My recent blog post on the New York City Department of Health's expanded recommendations for meningitis vaccination sparked some lively discussions and raised some provocative questions, prompting me to write this follow-up.
My primary objective in the previous post was simply to alert readers that the DOH had expanded its meningitis vaccine recommendations to include all HIV-positive men in New York City who have sex with men, and all men in NYC who regularly hook up with other men for sex at bars or parties or through websites or apps, regardless of their HIV status. This represented a change from the previous recommendation, which had applied only to specific Brooklyn neighborhoods (Bedford-Stuyvesant, Brownsville, Bushwick, Clinton Hill, Crown Heights, Downtown Brooklyn, Dumbo, East New York, Prospect Heights and Williamsburg), not to all of New York City.
My secondary objective was to encourage readers to spread the word not only through mainstream channels like Facebook and Twitter but by posting a link to the DOH alert on their own gay social media profiles, especially given that health officials were cited in a New York Times article as saying that outreach to at-risk populations through gay organizations was difficult because not all men who have sex with men identify as gay or bisexual.
However, some readers objected that I did not include enough medical information about the disease itself, including how it is transmitted and what the signs and symptoms are. Others had concerns about the DOH "targeting" gay men with their vaccine recommendations in a way that seemed stigmatizing and marginalizing. I addressed as many of these issues as I could in the comments, but I thought some of these questions warranted a fuller discussion, so here we are.
First, a quick rundown on some of the medical facts. Meningococcal disease, commonly referred to as meningitis, is a severe bacterial infection of the bloodstream. Common symptoms include high fever, headache, vomiting, stiff neck and a rash. Symptoms may occur two to 10 days after exposure, but usually within five days. While it is not generally considered a sexually transmitted disease, the DOH believes that the current strain is circulating specifically among men who have sex with men and may be transmitted during intimate encounters, including sexual encounters.
Moreover, the outbreak has now spread beyond New York City. In a March 25 press release the New York State Department of Health revealed that a 23rd case had occurred, affecting a man who lives elsewhere in the state but spent significant time in the city. In response to this latest case, the New York State Department of Health has expanded the recommendations previously issued by New York City to include men who have sex with men who live outside New York City but have traveled to New York City and hooked up for sex with men they met at bars or parties or on websites or apps since Sept. 1, 2012.
In the remainder of this post, I want to discuss how the medical questions and the political issues are inextricably linked, inevitably intertwined and hopelessly entangled. The big question, I think, is this: How, if at all, should we reconcile the dictates of public health policy with the social, cultural and political concerns and sensitivities of specific populations? Another way of putting this is to ask whether the DOH recommendations are "good for the gays." But is that really a reasonable question to ask when New Yorkers are dying of meningitis at an unusual rate and this elevated mortality appears to be occurring specifically among men who have sex with men, whether they identify as gay or bisexual or not?
The DOH vaccine recommendations are based strictly on the epidemiologic evidence, ideally free from considerations of political expedience. In other words, the DOH epidemiologists look at the data they have collected on the people who have contracted the infection, and they say, "OK, what risk factors for this infection did these people have in common?" According to the DOH, this outbreak is occurring in New York City almost exclusively among men who have sex with men. That's where the data point, so that's whom the recommendations target (now expanded to include men who live elsewhere in the state but spend significant time in the city and meet the other risk criteria).
A number of readers expressed frustration with the part of the recommendation that singles out men who hook up for sex at bars and parties and on websites and apps. Some felt that the DOH was targeting gay men based on "lifestyle issues" that had no medical relevance. However, here again, it's not a matter of nefarious Gayle Rubin-style assumptions about "good sex" and "bad sex." Rather, it's a matter of epidemiologic data and risk factor analysis. I asked the DOH why it was relevant that these men are meeting other men at bars or parties or on websites or apps. According to the DOH, these methods of meeting partners have come up repeatedly during their case investigations, making the very fact of hooking up via these venues or channels relevant to the definition of risk, and helping the DOH to focus its vaccine efforts.
OK, fine, but sometimes gay men bring their straight friends, including straight female friends, to bars and parties with them. Or men and women, regardless of sexual orientation, might be working at these bars as bartenders, barbacks, bouncers, dancers or what have you. Why don't the DOH vaccine recommendations include them? Again, the data provide the basis for the recommendations. According to the DOH, rates of meningitis among New York City residents other than men who have sex with men are not higher than expected according to statistical norms. Thus, at this time, the vaccine is not recommended for members of any population group other than men who have sex with men. If the pattern of infection changes, the vaccine recommendations will change too (as they now have been expanded to include men from other parts of New York State who spend time in New York city and meet the other risk criteria).
Finally, some readers thought that the whole alert was alarmist. According to the federal Centers for Disease Control, about 1,000 people in the U.S. contracted bacterial meningitis each year between 2005 and 2010. What qualifies 22 cases in New York City in three years as an outbreak, even with seven deaths? Isn't this well within normal occurrence rates? Again, the data drive the policy response. Outbreaks are defined as an unusual number of cases in a population. According to the DOH, the number of meningitis cases currently occurring among men who have sex with men is elevated and sufficiently unusual to qualify as an outbreak.
Moreover, this particular strain of meningitis appears to be particularly invasive and deadly. Based on DNA fingerprinting, the DOH knows that the current outbreak is a variation of a strain that has been in New York City at least since 2003. According to the DOH, about 10 percent of the population can carry this bacteria in their mouth or nose at any time. Because this strain of meningitis can exist in this carrier state, it is much more difficult to eradicate. The vaccine offers protection, but many of the people who are at risk do not know they are at risk or do not believe that the risk is significant enough to warrant getting vaccinated. The DOH is particularly worried about this strain of meningitis, because it can cause illness very quickly, and almost a third of those who have become sick have died. That's why the DOH is insisting on the importance of vaccination for all men who have sex with men in New York City, regardless of HIV status, as soon as possible. Meningitis is not generally considered a sexually transmitted disease, but the DOH believes that this particular strain is circulating specifically among men who have sex with men and may be transmitted during intimate encounters, including sexual encounters.
Now, I know perfectly well that the personal is political. I know perfectly well that the medical-industrial complex has used its knowledge and power to marginalize, stigmatize, harm and oppress vulnerable groups. I know all about the Tuskegee syphilis experiment, in which the U.S. Public Health Service deceptively withheld treatment from black men enrolled in a treatment study in Macon County, Ala., from 1932 to 1972, to study the effects of untreated syphilis. My own brother, Frederick Owen Broder, was a victim of the hepatitis B studies at the Willowbrook State School for Children with Mental Retardation in Staten Island, N.Y., in which developmentally disabled children and adults were infected with live hepatitis from 1956 to 1971 in order to develop a vaccine. And, of course, I myself am a survivor of the AIDS epidemic, having testing HIV-positive in 1990 and endured years of no access to health insurance and no effective treatments until ACT UP brought the pharmaceutical industry to its knees and to the bargaining table so that lifesaving therapy was available by 1996, when I was still healthy enough to benefit from it.
Is there a political dimension to the DOH vaccine recommendations? Of course there is. First, there's a political dimension in the original, Aristotelian sense that "humankind is by nature a political animal" (Greek "ho anthropos phusei politikon zoon"), meaning a being that lives in cities (Greek "poleis") and has an interest in city affairs (Greek "ta politika"). Second, there's a political dimension in the Foucaultian sense that medicine is a form of both knowledge and power that may be used to regulate the bodies and lives of citizens ("biopower"). And, finally, there's a political dimension in the sense of identity politics, the "personal is political" sense that I alluded to earlier, derived from feminist thought in the 1960s, whence it trickled into gay liberationist thought in the 1970s and remains a tenet of postmodern critical race, class, sex and gender theories. All these senses overlap and intertwine. And all these senses provide a basis for a critique of public health policy measures that categorize citizens according to their race, class, gender, sexuality or any other aspect of their identity.
But in the case of the current meningitis outbreak in New York City and the DOH response to it, I think some folks are eager to pick a fight where none is warranted. In its handling of this meningitis outbreak, the DOH, far from being suspect, appears to be exemplary, following the epidemiologic data, not the social, cultural or political winds, and couching its recommendations in terms of "men who have sex with men," rather than using terms like "gay" or "bisexual" that might exclude men who are at risk but do not identify with either of those labels. Are critics of the DOH identifying legitimate issues of race, class, sex or gender discrimination, or are they simply eager for a fight with the public health establishment because they miss the good old, bad old days of die-ins and human ashes strewn on the White House lawn? Here and now in New York City, we have a health department that is aware of social and cultural realities around sexual identities and sexual practices. We should praise such a health department. Indeed, we should celebrate such a health department as a victory for decades of struggle around civil rights, women's rights, LGBT rights and disability rights, not rail at it in misplaced, knee-jerk anger.