Vaccination in perspective

To understand debates over vaccination, it’s valuable to look at the history and politics of vaccine development and policy-making.

Australian government health departments and leaders of the medical profession are united in supporting the standard programme of childhood vaccines. Vaccination rates in Australia are high and stable. However, a small number of citizen vaccination sceptics continue to raise concerns.

In the 1990s, Meryl Dorey set up what became the Australian Vaccination Network (AVN), around the same time as vaccine-critical groups were formed in several other countries. Then, in 2009, some citizen vaccination proponents set up Stop the Australian Vaccination Network (SAVN), dedicated to discrediting, silencing and destroying the AVN. There has been a ferocious struggle between SAVN and the AVN. SAVN’s campaign was instrumental in politicians bringing in measures to pressure parents to have their children vaccinated, even though some pro-vaccination researchers opposed the measures.

            SAVN is strident in its advocacy, with the mantra “Vaccination saves lives.” AVN members, and quite a few others, remain sceptical. They continue to question the effectiveness of vaccination, raise the alarm about adverse reactions, and suggest vaccination may be implicated in diseases such as autism.

Both sides adopt the mantle of science, claiming the evidence supports their viewpoints. SAVN denigrates vaccine sceptics as deluded or ignorant. Some vaccine critics say proponents are in the thrall of the pharmaceutical companies.

In this highly polarised debate, there is little room for anyone to take an intermediate position, for example saying that many vaccines are worthwhile but others are unnecessary. However, this might well be the view of some parents, though they are given little support to express their views. Any reluctance about vaccination can lead to the stigma of being called an “anti-vaxxer.”

Immunization: How Vaccines Became Controversial

Stuart Blume is emeritus professor of Science and Technology Studies at the University of Amsterdam. He has a lifetime of experience researching the politics of science and technology, and two decades ago began studying the vaccination issue. His approach can be called social history: a study of history taking into account social and political dynamics. Blume brings to the issue the perspectives of science and technology studies, seeing science and technology as subject to social processes.

            Blume decided to write a book summarising insights from his research. The result is Immunization: How Vaccines Became Controversial, recently published. I wrote one of the endorsements on the book jacket.

There is much here to ponder. The book does not mesh neatly with either the pro or anti positions in the usual public debate.

Blume tells two sorts of stories, one about vaccines and one about vaccination policy, and neither is a just-so story. Many traditional histories present science as a continual upward trajectory of discoveries and the overcoming of misguided beliefs. Blume, though, follows the path of historians of science who report on uncertainties, mistakes and unproductive paths. The implication is that present knowledge may be just as precarious, in its own way, as past knowledge.

Knowledge about vaccines and the immune system developed gradually, and for many decades there was no assumption that vaccination would prove to be a major route to public health. Smallpox was the initial target for vaccination, but there were many other killer diseases, such as diphtheria and tuberculosis, and other ways to address them besides vaccination. Today, with the focus on vaccination, it is sometimes forgotten that infectious disease can also be addressed through quarantine, sanitation, improved diet and general increases in the standard of living.

Vaccination campaigns are not always the best strategy to improve health. Blume highlights a problem with the polio eradication campaign. In a number of poor countries, resources for public health interventions were siphoned off to support polio eradication, which meant that impoverished people, needing basic medicines, were instead offered polio vaccinations, something less important for their own health.

A related tension permeated vaccination development beginning in the 1980s, when commercial considerations became paramount. Effort was put into developing vaccines for problems in affluent countries, where money could be made, while major illnesses in impoverished populations were left unaddressed.

Stuart Blume

            Blume notes that vaccination is often treated in isolation, as a special method of promoting public health, and not compared with other methods. To counter this tendency, he presents vaccination as a technology, in the broad sense of a set of techniques and artefacts, that can be compared to other public health technologies such as sanitation. He sees vaccination as a socio-technical issue, as having both scientific and policy dimensions, and as shaped by social, economic and political influences in both these dimensions.

Blume addresses vaccines separately, rather than as a group. As a result, he does not make a universal judgement about vaccination, as a good or bad thing. In these ways, Blume offers a different perspective than the one taken by most of the campaigners for or against vaccination.

One of the peculiarities of the vaccination debate is that nearly all the disagreement is about whether vaccination is beneficial or harmful, for example whether it has led to declines in infectious disease or whether there are significant numbers of adverse effects. Seldom are comparisons made with other ways of improving health, in particular children’s health, for example addressing poverty. Blume notes some of the disagreements about early vaccines.

As many infectious-disease killers were brought under control in western countries, while others such as HIV were proving too difficult, vaccine developers turned to other diseases, seeing opportunities for profits. Blume writes that the rise of neoliberalism led to significant shifts in the rationale for new vaccines. Whereas previously companies and scientists had freely shared information and vaccines in a common commitment to public health, from the 1980s onwards the pharmaceutical industry became more dominant and less public spirited.

Government health departments in different countries responded to industry pressure in different ways. It became more common to use cost-benefit analysis, especially given that many new vaccines were highly expensive. Health departments sometimes approved new vaccines without as much evidence as they might have required earlier.

            Cost-benefit analysis is not a good way to promote vaccines to the public. In several cases, notably measles and mumps, companies adopted a “rebranding” strategy to convince parents that diseases they had known as a routine and unthreatening part of childhood were actually killers to be feared and thus protected against using vaccines.

Blume believes that vaccines have saved millions of lives. Yet he is also sceptical of many of the latest vaccines, developed not as part of a public health agenda but by pharmaceutical companies whose primary aim is profit. Furthermore, there are dozens of new vaccines under development, many of them targeted at non-infectious diseases such as breast cancer.

Vaccination seems to have become a single-method solution for health problems, overshadowing primary health care that addresses the conditions that cause disease in the first place. Think how much easier it is to sell a vaccine than to address poverty and inequality, or illnesses due to industrial chemicals.

Vaccine hesitancy

For many readers, the most interesting part of Blume’s book will be the final chapter in which he addresses current anxieties about vaccination, especially in the west. He dismisses the idea, common among vaccination promoters, that the source of the anxieties is vaccine-critical groups such as the AVN. Sociologically, this explains neither the existence of the groups nor their alleged influence. It is like saying the reason people are concerned about economic inequality is because of protesters.

Blume cites research into the attitudes of parents that suggests something deeper is at play. Rather than dividing people into vaccine-acceptors and vaccine-refusers, Blume addresses a widespread vaccine hesitancy that affects many parents, especially well-educated ones, even when they adopt all the standard vaccinations.

Rather than vaccine-critical groups being the cause of vaccine hesitancy, it is better to understand them as a result of changed perceptions. Blume says vaccination has, for many people, become symbolic of a more general unease and sceptical attitude about the role of pharmaceutical companies and the medical profession. He notes that the usual survey research carried out by vaccination proponents can pick up demographic variations in parental concerns but does not get to their source.

It is perhaps relevant that citizens have no say in the development of vaccination recommendations, and even politicians are usually left out of the picture, as decisions are made by international organisations subject to corporate lobbying. This does not mesh well with people’s increasing knowledge about health matters. The experts might be right but nonetheless be distrusted.

Immunization: How Vaccines Became Controversial provides great insight precisely because it eschews the easy generalisations made by vaccination partisans. Vaccine development was not a straightforward linear process, and vaccination policy has been subject to a variety of influences. Vaccination is usefully seen as a technology, as just one of several approaches to promoting health, and thus judged in a wider context than a narrow calculation of benefits and risks. The contemporary vaccination debate is not just a matter of pro and anti, but should be seen in the wider context of attitudes towards social institutions and citizen participation in decision-making.

Blume does not offer easy answers, but more usefully points to the complexities and contradictions in the history and social dynamics of vaccination. It is essential reading for anyone who wants to get beyond the usual partisan positions in the vaccination debate.

Brian Martin

Opiate addiction in a market economy

In the US, there has been a huge increase in deaths from heroin overdoses. Why?

In the past two decades, opiate use in the US has soared, and so have deaths from overdoses. The amazing story explaining why is told by journalist Sam Quinones in his 2015 book Dreamland: the true tale of America’s opiate epidemic. Quinones spent years interviewing users, parents of users, drug dealers, researchers, police and others. Dreamland is fascinating reading, telling the stories of individuals and communities caught up in the opiate epidemic.

There are two parallel stories involved, involving legal and illegal drug use. The legal side concerns painkillers. US doctors have long used morphine as a painkiller, but only as last resort because of the risk of addiction. Then came the “pain revolution,” during which opiates became acceptable and often prescribed in ever-increasing amounts.

The change in attitude was driven by commercial considerations. The company Purdue Pharma developed a time-release opiate pill, gained government approval for its sale and embarked on a massive marketing campaign to win over doctors. A key part of the sales pitch was that because there was no euphoria from an immediate hit, the drug was hardly ever addictive. To back this claim, Purdue representatives referred to an obscure publication.

Quinones found that doctors went along with these claims, with no one bothering to look at the publication. Its authors had forgotten about it and didn’t know it was being used to justify massive opiate prescribing. (Like Quinones, I’m not distinguishing between opiates and opioids.) As it turned out, the claims about there being little addictive capacity were wrong.

The marketing pitch was that if someone has pain, prescribe Vicodin or OxyContin, and if the pain continues, up the dose. Before long, huge swathes of the population were seeking prescriptions. Some unscrupulous doctors set up pill dispensaries, writing scripts for anyone who asked. Users would get their prescriptions filled at a low price subsidised by the government and sell portions to others to maintain their habit. At these dispensaries, lengthy queues would form of people waiting for their drugs.

The areas of the country most affected were those where the economy was in decline, so many residents faced bleak times. Quinones tells about small and mid-sized towns in Ohio and neighbouring states, subject to deindustrialisation and despondency about civic pride and public life. Addiction took hold, but it took a while before authorities realised the scale of the problem. One reason was that the parents of those most affected were ashamed to admit their son or daughter was an addict. They were white middle class.

The Mexican connection

In the small Mexican state of Nayarit, poppy seeds grow abundantly. Boiled down, they form a sticky substance called black tar. It is heroin. Some entrepreneurs from Nayarit came to the US and began building a heroin franchise operation. It was like nothing before.

Previously, most heroin imported to the US came from Asia, especially Afghanistan, brought in through New York and distributed by gangs. This heroin was often cut, namely adulterated, as it moved down through the distribution chain. Many small-time dealers were themselves addicts; dealing is a way of making money to support a habit. The heroin business is highly profitable, leading to violence between operators and drawing the attention of the police. It is devastating to poor inner-city areas, especially black neighbourhoods.

The Nayarit entrepreneurs developed a different model. They brought in poor young men from Xalisco, a small city in Nayarit, who were willing to work at low pay in the US because the alternative was backbreaking work on sugar fields at even lower pay. These young men were paid a wage, so they had no incentive to adulterate the heroin they delivered. Furthermore, they were not users themselves. They lived in barren apartments and were given old cars to make deliveries. After a few months they were sent back to Mexico.

            The Nayarit entrepreneurs had several rules. They did not use violence and did not carry guns. They sold only to whites, as this was considered far safer. And they marketed only in areas where the previously established heroin operations were absent, such as Portsmouth, Ohio.

The Nayarit operators used a pizza-delivery model. They prepared black tar in carefully measured amounts tied up in balloons. They would hand out a mobile phone number to prospective users. When they received an order, a courier (one of the boys from Xalisco) would drive to the location with balloons of black tar in his mouth and spit out the appropriate number, for example two balloons for $40. It was high quality heroin provided promptly and reliably. For white addicts, this was enticing. There was no need to go to a seedy neighbourhood and negotiate with addict sellers.

            The operators would check in with their clients to ensure service was satisfactory, calling to ask whether the courier was on time and provided the goods. If a client didn’t call for a few days, the operators might ring and ask if there was a problem. They would lower prices to build their clientele, and sometimes give out free samples to win favour.

            If police pulled over a courier, he would swallow the balloons. Initially, police sent couriers back to Mexico. They were replaced within days. Later, some courts sent couriers to jail with long sentences. They were replaced too, with little interruption to business. Xalisco seemingly had a bottomless reservoir of poor young men willing to take chances to make money. Their reward was to impress their friends and families back home by taking them to expensive restaurants and building nice houses.

The Nayarit heroin operation happened to expand at just the time that opiate addiction was dramatically expanding due to sales of painkillers. For example, a high school football player might be injured and given OxyContin for the pain, developing an opiate habit. To maintain the habit, it was easy to switch to black tar, provided so conveniently.

The first major signal of this emerging opiate problem was deaths due to overdoses. A few individuals, in different parts of the US, started expressing concerns, but it was difficult to gain attention due to the pain revolution and the low profile of the black tar distribution operation. It was striking that the death were not blacks in big cities but whites in small towns. In many cases, parents did not know their children were addicted until they overdosed and died. The parents included politicians, doctors and judges. So why didn’t they speak out? The reason, according to Quinones, was shame. In white suburbs, heroin addiction was stigmatised as something happening somewhere else, to a different class of people. Many parents made up false stories about how their children had died. So it took a while before a few courageous parents started speaking out, raising the alarm.

Drugs and profit

In the US, there has been a so-called war on drugs since the 1930s, when federal authorities began a scare campaign about marijuana, whose use then was concentrated in immigrant communities. Illegal drugs were demonised. Meanwhile, legal recreational drugs, notably tobacco and alcohol, were massively advertised. Then came pharmaceutical drugs, also massively advertised.

            Drug issues are difficult to summarise briefly, especially because government pronouncements, media reports and advertising have cemented in certain attitudes. A simple contrast is between a policy of harm minimisation and one of regulated markets.

Markets are never “free,” but are shaped by government regulations, cultural expectations and social values. In the US, regulations enabled the profit motive to foster addiction and destroy communities.

The company selling legal opiates, Purdue Pharma, ended up making billions of dollars per year on the back of a massive marketing operation based on the claim that time-release opiate painkillers were hardly ever addictive. Profits drove the rapid expansion of use.

Making addictive drugs illegal is a different way to regulate a market. The trouble is that when the demand is inflexible, and alternatives are less enticing, this creates a strong incentive for organised crime. The result, often, is distribution via gangs, reliance on violence and corruption of the police and other authorities.

What is fascinating about the Xalisco distribution network is that it offers a different model for success in selling illegal goods: agents paid a salary rather than a commission, provision of high-quality service and goods, and avoidance of violence.

The US model for dealing with drugs has been disastrous for the people there and in the rest of the world. Tobacco is the world’s most damaging drug, and it was entrusted to large corporations with a huge incentive to expand sales. Alcohol is another damaging drug, again promoted heavily. Then there are pharmaceutical drugs, including morphine. Meanwhile, making some drugs illegal created different sorts of markets. The US war on drugs has contributed to corruption and the world’s highest imprisonment rate.

Quinones does not engage with arguments or efforts for law reform or a different way of managing drugs, instead simply telling the story of the different players in the US morphine/heroin saga. A compelling treatment of the US war on drugs is Johann Hari’s book Chasing the Scream.

In the US, there seems no end in sight for the toxic relationship with drugs. If ever there was a case for moving away from profit as a driving force, this is it.

There has been one good result. Overdose deaths in white middle-class areas have changed the attitudes of some politically conservative communities and politicians, creating more understanding and sympathy for opiate addicts. Perhaps there is some hope for change.

Sam Quinones

PS In recent months there has been some media coverage of opiate addiction problems in Australia.

Brian Martin