Sunday, April 3, 2011

Michael Willrich's Look Back at Smallpox and the Fight Over Vaccines

Antivaccinationism was an international phenomenon, but everywhere it reflected the social divisions and political tensions of its time and place.

These words pop up earlier in Michael Willrich's new book Pox: An American History. Despite the past-tense used, that statement could easily apply to anti-vaccine sentiments today. I just finished reading this book the other day, and thought I would share some thoughts.

Willrich focused his narrative on the social and political landscape of civil rights, Progressivism and how smallpox and its vaccine shaped the landscape right around 1900. Although antivaccinationists had been around since the very first discovery of innoculation in the 18th century, the late 19th and early 20th centuries presented a ripe environment for testing the bounds between personal liberties and government powers.

As Willrich recounts, in the late years of the 1800s, smallpox outbreaks started to pop up around the United States. It had been a generation or more since the disease had last been seen in many communities. Those most frequently infected first were African Americans, who, due to racial prejudices of the time, often existed in crowded communities, many times traveling from one place to another as laborers. This factor helped to ensure that white America paid little attention to the beginnings of the outbreaks, helping smallpox to gain a foothold in every community where it cropped up. Worsening matters was the fact that, in many cases, a newer, less deadly strain of smallpox (variola minor) was the culprit. Local governments and even many physicians, unfamiliar with the slightly milder strain, did not believe that the outbreaks were worth worrying about, even going so far as to suggest that it was a disease unique to "negroes", and that whites could not be infected.

It's worth briefly discussing the two strains of smallpox: variola major and variola minor. Both strains left disfiguring pockmarks on their victims. V. major, however, often had a much more serious fever and extensive rash. It had a 30% mortality rate, though rarer types of v. major were almost universally fatal. In contrast, variola minor had milder symptoms and a mortality rate of a bit under 1%. In both cases, first symptoms (fever, malaise, etc.) began anywhere from 7-17 days after exposure. Fever and aches, sometimes severe enough to lay a person low, lasted about 2-4 days, after which, the patient would begin to feel better. That's when rashes would form and burst in their throat and mouth, making them extremely contagious to anyone nearby. It's important to note that this period, lasting around 4 days, was before any rash appeared on the body. Given the timeline of the virus, and the nature of those most often infected first, it is very easy to see how quickly the disease could spread from one community to another.

As public health officials began to see how quickly the outbreaks spread, mandatory vaccination was often implemented. As Willrich describes in numerous narratives throughout the book, when communities didn't voluntarily bare their arms, force was often used, even to the point of vaccinating under the barrel of a policeman's gun. Again, social and racial divisions played a major role in just how much force was used, as well as who could get out of vaccination altogether. While upper class, wealthy and influential individuals were spared the, in their minds, ignominy of vaccination, the lower classes were set upon with sometimes unforgivable brutality.

As if the actions of health officials weren't enough, vaccine production of the time was fraught with problems that, thanks to advances in science and medicine, we do not see today. Heat could often render the vaccines useless, so even those who did get vaccinated would still get sick. Methods of production (growing a related virus, vaccinia, in cows and collecting the pus or collecting matter from the sore in a human) could often lead to contamination with tetanus or syphilis, as well as some skin diseases. Even a good batch of vaccine could result in rendering the patient's arm sore for several days to over a week, leaving them unable to work.

A number of factors, then, contributed to antivaccine sentiment during the period: lower classes distrust of government officials, prejudices viewing the new outbreaks as a disease only of the unsavory members of society, potential contamination of the vaccine, loss of work with no job security or compensation, a perception that the disease was mild and nothing to worry about. At a time when education about the vaccine and the disease was scant, many people's fears were understandable, if not always warranted by the truth of the matter.

In that atmosphere, some people would seek false vaccination certificates from physicians willing to provide one, at a small fee, of course, in an attempt to avoid mandatory vaccination. Others would resort to faking the vaccination scar by using acid. Even a strong proponent of mandatory vaccination, C. P. Wertenbaker, made it a cause to improve the safety of vaccines, writing to manufacturers (who were completely unregulated and could be set up by just about anyone with some cattle), encouraging them to use glycerinized lymph to reduce the possibility of bacterial contamination.

This latter aspect, of vaccine safety, became a major issue following outbreaks of tetanus in Camden, NJ and St. Louis, MO. The common factors among the tetanus cases were vaccines made by a single producer. The call was raised that, for too long, vaccine makers had gone unregulated, culminating in the Biologics Control Act of 1902. The laws, giving the Federal government authority to license and inspect makes of biologics (vaccines, sera, etc.), ran counter to the strong libertarian sentiments of the era. The idea that no individual should have any undue restrictions placed on their freedom by any government was really at the heart of the American identity. Running counter to this, though, was the responsibility of a government to protect the well-being of its citizens. Where freedom and public health met, Progressives would insist that the welfare of the majority was more important than personal freedoms.

Interweaving Willrich's stories of individual resistance to vaccination are accounts of individual health officials, frustrated with the resistance as they do their utmost to protect people from the disease by the most effective means. In their desire to prevent unnecessary illness and loss of life, the vaccinators often went about their rounds with several police officers as escort, as anything from small-scale violence to outright riots were a possibility. Even pesthouses to treat and quarantine smallpox patients were set ablaze. Ignorance, fear and politics were ever a hindrance to rapid and successful containment of outbreaks.

In the end, the ultimate test of the government's authority to require vaccination was the Supreme Court case of Jacobson v. Massachusetts. That case established the right of a government to require vaccination of its citizens, while also setting limits, such as exemptions for medical contraindications. That case has stood since then, confirming that, in the case of infectious diseases, each person bears a responsibility to those around them, that the public welfare and good of society trump personal liberty.

Pox is a very well-researched and detailed book. By couching the facts in personal stories, Willrich's book makes for a relatively easy read. He acknowledges the benefits of vaccines and that it is sometimes essential to take on personal risk for the benefit of others. Ultimately, he suggests that the best means of establishing a quality vaccination program is through education and understanding, rather than through a paternalistic approach of forcible immunization. He warns that a reflexive dismissal of those with concerns about vaccines as "ignorant and irrational" is intolerant and a folly to be avoided.

In today's society, Willrich's message is something that should be remembered by those who support vaccination. Not everyone who fears vaccines is what I would call an "antivaccinationist". Many are people who have read something online or in a book that convinced them to distrust vaccines. While their fears are understandable, education may be the best way to reach them. It may be a long, slow process, but may ultimately be better than a brute force approach. This is in contrast to those who actively promote misinformation and propaganda about vaccines. Those who, no matter how much evidence is presented to them, remain adamant in their ignorance or, in some cases, outright dishonesty. It is this latter sort that I would term an "antivaccinationist", examples of which abound in Pox, many of whom eerily resemble the...ahem..."luminaries" of today's anti-vaccine movements. In fact, I would go so far as to say that many of today's antivaccinationists would be right at home in 1900 America, so similar are their arguments and outlooks on vaccines.

Where I think Willrich falls somewhat short is that, in his appeal to understanding and fairness, he seems to dismiss that there are instances where a more blunt and occasionally confrontational attitude is not only appropriate, but essential. A perusal of some of the popular pro-vaccine web sites will turn up several stories of how just such a style succeeded where strict adherence to calm education failed.

The only other quibbles I have with the book are that, for a couple of the stories Willrich recounts, a map may have been useful. Also, an appendix listing the major characters that appear throughout, as well as a timeline of significant events could aid the reader.

Pox is a book worth reading, if for nothing else than the historical context it offers and the insights into why people distrust vaccines and why health officials support vaccines so strongly. In the end, I'll leave off with the closing line of the book, a statement that everyone involved in the discussion, whether pro- or anti-vaccine, should keep in mind:

Unthinking scientific triumphalism is no sounder an approach than antiscientific denialism to the social conflict and political contention that are likely to continue to haunt the human quest to make ours a healthier world.

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