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"You have to convince providers that they're not doing a perfect job," says Taylor.
Another roadblock to inoculation compliance, she says, is the schism between private and public health care, essentially two separate delivery systems, one for the rich, one for the poor. "It's much easier to coordinate immunization programs when you're dealing with a system that works in lock step," she says. Diversity among clients poses challenges as well.
"We have to tell people about the disease in at least six languages," says Taylor. "And some cultures don't necessarily understand or agree with the immunization concept. There is definitely a perception in at least part of the African-American community," Taylor gives an example, "that immunization is a government plot."
But the effort to break through those barriers is particularly important in San Francisco, which suffers a rate of acute hepatitis B -- active disease -- that is more than double the rate in the U.S. as a whole, according to the city Department of Public Health. A large population of drug users and people with multiple sex partners is one cause -- adults and teens spreading it to adults and teens. But another cause is mother-to-child transmission, which is the major route of infection for immigrants from countries where the disease is endemic: Southeast Asia (with one of the highest rates of infection in the world), most of Africa, the Pacific Islands, the Middle East, China, and the Amazon basin, according to the CDC. Health experts say nearly a third of all births in the city are to women from these areas.
But some Asian families don't believe in blood tests and inoculations, says Rosemary Lee, public health nurse and coordinator of the city's "Newcomers Program," which provides health guidance to the newly arrived. Instead of the Western approach, which sees disease as an invader that must be conquered with syringes and surgical knives, many Asians -- and people everywhere who practice alternative medicine -- might seek to heal themselves with acupuncture, herbs, or homeopathy, Lee says. "And in many cultures, you keep things in the family or don't tell at all," Lee adds. "For example, if you are a young woman with hepatitis B, you might not want your in-laws to find out and accuse you of bringing disease into the family."
Then, too, it's difficult for people in any culture to volunteer for three shots over about a six-month period -- not to mention remembering their appointments for an event almost universally abhorred. (An informal attempt by this writer to convince six friends to get immunized proved fruitless: "Needles make me faint!" one man protested.)
But the most critical roadblock for most people, experts say, is the world's biggest health problem: lack of money. President Clinton's Vaccines for Children program provides free vaccines to anyone 18 or younger who is on Medicaid-eligible, uninsured, or whose provider does not cover immunizations. But adults are on their own. And for an uninsured adult, a full series of hepatitis B shots can cost $150 to $300 or more. SmithKline Beecham and Merck & Co., the two pharmaceutical behemoths that produce the product, sell it to the federal government wholesale at about $40 a dose, or $120 for the three-dose series, one of the highest prices ever for a vaccine.
The pharmaceutical companies say the vaccine isn't pricey, considering the expensive research it represents and the protection it affords. "Our hepatitis B vaccine is the world's first genetically engineered vaccine, and it's much more costly to make than the old vaccines," says SmithKline spokesperson Jeremy Heymsfeld. "We certainly strive to be competitive and we want people to use our products, and that's why we're in business -- to improve health."
Public health officials say something different.
"It's unconscionable," says hepatitis expert Girish Vyas, when asked about the price. Vyas, a UCSF professor and researcher, says, "The same vaccine that you get here you can buy for $20 a dose in Hong Kong." (In some competitive bidding situations -- for a UNICEF vaccination program in Indonesia, for example -- the price per dose drops below $1.)
"Cost here is the major barrier," agrees Melissa Jones of the Public Health Department's San Francisco AIDS office, the project coordinator of the Young Men's Survey. The recently completed project, which assessed sexually transmitted diseases and health lifestyles among young gay and bisexual men, offered free hepatitis B tests and vaccinations to at least 120 men, Jones says. In far greater numbers than the general public, most of the interviewees, she adds, "were very conscious of hepatitis B, particularly in the sense that it's transmitted the same way as HIV. They just couldn't afford the shots because they didn't have health insurance."
Elsewhere, the immunization dance of denial persists even for those who can afford care. People aren't getting their shots, period.
Last year in California, only 57 percent of all children age 2 or younger had received their most basic immunizations: measles, mumps, rubella, polio, tetanus, diphtheria, whooping cough, and meningitis, according to Les Burd, hepatitis prevention coordinator for the California Department of Health Services.
That's an improvement, notes Burd: In 1992, only 48 percent were immunized by age 2, he says. In fact, in 1992, according to the CDC, only four in 10 children in nine major cities were properly vaccinated, with the loser, Houston, Texas, at only 10 percent compliance. San Francisco's rate has been hovering at about 49 percent, the state Department of Health Services reports.