Immunization

How Vaccines became Controversial

Stuart Blume

• Publisher: Reaktion Books
• Year: 2017
• ISBN:
  9781780238685
• Topic: History
• Subtopic: World History
• Index: History

As the world pins its hope for the end of the coronavirus pandemic to the successful rollout of vaccines, this book offers a vital long view of such efforts—and our resistance to them. At a time when vaccines are a vital tool in the fight against COVID-19 in all its various mutations, this hard-hitting book takes a longer historical perspective. It argues that globalization and cuts to healthcare have been eroding faith in the institutions producing and providing vaccines for more than thirty years. It tells the history of immunization from the work of early pioneers such as Louis Pasteur and Robert Koch through the eradication of smallpox in 1980, to the recent introduction of new kinds of genetically engineered vaccines. Immunization exposes the limits of public health authorities while suggesting how they can restore our confidence. Public health experts and all those considering vaccinations should read this timely history.

ONE

WHAT DO VACCINES DO?

Hope

If its films are any kind of guide, the English-speaking world views the prospect of a pandemic with the fascination of a trapped man watching an approaching snake. There is a sense of horror, of inevitability. Films about epidemics show us people in their thousands (or more) dropping in the streets, social disintegration and approaching havoc. However, there is a catharsis. In many of these films there are heroes or heroines, doctors or scientists, who ultimately save what is left of the human race. Some of these movies, such as John Ford’s 1931 film of Sinclair Lewis’s novel Arrowsmith, were made long ago, but most are fairly recent. Think of the 1995 film Outbreak, starring Dustin Hoffman and Morgan Freeman. Or the 2007 film I Am Legend, starring Will Smith. Or the popular TV series The Last Ship. Or Steven Soderbergh’s gripping 2011 version, Contagion. Soderbergh’s film opens with an American business executive, Beth Emhoff, taken ill on her way home from Hong Kong. She’s coughing and sweating. We see others similarly affected, in Hong Kong, London, Tokyo . . . This is turning into a public health emergency though it is totally unclear how it started, or where, or what is causing it. It is a private tragedy as well. Of course it is many private tragedies, but the film focuses on how Beth’s collapse and rapid death affect her family. Her husband Mitch is at first incredulous, then bereft, then put into an isolation ward, and finally discovered to be immune. The public health side of things focuses on the Center for Disease Control (CDC) based in Atlanta, Georgia, and in particular on an epidemiologist named Erin Mears who has to trace and map the spread of the disease, on her boss Ellis Cheever, and on Ally Hexhall, a virologist who’ll be given the job of identifying the causal agent, which proves to be a virus. The action shifts to Geneva, where the World Health Organization (WHO) is based, and where reports are coming in of deaths and millions of cases from some of the world’s most densely populated metropolises. The WHO, which has developed protocols for dealing with this kind of emergency, is going to send Dr Leonora Orontes to investigate. What precautionary measures should governments be advised to take? Should schools be closed? Is there a risk of panicking people needlessly? How does the virus spread? Epidemiological investigation would have to establish how infectious it is. What kind of virus is it? Is there a chance that a known pathogen (anthrax? smallpox? ‘Bird flu’?) has been turned into a weapon and that this epidemic has been started deliberately?

It’s the work of epidemiologist Mears (out in the field) and of the virologists manipulating samples in their laboratories that forms the core of the movie. Because Mears is able to establish that Beth was ‘patient number 1’, and that she became sick as a result of eating some infected poultry, and because the virologists succeed in identifying and then growing the virus, a vaccine can be made and mankind saved. But this isn’t a documentary, so it’s embellished by a number of dramatic flourishes, some of which point neatly to real-life complications, dilemmas and concerns. Orontes, who is dispatched to Hong Kong, suspects that that is where it all started, but discovers that the authorities are anxious to prevent any such announcement being made. Moreover, plenty of people think there is money to be made. We are introduced to Alan Krumwiede, an influential (but shady) blogger, who claims that there’s a simple, cheap ‘natural’ cure for the disease, which the public health ‘establishment’ and the pharmaceutical industry are keeping secret. They want to develop and profit from an expensive vaccine. We subsequently learn that he is hoping to make money himself from this plant extract. Demand becomes insatiable, and riots break out at drugstores across the USA as people try to get hold of it. There are roadblocks and looting. The impression we are given is that the social disruption caused by the epidemic is at least as serious, and certainly as frightening, as the virus. An epidemiology of fear is evoked. As one of the characters points out, in order to get sick you have to be in contact with an infected person or something that they’ve touched. In order to get scared you just have to get in contact with TV or the Internet.

If this dramatic rendering is compared with the histories of real epidemics – comparisons that characters in the movie often make – it is clear that the film-makers did a great deal of preparatory research. (I wasn’t surprised to be told that that they’d visited the World Health Organization to learn how epidemics are dealt with.) Though the likelihood of an epidemic leading to social breakdown surely varies from one society to another, a documentary about a real-life global epidemic could draw on this account of a fictional one. It is not just that the story is a distillation from real-life happenings. It is also that it provides a script: a resource for writing about epidemics. Nearly thirty years ago the eminent historian of medicine Charles Rosenberg offered a dramaturgical way of writing about epidemics.¹ Inspired by Albert Camus’ novel The Plague (1947), Rosenberg suggests that in the past epidemics tended to evolve in a well-structured narrative sequence. Act I of the imaginary play is a community’s reluctant acceptance and public acknowledgement that disease has struck. Act II, which he calls ‘Managing Randomness’, involves the search for some explanatory framework: a way of making sense of the fact that some die while others survive. It is this framework that can provide a guide to action and to control. In earlier times this framework tended to be rooted in widely held assumptions about proper and responsible behaviour. Then, in Act III, a ‘public response’ is negotiated: a set of ‘collective rites integrating cognitive and emotional elements’. Whether these rites emphasize collective fasting and prayer, or quarantine, they represent an enactment of community solidarity. Finally, in the last act of Charles Rosenberg’s narrative, the number of cases has declined. The epidemic is under control. Some have died and others have recovered. Now there is time for remembering and reflecting, though this can probably be entrusted to the historians. ‘Has a heedless society reverted to its accustomed ways of doing things as soon as denial became once more a plausible option?’ ‘Epidemics’, Rosenberg notes, ‘have always provided occasion for retrospective moral judgment’.² If this was a reflection on an era when there were no virologists, written for an age when time and space hadn’t been compressed to the extent they are today, then Contagion provides us with an update. It offers a way of imagining and writing about epidemics as they evolve, as they spread, and as the desperate search for control – today centred more on the laboratory than on the house of prayer – gathers pace.

Fear

When we are told that some horrific pandemic is in prospect – something like the 1918 Spanish flu that killed tens of millions of people (an estimated 3 to 5 per cent of the world’s population), or that a previously unknown virus has emerged from its remote jungle home (as in Contagion) – we now turn expectantly to virologists like Ally Hexhall and the high-security labs in which they go about their business. An example that hit the news in the first weeks of 2016, and that almost no one who wasn’t a virologist had heard of up till then, is the Zika virus. It was discovered in the Zika forest, in Uganda, by researchers who were actually investigating yellow fever. Both viruses, and that responsible for dengue, are spread by the same species of mosquito, Aedes aegypti. Infection with the Zika virus was nothing to panic about. Although the virus had been found in 1947, the first reported case of someone becoming sick from it was only in 1964. After three days of fever and some aches and pains, the victim had fully recovered. Studies showed that many cases of infection were totally without symptoms. But as the virus was carried further afield its effects appeared to change. Epidemics in various Pacific islands in the early 2000s showed more serious symptoms, in particular Guillain-Barré syndrome. And then it found its way to Central and South America. Evidence began to accumulate that if a pregnant woman became infected her baby might be born with an abnormally small head (a condition known as microcephaly). A significantly higher than usual number of babies have been born with microcephaly in Brazil, where the virus has spread rapidly. Researchers are discovering that it is not only mosquitoes that spread it. Some women seem to have picked it up from infected semen and possibly even from sweat. Work on developing a vaccine is under way: in Brazil’s Butantan Institute; in the U.S. National Institute of Health; in pharmaceutical giants like GSK and Sanofi Pasteur; and in some small biotechnology companies. Estimates as to when it might become available differ enormously. Of course it is not as though nothing is being done while the vaccine is being developed. While the scientists are working, something has to be done to help people who are affected (there is no anti-Zika drug yet) and also to limit the spread of the contagion. Simple measures like covering barrels of drinking water can help. Restricting people’s movements, especially people who might be infected, has been used for centuries to limit the spread of infectious disease. Now there are new and more sophisticated ways of identifying people who might be infected. That is why, a few years ago, many airports installed thermal scanners. They were intended to identify passengers whose raised body temperature indicated possible ‘swine flu’.

Writing in 1986, as the world was struggling to come to terms with the start of the AIDS epidemic, Roy Porter, Britain’s pre-eminent historian of medicine until his death in 2002, wrote:

What’s dangerous about fear, however, is that it rarely comes neat, but is always manipulated and exploited. As a consequence, its objects become displaced and its functions perverted . . . The Black Death, for instance, was said to be the doing of the Jews (who were massacred all across Europe for their alleged responsibility) . . . And later, in the 19th century, the new, terrifying cholera pandemics were similarly exploited to exacerbate social alarm. Arising from the degraded depths of Asia and then, when sweeping across Europe striking down the lumpenproletarian scum, cholera was, in the eyes of many official spokesmen, nature’s way of demonstrating that the great unwashed were intrinsically polluted, and diseased.³

Without questioning the seriousness of the disease, Porter was concerned that fear of the AIDS epidemic was being whipped up because media moguls were convinced that ‘fear sells newspapers’. Keeping out people who are different from ourselves, especially when they are suspected of carrying disease, still has great emotive, and thus political, force. While there is much to be said for restricting the movement of infectious individuals, the emotive appeal of quarantine easily spills over into generalized fear of groups that are thought to be not only susceptible but also carriers of infection. For example, at the start of the AIDS epidemic in the U.S. in 1981, immigrants from Haiti appeared particularly numerous among those affected, resulting in stigmatization and exclusion of people from Haiti, sick or not.

The dramatizations of a pandemic in a movie like Contagion and the forecasts produced by virologists and by the pharmaceutical industry feed into and off one another. The movies are based on a reading of previous epidemics, but at the same time they provide a discursive resource – a kind of plot – for virologists thinking and writing about the future. Nathan Wolfe’s The Viral Storm: The Dawn of a New Pandemic Age was published by Penguin books in 2011, the same year that the movie Contagion was released. Wolfe, who is a virologist, suggests that the term ‘pandemic’ should be used to describe the spread of a virus from a few people to many people in many places, and quite irrespective of its deadliness. ‘In fact, from my perspective,’ he writes, ‘it’s possible we could have a pandemic and not even notice it.’⁴ If a handful of people were infected with a virus that produced no symptoms of illness, and if those people were distributed over the various regions of the world, then this would constitute a pandemic. While far from the imagery of the pandemic disaster movie, from the perspective of The Viral Storm any virus is a potential source of danger. There is a great deal in the book about the deficient animal husbandry and butchering practices that give rise to new viral threats. The hunting and butchering of wild animals, the mingling of household pets and animals intended for human consumption, and intensive animal farming: all of these practices influence the likelihood that a virus to which its animal host had adapted will enter a human population with potentially disastrous consequences. And of course the growing interconnectedness of people everywhere, thanks to modern means of transportation, offers the virus vast intercontinental possibilities. Wolfe tells us that a collaborator of his had examined the rate at which new viruses had been identified over the past century. That study suggests that in the coming decade an average of at least one or two new viruses per year are likely to be found: a result of growing mobility, lifestyle changes and increasingly sophisticated virus-hunting. Wolfe, like a number of other authors, leaves us in no doubt that future influenza and possibly other pandemics are inevitable. As director of ‘Global Viral Forecasting’, he wants to convince his readers that pandemics don’t occur randomly, and that with the right surveillance tools they can be predicted – and prevented. ‘Prediction and prevention of pandemics will not be easy, but there is much we can do right now, and the advances that are steadily occurring will allow us to do even more in the future.’⁵ A study published in the same year by researchers at the European Centre for Disease Prevention and Control proceeds along similar lines.⁶ Previous work had suggested that hundreds of human pathogens had emerged or re-emerged over the previous half century. These authors set out to identify plausible threats facing Europe in 2020 ‘on the basis of current knowledge about disease as well as about changing social-ecological contexts’. All of their scenarios make depressing reading.

As in most of the pandemic disaster movies – and hopefully without the almost complete destruction of the human race that some display – mankind will be able to ride the storm, at least if provided with comprehensive surveillance using the very latest computer and information technology, and given sufficient investment in vaccine development. Of course, how far all this technology, or the best efforts of virologists and the pharmaceutical industry, can help human communities deal with the panic and social disintegration displayed in the movies, is a separate issue. Could it be that epidemic preparedness requires something in addition to the ability to rapidly produce a new vaccine? Certainly, fears of bioterrorism have provoked calls in the United States for emergency powers that would legalize the involuntary sequestering and examination of suspects – not suspected terrorists, but people merely suspected of having been infected by one or other ‘weaponized’ pathogen.

If the havoc wrought on a community depends on how its members respond, then a movie like Contagion does more than entertain. Watching a movie like this should not only reinforce our trust in the white-coated virologists, but it should also enable us mentally to rehearse how we’d behave. Will we trust what government representatives, the CDC people in the movie, have to say when they explain the risks they believe we face?

Immunity

What do we hope for from the scientists? What exactly is it that Contagion’s scientists are trying to develop? Wikipedia gives us a nice simple definition of what a vaccine is: ‘A vaccine is a biological preparation that provides active acquired immunity to a particular disease.’ That helps somewhat. It is biological – made from something found in nature – and it is connected to a particular disease. So it is not like a tonic or an aspirin. But what is particular about what a vaccine does? What is ‘active acquired immunity’?

Many kinds of microscopically small organisms potentially threaten the human body. Our planet is inhabited by far greater numbers of viruses, bacteria, parasites and fungi than of any other kind of living organism. They are not all bad. We humans coexist quite happily with some of them. Indeed some of the bacteria that live in our guts, stomachs and genitalia actually help us avoid infection, or they help us digest the food we consume. All the foreign microorganisms in the human body, whether helpful or harmful, display distinctive markers which the immune system can recognize. If a harmful invader is signalled, then the immune system has the job of destroying it. A vaccine is a substance that helps it do so. Vaccines usually contain antigens, which are bits of the disease-causing organism, which stimulate the body’s immune system to fight off a potential infection. The vaccine helps the immune system to recognize the pathogen and to launch the right kind of counter-attack before the sickness has taken hold.

Vaccines help my body’s immune system protect me against infection. If we go on to ask how they do that, things get complicated. This is not only because the immune system has a range of defensive weapons at its disposal, but also because the science of how it works, immunology, is rapidly advancing. There is a special circulatory system that carries ‘lymph’, a transparent fluid containing lymphocytes, around the body. The lymphocytes are crucial participants in the body’s defences. There are B cells, which grow in bone marrow, and T cells, which mature in the thymus, up in the chest. A useful document produced by the American National Institutes of Health explains that the B and T cells have somewhat different functions and are responsible for distinct forms of immunity.⁷ B cells produce antibodies that circulate in blood and the lymph streams and attach to foreign antigens to mark them for destruction by other immune cells. B cells are part of what is known as antibody-mediated immunity. B cells have a range of functions, one of which is overall coordination and regulation of the body’s immune response. There are also T cells that, like the B cells, patrol the blood and lymph. But these T cells can do more than recognize a foreign invader; they can also attack and destroy cells that they recognize as foreign. T cells are responsible for what is known as ‘cell-mediated immunity’. Some of the T cells are there to prod B cells into making antibodies, as well as activating other T cells and immune system scavenger cells called macrophages. There are T cells which can turn into killer cells that attack and destroy infected cells, as well as circulating scavenger cells known as phagocytes, which have the job of engulfing an unwelcome microbe. And crucially, there are also memory cells. When the army of B and T cells begins its work of defe...