Sometimes what is not said is more eloquent than what is. The implicit often has a more powerful effect on the imagination than the explicit; as Emily Dickinson put it, “Success in Circuit lies.” A recent article in the New England Journal of Medicine about Hepatitis C was eloquent in its omissions.
Hepatitis C is a virus infection which for many years causes no symptoms but which often goes on to produce chronic liver disease, cirrhosis, and cancer. About 85 percent of people infected with the virus develop chronic liver disease.
The article in the NEJM is titled “Hepatitis C in the United States.” The authors provide an estimate of the number of people infected with the virus: between 3.2 and 3.5 million.
The infection can now be treated so as to prevent its long-term consequences. Unfortunately, the treatment is expensive: about $70,000 per head for a full course, according to the authors. If every person who tested positive for the virus were treated, the cost would therefore be between $224,000,000,000 and $245,000,000,000. That is some stimulus to the economy!
The cost of treatment might come down (or, of course, go up, as new and costlier treatments are discovered). Not everyone who is infected needs treatment. Perhaps a vaccine will be developed and the problem in effect will go away. For the moment, though, we must deal with the silent epidemic – as the assistant secretary for health, Howard Koh, called it – with the tools now available to us.
Because the infection causes no symptoms at first, other than a non-specific flu-like illness at the very beginning (and then not always), many people who are infected do not know that they are. One study suggested that approximately 57 percent of those with the infection had been tested for it and identified as suffering from it. Another study suggested that of those who had tested positive, 50 percent were aware that they were infected. Most people who had tested positive and were aware that they were positive were in receipt of follow-up and treatment. The article suggests that approximately a third of people in the U.S. infected with Hepatitis C receive medical treatment for it (the discrepancies in the figures are caused by the fact that different studies measure different things and the authors’ final estimate is drawn from all of them).
The authors say:
[The] big picture suggests that there are many points of intervention –or opportunities – to improve the identification and care of patients with HCV and to mitigate the increase in hospitalizations and deaths resulting from HCV infection. For example, the CDC recently recommended a one-time test for everyone born between 1945 and 1965 to help identify the many people who would not be targeted for testing as the result of established risk-based testing strategies…
What is so extraordinary in an article titled “Hepatits C in the United States” is that there is no mention whatever of what those risks actually are. In the United Kingdom, for example, it is estimated that 90 percent of cases result from intravenous abuse of drugs. Another important risk factor is tattooing, which, alas, is becoming ever more popular among the young. The authors omit altogether what they call “the big picture.”
What accounts for this? I suppose it must be the fear of appearing censorious, of appearing insufficiently non-judgmental. We laugh at the Victorians for their resort to euphemism and their tendency to avoid embarrassing subjects, but are we any better? Are not the authors of this article in the NEJM just like Mr. Podsnap in Our Mutual Friend who feared to bring a blush to the cheek of the young person?
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