Effective immunization programs protect our communities and our way of life from innumerable communicable diseases, while encouraging development efforts abroad. Eradication is a laudable goal that can only mean better health for all. Thus, it matters not if anti-vaccinators are radical militants or Hollywood celebrities; they stand with each other, and with these preventable diseases
Whither the Endgame of the Anti-Vaccination Movement?
By Lawrence C. Loh, MD, MPH, CCFP, FRCPC*
Adjunct lecturer at the University of Toronto’s School of Public Health, co-founder and Director of Operations at The 53rd Week
A roadside bomb detonates in northwest Pakistan, and militants open fire on a convoy in an hour-long attack that kills 12 and wounds dozens more. This attack successfully disrupts the delivery of polio vaccine to a remote area of the subcontinent, delaying and hampering ongoing efforts to eradicate poliovirus from the face of the earth. Meanwhile, across the world, in a boardroom meeting in Canada, a group of public health professionals fall silent at news that containment of a measles outbreak has failed. Despite their best efforts, what started as a few cases in a school with poor vaccination coverage has now exposed people in retail settings, transport terminals, universities, and healthcare facilities. These widespread community exposures are compounded with declining rates of vaccine coverage, which all but assure ongoing spread. Measles remains as infectious at it has ever been.
These professionals are fighting the same war that humanity has waged against disease and contagion for millennia. These scenes are battles, repeated all over the world, to that cause; battles of recent times that have not gone well. Increasingly, public health encounters opposition from the very people who they are trying to protect from these diseases. Be it allegations that vaccination is a Western plot to sterilise Muslims, or misguided beliefs based on spurious or fully retracted research, a small but vocal minority in populations cling to their beliefs, spread misinformation, and make it easier for the diseases to spread and win battles. A decision to not vaccinate threatens overall community immunity, allows the re-establishment of disease transmission in the public, and threatens to undo the work of decades of battles won against vaccine-preventable diseases.
As with any conflict, there are sides, each with their own resources and special weapons. In the fog of war it is often difficult to determine which side will be victorious, and sometimes difficult to see which side is the “right side”. To make this analogy easy, let us define the “right side” as the side you’re meant to cheer for when you’re watching the hindsight Hollywood depiction years later. In this sense, public health professionals and advocates will argue that they make a compelling case for being that side. Their weapons and tools are immunisation, surveillance, and isolation, all backed by research and evidence that prove their effectiveness in turning the tide.
Deploying these resources has brought about measured successes, including the eradication of smallpox and the bringing of polio to the brink. Immunisation and related efforts have prevented innumerable cases of diseases worldwide, directly alleviating human suffering and protecting healthcare resources while indirectly driving the educational, social, and economic development of nations.
So who is on the other side? For centuries, the diseases that plagued society stood alone on the other end. As outbreak after outbreak crippled children, scientists raced to discover an effective way to treat or prevent disease while societies stood together to support these efforts. The discovery of vaccination meant that slowly, one by one, former scourges fell to the ingenuity of science and innovation. Diseases like diphtheria, measles, and mumps, all became far less commonplace. As communicable disease rates plummeted, civilisations flourished. Quality of life improved, economies thrived, and non-communicable diseases began to replace vaccine-preventable diseases as contemporary concerns.
In their near defeat, the vaccine preventable diseases found an unlikely ally. Their virtual disappearance made them less of a threat to human society. Through success, though, vaccination turned out to be its own worst enemy perhaps; by removing these diseases from public consciousness, vaccines themselves have come under scrutiny. The spectre of crippling polio was replaced by pointed questions about vaccines. A spectrum of reasons -”conscientious” objection, anti-establishment views, religious re-interpretation -brought together with junk science and double-agents – has succeeded in giving vaccine preventable diseases a breakthrough in areas which have not seen battle for many years.
Celebrities make spurious claims about long-disproved, barely rational linkages between immunisations and any number of diseases. Healthcare workers taking care of vulnerable populations still continue to resist policies that make immunisation with flu vaccine mandatory. And as they do, the diseases return with a vengeance. Measles, once nearly eliminated in North America, now leaves communities all over the continent stricken. Public health departments struggle with limited resources to control outbreaks of pertussis.
Thus, to return to the analogy: the war yet rages on, but today, the sides and their resources are far more complex. Public health and their allies continue with their tools of immunisation, surveillance, isolation, prophylaxis, and prevention, while anti-vaccination folks have aligned with these preventable diseases, spreading their opinion and sharing misinformation that leads people to opt-out of vaccination. That much is clear.
As with any war, there is also strategy involved. And for at least one of these sides, the endgame is absolutely clear. Those that stand on the side of immunisation are looking to defeat these diseases. After the success of smallpox, with polio on the brink, these groups would imagine a world where the threat of many of these communicable diseases is eliminated or minimised as much as possible. Their endgame is the safeguarding of health through prevention, and through the eradication, of vaccine preventable diseases.
The polio endgame
The polio campaign is one of the most demonstrable examples of the strategic goal of those who support immunization. Polio, once an endemic virus spread by fecal-oral transmission, once darkened many families’ hopes with paralysis and iron lungs. Today, it is endemic in three final countries in the world: Pakistan, Afghanistan, and Nigeria. The formerly perceived impossibility of interrupting poliovirus transmission in India came to pass in January 2014, with endemic transmission of polio not seen in this populous nation for 3 full years.
Driven by the World Health Organization (WHO), Rotary International, the United States Centers for Disease Control (CDC) and the United Nations International Children’s Emergency Fund (UNICEF), the Global Polio Eradication Initiative oversees ongoing programs in polio endemic areas, research, and fundraising worldwide. An ambitious goal of no wild-type transmission of polio by 2014 has been set. There are detailed, outlined plans to strengthen surveillance systems and secure polio vaccine stocks and certify regions as polio-free while synchronising an eventual change from oral polio vaccine to inactivated polio vaccine.
Efforts to eradicate polio drew their inspiration from smallpox eradication efforts. To date, smallpox remains the only such disease eradicated. It had the benefit of a very effective, heat-stable vaccine that could be transported to myriad far-flung locations and administered with a bifurcated needle that was readily available in remote outposts and could be readily re-sterilised. Trained local staff, together with international experts, would quickly identify outbreaks of smallpox and deploy the vaccine to prevent its spread. In the last days of smallpox, efforts intensified; cases were actively sought out and their close contacts vaccinated. Hard work paid off when the last case of smallpox was reported in 1977 in Somalia.
Polio eradication efforts stand on the cusp of a similar victory. It has been a far more challenging road, but the endgame and strategy remains the same -use vaccination to wipe an otherwise incurable disease off the face of the earth. Provided diseases meet certain criteria, they could all theoretically be a candidate for eradication. And the optimists in the public health field often highlight that a world without vaccine-preventable diseases would be a wonderful world indeed.
As Poonam Singh, the South-East Asian Regional Director for the World Health Organization, stated on India’s being certified polio-free: “Such an achievement can also be reached for diseases such as measles and rubella […] eradication helps to reduce poverty and give children and families a greater chance of leading healthy and productive lives.”
In the ongoing struggle against communicable disease, those who would vaccinate espouse a clearly defined strategy with unequivocal goals.
The rise of the anti-vaccinators
One wonders what vision those who are against vaccines hold. Much vaccine refusal is rooted in fear: fears that certain vaccines are linked to autism (a research finding since retracted and heavily discredited); fears of the contents of vaccines; fears of societal medicalisation; moral fears of promiscuity in adolescents. Despite the disease-free modern world we live in today as a tribute to earlier immunisation programs, vaccines have become the enemy, and are feared.
Many famous anti-vaccine activists are successful because they appeal to base human fears of the unknown. In a world where measles or mumps no longer causes encephalitis (brain inflammation), they become an unknown. “What is this vaccine really doing to our kids? How can we know it is preventing what it claims to be preventing? How do we know it isn’t necessarily causing something worse? “
Anti-vaccinators trot out stories of their children. Their stories tug at heartstrings, and they support their views with whatever “evidence” they can find, rather than let evidence dictate their views. And in doing so, they influence a too-often persuadable public to not vaccinate. Other members of the public find other reasons to not vaccinate: “big pharma is screwing us”, “it’s not the natural solution I ascribe to”, or “I’m simply just scared of needles”.
The end result is still the same. The collective immunity that protected our communities from these diseases and drove the prosperity of the 1960s-2000s is now dropping across continents. Measles outbreaks from the Netherlands get imported into our backyard here in North America. Pertussis has returned with a big whoop and cry. Public health departments, struggling to cope with rising obesity, cardiovascular disease, cancer and diabetes (the other by-products of affluence: chronic disease) now contend with re-established transmission of diseases once thought eliminated.
And through it all, anti-vaccinators get what they wanted; they did not need to take a vaccine. In many ways, this reflects the “me-first” nature of today’s society. They get what they wanted. Never mind that with the return of these diseases, the weak and infirm are more vulnerable to being exposed, infected, and dying. Never mind the economic impact that new measles outbreaks will cause as tourists flee and business close to prevent spread. And of course, as diseases re-establish transmission in communities, at least their kid didn’t have to get vaccinated, never mind that someone else’s kid manages to contract meningitis.
A story of two endgames
Thus, returning to the initial premise that there are two sides, we can see that each side’s strategies and resources drive towards very different ends.
Those who would vaccinate propose an endgame where collective health is a target to be aimed towards. They recognize the importance of collective immunity in interrupting disease transmission, and are acutely aware that public health departments need to be able to focus on the challenges of our time. Health needs to be able to turn back obesity, chronic disease, and mental health issues without also worrying about preventable communicable diseases.
Those who would vaccinate believe the world would be a better place without polio, mumps, measles, meningitis, whooping cough, Hepatitis B, cervical cancer, and any other number of diseases. These are the people who are putting themselves out there every day; working tirelessly to deliver immunisations, educate the public, and in some cases, putting themselves in harmâs way for the cause of polio eradication.
They recognize that the modern societies we live in today have enjoyed economic prosperity and development owing to the immensely effective control of communicable disease through hygiene and vaccination. They want to address communicable disease because today’s challenges are increasingly non-communicable: over a quarter of most adults in the industrialised world are obese, while depression and injuries take their toll on the younger, more productive members of our society. Tobacco and unsafe alcohol use continue to take lives every year and years off of lives.
They also recognise that in the developing world, immunisation remains one tool in an arsenal against poverty; it guarantees a modicum of health for those who live in indigent settings; it allows healthy children and youth to make use of education and social services to become productive members of a growing nation and economy.
On the other side, what precisely is the anti-vaccination endgame?
In a world where vaccinations are shunned, we have the return of outbreaks that bring fear and hamper efforts on other critical public health issues of our time. Massive recurring measles outbreaks become de rigueur; when one pops up, isolation protocols disrupt daily life, bankrupting small businesses while turning schools and community centres into ghost towns. Public health efforts to address other issues (chronic disease, or mental health) go by the wayside as outbreak after outbreak calls for containment.
People remember the halcyon days where adequate population coverage meant that they could travel without having to regularly check their immunity at their physician’s office. Influenza strikes more people harder due to more frequent transmission and mutation. Eventually, driven by a massive swing in popular opinion, governments de-list immunizations from public insurance plans. Some individuals pay for immunizations privately and benefit, but society as a whole does not reap the benefits of collective immunity because there simply arenât enough people vaccinated.
This dystopian future serves to illustrate a simple point: ask an anti-vaccinator what their endgame is. We need to challenge their assertions beyond the surface answer. Dig deeper, and genuinely explore how they see the future. No matter how much one believes in celebrity star power, natural solutions, or even the non sequitur “because I believe in being healthy”, the fallacy of an anti-vaccine argument unravels very quickly when taken to its logical question of “But what if we as a society chose not to vaccinate? What then?”
Effective immunization programs protect our communities and our way of life from innumerable communicable diseases, while encouraging development efforts abroad. Eradication of polio and other vaccine preventable diseases is a laudable goal that can only mean better health for all.
Thus, it matters not if anti-vaccinators are radical militants or Hollywood celebrities. By refusing to vaccinate, they stand with each other, and with these ancient, preventable diseases.
Seen in the stark light of the endgame and goals, “the right side” in the vaccination debate becomes quickly obvious.
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*Dr. Lawrence Loh is a global public health and family physician based in Vancouver. He serves as a Medical Health Officer at Fraser Health Authority and as an adjunct lecturer at the School of Public Health at the University of Toronto. A proud alumni of the Schulich School of Medicine at the University of Western Ontario, he completed his residency at the University of Toronto and obtained his Master of Public Health from the Johns Hopkins Bloomberg School of Public Health. He serves as co-founder and Director of Operations for The 53rd Week and is committed to reducing the harms and maximising the outcomes of short-term global health experiences through awareness advocacy, innovation, and research.
To learn more about what The 53rd Week is doing to improve short-term volunteerism abroad, visit www.the53rdweek.org