitamin supplements.Many skin conditions are the result of dietary habits and the more white sugar, fats and animal protein our diet contains, the smaller the reserves of certain vitamins, and this most definitely includes Niacin. This vitamin also plays a major part in cholesterol problems and if the skin is blemished, as it can be with cholesterol deposits, Niacin will help to put this right. We sometimes overlook the fact that our food does not contain the nutrients it used to, and vitamin supplements are therefore increasingly necessary.The definition of ‘vitamin’ is an organic food substance, essential for the normal metabolism of other nutrients, the promotion of growth and the maintenance of health. Not all vitamins can be synthesized within the body. Vitamins are essential for regulating the metabolism, they help to convert fat and carbohydrates into energy, and they assist in the formation, growth and repair of bone tissue. Vitamins are also essential for reproduction, formation of antibodies, coagulation of blood, formulation of intercellular substances, and for the integrity of bone, skin, blood and nervous tissue. They function as co-enzymes for innumerable chemical reactions concerned with the metabolism of food on which the nutrition of the body really depends. It is also true that essential micro-nutrients, or metabolic activators, have a specific activity in the prevention of deficiency diseases and that the same nutrients are important to life’s process.*37\147\2*

THE NEW GERM THEORY OF DISEASE: TOOLS OF DOMESTICATION

April 25th, 2011

Although the conquest metaphor has limited applicability in the control of infectious diseases, the diversity of warfare situations offers a diversity of metaphors. The matches should not be surprising, because in a very real sense we are in a state of war with many of our microbes. They are invading us. We are killing them. The mistake in the standard war metaphor was in thinking that there was only one successful solution: unconditional surrender. In real warfare as in antimicrobial warfare we have learned, sometimes very painfully, that there are other solutions.Consider the Soviet war in Afghanistan. Although the Soviet Union had overwhelming superiority in fire power, the United States saw that it could tip the balance in favor of the Afghan rebels by providing Stinger missiles, which could knock out the main Soviet threat: attack helicopters. The United States provided this weapon after considering which of the two sides was more dangerous to U.S. interests. There was no opportunity to groom a successor. If there had been, the U.S. government might have called on the CIA to deploy a different strategy. Whether one supports or condemns any such covert action depends on how one weighs the expected geopolitical benefits against the compromises of individual rights and national sovereignty. The quality of the assessment depends on the range of strategies considered.Health policy strategists have a wider range of opportunities because bacteria and viruses do not have rights. They are free to use any strategy regardless of the destruction that is imposed on innocent microbes. Yet in spite of this freedom of action, health strategists have not drawn on the range of tactics the CIA employs. Imagine how much less effective it would have been if the United States had intervened in Afghanistan by battering down both sides. Yet that is just what vaccination programs attempt to do. Instead of making vaccines that favor the mild strains by selectively knocking out the truly dangerous opponents, or by grooming the microbial successor, we have been trying to make vaccines for over two centuries that knock out all the variants of a target microbe, whether the variants are mild or extremely dangerous. When a vaccine does that, we no longer have the mild variants predominating in the wake of the campaign to protect against the harmful variants.If vaccine efforts lapse, as they often do, then the mix of pathogens that was there before the vaccine effort will quickly expand to fill the void. If only mild variants are left, the situation is more stable against reinvasion by harmful variants. The overall kill rate is lower, but it is selective; the outcome is thus more favorable.The second most cost-effective vaccination program in history, the one that controlled diphtheria, inadvertently showed how well this selective strategy can work. The people who made the diphtheria vaccine may have thought of their efforts as an all-out war to eradicate an enemy, but the bacterium that causes diphtheria, Corynebacterium diphtheriae, was not eradicated by the vaccine program. Rather, the vaccine selectively suppressed the dangerous competitor, altering the balance in favor of the benign competitor. This selective intervention virtually banished diphtheria for more than a half century without the need for an all-out eradication campaign. If we understand why this campaign worked so well, we might use it as a model for other vaccine campaigns.The diphtheria bacterium causes most of its damage as a result of a toxin it produces when it is short on resources, particularly iron. The toxin costs the bacterium about 5 percent of its protein budget, but the investment pays back dividends because the toxin kills the cells of the respiratory tract near the bacterium, thereby liberating the nutrients the bacterium needs. The diphtheria vaccine was made by modifying this toxin a little so that it no longer damaged respiratory tract cells but still caused the immune system to generate antibodies that would recognize and sequester the unmodified toxin. If a toxin-producing C. diphtheriae invades a person who has been vaccinated, the toxin is sequestered by antibodies before it can destroy a person’s cells and provide nutrients for the bacterium. The 5 percent cost of toxin is simply a drain on the bacterium’s ability to compete with toxinless bacteria. The overall effect is that the strains that do not produce the toxin win out over the harmful strains. Wherever the strains left in the wake of a diphtheria vaccination program were assessed, the same trend occurred: the toxin-producing strains vanished, replaced by the milder, toxinless strains. That is a good outcome for us because strains that do not produce toxin not only fail to cause diphtheria but also protect us against the harmful strains that do. They therefore act like free live vaccines.These arguments lead to a simple rule for vaccine development. Whenever possible, use virulence antigens: those components of a pathogen that make viable, benign organisms harmful. Doing so will generate an immune response that selectively protects against the harmful organisms. Including antigens against components of the pathogen that do not make it virulent must be avoided. Otherwise the vaccine will remove mild strains that could further suppress the harmful strains.This virulence antigen strategy has been used inadvertently in one other vaccine program, the one against Hemophilus influenzae, which has been an important cause of encephalitis in children. That program was so successful that it left researchers scratching their heads. But extraordinary success is what one should expect from virulence antigen vaccines. The strategy should be applicable to all vaccines, yet it has not been considered as part of the strategy for making any vaccine, largely because vaccine developers tend not to look at their task from an evolutionary point of view.The virulence antigen strategy requires that vaccine experts shift away from eradication as a goal. This shift is dictated for some diseases by the ability of vaccines to prohibit disease but not infections. When children are vaccinated against pertussis (whooping cough), for example, the disease is generally prevented but the organism is still present and transmissible. Prospects for eradication by such vaccines are obviously very dim, no matter how pervasive the vaccination program. We can expect to be living with the agents. If we have to live with the organism anyhow, we should make it a benign organism that supplements vaccination efforts rather than a mix of largely harmful organisms. Pertussis vaccination is a perfect candidate for a virulence antigen strategy, not just for this reason but also because virulence antigens are already identified and can generate a protective effect that is comparable to the best vaccines available. The pertussis vaccines that are currently being used have other antigens, particularly one called filamentous hemagglutinin, which trigger immune responses that suppress benign strains as strongly as harmful strains.*62\225\2*

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