Allen: Vaccine

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Arthur Allen, Vaccine : The Controversial Story of Medicine's Greatest Lifesaver. New York : W.W. Norton & Company, 2007.523 pages with notes and index.

This is a rich and stimulating book. The story of vaccines and vaccination, from the earliest use by Edward Jenner in 1796 to most recent times is really several stories, each with its own failures, successes, and social context.

Americans had not been routinely vaccinated against smallpox for 10 years, and the vaccine had not been updated in any way. The inoculation Bush received [in 2002 when bio-terrorism worries led to vaccination of military personnel and some government officials] was little different in its technique from that first described by Edward Jenner, an English country doctor, in 1796. Vaccinia, which Jenner found growing on cows, was the "shot" that put the vacca in vaccination; Louis Pasteur gave the name vaccines to his concoctions against rabies and fowl cholera a century later in tribute to Jenner. Smallpox vaccination was one of the first successful medical interventions; because of it, smallpox became the first and only contagious disease ever eradicated. In a rare case of cold war cooperation, the Soviet and U.S. governments worked together through the U.N. World Health Organization marshalling thousands of medical personnel to chase down the deadly virus and administer the knockout blows of vaccine that quelled smallpox. Its defeat, in 1980, was the culmination of an era of passionate medical idealism; campaigns to eliminate other infectious diseases—malaria, polio, measles, and hepatitis B—came on its heels. [p. 12]

Rightfully, the first act belonged to the fascinating history of the smallpox vaccine, one that stretched over nearly 300 years from Jenner's first vaccination to the announcement of its eradication. When Allen writes that the inoculation was "little different in its technique", it's more similar than one might imagine. Vaccination has become almost symbol of modern medicine, shining laboratories and doctors in white coats, so it may surprise some to discover that smallpox vaccine even in the first half of the twentieth century was still produced by infecting cows and later harvesting the vital ingredient; the laboratory of one's mind was likely a farm in Pennsylvania. But today the vaccine arrives in little vials rather than one the hoof, as it once did.

The public's confidence in direct-from-cow vaccination was nowhere more vividly exhibited than in Paris. The French had a soft spot for Jenner, one of those rare foreigners—a Jerry Lewis of the nineteenth century---whom their nation showered with love. Pasteur would do Jenner the ultimate honor by naming his chicken cholera and subsequent attenuated viral concoctions "vaccines"—thus assuring that Jenner's genius would remain imprinted on our language. French vaccine distributors developed a remarkably open and direct system of bovine vaccination that, if nothing else, was entirely transparent. Upon learning that smallpox had broken out in a given neighborhood, Drs. Chambon and St. Yves Menard, the official Parisian vaccinators, would immediately cart a vaccinia-infected cow to the scene. When they reached the affected neighborhood in the Marais, say, or Belleville, the doctors set up a vaccination station in the courtyard of an apartment house, or in the street in front of it—a peculiar amalgam of the rustic and cutting-edge scientific. with all the street urchins watching.

"Occasionally, from want of space in the porter's lodge or other reasons, the calf, after being removed from the van, is allowed to remain in the street, its halter being held by an attendant, while another assistant, taking his seat on a camp stool, proceeds to collect lymph from the inoculated area of the animal's side and abdomen with the aid of clamp forceps and lancet," a British doctor reported from the scene. "Infants or adults are brought out into the street, and the extraordinary spectacle may be witnessed of vaccinations being carried out by the medical staff surrounded by an interested crowd of sightseers." During epidemics, people who might have objected to vaccination "from an unknown source, find all their objections ion this score removed when they actually see the calf which serves as vaccinifer." The sight of one of these placid, rather clean farm animals seems to have reassured Parisians, for whom c'est vache is an expression of endorsement. In one illustration from Le petit journal in 1905, a furry-faced cow with an expression of stoic contemplation submits to a mustachioed technician, who tweaks lymph from a shaven teat and hands it on a lancet to a doctor in a top hat. [pp. 62—63]

The new science fired the imagination and was not seen as a politically liberal or conservative issue. Early in the twentieth century, attitudes were different about public health initiatives.

The 1921 Sheppard-Towner Act, a piece of vintage Progressive reform, provided matching federal funds for states that funded health services for mothers and children. Herbert Hoover's 1930 White House conference on child welfare helped cement this intervention in what had formerly been considered family matters, as did the 1935 Social Security Act, which provided for an expanded national public health program. Private foundations were also increasingly involved in public health. The Rockefeller Institute for Medical Research had been established in 1902, and quickly acquired a reputation as the premier scientific institution of it s type in the world. Nobel prizes rained down on its scientists for discoveries on the nature of bacteria and viruses, cell biology, biochemistry, and anatomy. The Rockefeller Foundation and its International Health Board were created in 1913 to translate basic research into advances against infectious diseases that plagued America and the world.

Success brought publicity. In 1925, sled dogs managed to transport lifesaving toxin-antitoxin from Anchorage to Nome, where an outbreak of diphtheria had sickened children. Leonhard Seppala, the Norwegian driver of the run since immortalized in the annual Iditarod race, toured cities in the lower 48 the following year with 40 Siberian Huskies, including Togo, his big lead dog (Balto, who led the final stage to Nome, gained most of the celebrity, including several film portrayals and a statue in Central Park.) Seppala and the dogs mushed through Seattle, Kansas City, Dayton, Detroit, and Providence before reaching New York City, where the explorer Roald Amundsen presented Togo with a medal at Madison Square Garden. [p. 127]

The mention above of "attenuated viruses" tells us much about how vaccines are developed and why it can sometimes take so long to develop. The process is surprisingly Darwinian in action. Once a viral pathogen is finally isolated, then a culture must be found in which it can grow. Then begins a long string of trial-and-effort attempts to force the virus to evolve just a little bit so that it becomes markedly less virulent but still capable of provoking the creation of antibodies in a vaccinated individual. To accomplish this, various hosts are infected, sometimes in succession, to force the virus to adapt to new environments in the hopes of producing the suitable "attenuated" form. All of this can take time and consume significant resources.

The march of success for vaccination continued through the early decades of the twentieth century, culminating in the creation of the vaccine for polio, which made a celebrity of Jonas Salk, even though he was not the only researcher working on the problem, nor was his vaccine ultimately the most popular in the fight against polio. Conquering polio came at a different time, though, and public attitudes were starting to shift.

Throughout the interwar period, the depression, and World War II, polio plagued the cities. Its ravages were rarely on the scale of earlier epidemics, but its unpredictable spread was even more terrifying. Struggling with the medical mystery, the public tried to explain polio as the result of "unnatural" and "newfangled" aspects of modern life. Some theorized that flies on bananas, a popular new forod for children, were spreading the germ. Others became convinced that polio grew in the new store-bought wheat lour and bread, or was generated by electrical fields or auto exhaust. In a letter to the Rockefeller Institute, one concerned citizen contended that the digging required for New York's new skyscrapers was stirring up germs—a fresh gloss upon Sydenhan's "epidemic constitution." Or perhaps, others theorized, pasteurization ha removed something wholesome from milk that had protected kids from polio.
[...]
Polio was not the greatest killer of postwar America. It was not even the greatest microbial threat. The worst polio epidemic year in America, 1952, saw 57,000 cases, with 3,145 deaths and roughly 20,000 cases of permanent paralysis that could be mild to severe. That same year, by comparison, 24,000 people died of tuberculosis and 46,000 died of pneumonia and flu. In single years earlier in the century, diphtheria, whooping cough, scarlet fever, and even measles had each caused more death and disability. But in 1952 there were ways to deal with flu, tuberculosis, pneumonia, and other infectious diseases—vaccines, antibiotics, and quarantine measures honed by decades of experience. If you followed medical advice and made a concerted effort you might avoid the worst effects of these diseases. Polio, on the other hand, struck randomly among the rich and poor, from childhood into young middle age. It was an "un-American" disease that showed no respect for those living clean, wholesome, hardworking lives. Its mysterious arrival every few summers undercut the nation's sense of technological advancement. Polio cases multiplied in the 1940s and 1950s, and the National Foundation took every opportunity to publicize these tragedies, keeping the disease in the public's mind. [pp. 168—170]

Allen's book reveals that the history of vaccination is an ethical minefield, filled with dilemmas. Undeniably vaccination works to protect the larger society from the scourge of communicable diseases; undeniably, vaccination can be deadly to a few people who receive it. The response to the dilemma seems impossible, and which course is taken by public health official and how the public responds is complicated. Attitudes and policies continue to vacillate today.

Surely one of the biggest challenges facing the author of a compendious book like this one is how to pull together all the facts and bits of history that go together to make a coherent narrative. Allen does this with skill and keeps the story moving along quite nicely. I learned a lot from this book, and I actually enjoyed the process of discovering what would turn up next as I read. Allen shows us what the best in science writing can be. In the end, human interest can add spice to the story, but vaccines and vaccination are still the main character.

-- Notes by JNS