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