Vaccine hesitancy and Anti-Vaxxers

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if you have spent any time on social media, chances are you will come across anti-vaxxers. Since they tend to take this as a slur, I will abide by their wish and use a more accurate term. After all, not all of them came from this side of conspiracy land from the beginning. However, not that they realize it, they are pro-disease. And from the outset, it should be said. Some are dealing with very sick children, that they believe their kids’ health challenges were caused by vaccines. So there is that, and a little empathy. However, they are victims of a slew of quacks, snake oil salesmen, and other less than reputable characters.

As much as we would like to think they are confined to the present, no they are not and before we delve into the history of this, let me say this. Most of these people are not very well educated in the science behind vaccines. Nor do they have a memory of a world where children did not make it to their fifth birthday. Nor do they remember a time when children were many times not named until after their first birthday. The reason for this was that parents were not sure their babies would make it. Diseases for which we have developed vaccines used to kill and their victims tended to be young. If a child survived, then they’d survive the next time the disease made the rounds. Not that we understood this concept until fairly recently in human history: They became immune. Vaccines, without getting too technical, do the same without risking death or disability.

The first effort at an effective vaccine came with smallpox. With good reason, people feared the disease. And pretty early on people noticed certain things about it. If you scratched the pus out and administered the liquid to somebody else, they avoided getting sick. This process, called variolation, had a very high risk of causing full-blown disease. Nor was it pleasant, and in an age when dirty tools were used, there was a risk of getting sick from many other things. Then came Edward Jenner, a British country doctor. According to the CDC summary:

The basis for vaccination began in 1796 when an English doctor named Edward Jenner observed that milkmaids who had gotten cowpox did not show any symptoms of smallpox after variolation. The first experiment to test this theory involved milkmaid Sarah Nelmes and James Phipps, the 9 year-old son of Jenner’s gardener. Dr. Jenner took material from a cowpox sore on Nelmes’ hand and inoculated it into Phipps’ arm. Months later, Jenner exposed Phipps a number of times to variola virus, but Phipps never developed smallpox. More experiments followed, and, in 1801, Jenner published his treatise “On the Origin of the Vaccine Inoculation,” in which he summarized his discoveries and expressed hope that “the annihilation of the smallpox, the most dreadful scourge of the human species, must be the final result of this practice.”

And then the fun started. The previous method, with all its risks, was mainstream. Never mind it could cause the disease. Not was Jenner’s method more pleasant, and in the age before the germ theory of disease, it could still have nasty effects, such as an infection. Resistance to this new more effective method came swiftly. And some of the things you hear modern-day pro-disease activists say were very real talking points as well. Some things have aged very well indeed

This is a critical point on this. While we live in a world where a small, but growing group of people claims all kinds of horrors, it’s not the first time this happens. Vaccines, partly because how they work may seem like magic to people who are poorly educated in medical or scientific principles. They just know that you get a shot or any other means of administration. And like magic, you are supposed to be protected from diseases that they have no personal experience with. If the vaccine works, in most cases they should not experience it either.

Vaccination seems like an imposition and an invasion of their rights. They are aware of positive rights but have no concept of negative rights. These are the ones that transfer to society to ensure the public good. Things like regulations to ensure safe food and public health measures are such rights. They can impinge on your personal rights but ensure the public welfare. These activists also tend to use terms like liberty as a weapon against any information, without understanding that liberty is hardly absolute.

Some of the arguments, in particular, those involving liberty and freedom go to the late 18th century, Edward Jenner, and the beginning of the modern vaccine system. People, even some doctors, distrusted this vaccine. For some it was religious. If God wished you to get sick, why interfere?

Jenner’s method was based on observation. He used a thesis and tested it in a primitive, if albeit morally repulsive by modern standards, clinical trial. More on this bellow. However, his efforts led in time to the eradication of this scourge.

The first use of a vaccination campaign in what was to become the United States was in Boston. This is well before Jenner and it used a common method of variolation described above. According to Harvard University:

On April 22, 1721, a British ship arrived in Boston Harbor. On board, one of the sailors had begun to exhibit symptoms of smallpox. He was quickly quarantined, but several more members of the crew soon fell ill with the disease. An outbreak of the disease spread quickly through the city [1]. As the epidemic worsened, Cotton Mather reached out to the medical community of Boston, imploring them to use the inoculation method. One physician, Zabdiel Boylston, heeded his call, but most other doctors were hostile to the idea. At the forefront of the anti-inoculation contingency was one of Boston’s only physicians who actually held a medical degree, Dr. William Douglass. The arguments against inoculation were varied, ranging from disagreement on religious grounds to scientific uncertainty. While many argued that inoculation violated divine law, by either inflicting harm on innocent people or by attempting to counter God’s specific will, the main argument that Douglass made was that inoculation was untested and seemingly based on folklore. Douglas feared that unchecked use of inoculation would only quicken the spread of disease throughout the city [8].

By modern standards, this argument seems highly sensible. The use of a poorly researched medical technique, particularly one as potentially hazardous as intentionally exposing healthy people — including children — to smallpox, would be highly unethical today. To many professional Boston physicians, inoculation must have appeared as unscientific as other contemporary treatments such as bleeding and purging, which were still common practice during the early 18th century.

But as the epidemic began to diminish in early 1722, Mather and Boylston had collected surprisingly thorough data that made a clear argument for the effectiveness of inoculation. Boylston, who had personally inoculated some 287 people, recorded that of those inoculated only 2% had died. In comparison, the mortality rate of the naturally occurring disease during that year was 14.8% [1].

This experience made some important points. Vaccination worked. And if you doubt it, Smallpox is no longer a thing. But so was resistance to vaccination and the power of the state. Mind you, going back to at least the medieval period, the state has had a lot of power over citizens in-extremis. Pandemics are one of the most fearsome moments, which allow the state the ability to declare civil rights moot, force quarantines, remove family members and force care if need be. Those rights of the state remain, and for the most part, remain dormant.

When Jenner developed his new method, it quickly spread. Smallpox was the first disease for which we developed an effective vaccine, that was less dangerous than the older method. Cowpox conferred immunity to smallpox, but it was far less dangerous. It’s not like Jenner, or those who adopted the methods understood this in a modern way. The germ theory of disease was in the future.

Colonial Mexico was the next place where a mass vaccination campaign was attempted. Smallpox was a scourge, with frequent epidemics in Mexico City and other large colonial cities. They were usually quarantined, or large areas of the cities were. These came with prayers at colonial churches and other requests to god for deliverance.

This pattern existed in every city where the disease, or others, took hold. By 1803 an expedition was launched to New Spain and other areas of the vast colonial holdings. What those people brought was the Jenner method of vaccination. What was called vacuna, deriving from the word cow.

Like in English talking North America, or England, there was resistance to this. Arguments ranged from personal liberty to religious arguments. The former makes sense since New Spain was awash with ideas from the French and British Enlightenment.

The Council of Indias placed the Catholic Church as the authority to ultimately enforce the campaign. They had positive control over the civilian population, equivalent to modern law enforcement. This includes religious control in the form of the Office of the Holy Inquisition.

This, on the face of it, made sense. However, not all members of the church were ready to embrace this crazy idea, and in fact, at times prevented the work of members of the campaign. However, the results are quite mixed. Partly because the campaign continued in the midst of a war for independence that started in 1810.

New Spain saw something else, which is part of modern-day United States Law as well. The authorities it had to enforce quarantines and remove sick people from homes and take them to the hospital were extensive. It did not matter if it affected commerce. This was a Bourbon reform that was not just limited to Mexico, or to that era. It is understood in the concept of negative liberty, which extends to the rights of the state in-extremis. I will have more to say about this bellow.

The city of London saw frequent epidemics even after Jenner. The government decided to do something. They mandated vaccines, which had a critical role in reducing deaths due to smallpox. Remember, there was no disease that was more feared. And thanks to vaccination, these are mostly tales now, since there is no more smallpox in the wild.

However, the movement in the 19th century had some commonalities with the present one. This includes talking points.

A number of distinctive features of the anti-vaccination movement emerge from Durbach’s fascinating account. She reveals the movement’s cross-class character: though some of its leading figures were derived from the upper classes, its activists were largely drawn from the lower middle and respectable working classes (women as well as men). The anti-vaccinationists’ rejection of government and medical coercion in relation to health reflected a wider suspicion of state intervention in personal and family affairs. Activists were often also religious dissenters, trade unionists and radicals; they were opponents of vivisection, and supporters of temperance, vegetarianism and alternative medicine. As well as being an effective parliamentary lobby, anti-vaccinationism was a militant mass movement, given to carnivalesque demonstrations and riotous protests.

Here the differences between the nineteenth century movement and contemporary anti-vaccination campaigns are more striking than the superficial parallels noted by Durbach. Though today’s anti-vaccinationist campaigns get some support from quirky aristocrats, their base of support is almost exclusively middle class. Activists object to particular vaccines (in Britain mainly MMR, in the USA mainly those containing mercury). They have no objection to state intervention in any other area and, though some favour homeopathy or other alternative therapies, many seek to justify their concerns about vaccine safety with reference to mainstream medical science. Indeed some of the most prominent campaigns are careful to point out that they are not ‘anti-vaccine’ but simply concerned to promote ‘informed choice’ by parents.

The similarities though matter. Like their Victorian counterparts, many believe the decrease in disease comes from good sanitation and nutrition. While both play an important role in the take-off of western societies, they are hardly a singular explanation. Vaccines were essential in decreasing death rates. And in fact, the crash in cases coincides with the introduction of vaccines.

In the end, though, English activists achieved their goal. Mandatory vaccination for smallpox was removed. In the United States, this went all the way to the Supreme Court. In Jacobson v Massachusetts the court found compulsory smallpox vaccination was constitutional.

As smallpox continued to decrease, other diseases for which there were no vaccines continued unabated. Polio replaced smallpox in the fear category. It was so bad that kids avoided the pool in the heat of summer. Locally health officials also used old tools to try to prevent the spread of the disease.

The first epidemic was in Vermont in 1894. You could say it was an emergent disease. It became a source of constant panic and affected many. This includes President Franklin Delano Roosevelt who got it as an adult and came permanently disabled.

Patients were taken to the hospital, and quarantines were often used. With the increased knowledge of the cause of disease and the discovery of what caused many diseases, the race was on. Once the first of two competing vaccines were developed, the oral Sabin vaccine and Salk vaccine, he Salk Vaccine was used in massive inoculation drives. There was very little in the way of clinical trials. Like the Jenner method two centuries before, it was about eradication.

And like the Jenner Smallpox vaccine, an early batch of the Salk vaccine did cause some people (200) to get the disease. However, the numbers of actual cases crashed. People celebrated, and we are near the point when polio will be completely eliminated. This is a good thing.

Incidentally, the way either Jenner, or the Salk vaccine, were administered would not be allowed today. Medical. Research has increased the number of safety standards to avoid medical research the way it used to happen. These days vaccine deployments involve clinical testing.

The Ebola vaccine approaches the deployment of the Salk vaccine because of the seriousness of the disease. However, we have had sped up clinical trials. According to StatNews:

There are a number of experimental Ebola vaccines at various stages in development, but the Merck vaccine is the only one to date that has been shown to work in people. (The others may well work but their developers haven’t yet been able to prove that with Phase 3 clinical trials.)

In a clinical trial in Guinea during the disastrous West African outbreak, the Merck vaccine was shown to be highly effective and to generate immune protection quickly — two factors that are highly desirable in a vaccine designed for outbreak response.

The plan is to use a “ring vaccination” approach, vaccinating people who were in contact with cases to try to prevent onward transmission. That was the approach used in the Guinean trial.

The response in the Democratic Republic of Congo is not dissimilar to Salk’s promise. People are willing to take a few more risks. However, it has far more safety standards than earlier deployments in-extremis.

Andrew Wakefield once held a medical license in the United Kingdom and published a paper in the Lancet linking the MMR vaccine to autism. Since he lost his license and the paper was retracted. He remains one of the leaders of the modern-day incarnation of the pro-disease Lobby.

One thing Wakefield has refused to speak off is that his research came in the midst of research into an alternative to the MMR vaccine. He had a financial stake in it. His paper though was picked by the media who ran headlines about the link between autism and the vaccine.

There has been a lot of research trying to replicate this finding, which has not. However, it has increased our knowledge of the spectrum disorder. This includes the fact that autism starts in the womb, and just happens to first express itself at the same time some vaccines are administered.

Then there are others, such as Jenny McCarthy who embraced Wakefield. In 2007 she said her son Evan was autistic and had seizures. She embraced the idea that it was due to vaccines and has become the spokesperson for the movement. Her experience was very public, and she took it to the media. Oprah and others embraced her, and as they say, the rest is history.

The movement has slowly grown and joined by mostly white middle-class moms who have children with multiple things they claim to come from vaccines. It is these moms who refuse to vaccinate or do so at lesser rates or out of schedule. And some have solid cases to make since adverse reactions do occur with anything you take.

Robert Kennedy Jr is another of the big-name activists who claim all kinds of ills. And with this growing hesitancy, we are starting to see the return of diseases that are neither mild or beneficent. In time outbreaks can become epidemics, and finally pandemics.

The first thing they do is use a personal anecdote. I will use one of my own. When I was a medic in Mexico, I participated in the vaccination campaigns. I talked to madrecitas y abuelitas who remember burying children in the first years of life who died from very preventable diseases.

Most people fear needles. It is a normal thing. Children at times ran from their parents because they did not want a shot. And if you remember your childhood, I do mine, that makes sense. However, we always had a line, and a few times we ran out of doses and had to come back. People wanted their children to get those vaccines. Their vaccination record was not just required for school, it was a point of pride. It is still required to access both public and private schools, and children can access those vaccines in school. Yes, the obvious exceptions are also allowed, none is a barbarian.

People in many poorer areas of Mexico still remembered what middle-class Americans have forgotten. It would be good if these middle-class people went to cemeteries, old ones. The story is literally written in stone, but we have lost collective memory of a time when children did not live beyond their fifth birthday.

Anecdotes are what they are. They can be powerful. I knew better than to just rely on these powerful personal stories. Vaccination data and disease data tell the story even better. We have eliminated smallpox, and globally are close to eliminating polio. However, measles is coming back, with a few other diseases. We have outbreaks at present and the United States is in danger of having measles become endemic in our population. In other words, we will lose the elimination status.

According, once again, to StatNews:

The Rockland County and Brooklyn outbreaks have dragged on for eight months. If transmission from either of those outbreaks continues until late September, the United States will likely lose a hard-fought and prized status — that of a country deemed to have “eliminated” measles.

And if that happens — Venezuela and Brazil are the only other countries in the Americas where measles is considered endemic, or constantly circulating — the implications could be profound, experts say.

While there would be no international penalties involved, the rollback of measles elimination status would mean more than just the crossing of a psychological divide. It would be a harbinger, experts say, that the U.S. could face far larger outbreaks in the future — epidemics that could strain the capacity of health departments that already struggle to extinguish each and every chain of measles transmission that occurs in the country.

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Public Health Measles warming sign Mexico City Airport Personal Collection

Speaking of Mexico. The Department of Health will have to add the United States to the placards at the airport warning people of signs and symptoms for travelers returning, from among other places, Europe. They could also require proof of vaccination if you travel to the country before a visa is issued. These used to be standard for things like Cholera.

What are the other favorite tactics? Projection, claiming people do not understand. Quoting scientific articles via pub med that many times do not say what they think. Attacking those who tell them a child died or got sick from a preventable disease. They also tend to discount the science behind vaccination.

Many times they also believe a slew of other conspiracy theories and lack real understanding of the legal system, or how government works. Big pharma is a demon to be destroyed. They tend to love natural anything as well.

So what happens if we have a pandemic? Remember what I wrote of Colonial Mexico? The same authorities exist in present US Law. If a Declaration is issued quarantines can be ordered. The last time that happened federally was the Spanish flu.

Wide authorities are granted under law, including the treatment of sick people, and if need be a stop to commerce or transit between states. A similar authority exists at the state level to prevent free movement between counties.

The last time we had any conversation on this was during the Ebola epidemic of 2014, and the return of health care workers. The nurse who was ordered to quarantine had no rights to appeal under those authorities. And we can argue if it was adequate or not. However, she did sue.

Will we have a pandemic? There is always a possibility. But it increases in risk when either we face emerging diseases, or people refuse things like vaccines for common diseases en-mass.

A note on these people and empathy. Many of them honestly believe vaccines caused a series of maladies. And in a few cases, they do have children who had adverse reactions. And in that case, they can get exceptions. In fact, adverse reactions are reported as a matter of course.

However, there are people out there who cannot get vaccinated for a series of very valid reasons, among others Cancer.

The logic behind recent California bills, as well as Italy and Romania, is to reverse this trend. This very vocal minority will continue to scream fire in this very crowded theater. The alternative is to continue to see less compliance in vaccination rates and the return of highly preventable diseases.

Perhaps a new chapter on the lethality of these diseases will be written in stone. One reason why London finally relented and got rid of smallpox mandatory vaccination was that a lot fewer people used to get sick. Plainly put, people forgot. We are a few generations removed from that reality. We no longer have madrecitas y abuelitas who remember.

Historian by training. Former day to day reporter. Sometimes a geek who enjoys a good miniatures game.

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