Between Hope
and Fear
A History of Vaccines
and Human Immunity
Michael Kinch
For My Parents, Sue and Frank Kinch,
for their inspiration and love and
for ensuring I was protected through immunization
Contents
Introduction
1.Pox Romana
2.Vaccination & Eradication
3.Becoming Defensive
4.The Wurst Way to Die
5.Spreading Like Viruses
6.A Sense of Humors
7.Lost In Translation
8.Breathing Easier
9.Three Little Letters
10.When Future Shocks Become Current Affairs
Epilogue
Endnotes
Acknowledgments
Index
Introduction
An underground conspiracy has been quietly targeting the scions of some of America’s most wealthy, accomplished, and educated families. The headline of the December 1, 2016 edition of a key mouthpiece of the elite, The Harvard Crimson, captures one example: MUMPS OUTBREAK GROWS TO 5, CASES SUSPECTED AT YALE.1 The article decried the growth of a disease that had already claimed dozens of victims at the vaunted Cambridge campus over the previous year. Otherwise healthy coeds were reporting to the health clinic in record numbers, complaining of a sore and swollen neck, malaise, fever, and difficulty swallowing. These were the textbook (though rarely encountered in the real world) symptoms of a disease known widely as the mumps (whose etymology reflects its Dutch ancestry for a word meaning ‘grimace’ or ‘whine’). As the infection progresses, some patients require intubation, and about one in ten cases progresses to a swelling of the covering of the brain, a sometimes fatal condition known as meningitis.2 As the number of cases at Harvard increased, reports speculated about the cancellation of the 2016 winter graduation ceremony and possible spread of the infectious disease to their rivals’ campus in New Haven. This broadening of the outbreak was a consequence of the Elis’ hosting of “The Game” (and an unintentional payback for the 21–14 loss handed to Harvard by their rivals just weeks before). The annual football matchup between Harvard and Yale recalls memories of raccoon coats and small bullhorns from a Jazz Age long since passed, but it might in the future be remembered as a turning point that foreshadowed the dramatic rise of a larger malady, which threatens to unleash not just one but a looming constellation of future pandemics.
Unlike most public health crises of the modern world, the affliction at the heart of this book is less likely to affect the blighted poor or dispossessed and more likely to plague the more genteel elements of society, which include individuals with the highest incomes, most prominent pedigrees, and advanced academic credentials. Nor are the symptoms being felt very far outside of the United States. While its roots are British in origin, the problem is manifestly American. The abilities to diagnose its symptoms were honed more than a century ago, but despite, and perhaps because of, the advent of the extraordinary scientific and public health breakthroughs of the late 19th and early 20th centuries, the newly minted physicians of the 21st century are less prepared to deal with the fundamental causes of this disease than their counterparts from the Jazz Age. These symptoms are indications long since written off and include measles, mumps, rubella, chicken pox, polio, bacterial encephalitis, diphtheria, and whooping cough. The disease itself is not these individual maladies, each of which is horrific in its own way, but manifests as a growing forgetfulness of the agonizing and terrifying ailments that have threatened man since time immemorial and are now returning en masse, often infecting an unwitting population that assumes they have already been protected.
The risk is not indeed any of these pathogens but instead reflects a knowing and intentional decision to avoid or delay vaccination against childhood and adult diseases. Many of the nation’s most elite, wealthy, and progressive minds suffer from a false sense of believing they have special insight into truth. They have knowingly jeopardized themselves, their children, communities, and their country by exposing them to life-changing injury and death. Worse still, we now know individual decisions not to vaccinate unintentionally triggered a backlash that collectively threatens all children and young adults, regardless of whether their parents chose to have them vaccinated. The decision to oppose vaccines blurs political lines, as evidenced by a Republican president of the United States calling upon a senior member of the Kennedy family to lead a forthcoming campaign against vaccines.3, 4
The rise of activism against vaccines is not a story of intended malevolence. Quite the opposite; the motives for avoiding vaccination are based on agonizing fears of a different spectrum of diseases, those associated with autism. Consequently, fears of a poorly understood disease rendered future generations susceptible to well-known and easily preventable disorders. This vulnerability has been greatly increased through the intentional fraud of one man, Andrew Wakefield, who has a dubious track record full of inaccurate research methodologies and error-prone data analysis. Although stripped of his credentials and discredited widely and repeatedly by the medical community, both for scientific and ethical lapses, Andrew Wakefield is but the latest symptom of a disease that has been manifest since a time even before the first vaccine was tested.
While the media has largely focused on a small subset of highly visible anti-vaccinators, the campaign against vaccination has rendered the entire American population, both those who have been vaccinated and those who have not, susceptible to a recurrence of common childhood diseases. Worse still, some preventable diseases that are merely annoying in young children can instead manifest themselves as life-disrupting and deadly diseases in older children and adults.
This book conveys a story of vaccine-preventable infectious diseases and the national and global implications of poor decision making, often by a relatively small number of highly educated and powerful elites. The title reflects a recurring theme in the book, which contrasts waves of discoveries of life-saving vaccines against a seemingly inevitable and irrational rejection by fringe elements in the public.
By blending an understanding of the scientific discovery with an evolving view of disease through the years, this book conveys the challenges posed by infectious disease and relates a story of unparalleled successes in vaccines that have raised both the quality and quantity of life for all people. The improvements have been so remarkable that many Americans have long forgotten or never experienced the dread that accompanied each seasonal cycle as different pandemic diseases accompanied changes in weather and interpersonal contact. For example, spring was associated with waves of chicken pox, summer with polio and whooping cough, autumn with mumps, and winter with measles and influenza, to name but a few. These diseases triggered not minor worries by parents about the need to take time off from work to care for a sick child but unspeakable horrors that could shorten or end their children’s lives. Paralytic fear of polio frequently emptied the swimming pools and summer camps of Depression-era America, condemning children to remain indoors and away from friends all summer for fear of contracting a disease that might otherwise sentence a child to a lifetime (albeit a short one) in the dreaded “iron lung.” Such anxiety persisted until the miracles of the 1950s, which witnessed the introduction of waves of seemingly miraculous vaccines.
To properly understand the impact of vaccines, it is necessary to recall the devastation wrought by infectious diseases before the invention of the vaccine. Going back as far as ancient Egypt, we rediscover the history of various infectious diseases, starting with smallpox. This disease shared the nefarious property of being both highly infectious and comparably deadly and likely killed more humans throughout hist
ory than any other cause. The early chapters convey the symptoms and transmission of smallpox as well as the personalities that both defined the disease and laid the groundwork for its eradication. The little-known events leading up to the discovery of the smallpox vaccine represent some of the more fascinating discoveries in the post-Renaissance era, sweeping away long-held superstitions. The characters involved in these discoveries are as interesting for their intrepidness, curiosity, and motivation to protect those they love as for their fundamental contributions to science or health. The 18th-century discovery of the vaccine laid the groundwork for a Herculean task two centuries later to utterly eradicate the disease from the planet, an achievement that arguably surpasses all other human achievements.
The early example of a smallpox vaccine provides a backbone to a larger story of a never-ending war against infectious diseases, a conflict as old as life itself. We evaluate the nature of our allies and enemies and the struggles against these opponents in a never-ending war. Our most important partner is a remarkably complex and adaptable immune system, a virtual organ comprised of trillions of individual proteins and cells that patrol the body in a manner nearly identical to the most sophisticated modern military organization, including the use of guided missiles and deadly forms of chemical warfare. This natural army within each of us evolved over the epochs of time to attack potential pathogens.
Counted as both friend and foe are massive numbers of microorganisms, including bacteria and viruses. As our understanding of these tiny pathogens has increased, so has our appreciation for the complexity of what it means to be human, as each of us is composed of more microbial cells and DNA than human cells and DNA. Most of the bacteria and even viruses we are in constant cohabitation with are benign and provide essential services. We are presently in the midst of an exciting renaissance, begun only within the past few years, of understanding ourselves afresh within the context of these interactions with our microbes. Accumulating knowledge reveals the essential roles microbes play in defining an ever-increasing array of “human” functions, from the most elementary roles in assisting the digestion of foods to regulating emotions and even personality. When these relationships go awry, as with any other relationship with an intimate cohabitant, a breakup or quick hookup with a new and different partner can spell disaster. Our knowledge of diseases caused by a misfiring microbiome is increasing, almost by the day, and includes obesity, heart disease, breast cancer, and susceptibility to various infectious diseases, the last of which remains historically the largest mass killer in human history.
The past decade has witnessed a dramatic uptick in the emergence of infectious diseases, not simply those caused by exotic pathogens such as the Zika or Ebola viruses but also those caused by familiar and preventable childhood pathogens. Rather than rising to meet this new challenge with existing and proven measures, the response, if any, has been lackluster. The airwaves are more likely to resonate with the concerns expressed by well-intended but misinformed big personalities, such as Jenny McCarthy or Donald Trump, both of whom embrace the “anti-vaccinator” movement. Likewise, a quick search of the local bookstore or web retailer is more likely to reveal long-debunked yet pervasive works glorifying disproven links between vaccines and autism or spectacular claims of conspiracy. The rising volume of vaccine denial, which tends to focus on the refuted link between vaccination and autism, has generated a self-propagating meme that has increased the tenor and virulence of conversation about the need for proper vaccination. The volume and advocacy of false facts by an obnoxious and loud minority has overwhelmed the fact-based attempts by credible sources to expound the extraordinary health benefits of vaccination.
Unfortunately, the scientific community has largely demurred from confronting these loud disagreements. Specifically, most scientists, physicians, and educators have been trained to objectively analyze data and reach principled and defensible conclusions and thus have correctly dismissed the call of anti-vaccinators as “crackpots.” A recent conversation with a key vaccine specialist about the vaccine denial subject elicited a typical response that this has been scientifically refuted and thus is no longer an issue. Despite the technical accuracy of such responses, the messages conveyed by the anti-vaccinators continue to resonate with the key demographic, including educated and affluent parents. The consequences of the failure to follow through with keeping current with childhood vaccination recently passed a tipping point that could threaten the health of our nation if not reversed. In fact, I was in part motivated to write this book upon learning of an outbreak of mumps at nearby University of Missouri. Similar outbreaks have been documented at Harvard, Yale, the University of Washington, and many other institutions over the past year.
I serve as an associate vice chancellor and professor at Washington University in St. Louis, one of the top five medical schools in the nation. As such I have been witness to and have been actively engaged in the science, public health, and policy implications of vaccine denial and the real-world outcomes of failing to vaccinate. Since earning a doctorate from Duke University as an immunologist, I have split my career between the biopharmaceutical industry and academia, most recently leading drug development at Yale University before joining Washington University in 2014. My responsibilities have included leadership of two of the world’s leading biomedical research centers, which share the responsibility of analyzing and supporting drug and vaccine research and development.
Prior to Yale, I lived in suburban Washington, D.C., working within its thriving biotechnology community. These experiences include leaving a tenured professorship at Purdue University to help guide a medium-sized biotechnology start-up by the name of MedImmune into a large biotechnology juggernaut of the industry. In 2006, I left MedImmune to take on the challenge of leading research and development for a start-up company focused on emerging infectious diseases. In this role my time was spent leading research and development of new medicines for diseases that were largely unknown to the public (at the time) but which we knew were percolating in the background, representing threats from nature and man (since a major focus of the company was bioterrorism, a subject addressed in this book). The primary focus of my work at the time was the Ebola virus, a pathogen that came to the public’s attention due to a natural outbreak in West Africa. My charge at this company also included the development of medical countermeasures for Marburg virus, Rift Valley fever virus, chikungunya virus, Lassa fever virus, dengue fever virus, and pandemic influenza viruses, all of which have been implicated both as bioterrorist weapons and as naturally occurring events. To paraphrase one of my former CEOs, a past head of the secretive Defense Advanced Research Projects Agency (DARPA), “Mother Nature is a most dangerous and inventive terrorist.”
During this same period, I was a witness to, and a reluctant participant in, a series of incidents that vaguely recall the situation with vaccines today. In the early autumn of 2002, while attending a company meeting, my administrative assistant quietly slipped me a note stating there had been multiple shootings in and around Silver Springs and Olney, two communities in northern Montgomery County, Maryland. These shootings were not far from my home outside Olney and the school where my daughter had just started kindergarten. Just after announcing the news to the team and dismissing the meeting, I found myself speeding towards my daughter’s school while radio news constantly updated the ongoing story of the shootings, which tracked ever farther northwards and nearer the elementary school. Tracking on a parallel course just to the west, I arrived at the elementary school, ran to its front door, and was confronted with the terrifying reality that the school appropriately was subject to a lockdown. Standing alone in such a prominent and exposed place created an exceptional vulnerability. After a frantic spate of door knocking, I was eventually recognized as a parent (and not a sniper) and let in to fetch my daughter.
Over the next three weeks, the D.C. sniper attacks riveted the nation. An early lead in the investigation surfaced from a witness in Silve
r Springs, who noted a late-model white box truck near the first shooting.5 Later witnesses of other shootings, both on that fateful first day and thereafter, confirmed the presence of a white box truck at the time of each shooting. Within hours, the entire Eastern Seaboard was actively seeking (or avoiding) white box trucks. Anyone living in Montgomery County during that time can recount stories of loading groceries or refilling gas tanks, when the appearance of a white box truck triggered a duck-and-cover instinct or the famous zig-zag walk, both of which became almost ritual practices meant to avoid being the next victim of “the sniper.”
With hindsight, we now know the conveyance for the snipers (you may recall there were two, not one) was not a white box truck but a dark blue 1990 Chevrolet Caprice sedan (about as different a vehicle from the suspected white box truck as one can imagine).6 As much angst as the sudden arrival of a white box truck had triggered in the Washington suburbs in that autumn of 2002, it must have been even more troubling for the many legitimate drivers of white box trucks, as the news and traffic reports of the day were replete with stories of countless vehicles pulled over (snarling the already atrocious traffic of the Beltway) and drivers interrogated by nervous officers at gunpoint.
From the first moments of the attack, the idea that a white box truck was responsible for the sniper attacks was burned into the minds of well-intended witnesses all throughout D.C., the Eastern Seaboard, and nationwide. The initial reports were corroborated by honest witnesses seeking to assist in the investigation. However, if anything, the “chatter” generated by such spurious leads only served to delay the identification of the correct vehicle. Indeed, the linkage of the snipers with the blue sedan provided the essential breakthrough that triggered the suspects’ arrest and abrupt conclusion of the crisis.
A similar phenomenon has occurred with the vaccine-autism link. In recalling the first time their child demonstrated overt symptoms of autism, many parents linked the disease with a recent vaccination, particularly when prompted to do so. However, pediatric vaccination schedules are about as ubiquitous as white box trucks in metropolitan Washington and about as relevant to the investigation of the causes of autism. Nonetheless, the belief in the vaccine connection is often staunchly defended and perhaps represents a tangible source for blame by frustrated and devastated parents. Such is the genesis of a challenge that has furthered the magnitude of the overall pain of autism by promoting an avoidance of vaccines in a misguided attempt to protect children. Instead, these choices have endangered not only their own children but also their friends, siblings, neighbors, and, if allowed to fester, quite possibly the entire nation’s health.
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