The anti-vaccination movement goes back more than 150 years: its history holds lessons for today

To be clear: when there’s a new vaccine, I’m the first in line, with my sleeve already rolled up. I’ve had a lot of diseases I wish I had been vaccinated for: measles, mumps, rubella (or German measles), chickenpox, influenza H1N1 (just before the vaccine was available), and pertussis (childhood vaccine must have worn off). So if you read the title and you’re looking for confirmation of anti-vaccination views, you’re in the wrong place.

Until recently, my view of vaccination was the standard one that I read in the Canadian Medical Association Journal when I was working there: humanity was plagued by terrible illnesses; Edward Jenner discovered vaccination in 1796; smallpox has been wiped out; we’re working on the other ones. The end.

IMG_0809But my view changed last month. It started with a book I found among my parents’ collection, called Man’s Redemption of Man by Sir William Osler, who basically invented modern medicine at McGill and Johns Hopkins universities. It was the text of an address he gave at the University of Edinburgh in 1910. He said, “A great deal of literature has been distributed, casting discredit upon the value of vaccination in the prevention of smallpox… Some months ago, I was twitted by the Editor of the Journal of the Anti-Vaccination League…” Whoa, whoa. There was an anti-vaccination movement in 1910? They had a journal?

I began to read about the history of the anti-vaccination movement. And I discovered the following, which I didn’t know and I bet many of you didn’t know either:

  • The anti-vaccination movement was born shortly after the discovery of cowpox-based vaccination for smallpox.
  • At the time, no one understood how vaccination worked, least of all its discoverer Edward Jenner, simply because doctors didn’t yet understand what caused diseases.
  • Compulsory vaccination was enforced in many countries on an unwilling populace.
  • Many children died as a result of vaccination, mainly, it seems, because of infection of the cowpox blisters with bacteria such as strep.

I started with Bodily Matters: The Anti-Vaccination Movement in England, 1853-1907 by Nadja Durbach (Duke University Press, 2005), an academic study of the birth of the movement. As Durbach shows, the early rollout of smallpox vaccination in its home country was a public policy disaster.

During this period, people tended to practise folk healing using herbs. Only well-off people had ever even had a physical exam by a doctor. Nobody really understood how illnesses happened, or that one illness was spread in a different way than another, so people blamed “filth” and “miasma” (bad smells from sewage and swamps). Some people thought that quarantine and isolation were a good way to prevent disease spread, but others experienced serious stigma from a disease “placard” posted on their house and tore the placards down. Medicine and physicians were just becoming a scientific, regulated practice and profession, and trying to stake out territory among a suspicious population. Civil liberties were a strongly held concept, and citizens defended their freedom to make their own choices. Working people had acquired a basic education and started to complain about how they were treated, at the same time as public health officials saw them as the source of “filth” and contagion. Into this morass came a smallpox epidemic, and the first compulsory vaccination law in 1853.

At a certain point in this story, I started seeing the situation from the parents’ point of view. They didn’t know what caused smallpox, or how this vaccine worked. Public health officials literally broke down their doors and attacked their children with a lancet, often causing wounds in several places. And a percentage of children died of after-effects. Other parents heard these stories. Talk in the streets was that the vaccine came from cows or the grease on horses’ hooves and would turn your baby into a cow-monster. While parents were used to a certain risk of child mortality, attributed to God’s will, they were afraid of an unproven, manmade “operation” that they couldn’t control. One man who was convicted said he would pay the fine rather than have a baby vaccinated, as a previous child had died as a result of vaccination.

I can see it. If you feel there is a risk of losing a child, you don’t care much about the greater good of society.

At the same time, middle-class protestors opposed vaccination on the grounds of civil liberties and often conflated it with opposition to vivisection. They felt the government was conducting a huge experiment on the population without consent.

Did the officials allay parents’ fears and provide them with reassurances? Somewhat in the public press, but not in the actual encounter, which looked like state oppression to the working people targeted by the law.

So the whole thing got mixed up in class perceptions, the role of the state and civil liberties.

Which brings me to the anti-vaccination riot in Montreal in 1885. Quebec was in the middle of smallpox epidemic that ultimately claimed around 3000 people in the city and around 2500 in the rest of the province. As Michael Bliss documented in his excellent book Plague: A Story of Smallpox in Montreal (HarperCollins 1991), the anti-vaccination movement had come to Montreal as well. Top doctors were divided on the effects of vaccination, and there was a rough division by ethnic group and class, with working-class francophone people targeted for vaccination and defended by francophone doctors who treated them. Newspapers and employers urged compulsory vaccination, but many Catholic priests and a few influential intelligentsia argued against it. On September 28, a crowd of men and boys pelted an East End health office with stones, breaking windows. They paraded around the city, breaking windows of pharmacies that handled vaccine. They also converged on the private homes of a member of the provincial board of health and an alderman who promoted vaccination. They called out “Down with vaccination!” The same day, 79 people died of smallpox.

Back in England, a royal commission on vaccination sat for seven years before recommending, in 1896, exemptions for “conscientious objectors.” Once this was introduced into law two years later, much of the wind slowly went out of the anti-vaccination movement. It had, in fact, won.

But the movement has flared up again with each new vaccination, as you can read more about on the History of Vaccines, a fascinating site created by the College of Physicians of Philadelphia.

Why does anti-vaccination keep coming back? Can this history teach us anything?

Most countries do not make vaccination compulsory or punish objectors, because governments have learned that that does not work. In fact, it backfires. But in Australia, the government has withheld social payments from parents who do not vaccinate their children since January 2016, fanning an anti-vaccination movement. The measure also targets people on welfare, repeating the mistake of treating the poor as a reservoir of disease.

What does work is education — about the causes of disease, about how vaccines work, about the real but rare risks involved in vaccination. And about the real risks of disease.

I think the cause might also be aided by admission that “mistakes were made” in the past and that today’s scientific and ethical oversight prevents the gross excesses of early vaccination.

In most communities, parents weigh the benefits against the risks of vaccination and opt for vaccination. There is also peer pressure to vaccinate children as the right thing to do for their health.

But I wonder how many people remember their parents or grandparents speaking against vaccination and are influenced by that history. How many are still fighting a 150-year-old fight for what they see as their liberty?

Where will the next pandemic come from?

You know how “pandemic” is just a word until you’re in bed delirious, feverish, shaking with chills, as one day blends into another? This was what happened to me in the fall of 2009. Unfortunately for me, I had been in hospital for routine surgery at the end of September. The nurse working closely over me a day or two after the surgery suddenly said, “Oh, I don’t feel good.” I told her to go home, and she vanished, but, sure enough, the next day I started feeling sick. The nurses figured I had caught a cold, and I was discharged. Once I was home, the fevers started. My husband took me to the hospital when I complained my chest felt weak. After many hours in an isolation room, I got a chest x-ray and a shot of toradol (which helped). The doctor told me they weren’t taking blood samples any more, as all influenza was coming back H1N1. She gently told me I had a mild case. I told her I had never been sicker from “just” influenza in my life. She told me cases were considered mild if the patient could breathe.

With this personal reason to take an interest, I became fascinated by the response to H1N1.

Remember, with avian influenza popping up occasionally and SARS a recent memory, there had been a huge amount of public health work on the possibility of a pandemic. But a lot of it was based on likely scenarios – a serious influenza, discovered in Asia, spreading rapidly around the world through person-to-person contact and international travel.

The big problem with epidemics is that they are unpredictable. They might be caused by any type of pathogen: bacteria, virus, prion, or something completely new. Existing pathogens might suddenly become deadly: SARS and the new coronavirus (which I recently wrote about in the Canadian Medical Association Journal) are from a virus family that normally causes “colds.” And pathogens can come from anywhere on the globe. While avian influenza (see my article on the new avian influenza virus in CMAJ)and SARS came from southeast Asia, H1N1 was first found in Mexico. The novel coronavirus is emerging in the Arabian peninsula.

Each pathogen has its own way to spread: food-borne, air-borne, water-borne. Some, like influenza, are incredibly contagious; SARS is less so. There is an inverse relationship with lethality and incubation: illnesses that strike quickly and kill many tend to disappear, for obvious reasons – the hosts don’t have time to spread them around. Instead, diseases with a 100% death rate (like HIV before recent drug regimens) tend to have a long period of incubation and illness; those that strike quickly like influenza have lower death rates.

Unlike H1N1, for most pathogens there are no vaccines. There is very good work being done on vaccines for certain pathogens. However, the development path for a vaccine is a long one, and often involves academic, public and private sectors.

Given this uncertainty, coupled with the unprecedented rate of international travel and the lack of strong public health systems in many countries, the chances of more pandemics during my lifetime are high. The worst-case scenario is an epidemic in a region that has remained off the international surveillance radar that simmers and flares up in the absence of a public health response. If it has a long incubation period (allowing travellers to take it around the world), a high death rate, and no vaccine, we’re in trouble.