Ebola - misplaced priorities

In March of 2014 an outbreak of Ebola, a hemorrhagic viral infection, began in the West African nation of Guinea; It subsequently spread to neighboring countries (Liberia and Sierra Leone); It has a death rate of 50-70%; It is spread primarily through contact with body fluids of any kind. Here and here are links to more technical information about this virus.

Since this is the largest outbreak known to date there have been multiple mis-steps by a variety of people and agencies attempting to address this - not the least is the bone-headed decision of politicians to not close our border or ban in-coming flights from areas of the world that have been the focus of the epidemic. Quarantine can be an effective measure in control of infectious disease and limiting immigration (legal or illegal) and banning travel from affected areas would be forms of this (of course, this does not apply to certain physicians who work as journalists in the MSM).  Oddly enough, while those responsible for protecting the public's health will not ban travel from affected areas nor close the borders, they will consider putting healthcare workers who have cared for patients with Ebola on a "no-fly" list! Go figure. Because this is the most significant outbreak yet experienced the situation is fluid and we are continuing to learn more about Ebola and how best to deal with it.

There is currently no vaccine approved for use, though one is in development. Currently, the treatment is symptomatic and supportive - there are no specific medications targeting Ebola at this time, though zMapp is a treatment/medication in development, as is Brincindofovir or Chimerix.

While the mortality rate is high some do recover. Those who recover are a reservoir of known effective treatment - antibodies. If we're going to send the military to Africa to help manage the Ebola crisis surely we can unleash their brainpower and manpower to organize the collection and use of immune-globulin from those who have recovered. Dr. Brantley has already provided this for several people. Apparently a black market for the blood of Ebola survivors has emerged. While one might survive Ebola, surviving a transfusion reaction from receiving blood of the wrong type can kill you very quickly! Or you may survive Ebola only to come down with HIV (or some other blood borne disease) from unscreened blood.

Since intravenous fluids are standard supportive treatment for those with Ebola why not use Vitamin C as an adjunct? Another nutrient that may be important as an adjunctive treatment of Ebola is selenium, see here also.

With a mortality and morbidity as high as Ebola's why limit treatment options? There is little to lose and lives to gain. What stops us is the prejudice of pride. We're waiting for man-made options (zMapp/Chimerix/vaccines) while there are other God-provided resources that are not considered. Even if they are not "the" answer, why limit ourselves in the face of such a significant threat? The risk of death in Ebola is high, while the risk of these treatment options is low - that's a ratio that favors their use as there is a theoretical basis for potential benefit with low likelihood of harm. These treatments are available for immediate use and are also relatively low in cost and technical complexity (unlike vaccines or the medications that are currently in development).

If the priority is people there is every reason to begin using IV vitamin C, selenium supplementation and use of immune globulin. If pharmaceutical profits and never letting a good crisis go to waste are the priority, then we'll just have to keep waiting.

EV-D68: Is there a vaccine-link?

First off let me give credit where credit is due - the genesis of this blog post comes from a Facebook post of a friend, Cynthia Janak, who re-posted the information from someone else (I will update this post once I have her permission to be named - Tami Rainmom, updated Oct 10, 2014). I had seen reports linking illness from Enterovirus 68 with vaccines but was personally skeptical of the link primarily because vaccination is so widespread and EV-D68 is common, so linking vaccination with EV-D68 would be difficult. What is new is the virulence of this strain of EV-D68, leading to many children needing to be hospitalized for treatment with reports of some also becoming paralysed.

To be sure, this does not prove anything - it does not link vaccination with EV-D68, but it is intriguing and may well be a smoking gun. At the least it is an avenue that begs further research - the real question is if it will be pursued. I will not be surprised if concerned citizens are told "move along, nothing to see here" ... so as not to disturb the status quo of "there must be a vaccine for that"! So very many are extremely inve$ted in not changing a thing when it comes to vaccination (other than requiring more vaccines).

Also, enteroviruses are not new (nor is the virus implicated in the current outbreak), but what is concerning is the reports of increased virulence. Entero-virus means it can live in the gut and there are many different types, causing many kinds of illness. The virus that causes polio is one of many types of enteroviruses.

Contamination with residual DNA from the culture on which a viral antigen is grown is a known issue in vaccines - it is simply not possible to remove all such contamination from the final product. For that matter, it is not just residual DNA that contaminates vaccines, but also animal viruses as well (depending upon the cell culture used) ... and insects are now also being used as a culture medium too, so add insect diseases and DNA to the growing list of potential vaccine contaminants.

This link will take you to a Google doc for a patent that degrades residual DNA from the original cell culture in which a vaccine antigen is grown. According to the patent this
product:

"Specifically, the invention provides an improved method of degrading any residual functional cell culture DNA remaining associated with the cell culture generated product."

Improving the degrading of functional DNA means there may well be some remaining functional DNA left. In other words, this product purportedly leaves less functional DNA remaining than other products (or perhaps previous versions of this product). Functional or no, I do not want to be injected with any DNA! Do you? Do you want your children injected with DNA, human/animal/insect? The issue of residual DNA in vaccines is not new - there are several vaccines produced using cell lines formed from aborted babies (among them, chickenpox vaccines) - see this post.

The document lists the types of antigens for which/on which this product/invention might be used - among the long list is:

"[0037] Enterovirus: Viral antigens may be derived from an Enterovirus, such as Poliovirus types 1, 2 or 3, Coxsackie A virus types 1 to 22 and 24, Coxsackie B virus types 1 to 6, Echovirus (ECHO) virus) types 1 to 9, 11 to 27 and 29 to 34 and Enterovirus 68 to 71. Preferably, the Enterovirus is poliovirus. Enterovirus antigens are preferably selected from one or more of the following Capsid proteins VP1, VP2, VP3 and VP4. Commercially available polio vaccines include Inactivated Polio Vaccine (IPV) and Oral poliovirus vaccine (OPV)."

Has anyone examined the vaccine history of those who have come down with EV-D68? Is recent vaccination for polio a common variable? Did they all receive the same vaccine from the same manufacturer? Same lot? Click here to see Wyeth's response to a "hot lot". Is it possible that there has been some kind of synergistic interaction (or recombination) between the polio vaccine (or some other vaccine) and this virus that has lead to the increased virulence and paralysis?

Widespread use of antibiotics has lead to the problem of antibiotic resistance which can make it difficult to treat pathogenic infections (and their widespread use also affects beneficial bacteria as well). There is research linking widespread vaccination with mutations in pathogens that may well be implicated in their resurgence (specifically whooping cough or pertussis). Other mechanisms are also discussed in this brief post.

Interestingly enough, a Dr. Jackson is quoted in this article that the primary strategy (aside from symptomatic treatment of those who are ill) is to let the virus run through the community (also known as "the herd"). This begs the question if perhaps that might not be a reasonable strategy for so many other infections. Why are we spending so much money and accepting risks to our health by vaccinating against infections that are generally mild, self-limiting and seldom result in serious short or long-term sequelae?

Given that vaccines are increasing the possibility of genetic recombinations (both in our own DNA as well as among pathogens) people (parents of children and all other adults) should be able to determine for themselves, free of coercion or manipulation, if they will or will not receive any vaccine.

There are so many unknowns - those who perceive vaccination as providing more benefit than risk should get them, those who believe the risks outweigh the possible benefits should not be punished for declining this invasive medical intervention.

Why do normal (real) science when you can do post-normal science?

Recent disclosures regarding the conduct of studies in vaccine safety by the CDC should lead everyone to ask some pointed questions regarding their safety and efficacy. A whistleblower has come forward alleging studies regarding the MMR vaccine were spiked in order to obtain particular results.

There are links to four articles below, none of which are directly about vaccines, but all of which inform the current controversy.

The concept of "post-normal science" has been developed and discussed since the early 1990's, and this writer wonders if it has been applied (even without intending to be) to studies of vaccines.

This quote of Steven Mosher (#1) describes a "post-normal" situation:

Science has changed. More precisely, in post normal conditions the behavior of people doing science has changed.

Ravetz describes a post normal situation by the following criteria:

1. Facts are uncertain
2. Values are in conflict
3. Stakes are high
4. Immediate action is required

The first three criteria would certainly apply to many aspects of medicine, including
vaccination - the fourth, not so much. Part of what is so appalling about the concept of "post-normal science" is the assumption that immediate action is required - given the first three
criteria the appropriate response is to slow down until more is known as taking immediate action can result in catastrophe if the intervention is ultimately found to be detrimental.

Here is a diagram (from #2) to explain the difference between traditional science ("applied science" - green area) and "post-normal science" - (red area);

It could well be argued that quality has always been the effective principle in practical research science, but it was largely ignored by the dominant philosophy and ideology of science. For post-normal science, quality becomes crucial, and quality refers to process at least as much as to product. It is increasingly realised in policy circles that in complex environment issues, lacking neat solutions and requiring support from all stakeholders, the quality of the decision-making process is absolutely critical for the achievement of an effective product in the decision. This new understanding applies to the scientific aspect of decision-making as much as to any other.

Figure 1

Post-Normal Science can be located in relation to the more traditional complementary strategies, by means of a diagram (see Figure 1). On it, we see two axes, "systems uncertainties" and "decision stakes". When both are small, we are in the realm of "normal", safe science, where expertise is fully effective. When either is medium, then the application of routine techniques is not enough; skill, judgement, sometimes even courage are required. We call this "professional consultancy", with the examples of the surgeon or the senior engineer in mind. Our modern society has depended on armies of "applied scientists" pushing forward the frontiers of knowledge and technique, with the professionals performing an aristocratic role, either as innovators or as guardians.

Of course there have always been problems that science could not solve; indeed, the great achievement of our civilisation has been to tame nature in so many ways, so that for unprecedented numbers of people, life is more safe, convenient and comfortable than could ever have been imagined in earlier times. But now we are finding that the conquest of nature is not complete. As we confront nature in its reactive state, we find extreme uncertainties in our understanding of its complex systems, uncertainties that will not be resolved by mere growth in our data-bases or computing power. And since we are all involved with managing the natural world to our personal and sectional advantage, any policy for change is bound to affect our interests. Hence in any problem-solving strategy, the decision-stakes of the various stakeholders must also be reckoned with.

This is why the diagram has two dimensions; this is an innovation for descriptions of "science", which had traditionally been assumed to be "value-free". But in any real problem of environmental management, the two dimensions are inseparable. When conclusions are not completely determined by the scientific facts, inferences will (naturally and legitimately) be conditioned by the values held by the agent. This is a necessary part of ordinary research practice; all statistical tests have values built in through the choice of numerical "confidence limits", and the management of "outlier" data calls for judgements that can sometimes approach the post-normal in their complexity. If the stakes are very high (as when an institution is seriously threatened by a policy) then a defensive policy will involve challenging every step of a scientific argument, even if the systems uncertainties are actually small. Such tactics become wrong only when they are conducted covertly, as by scientists who present themselves as impartial judges when they are actually committed advocates. There are now many initiatives, increasing in number and significance all the time, for involving wider circles of people in decision-making and implementation on environmental issues.

The financial stakes in vaccination are high - for the companies that make these products, along with those recommending them. The personal stakes are high for all who are required to be vaccinated in order to keep their jobs or participate in public school/daycare - and who must accept the personal and financial consequences of any adverse effects - in other words, accepting nearly all the risk. Increasingly there is reason to believe uncertainty is high in regards to vaccination - uncertainty that the risk/reward ratio may not be as accurate as it has been portrayed.

If one study was thrown, might others have been thrown as well?

What other "irregularities" might have occurred? Paul Thorson is implicated (indicted, actually) in wire-fraud/improper use of funds (#3) and has yet to be extradited from Denmark to answer the charges against him (well, at least for how he used the money entrusted to him for the sake of researching vaccine safety). But if the funds allocated for research can not be accounted for can the findings of the research be trusted? Both issues involve numbers - if you'll fudge one set, might you also alter another?

In 2005 Ioannidis (#4) published an essay titled "Why Most Published Research Findings
Are False" reviewing factors that lead to the publication of findings that are later found to be false or incorrect. In this paper he develops several corollaries regarding the likelihood of true findings in a research paper - two in particular are applicable in vaccine science:

Corollary 5: The greater the financial and other interests and prejudices in a scientific field, the less likely the research findings are to be true.

Conflicts of interest and prejudice may increase bias, u. Conflicts of interest are very common in biomedical research [26], and typically they are inadequately and sparsely reported [26,27]. Prejudice may not necessarily have financial roots. Scientists in a given field may be prejudiced purely because of their belief in a scientific theory or commitment to their own findings. Many otherwise seemingly independent, university-based studies may be conducted for no other reason than to give physicians and researchers qualifications for promotion or tenure. Such nonfinancial conflicts may also lead to distorted reported results and interpretations. Prestigious investigators may suppress via the peer review process the appearance and dissemination of findings that refute their findings, thus condemning their field to perpetuate false dogma. Empirical evidence on expert opinion shows that it is extremely unreliable [28]. 

Corollary 6: The hotter a scientific field (with more scientific teams involved), the less likely the research findings are to be true.

There is tremendous financial COI among those involved in vaccine science and involved in making "recommendations" for vaccination.  The market for vaccination is in the billions (yearly), with little risk of accountability for any adverse effects. Well-paying and prestigious careers are made by many who are beholden to the doctrine of vaccination - in academia, governmental bureaucracies (CDC) and private multi-national pharmaceutical companies.

Lastly, Mr. Patrick Michaels, in a piece for Townhall.com (#5), "The Threat to the Scientific Method", reviews some of the history for how and why the process of science has been undermined - basically how the "publish or perish" phenomenon has impacted how science is done.

Pretense masks arrogance in strutting around trumpeting one's presumed objectivity as a scientist when further, and more objective analysis reveals this to be an abject lie.

The only aspect of "post-normal science" this writer agrees with is that it seems to (more) openly acknowledge everyone has an agenda - the problem is that the agenda is influencing results and driving policy rather than facts and truth ... and few are willing to be patient to wait for facts and truth to be known and understood. There is an abundance of evidence that many are harmed when this is allowed to prevail. History has already shown that, and will no doubt show it again. Because of this we should err on the side of both freedom and caution, allowing each individual to determine for themselves whether they will, or will not, receive a vaccination.



#1)
http://judithcurry.com/2012/08/03/post-normal-science-deadlines/

#2)
http://www.nusap.net/sections.php?op=viewarticle&artid=13

#3)
http://www.ageofautism.com/2014/08/cdc-frauds-connections-between-the-destefano-paper-and-the-thorsen-affair.html

#4)
http://www.plosmedicine.org/article/fetchObject.action?uri=info%3Adoi%2F10.1371%2Fjournal.pmed.0020124&representation=PDF

#5)
http://townhall.com/columnists/patrickmichaels/2014/07/21/the-threat-to-the-scientific-method-n1864397/page/full

Opacity isn't science ...

In theory, science (http://dictionary.reference.com/browse/science), the process of discovering factual information and verifying that it is true, must be transparent and open.

On August 25, 2014 the CDC released a statement (http://www.cdc.gov/vaccinesafety/Concerns/Autism/cdc2004pediatrics.html) addressing the controversy swirling around a whistleblower who has come forward alleging the scientific process was corrupted in research looking at the relationship between autism and vaccination.

They do not directly address the allegation made by one of the authors of the study in question. It seems they are circling the wagons to protect the status quo. Hopefully this initial response will be followed with one that more completely addresses the issues involved. Since one of their employees is making the allegations they may not yet be at liberty to be more forthright - though if that is truly the case why didn't they say so?!

This statement is very interesting:

 "Additional studies and a more recent rigorous review by the Institute of Medicine have      found that MMR vaccine does not increase the risk of autism."

The whistleblower implies the IOM review was compromised by the results of this study that he alleges was gerry-rigged to arrive at pre-determined results. He further alleges that he informed his co-workers and supervisors of his concerns about the methods of analysis that were being used and the conclusions being drawn.

The selective framing of this statement is also worth looking at:

"Vaccines protect the health of children in the United States so well that most parents today have never seen first-hand the devastating consequences of diseases now stopped by vaccines."

Those sounding the alarm regarding risks of vaccination do not deny that becoming ill from any disease can cause sequelae, sometimes devastating. Yet having seen first hand what can happen as a result of vaccination they simply want to be able to make a medical decision for themselves or their minor children without being harrassed or have receipt of service be tied to vaccination status. They want others to be spared the pain and suffering with which they and their loved ones have had to cope.

Use of the word "protect" is also very telling - a more accurate choice of words would be "reduce risk" - even those who promote vaccines acknowledge they do not work 100% of the time, even when so called "herd immunity" is achieved. The concepts of protection and risk reduction are not equivalent, nor are the inter-changable.

Then there is this:

"The data CDC collected for this study continue to be available for analysis by others. CDC welcomes analysis by others that can be submitted for peer-review and publication. For more information on how to access this public-use dataset please go to the this webpage." 

Obtaining the data is not as simple as this statement may make it seem - ask Dr. Brian Hooker. While access to data should not be without boundries, especially when it may contain sensitive information (ie: personally identifiable records) one wonders why it would require years of FOIA requests? This seems like stone-walling. Here is a link to a story with information about his efforts to obtain other information pertaining to the issue of vaccines and any link to neuro-developmental problems: http://healthimpactnews.com/2014/big-pharma-tries-to-discredit-documents-hidden-by-cdc-linking-vaccines-to-austism/ Please note: it took him 10 years and >100 FOIA requests. Our employees (ie: those who serve the people of the United States who happen to work at the CDC) should not be making it so difficult for us to review their work - WE PAY THEM!!

As always -
Those who perceive vaccination to be beneficial should get whatever vaccine they want.
Those who believe vaccination is risky should not be penalized for declining vaccination, nor should they be manipulated into acceptance.



link to original video:
http://vimeo.com/user5503203/review/103711143/91f7d3d4d8

CDC Statement:
http://www.cdc.gov/vaccinesafety/Concerns/Autism/cdc2004pediatrics.html

Snope doggy-dog ... snooping, not reporting

The rumor-debunking website snopes.com has waded into the controversy surrounding the CDC whistleblower with this post:
http://www.snopes.com/medical/disease/cdcwhistleblower.asp

The bias in what they have written is palpable.

Snopes derides concerns about the link between vaccines and neurological problems (primarily autism) as a "conspiracy theory" - the only conspiracy is the concerted effort to dismiss these concerns ... concerns the whistleblower's allegations absolutely validate.
The whistleblower's allegations are themselves validation of the conspiracy so many want to deny - all the more so if his statements are proved to be true. His allegations are validating because he was involved - he was part of the "conspiracy" and he is coming forward admitting as much! He is a witness as well as a whistleblower - he should be commended for his honesty and protected while further investigation is done (just not by Snopes!)

They cite the iCNN source - but that is secondary at best, as it is the whistleblower who made the allegation and first disclosed this to Hooker/Wakefield.

They allege Wakefield's original Lancet study regarding GI issues associated with autism first planted the "seed of fear" about the link between vaccines and autism - um, no. It was moms and dads who know and love their children who first correlated loss of skills and other neuro-developmental changes/degenerations with receipt of vaccines. (Silly mommies and daddies, what do they know - they are not scientists!) There was no need for any scientific paper to cause concern about undesired consequences of vaccination - indeed that has been brewing since Jenner first proposed it as a medical intervention. Controversy about vaccination is nothing new, nor is the use of fear and manipulation to force it upon those who do not want it.

The Snopes peice states "anyone can submit content" to iReport on CNN - as if any story not having the blessing of an officially sanctioned outlet isn't valid? Kudos to CNN for having this platform and making it available - others can do their work for them and alert them to developing stories and give them the chance to have first crack at what may well develop into something important - if CNN recognizes it! Does Snopes think crowdsourcing is only valid if it's promoting ALS fundraisers?

This writer doesn't pretend to be unbiased. Neither should Snopes. Ronald Reagan could not have been more correct in saying "trust, but verify"!

Blowing the whistle on the MMR ...

Over the last week the news that a whistleblower from the CDC disclosed the use of post-normal science (ie: a gerry-rigged study that obtains pre-determined results) to create a study providing results that could be used to justify the status quo for vaccination.

The first link below is to a video recording the confession of the whistleblower to Brian Hooker (apparently made by Dr. Andrew Wakefield). Link #5 is to Brian Hooker's re-analysis of the data from the original study (link #6, abstract only);

The video makes some alarming comparison's to the infamous Tuskegee Syphillis experiment as Dr. Hooker's re-analysis shows a significant corelation between MMR vaccination and autism in black male children - especially if they receive the MMR "early" (before 36 months).

The study in question is about the MMR - there may be something unique about it which impacts autism/ASD, but given the complexity of human life, autism/ASD is likely multi-factoral. It may not be just the vaccine antigen which is problematic - many other ingredients in vaccines could be contributing to adverse effects of vaccination (not just autism ... ) - mercury, aluminum, human and animal dna, viruses, among others.

But if the allegations are true, it could lead many to question the legitimacy of many studies proporting to show the safety of other vaccines - indeed there is already reason to question vaccine safety as many studies do not use a true, inert placebo (like saline) in comparison to a vaccine - vaccine A is compared to vaccine B and if the results of side effects are similar vaccine A is declared "safe";

Given the amount of money involved in the whole vaccination paradigm this type of scandal is not surprising. Many people have rea$on to maintain the vaccine $tatu$ quo.

Given the cozy relationship (technically referred to as CONFLICT OF INTEREST) between those responsible for vaccine policy (and by extension those doing studies to support said policy) this is not surprising.

What would be downright SHOCKING is if someone actually did something about it:

• Made changes to eliminate conflicts of interest (in other words - stopped the revolving door between the companies that make the vaccines and benefit from government policy regarding vaccines and those setting government policy regarding vaccines). If you work for pharmaceutical companies you would be prohibited from working for government agencies directly or indirectly involved in vaccines and vice versa. Not a token 1 year waiting period either. 

• Another practical suggestion would be to remove the legal liability shield from the companies that make vaccines. 

• Does the ACIP (Advisory Committe on Immunization Practices) have full access to safety studies? Are they allowed to see this "proprietary" information? Perhaps they could develop a policy that they will not review a vaccine for addition to/inclusion in the vaccine schedule unless they have complete and full disclosure of ALL data from which safety studies draw their conclusions (not just the "results" of said safety studies). This, of course, is only relevant once the ACIP has been purged of those with conflict of interest! 

• Schools and workplaces could scale back on draconian mandates regarding vaccination status for students and employees. Even if results of studies regarding vaccination are not compromised the case for mandatory vaccination is still weak - simply from a civil and human rights standpoint.

Hopefully more information will come out, more details about they workplace culture in which the whistleblower worked and how that impacted the results of their studies.

The impact of money and politics upon science has a long history - just ask Galileo, Copernicus, Sammelweis, Pasteur (among others). Consensus isn't science, nor is it necessarily a guide to what is true. Far too often and for far too long medicine has made pronouncements about this or that treatment/procedure/medication only to find out after the fact that their initial enthusiasm (ie: recommendations/mandates/guidelines) was not warrented.

Good ideas, good products do not need mandates or manipulation to create demand. It is long past time for vaccines to live or die in a free marketplace of ideas and products. Those who want them should get them. Those who do not should not be penalized.


#1)
http://vimeo.com/user5503203/review/103711143/91f7d3d4d8
#2)
http://jonrappoport.wordpress.com/2014/08/22/breaking-cdc-whistleblower-thompson-in-grave-danger-now/
#3)
http://www.naturalnews.com/046566_autism_MMR_vaccine_CDC_whistleblower.html
#4)
http://www.naturalnews.com/046535_MMR_vaccines_autism_CDC_whistleblower.html
#5) - reanalysis of original paper
http://www.translationalneurodegeneration.com/content/3/1/16
#6) - original paper
http://pediatrics.aappublications.org/content/113/2/259.full.pdf
#7) - critique of Hooker's re-analysis
http://scienceblogs.com/insolence/2014/08/22/brian-hooker-proves-andrew-wakefield-wrong-about-vaccines-and-autism/

Breath of fresh air ...

Leave it to our northern neighbors to come to some common sense conclusions - three Canadian physicians have published an OpEd calling for health care workers to be able to accept or decline flu vaccination rather than imposing a mandate for an intervention with dodgy "evidence" for support (and they extend this to the alternate "choice" of wearing a mask for at least 6 months of the year).

They acknowledge that the over-hyped efficacy and under-stated risks of flu vaccination has eroded the public's trust. The writers of the article chose to get vaccinated because they believe it provides them with some benefit and they encourage others to do so as well - but they don't believe others should be forced to receive the vaccine if they do not want it (regardless of the reason).

I wonder if Canada's ACIP (or its equivalent) has members with conflict of interest issues?
Apparently Canada does not tie payments to healthcare providers/facilities to vaccination status of their employees (another conflict of interest linked to vaccines).

Kudos to Canada - if only the USA would import this kind of common sense.


http://www.thestar.com/opinion/commentary/2014/07/28/the_case_against_mandatory_flu_vaccination_for_health_care_workers.html