It was a weird, fascinating year for medicine. Did you know there was a mumps outbreak in the National Hockey League? Or that a man turned his amputated leg into a lamp and tried to auction it off on eBay? (Starting bid: $80,000.) I polled medical experts in a wide range of specialties to compile the 10 most important medical stories of the year.
No. 10: The NRA flexes its muscle.
Can you name our surgeon general? And where was this person during the Ebola panic? Or the Obamacare rollout? It turns out we spent much of 2014 without one—the position became vacant in July 2013—and it's because of an errant tweet. During the vetting process, it was revealed that Obama's nominee, a physician/entrepreneur named Vivek Murthy, had tweeted this on Oct. 16, 2012:
Tired of politicians playing politics w/ guns, putting lives at risk b/c they're scared of NRA. Guns are a health care issue. #debatehealth-- Vivek Murthy (@vivek_murthy) October 17, 2012
This led the National Rifle Association to lobby red-state Democrats to join most Republicans and vote against Murthy’s confirmation. Murthy testified that he would not pursue gun control legislation—he has no power to do so, and his primary interest is the obesity epidemic—but there were enough election-year jitters to scuttle his nomination. After the midterms, some Democrats, including Sens. Mark Pryor of Arkansas and Jon Tester of Montana, said they were willing to reconsider. Murthy was finally confirmed as the nation’s 19th surgeon general on Dec. 15.
No. 9: Human enterovirus 68 and xenophobia.
On Aug. 19, the Centers for Disease Control and Prevention was notified by a hospital in Missouri that it was noticing an increase in children hospitalized with severe respiratory illness—including many admitted to the intensive care unit. It turned out they were suffering from a somewhat obscure respiratory infection called enterovirus 68. From mid-August to Dec. 4, a reported 1,121 people in 47 states and the District of Columbia came down with it. There were three unusual things about this year’s enterovirus 68 outbreak: It was much larger than the sporadic cluster of cases that have been popping up since 2005. It appeared to be causing a poliolike syndrome that left children paralyzed. And conservative pundits erroneously tried to blame the outbreak on undocumented immigrants.
No. 8: Corporations get religion.
Hobby Lobby, the Oklahoma-based arts-and-crafts chain, challenged a new regulation requiring health insurance provided by employers to cover emergency contraceptives. The company was founded by a man named David Green, who argued that his family's religious beliefs forbade them “from participating in, providing access to, paying for, training others to engage in, or otherwise supporting abortion-causing drugs and devices.”
Oral arguments at the Supreme Court in Sebelius v. Hobby Lobby were heard on March 25. Three months later, on June 30, the court, citing the Religious Freedom Restoration Act, ruled 5–4 that Hobby Lobby and other “closely held” corporations could exempt themselves from the law based on religious preferences.
No. 7: The rise of e-cigarettes.
The list of celebrity endorsements, paid or otherwise, is enough to make anyone skeptical: Jose Canseco, Kevin Federline, Danny Bonaduce, and Stephen Dorff. Charlie Sheen declared that he, too, wants to be involved, announcing an electronic cigarette line called “Nicosheen” in partnership with everyone's favorite ex-con, Lenny Dykstra. They all rave about e-cigarettes, touting them as a cheap and healthy way to quit smoking. But a new study shows that e-cigarette vapors contain carcinogenic preservatives like acetaldehyde and formaldehyde, in addition to the highly addictive main ingredient, nicotine. Scores of cities chose to rewrite their laws in 2014, restricting e-cigarette use in smoke-free venues (the town of Westminster, Massachusetts, proposed banning them entirely), and experts from the world's leading lung organizations—including the American Thoracic Society, American College of Chest Physicians, and the European Respiratory Society—released a position statement on e-cigarettes calling for them to be “banned until more about their safety is available.” Perhaps inspired by this controversy, e-cigarettes became the go-to movie prop in 2014 for villains who need to look “too slick to be trusted.”
No. 6: MERS alert.
A lethal virus called Middle East Respiratory Syndrome Coronavirus, or MERS-CoV, was first recognized in 2012 in a man in Saudi Arabia who developed kidney failure and pneumonia. On May 2, the first imported case was confirmed in the United States. Nine days later, a second case of MERS appeared in the U.S. Both cases were diagnosed in travelers from Saudi Arabia. Although the cases were unrelated, it freaked out a lot of people. There is no vaccine, no cure, and as many of 60 percent of infected patients die. By June, the virus had been confirmed in 22 countries, including the United Kingdom, Egypt, Turkey, and Austria. Scientists figured out that the virus lives in camels (and possibly bats), and aggressive infection control measures quelled the outbreak—just as another viral pandemic in Western Africa started making news.
No. 5: Flu vaccine underwhelms.
This season’s flu vaccine has been underperforming. It is less than 50 percent effective against the predominant circulating strain of influenza, called H3N2. Many commenters asked why vaccine-makers don't include more strains—the current shot contains three or four influenza strains, depending on the brand. We could put more strains in, but that would drive the cost of the vaccine way up while providing little extra coverage. The vaccine-makers actually predicted the correct strains this year, but the predominant subtype has mutated ever so slightly, in a process called antigenic drift.
No. 4: Hacktivists hit Harvard.
This summer, Boston Children’s Hospital was targeted in a cyberattack reportedly instigated by the group Anonymous. It had to do with a highly publicized case in which a teenager named Justina Pelletier was taken into custody by child protective services because doctors were afraid she was being abused at home. Anonymous threatened the Harvard-affiliated hospital with retaliation if it didn't take disciplinary action against certain doctors, and the group demanded the immediate return of the child to her parents. The attack started off rather mildly: Hackers posted the personal information of doctors involved in the case. Then, weeks later, the hospital was subjected to attacks affecting its Internet connectivity. The group also employed “spear phishing” emails, attempting to get health care workers to open attachments that provided a way for attackers to get behind the hospital's firewall. The attacks ultimately subsided after members of Anonymous tweeted calls to back off.
No. 3: New drugs in the pipeline.
This was a great year for new treatment of three chronic, debilitating diseases: hepatitis C, congestive heart failure, and idiopathic pulmonary fibrosis.
Idiopathic pulmonary fibrosis is a chronic and ultimately fatal lung disease characterized by a progressive decline in the ability to breathe. An estimated 30,000 to 50,000 people are diagnosed with IPF each year, and the five-year survival rate is dismal. There is no good treatment; many physicians compare it with being diagnosed with terminal cancer. In May, however, a randomized, double-blind, placebo-controlled trial showed that a new drug called pirfenidone dramatically reduced disease progression, halving the rate of decline at one year of treatment. It wasn't a cure, but it was a bright spot for patients with this devastating illness.
There are roughly 200 million people in the world with hepatitis C. Until this year they had very few treatment options, and the ones that existed—which included a gnarly drug called interferon—weren't very effective and had lots of terrible side effects. And most of these drugs had to be administered intravenously. This year, the Food and Drug Administration approved a new oral treatment called sofosbuvir, which, in combination with another drug called ledipasvir, provides remarkably high cure rates for people infected with hepatitis C, genotype 1—the most common subtype in the United States, Japan, and much of Europe. The downside? Sofosbuvir is priced between $80,000 and $160,000 for 12 weeks of therapy. Thankfully, there are more oral treatments for hepatitis C in the pipeline, which should drive the costs down.
Heart failure occurs when the heart is unable to sufficiently pump blood to meet the needs of the body. For 25 years, the cornerstone of treatment has included an angiotensin converting enzyme inhibitor. This year, a new type of drug called a neprilysin inhibitor, which prevents an enzyme called neprilysin from degrading proteins that dilate blood vessels, was shown in a landmark trial to dramatically reduce the risks of hospitalization and death for patients with heart failure when given with another drug called an angiotensin receptor blocker.
No. 2: The Obamacare rollout.
It's unclear what the Affordable Care Act will look like (or if it will exist) in a few years, so for posterity, let's look at how it all started. Open enrollment began on Oct. 1, 2013, offering Medicaid eligibility to citizens with incomes at or below 138 percent of the federal poverty level in participating states. It also provided tax credits for private insurance purchased via marketplaces for people who weren't eligible for Medicaid but had incomes between 100 percent and 400 percent of the federal poverty level. The rollout was a bit of a mess, and on April 10, Kathleen Sebelius announced her resignation as secretary of Health and Human Services.
Tens of thousands of previously uninsured Americans enrolled in health insurance exchanges, and as the year drew to a close, the Obama administration claimed victory. But on Nov. 7, the Supreme Court made the surprise announcement that it would hear King v. Burwell, the latest challenge to the Affordable Care Act. The case hinges on the legality of the Internal Revenue Service extending tax credits to the 4.5 million people who bought their health plans in the 34 states that declined to establish their own health insurance exchanges. Expect a ruling in June.
No. 1: Coming to America: The Ebola Outbreak.
This story drowned out just about everything else having to do with medicine in 2014. Although it's fading from the headlines now, the worst Ebola epidemic in history isn't over. But rather than looking back, let's look ahead at what's to come.
As novel vaccines and treatments become available in the coming months, a practical and ethical issue will emerge: How should we use them? In particular, should we perform a clinical trial using a control group when the next promising, untested drug becomes available? Or should we just give the new drug to everyone? A well-designed, randomized trial would benefit medicine in the long term, but it might be at the expense of the people who have Ebola today. (If the new drug works and you have Ebola, you don't want to be randomly assigned to the group that doesn't get the drug; if the new drug turns out to be more dangerous than a lack of treatment, it could lead to even more deaths.) For the record, I think we should perform a randomized control trial when the next Ebola drug becomes available: It's the only way we'll really know if the new treatment actually works.