What the history of medicine informs us about a coronavirus vaccine.
Discovering a vaccine may not be our only hurdle.
Leicester:
In March 1885 during a global pandemic, up to 100,000 people (out of a city population of just below 175,000) took to the streets of Leicester, England.
The cause they protested against? Vaccination.
Smallpox was an extremely contagious, deadly disease that plagued society for thousands of years. However, in 1980, after extensive immunisation programs, it was (the first and only infectious disease) declared eradicated by the World Health Organisation. Studies show that without its eradication, there would be roughly five million deaths per year across the globe. This means since 1980, two hundred million lives have been saved.
In the UK, our immunisation program started in 1853 when vaccination against smallpox became mandatory to all children born in the country. Along with this compulsion, however, came significant levels of opposition.
Leicester had an abnormally large anti-vaccination sentiment. Smallpox immunisation rates in the city were some of the lowest in the country. In 1886, Dr J. C. McVail commented that due to the large number of anti-vaccinators in Leicester, once an outbreak of smallpox occurred:
“there will afterwards be fewer children left to die from diarrhoea.”
To set some context, at the time of the Leicester protest, the vaccine had been present in the UK for over 100 years and its success in preventing the disease was well known. In 1796, 18% of total deaths in London were attributed to smallpox (this was the year the vaccine was introduced to the city). A year later, with increased immunisation levels, only 3% of total deaths in London were caused by the disease, showing a clear correlation between the introduction of the vaccine and reduced smallpox deaths. This data and knowledge was widely disseminated in the late 1800’s meaning anti-vaccinators at the time were either one of three things:
- Choosing to ignore the data,
- Being provided unreliable and inaccurate data, or,
- Had limited access to any data at all.
In order to counteract these issues, the local government abandoned vaccination altogether and instead adopted what was known as the ‘Leicester Method’. It involved a system of complex quarantining and reduced social interaction across the city; the predecessor to our current global “lockdown”.
India:
Similar issues of opposition to the smallpox vaccination arose in India.
India was for years the endemic focus of smallpox. In 1963, over 80 per cent of global cases and 75 per cent of smallpox deaths occurred in the country due to people not voluntarily getting vaccinated. As a result, a stringent mandatory vaccination programme was introduced. It was effective in eradicating smallpox, but resulted in various human rights abuses.
House raids, coercion, physical restraints and manipulation were all used to enforce vaccination on the population. It was common practise for the vaccination teams to break into houses during the night, pin people down in bed and forcibly immunise them. To add to this, the programme was never democratically debated within the country, meaning its civilians were subjected by foreign bodies. As Juran argues, the programme:
“can be seen as a dictatorial colonisation of the body.”
Two main lessons can be learnt from the smallpox vaccination programme in India:
- Mandatory vaccinations work – India went from the endemic focus of smallpox to a year after the programme starting, having just one case.
- Methods of encouraging voluntary vaccination also worked – medical officers found that discussing with women the benefits of vaccination and the dangers of not, far more children were voluntarily vaccinated. Financial incentives also proved to be effective.
COVID-19:
So what do these two case studies this tell us about a coronavirus vaccine?
If/when we discover a safe and useable vaccination, we need to have methods to deal with anti-vaccination sentiment. Even with a smallpox vaccination available in the United Kingdom, it took nearly 150 years for the disease to no longer be endemic in the country (admittedly, other factors were involved). This is even more pertinent in current times as opposition to vaccination has been on a upward trajectory ever since Andrew Wakefields (now completely discredited) study in 1998 linked the MMR vaccine to cases of autism.
To ensure a similar time-lag does not occur for coronavirus, there are various methods governments could adopt:
- The sharing of pro-vaccination information
- Providing financial incentives (as shown in India)
- Making vaccination not compulsory, but strongly advised – (a 2005 survey concluded that parents who oppose mandatory childhood vaccinations rarely oppose the vaccines themselves, but are against the compulsion).
- Active discussion on the benefits of vaccination with affluential members of society (eg, the women in rural Indian communities)
- In areas of high vaccination opposition, the use of the next best alternative (quarantine in Leicester)
These methods may aid in increasing immunisation rates within a country but governments also have to balance public health provisions with personal liberties; a severe lesson learnt from the Indian smallpox eradication programme.
Where do we draw the line? Only allowing the vaccinated onto public transport? Only allowing vaccinated children back into schools? Or enforced mandatory vaccination of the whole country, with the threat of criminal prosecution if you disobey? These are the questions governments need to be answering before the rolling out of vaccination.
Finally, as Juran argues, public health is such a broad field ‘that it is impossible for its measures to be universally welcomed by an entire population’. Following this logic, all methods used to fight COVID-19 will receive some level of opposition from the public. As simple as it is, governments need to ensure that the most effective public health measures (whether that be a vaccination, mass quarantining or lax social distancing rules), are implemented to save lives.
The aim of this article is not to predict the future, nor is it meant to be overlly negative on the prospects of a vaccine. It is designed to provide insight into how we can learn from the past and ensure it remains in history books.
