Abstract
No man is an island entire of itself; every man
is a piece of the continent, a part of the main;
if a clod be washed away by the sea, Europe
is the less, as well as if a promontory were, as
well as any manner of thy friends or of thine
own were; any man’s death diminishes me,
because I am involved in mankind.
And therefore never send to know for whom
The bell tolls; it tolls for thee.
Meditations XVII Devotions upon Emergent Occasions, John Donne
According to the World Health Organization, measles cases have been rising around the world because parents are shunning vaccines. Around 173,000 cases were officially reported last year and the true number of cases is estimated at being almost 7 million. Approximately 110,000 people, mainly children, died last year from this vaccine-preventable disease and measles transmission is now occurring in countries that have not seen it for many years. We know from history, not least that of the voyages of captain Cook in the Pacific, of the devastating impact that measles can have in previously unexposed populations, with the decimation of the Hawaiian population in 1778.
As a doctor coming from a generation that routinely experienced most of the childhood infections in the early 1950s, and that has lived through one of the most remarkable public health interventions in human history, I am not alone in regarding this latest manifestation of apparent irrationality with frustration. Our parents had all too often to stand by and witness the awful toll that was routinely extracted from families by these diseases but which miraculously waned during the halcyon years of scientific progress and health services development that followed World War II.
Yet some clues as to what might happen could have been found from the earliest attempts to implement vaccination following Edward Jenner’s experiments and insights with cowpox in 1796. Jenner’s efforts to promote vaccination against smallpox using pus from the cowpox blisters of agricultural workers soon ran into opposition, not just from the church where it was seen as being against nature and intervening in the divine will, but also from the medical profession where it was seen by some as potentially taking the bread from their mouths. This irrational side to human nature has since been evidenced time and time again, whether with regard to vaccination and immunisation or other prophylactic measures which involve invasive procedures, however slight and safe, on apparently healthy populations. Well-publicised examples have included the polio vaccine and, more recently, the measles, mumps and rubella vaccination and the use of fluoride in water to prevent dental caries.
There is a story about two men travelling in a train in Africa, one of whom starts throwing powder out of the window; his companion asks him what he is doing. ‘Throwing powder to keep the elephants away,’ explains the first. ‘But there are none,’ says the second. ‘There you are, it works,’ comes the response. Part of the problem is making the seeming invisibility of prevention, visible; this requires imagination and creativity together with leadership and the effective delivery of services. A powerful way is through the telling of stories and through vivid metaphors such as that about the two men on the train in Africa. The alternative is to wait for a public health disaster to shake up the inertia and the forces of darkness.
Early setbacks with polio vaccination, prompted by cases that resulted from inadequately attenuated vaccine in the United States, led to public resistance to the vaccination programme. By 1958, only 53% of children in England and Wales who were eligible for inoculation had received the vaccine. It took the 1959 outbreak and the death of footballer, Jeff Hall, the 28-year-old Birmingham and England right back, to pull the nation to its senses. Diagnosed with polio two days after playing in the 1–1 drawn match between Birmingham City and Portsmouth, Jeff was dead within two weeks. In the days after his death, clinics nationwide reported lengthy queues and by mid-April there was a national shortage of vaccine with extra supplies being flown in from the United States. This proved to be a tipping point in achieving population coverage.
Most commentators attribute the contemporary retreat from vaccination to the now discredited anti-vaccination activist and former doctor, Andrew Wakefield. Wakefield’s claims, in 1998, that there was a link between the measles, mumps and rubella vaccine and autism and bowel disease had been given added credence by his publication with colleagues of an apparently scientific paper in the Lancet. This provided fuel for the miscellaneous coalition of anti-vaxxers internationally and set back the cause of vaccination by several decades.
In September 2013, a mumps outbreak of 66 clinical cases at a boarding school in the North of England was a straw in the wind. It drew attention to the toxic mixture of middle-class rejection of vaccination with the threat posed by particular closed environments where students were sleeping in communal dormitories. Subsequent work by the Boarding Schools Association also revealed the unsatisfactory situation to be found in many such schools with a lack of shared child health protocols, often poor links with the National Health Service and the failure to identify a specific person at board level to take oversight of school health issues. An additional element was often the poor knowledge of the immunisation status of students coming from overseas and the lack of systematic catch up initiatives. Since then, there have been a series of episodes with a large outbreak of measles centred on Swansea in South Wales involving hundreds of cases. However, it is only since the 2013 National Health Service reorganisation that systematic deterioration of vaccine coverage levels seems to have occurred across the country.
With recent falls in the uptake of other preventive programmes, including bowel, breast and cervical cancer, and aortic aneurysm, what is indicated is the fragmentation and weakening of the arrangements for public health and especially the links with the NHS, since the move of Directors of Public Health to local government. That it does not have to be like this is shown by the recovery in the measles, mumps and rubella vaccination in the north-west of England, with one of the strongest local public health systems and visible public health leadership, to herd immunity levels following the initial Wakefield dip.
Taken together, these various happenings can be seen as a potential disaster in the making. As with most disasters, in this case one best described as ‘slow burn’, there is a convergence of factors which in retrospect result in events that seem inevitable. In his book The Tipping Point, Malcolm Gladwell proposes a model for the take-off of fashion or trending social phenomena that identifies influential individuals (in this case, a charismatic doctor), running with an idea with a certain ‘stickiness’ and a congenial environment (in this case, primitive and magical thinking together with scepticism, the rise of individualism and a breakdown of trust with professionals and establishment organisations; arguably this is not helped in the United Kingdom by the anachronistic education system in which a large proportion of future leaders have no scientific exposure after the age of 16 years).
For the Danish poet, Piet Hein ‘problems worthy of attack prove their worth by hitting back’. The relevance of this insight to childhood infections should be clear; this is supported by recent outbreaks among religious and other groups who have taken oppositional stances to vaccination. That their beliefs should not be allowed to impact on the rest of society is now coming into sharp relief with calls for vaccination to be made compulsory in many countries. In Dubai, legislation has already been introduced and in Germany parents face fines of up to 2500 Euros if they fail to have their children vaccinated against measles. With over 900 cases of measles over the last 12 months in Britain, such action is now being mooted by England Secretary of State for Health, Matt Hancock, together with a ban on anti-vaccination posts on social media. We know from other situations where individual and collective rights come into conflict that culturally we have difficulty with such situations. It is probably best that we should first resolve the organisational and institutional factors, not least the current weaknesses in our public health delivery system, before resorting to the legislative option. Reinstating the prime role of local Directors of Public Health in providing visible leadership should be a priority.