Getting Hep

Hepatitis B is the Rodney Dangerfield of diseases: It just can't get respect. But it sure can kill you.

FACT: Anyone can get it. There is no established cure.
FACT: Like Marx, about 40 percent of those infected will never be able to pinpoint the source of their exposure. Far sturdier than HIV, the hepatitis B virus can survive for days outside of the body, posing a threat even to people who share a household (and might share a toothbrush or razor).

FACT: About 90 percent of those infected by the virus successfully shrug off its flulike symptoms and gain lifelong immunity, much as they would if they recovered from measles. But 5 to 10 percent never beat hep B. They become lifelong carriers -- forever capable of transmitting the disease to others, even if they themselves don't feel sick.

FACT: An estimated 200 million people worldwide and more than 1 million in the U.S. are lifelong carriers. Some carriers live for 20 or 30 years trouble-free -- which is why so many don't know they have it -- but up to a quarter of them suffer symptoms, including a risk of liver cancer 100-to-200 times greater than the general population.

FACT: It wasn't just college students like Marx who weren't receiving information or getting immunized. Obstetricians failed to tell pregnant women about the disease, though babies infected in utero or during birth stand as much as a 90 percent risk of becoming carriers.

Pediatricians ignored the vaccine for children, and parents failed to pursue it. Ninety percent of doctors, according to one study, didn't tell heterosexuals with multiple sex partners that they were at high risk. Most surprisingly, according to the national Centers for Disease Control (CDC), in 1991, barely half of America's health professionals themselves had been vaccinated.

One reason: Because the initial vaccine developed in 1982 was derived from blood, much of it donated by gay men, thousands of Americans feared that the serum might be contaminated with HIV. But even after 1986, when the vaccine was manufactured genetically -- the safest and most effective ever made -- thousands of high-risk hospital workers eschewed the three shots.

"Even the first vaccine was very safe, but it came out at a time when AIDS was just emerging and we were all very leery of any contaminant," says Dr. Julie Gerberding, a University of California at San Francisco (UCSF) professor and epidemiologist at San Francisco General Hospital. Gerberding herself was exposed to hep B through what she calls "a blood bath" early in her training when she was caring for a patient in cardiac arrest. Her body defeated the virus, which left her unscathed, immune and noninfectious. It also left her with a conviction.

"I believe everyone should be vaccinated," Gerberding says.
The sentiment is echoed by so many experts in the field, it's hard to imagine why it hasn't been heeded. But then, this is a story, like so many in the public health realm, about the difficulties of combating silent killers, the American character -- and the character of American medicine.

"The U.S. has spent nearly 100 years creating a paternalistic medical care delivery system which taught patients that they could not decide for themselves when they needed to take an aspirin," says Dr. Frances Taylor, director of communicable disease control for the San Francisco Department of Public Health.

Denial doesn't help. As obsessed with our health as we are determined to ignore it, most Americans -- this writer included -- wait for a hack or a tumor before we stop smoking; we wait for a heart attack before we stop overeating. Epidemics grow thanks to "the unknowing, the heedless, or the ineducable," as disease expert Arno Karlen puts it. We pursue risky sexual behaviors because they feel good, and the drive to feel good is one of the strongest in human nature. We pursue nanosuicides in order to feel more alive.

Our ambivalence derives in large measure from a confusion about responsibility: If we are sick, in the Western tradition, we wait for a doctor to tell us so and slap us with a prescription. Health education in school is inept, particularly since any topic having to do with sex -- let alone a sexually transmitted disease -- becomes highly controversial; even public health crises like AIDS don't get national recognition, don't permeate the media and the American psyche, until a Rock Hudson dies (and in the case of hep B, no such thing has occurred).

Health power resides outside of us; we are not provided the information we need to make informed choices about our own care. And the medical establishment traditionally ranks prevention and patient education somewhere near socialism on its priority list. Our medical schools stress cures, not wellness.

"We've spent 20 years trying to reverse that whole situation, but we pretty much haven't taken a first step when it comes to immunization," Taylor says. "Most people still believe the doctor should tell you when you need it."

And why aren't doctors doing the telling?
Because the liver is out of sight and out of mind. Pediatricians don't think about liver cancer when they see a gurgling, squirming baby, says Taylor -- hepatitis B trouble typically doesn't hit until adulthood, and since many family physicians don't see its dire effects, they don't necessarily worry about it or want to give babies yet another shot that will make them cry.

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