THR Web Features   /   February 4, 2015

From the Archives: "Public Health, Public Enemy?"

Guest Blogger

A well-to-do mother resistant to her daughter's doctor using a vaccine from their neighbour's child; illustrating the narrow-mindedness of the petty provincial middle classes. Wood engraving by G. Du Maurier, 1872. Wikimedia Commons.

In our Spring 2014 issue, the philosopher Donna Dickenson discussed the rise of personalized medicine in her essay, "In Me We Trust: Public Health, Personalized Medicine, and the Common Good." Dickenson's essay considered topics outside of the antivaccination movement, but we've excerpted her comments on it here in light of the recent outbreak of measles at Disneyland and the subsequent discussion in the media. You can read the whole article—including her wider analysis of personalized medicine—here.

Consider the antivaccine movement, which is of even greater importance to public health than hostility to communal blood banking. The first and only contagious disease to have been completely eradicated, smallpox, was defeated through vaccination. But as medical historian Arthur Allen notes in Vaccine: The Controversial Story of Medicine’s Greatest Lifesaver (2007), “While vaccination seems to be more efficient and safe than ever before, public ambivalence about the practice has rarely been higher.” A growing body of public opinion appears to view public health programs as no less threatening—and possibly even more so—than the diseases they are meant to protect us from.

It is not so difficult to understand why many people view those diseases as less of a threat than they used to be. In the nineteenth century, all social classes were more or less equally vulnerable to epidemics of maladies such as cholera, smallpox, and typhus. Perhaps those who had their own wells, provided they were clean, were somewhat protected against cholera arising from contamination of the public water supply, but that would mainly apply in rural areas. Whether rich or poor, city dwellers were all at risk. Infectious disease was no great respecter of social hierarchy.

But the very success of public health programs against the mass contagious diseases of the past, at least in better-off parts of the world, now leaves cancer and heart disease as the leading causes of mortality. For example, statistics for the United Kingdom in 1912 listed bronchitis, tuberculosis, pneumonia, and measles among the top ten killers, whereas pneumonia remained the only infectious disease among the ten leading causes of death in 2012. Ischemic heart disease and lung cancer occupied the first two slots in the 2012 figures. With the exception of a few tumors to which there is a viral link (such as Kaposi’s sarcoma, a tumor caused by human herpesvirus 8), heart disease and cancer strike one individual at a time, despite loose talk about “the cancer epidemic.” We die at an older age, but we increasingly die of individualized illnesses. Those are the ones many of us fear most.

Yet that doesn’t entirely explain why so many of us not only seem complacent about infectious disease but fearful of one of the most important mechanisms for preventing it. If anything has reached epidemic proportions, it is the distrust of government vaccine programs. Again, though one might get a different impression from high-profile campaigns in the United States against the vaccines for measles, mumps, and rubella, including appearances on The Oprah Show by prominent vaccination opponents, this sense of beleaguered hostility is not just an American phenomenon. A commenter on a Daily Mail newspaper article about a supposed link between the “swine flu” jab and a “killer nerve disease” wrote,

I find it very interesting that the vaccine does the opposite of what it’s supposed to do. Is anyone open to the thought that this is intentional? That the people in power are using this as a means for population control? And the fact that governments are in the process of making the vaccine MANDATORY?

Worldwide, popular reactions against vaccines for influenza, childhood diseases, and cervical cancer threaten immunization programs that public health experts see as crucial. When enough children are vaccinated against contagious diseases, the resulting population or “herd” immunity also benefits neonates, the elderly, and others too frail to be vaccinated. We could view population immunity as a kind of public commons to which we all contribute and from which we all benefit. But when too many parents opt out of measles, mumps, and rubella vaccination, with the sincere intention of protecting their own children, their decision subtracts from the vaccination commons and diminishes population immunity.

Distrust of vaccination is nothing new, of course. A 1907 description of the procedure as an “ancient, useless, dangerous and filthy rite” is indicative of the fact that, historically, resistance to mass vaccination was the norm rather than the exception. Nor was it purely irrational. In November 1901, over ninety people in the United States died of lockjaw a few weeks after receiving a smallpox vaccine contaminated with tetanus bacilli. In 1906, slightly fewer people died of smallpox—death resulted in 90 out of 15,223 recorded cases, mainly from exposure to the less virulent variant Variola minor—than had died from the contaminated vaccine five years before. Smallpox began to seem less of a menace than the means of preventing it—a judgment people also made, rightly or wrongly, during the “swine flu” pandemic of 2009.

Mandatory vaccination is no mere figment of that angry Daily Mail reader’s imagination. Laws passed in England and Wales between 1853 and 1871 required parents to vaccinate their children against smallpox, with official Poor Law guardians authorized to seize the pitiful assets of noncompliers and to forcibly inoculate infants. In England, the victims of compulsory vaccination were mainly defined by class. In the United States, race and ethnicity also entered the equation. A Saint Louis bacteriologist boasted in 1899 that he and his colleagues had prevented an outbreak when they “vaccinated the whole male negro population of the city, and as many women as could be captured.” Border officials in the early part of the twentieth century were empowered to forcibly vaccinate any Mexican immigrant without a recent vaccination scar—even though Mexico actually had better rates of smallpox vaccination at that time than the United States.

Public confidence in vaccination is arguably an anomaly that peaked with Jonas Salk’s development of polio vaccine in the 1950s and typified the “bowling together” mentality that social theorist Robert Putnam thought so typical of the time. Although the patriotism of two world wars and successful campaigns against other contagious diseases gave public health medicine a legitimacy it hadn’t always enjoyed, vaccine skepticism never died out entirely. Reinvigorated in our more contentious era, it retains the libertarian, antigovernment focus of this 1908 statement from the Anti-Vaccination League of America: “No State has the right to demand of anyone the impairment of his or her health.” What is new is that antivaccination movements are now well-orchestrated media and social networking campaigns, using the tools of “We-ness” to spread a message that threatens one of the cornerstones of We Medicine.

Antivaccination campaigns rooted in mistrust of public authorities are not confined to the Western world. In northern Nigeria, a massive public boycott of a polio immunization campaign has sabotaged efforts to reduce the high incidence of the disease. Two factors have engendered public skepticism: the legacy of mistrust resulting from a clinical trial of an oral antibiotic that ended in a U.S. federal lawsuit brought by thirty Nigerian families claiming lack of informed consent, and widely circulated allegations that the U.S. agents who tracked down Osama bin Laden were posing as a vaccination team. In India, similar hostility has been aroused by a drive to inoculate adolescent girls against the human papillomavirus (HPV). Some commentators have denounced the campaign as illustrating “how promotional practices of drug companies, pressure from powerful international organisations, and the co-operation of India’s medical associations to uncritically endorse a vaccine, are influencing public health priorities.”

Modern-day vaccine skeptics, wherever they are, are quick to see corporate interests behind public health policies. Such suspicions could be seen at work in the 2009 “swine flu” pandemic, which was widely condemned as a scare drummed up by the drug companies to create more demand for their products. (Actually, according to bioethicist Art Caplan, the companies weren’t even able to satisfy the demand that already existed: many had already moved out of the laborious and unpredictable area of vaccine manufacture.)

Curiously, however, public distrust of the economic motivations behind We Medicine isn’t matched by corresponding skepticism about corporate interests in Me Medicine, even though there are good reasons that it should be.

Donna Dickenson is emeritus professor of medical ethics and humanities at the University of London and holds honorary posts at the Universities of Oxford and Bristol. Read the rest of Dickenson's article here.