My House or Yours?
One evening about 5 years ago I learned of "chicken pox parties". There on a news group, a dozen people chatted about sending their kids to a "party" with such nonchalance you'd have thought they were planning holiday shopping and $5.95 lunch special afterwards. Perhaps they'd spent hours thinking over the pros and cons. But on the public forum those do-it-yourself infectors didn't question the public health risks, the possible complications, or the ethics of purposefully exposing your kids and family to highly infectious diseases that fortunate people in western countries get immunized against. If they had doubts they masked them with derring-do.
I was taken aback by this parental concept of fun and thought it some new and bizarre fad. Naturally I was curious. How would it work? "OK kids, now we're going to pass the communal drink cup around, then we'll play the kissing game..."? (I also rethought my entire childhood in a positively idyllic way, though I never forgot the sting of merthiolate.1)
These modern parental dalliances with infectious disease seem ironic. Public health's largest successes include the vaccination campaigns that eradicated or significantly reduced loathsome diseases such as smallpox, polio, yellow fever, measles, diphtheria, and tetanus. The UN reported last November that measles vaccination efforts, especially in Africa, have helped decrease measles deaths by two-thirds across the world since 2000.
Scientists and doctors toil to develop vaccines for ugly scourges like HIV and malaria, which are each responsible for mortally infecting up to 30% of some populations and when a recent AIDS vaccine trial failed, the collective global dismay was palpable. For diseases where vaccinations aren't available, citizens in developing countries latch on to promises from the public health community that millions of people's lives will someday be saved by immunization. Against this backdrop, suburban parents in western countries shun vaccinations, because in their country, in this day and age, the injections themselves seem more dangerous than the diseases.
It's tempting to think of these "chicken pox parties" as the privileged reserve of parents of a certain age who never saw the ravages of disease that previous generations knew intimately. Maybe if they saw a man crippled by polio; maybe if they had lived through the smallpox epidemics in New York at the end of the 18th century, where one in five victims died and in milder cases victims were left left blind. Maybe their mother or grandmother never described what it was like caring for a family during an outbreak of chicken pox as it swept through infecting each of six children.
But doubts about vaccines are perennial. Now parents air their vaccination suspicions via the web. Before the web, they talked on the phone, or at work, or in between hauling water from the well. This is not the fad of a select cohort of modern parents, convinced that a case of wild chicken pox is safer than a vaccine because they've never known anyone who died of the disease.
These unique "social events" seem shocking when they appear in your inbox. Go to any online article about any part of the whole wide topic of vaccination and peruse the comments section for horrifying rumors, misunderstandings, and cavalier-bordering-on-criminal pronouncements about never vaccinating kids. It's enough to make anyone shudder -- doctor, scientist, parent or casual reader. It's easy to see how those who claim that thimerosal is responsible for every imaginable childhood tic are dangerously misguided. It's less acceptable to question an authority who tags as crazy anyone who questions any aspect of vaccinations.
For Your Own Good -- Smallpox in New York
Naturally, vaccinations have an interesting and controversial history, like much of medicine. The tussle between public health campaigns and fearful citizens is part and parcel of that history. The first vaccinations introduced a wound with a sharp implement of some sort, then infected the area with a bit of virus from a sick neighbor or perhaps some pox in a jar. Vaccination became more sanitary, but the concerns about safety persist as with all cutting-edge medicine.
Along with the health worries, there has always been questions about the government's power to compel vaccination. When vaccinations arrived in the US from England in the early 1800's, people balked at what they saw as encroaching boundaries of government. At the time, American public health initiatives were more about trying to convince people not to do things, like "[let] their privy overflow into the street" says James Colgrove in "Between Persuasion and Compulsion:Smallpox Control in Brooklyn and New York, 1894-1902 (Bulletin of the History of Medicine 78.2 (2004)). As Colgrove's book title indicates, public health officials walked a fine line between persuading, cajoling and forcing public compliance, for many years without legal authority.
Health officials contained smallpox outbreaks by vaccinating households within a circumference of an infected household. If someone refused to receive the vaccine, authorities would station couple of policemen, the "Sanitary Police", to enforce a quarantine on the household. There are stories of people who made involved escapes from quarantined New York residences, only to be caught in New Jersey and hauled back for punishment.
While libertarians thought the government was overstepping, even when vaccinations became safer there were concerns about the deleterious effects of vaccinations. During several outbreaks of smallpox in New York in the late 18th century and early 19th century, rumors spread that the vaccine contained tetanus, despite significant efforts by health professionals to dispel such notions.
Arthur Allen writes in "Vaccine: The Controversial Story of Medicine's Greatest Lifesaver" that "Raggedy Ann", was named for a rag doll handed down from writer Johnny Gruelle's grandmother to his daughter Marcella and memorialized in Gruelle's books. Marcella died at 13 after receiving two smallpox vaccinations in school -- some fears were justified. According to Allen, the Raggedy Ann doll then became symbol for the anti-vaccination effort.
At the beginning of the 20th century, anti-vaccination advocates successfully brought two high profile cases to court to challenge the government's right to make vaccinations compulsory. In 1904, the New York state court decided in Viemeister v. White that the state could mandate laws curtailing individual liberties in order to protect public health. In 1905 the Supreme Court decided that all states have the right to legally enforce public health measures, in the infamous Jacobson v. Massachusetts precedent. This helped solidify government authority, and continued medical advances and quality control assured safety. However real and perceived hazards remain.
The same issues (legal, moral, individual liberty, public safety, medical safety) churn in the public arena today as during the smallpox vaccination campaigns of 100 years ago. People erroneously think modern issues are unique to our era but the underlying questions are the same. Is HepB really necessary for newborns they ask? Can I infect my own child with chickenpox? Can I skip vaccinations altogether and depend on herd immunity? States struggle with how to keep populations safe.
Additionally, people understand the profit incentives of pharmaceuticals and ask questions like: Is a cervical cancer vaccination really necessary for my 9 year old daughter? Since so many vaccinations are enforced by law there's an uncomfortable nexus of profit motives (pharmaceutical companies), individual health concerns (what are the risks of taking or not taking the vaccine), and public health concerns (how to prevent scourges and keep the public safe).
While vaccination is one of medicine's greatest coups there are still many issues and questions about vaccinating. Nevertheless among all the doctors, commentators and public health authorities who speak out, there's always one subset of the chorus who authoritatively treat all questions and concerns with the same universal knee-jerk dismissiveness. Is their approach the best public health strategy?
"Same, Same But Different" - Polio in Nigeria
Vaccination doubts are not the exclusive domain of "naive" westerners. Polio persists in countries like India, Afganistan, Pakistan and Nigeria where many people know first hand the crippling effects of the disease, yet still occasionally resist vaccination. In 2003, Nigerians in some northern states thought that polio vaccines contained HIV virus and/or sterility drugs, and began refusing vaccinations. Here's how the CDC described the problem (brackets mine):
False rumors about OPV [oral polio vaccine] safety adversely affected SNIDs [Subnational Immunization Days], with the greatest impact in Kano, where 25% of all Nigerian WPV [wild polio virus] cases occurred in 2003. Citing vaccine safety concerns, state authorities in Kano (which last conducted a SNID in April 2003) decided in August 2003 to suspend all SIAs [supplementary immunization activities]. Statewide suspension of SIAs at different times during 2003--2004 also occurred in Kaduna, Zamfara, and (to a limited extent) in Niger state. As a result of these rumors, public health managers and frontline health-care workers found it increasingly difficult to improve microplanning, training, and implementation of SIAs.
Unlike the New York Times, the CDC is not in the business of humanizing disease. The agency categorized the events but of course gave no hint as to where the false rumors may have come from. However it's worth looking at because Nigeria's history with vaccinations provides some insight into the quandary of public resistance to vaccination. For instance take these three recent events:
1) As Western AIDS denialists like Peter H. Duesberg influenced South Africa's Thabo Mbeki, some say a book by Edward Hooper published in 1999 called "The River: A Journey to the Source of HIV and AIDS" (Little, Brown) fed rumors throughout Africa that AIDS was spread to humans via a related simian virus contained in a oral polio vaccine (OPV) given to populations in the 1950's. Hooper theorized that OPV was developed when scientists used primary chimpanzee kidney cells as a substrate for the vaccine. The polio vaccine was tested in mass trials across Africa, Poland and Russia, but Hooper claimed that in Africa OPV led to HIV.
Hooper's book was well received. Reviewers from most major newspapers gave the book good reviews, and even more skeptical reviewers gave partial accolades. Robin Weiss of Science called the book "a towering achievement; right or wrong in its main conclusion, there is much to learn from Hooper's exposition" (Vol. 286. no. 5443, pp. 1305 - 1306). John Moore, in a Nature review called the book, "in many ways, superb. It is scholarly, thoroughly researched, well (if densely) written and deserves, indeed demands, to be taken seriously." ("Up The River Without a Paddle", 401, 325-326 (23 September 1999) | doi:10.1038/43778) However both journals disagreed with the central tenet of the book because Hooper based his conclusion on circumstantial evidence. Shortly thereafter no less than three research groups disproved Hooper's hypotheses in research that was published in Nature and Science. Nevertheless there's enough residual interest and belief in Hooper's book (and he continues to publicize and update his hypotheses), that the ideas he introduced persist today.
2) Africa has long been a place where clinical trials are conducted unlike the way they are in the US. When these trials don't work out the fallout hurts subsequent public health efforts. For instance take the recent example of Pfizer's Nigerian clinical trial of Trovan in 2006. Half the kids were given the antibiotic Trovan (Trovafloxacin) during a meningitis outbreak, and half were given ceftriaxone, the drug normally used to treat the disease. Kids from both groups died, but the focus was on the eleven of the kids in the trial on the test drug and others in the experimental cohort who remain permanently impaired.
The Washington Post covered the story in a series called the "The Body Hunters". Marcia Angell also outlined the trial in a New York Review of Books article, also called "The Body Hunters". Investigators who followed up on the clinical trials charged that the company breached medical ethics and said the trial wouldn't have been allowed in the US because it's unethical to do a trial of an unproven drug during an active epidemic. Among other issues, doctors gave inadequate or no informed consent to patients, and the dosage for the established (control) treatment was reportedly too low, which could have made the experimental drug (Trovan) look better.
National outrage over Pfizer's actions brought a group of Nigerian plaintiffs to New York where they unsuccessfully attempted to try the case in the US. Nigeria's suit against Pfizer continues to this day, and a lawyer for Nigeria recently testified about the US red tape complicating his attempts to summon to Pfizer executives.
3) In 2003 the idea that vaccine campaigns were nefarious sterilization efforts gained momentum after scientists reported that polio vaccines contained estrogen. A Muslim leader, Dr Ibrahim Datti Ahmed, secretary general of the Supreme Council for Sharia in Nigeria, claimed he had research proving western goals to "depopulate" Africa and introduce "adulterated" vaccines. Throughout history, the west has championed family planning, which has elicited abject suspicion, and led to occasional rumors about devious plots by western forces to decimate populations via birth control and vaccinations. Public health workers have diligently tried to solidify trust of vaccinations among Nigerians for decades.
But in 2003 the Nigerian polio vaccination program was forced to shut down so that politicians could test the vaccines suspected of being birth control agents and provide public proof of their safety. Such an interruption can have devastating health consequences. Vaccination rates fell to 30%. and the disease spread to Muslim communities around the world. Muslims tended to mount resistance to vaccinations people say, because they were wary of the war in Iraq and perceived animosity from the US to Muslims. Eighteen countries previously declared polio free incurred polio flare-ups and countries that hadn't seen polio since the 1980's had outbreaks.
Any of these incidents could have help spread fears about vaccinations. Hooper's ideas have been dispensed with and Trovan may have not have caused deaths, but the effect of these incidents has a far-reaching negative impact. Furthermore, when clinical trials are conducted in countries under circumstances that wouldn't be legal in the US, suspicion is not without foundation.
10 Billion Doses, 200 Side Effects.
During the interrupted 2003 polio vaccination effort, many Nigerians went unvaccinated, and the population became susceptible to another uncommon occurrence. The polio vaccine, made of attenuated virus, can occasionally mutate to a wild non-attenuated virus that causes infection. But the chance of this occurring increases when a large number of unvaccinated people give the virus more opportunity to replicate and mutate to the wild form.
The journal Nature reported that an outbreak of this type last fall ended up paralyzing 69 children. This is a rare occurrence -- the WHO expert interviewed by the journal pointed out that "10 billion doses of oral polio vaccine...administered worldwide were implicated in 9 outbreaks, accounting for fewer than 200 cases of disease" (Michael Hopkin, "Health officials fear Nigeria Polio setback" 12 October 2007 | Nature | doi:10.1038/news.2007.163). Despite how rare these occurrences, or the fact that they often occur when many people refuse to get vaccinated, the incidents feed suspicion.
Time reported that Nigeria's 2007 outbreak due to the wild-type virus was contained via collaborative public health messaging between religious, health and political leaders. However sometimes mischievous anti-immunization authors, politicians, organizations or religious leaders stir trouble by either malevolently or innocently blaming such an outbreak on vaccinations.
There are risks to vaccinations. There are risks to clinical trials. There are mistakes, and sometimes medical malfeasance. And there's a public disconnect when it comes to understanding risk, 200 side effects in 10 billion doses is very safe, but no one's content when their child has the adverse reaction. There's always the possibility that a few aberrant reactions to a vaccination can innervate fears in hundreds of people and derail a whole vaccination effort.
Some percentage of the population will always distrust vaccinations, no matter how good the messages. But another percentage of civilians have legitimate concerns. Public understanding of reasonable risks is further complicated by public health, pharmaceutical and political hesitation to admit errors for fear that people will shun vaccinations (or pursue litigation). So what do these suburban American families have to do with Nigerian villagers? People harbor distrust of government mandated vaccinations produced by for profit pharmaceutical companies. If all resistance, chicken-pox parties as well as questions about the necessity of cervical vaccines receive the same reception from authorities, as they do sometimes, this can lead citizens to distrust public health authorities and more vehemently shun vaccinations, ironically.
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1 Merthiolate is a trade name for thimerosal and was widely used as a topical antiseptic for children. You'd fall down scrape your knee, and then into the wound mom would pour this reddish-orange-pink stuff, a toxin, as it turns out that really burned and smarted. Barbaric.
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