In the years since the United Kingdom’s bold embrace of this new project, the number and breadth of social impact bond projects have expanded to include multiple private, volunteer, and public-sector organizations. We propose herein that the framework of a social impact bond could be one means of addressing the growing need to incentivize new vaccines. Specifically, programs might be developed to build a pipeline of different projects that identify and reward organizations and individuals that meet predetermined goals in the development of much-needed vaccines. Had such a program been announced in the UK a few centuries earlier, the farmer Benjamin Jesty might have been rewarded with more than a painting and a letter of thanks for his development and testing of the first smallpox vaccine.
Clearly, governmental incentives and mobilization will need to be deployed for urgent and critical needs such as a regional outbreak of Ebola or global risk of pandemic influenza. Though lacking the speed of such public-sector deployments, the bandwidth of most governmental agencies (e.g., CDC and NIH) is limited and often must be reserved for meeting urgent and important needs. However, new mechanisms such as social impact bonds could be deployed to address other important needs such as the discovery and testing of improved mumps vaccines. Because the rate of scientific innovation in the discovery and understanding of infectious diseases has never been higher and is expanding to an exponential degree, comparable innovation and entrepreneurship in financial instruments and other incentives are needed if we are to stem the inevitable plagues that constantly loom over humanity.
We end our story where it began. Despite all the old and new infectious diseases that are being constantly unearthed, our greatest susceptibility may again reside in one of our oldest nemeses. You may recall from chapter 2 that the United States and Soviet Union each agreed to store a single vial of smallpox material, one in Atlanta, the other in Moscow, which could be used as a source for the future development of a vaccine. However, much speculation suggests that the smallpox virus may be far more widely dispersed.
In 1992, a Kazakh colonel of the former Soviet (now Russian) army requested asylum in the United States. This might seem an odd request, since the Soviet Union had ceased to exist a few years before and was not deemed a significant threat. However, American officials were quick to grant the Kazakh, Kanatjan Alibekov (now known as Ken Alibek), the protection he requested, since Alibek arrived with a story that even Ian Fleming might not have been able to concoct on his most creative days.
Alibek told his CIA handlers that he was an expert in military medicine who had risen through the ranks to lead an offensive bioweapons program for the Soviets and their Russian successors. Specifically, he had been tasked with creating both microorganisms and toxins that could be used as tactical or strategic bioweapons. Alibek then went on to detail descriptions of a bioweapons program that both utilized the wild-type versions of many deadly pathogens and fabricated novel variants to maximize their ability to kill and spread disease. Among the disease-causing pathogens that were weaponized during Alibek’s reign were smallpox and variants meant to overcome Western safeguards. Alibek quickly discarded his Soviet upbringing and embraced capitalism, penning a memoir of his exploits as a bioweaponeer and founding a company meant to counter the obnoxious agents he developed as a Communist.61
The stories conveyed by Alibek were terrifying and, to be frank, may not be entirely accurate. Questions about his motives and the accuracy of his statements remain. However, the potential and perhaps likelihood that the Soviets and Russians have maintained not just a biological weapons program but one that has utilized natural and engineered smallpox is truly terrifying. Since its presumed eradication, smallpox immunization is no longer performed, which renders the world more susceptible than it has been for decades.
Even if Alibek’s claims are revealed to be less than accurate, the risk of a resurgence of smallpox is not inconceivable. For example, global warming has begun melting areas that have for millennia been frozen. As a result, graves of smallpox victims, especially those in the permafrost, may be warming to the point where the frozen virus within could regain the potential to rise from the grave. Worse still, knowledge of the DNA sequence could be exploited to facilitate the laboratory creation of a Frankenstein-like virus that could wreak havoc on an unsuspecting world.
Regardless of its source, natural or otherwise, the possibility that smallpox might reemerge is a source of considerable concern for the United States and its Western allies. Compounding this are continuing reports that smallpox exists within arsenals developed by North Korea and Russia. The alarm triggered by such concerns has caused the US government to quietly advance smallpox countermeasures, which include the deployment of new vaccines, as evidenced by the 2007 FDA approval of ACAM2000, a vaccine that is managed by the Centers for Disease Control and Prevention and the Department of Homeland Security.62 The approval of ACAM2000 three decades after the last natural smallpox infection and the fact that it has been included in stockpiles maintained by the federal government lend credibility to the stories propagated by Alibek and others. These facts should serve as a reminder that we face dangers from infectious organisms, both old and new, which can only be contained or prevented using safe and effective vaccines. At a minimum, such realizations must force us to recognize that vaccines have saved countless lives and that we will continue to rely upon these miraculous substances to ensure that we avoid future public health calamities.
Illustrations
Portrait of Lady Mary Wortley Montagu, wife of the British ambassador to the Ottoman Empire and progressive thinker. Without the knowledge of her husband, she directed the embassy’s doctor to subject her son, Edward (pictured) to variolation and later became famous for advocating the practice in the United Kingdom.
A photograph of the hide of “Blossom,” whose minor infection with cowpox provided the material expanded by Edward Jenner into the first true vaccine that would save billions of lives. The hide hangs on the wall of St. George’s at the University of London (although its authenticity is suspect) and Blossom’s horn can be found at the Edward Jenner Museum in Berkeley, England.
“The Wonderful Effects of the New Innoculation.” An 1802 cartoon from the Anti-Vaccine Society promoting the idea that cowpox immunization would cause its recipients to acquire bovine characteristics.
Portrait of Guy de Chauliac, a low-born peasant who rose to become the physician of multiple Popes and the first to describe the rather unpleasant manifestations of “pus,” which helped revolutionize medicine.
Simple but sophisticated. Shown is one of the first microscopes produced by Antonie van Leeuwenhoek. Although seemingly inauspicious, the manufacturing process needed to craft the lens (shown towards the top of the device) went to the grave with its inventor, and required more than a century to be reproduced so that microscopy could become commonplace.
A whole new world. Using his simple microscope, van Leeuwenhoek catalogued the unseen, including his hand-drawn pictures of a sample of sperm that revealed the seeds of life.
A photograph of Louis Pasteur, who successfully tested the first vaccine against rabies and went on to direct or inspire the creation of a remarkable number of vaccines in the late nineteenth century.
A photograph of Joseph Meister in 1885, months after he was bitten by a rapid dog and successfully treated by Louis Pasteur and his Paris team. Meister remained employed as a caretaker at the Pasteur Institute until his tragic death during the German occupation of Paris in 1940.
A 1905 photograph of Felix d’Herelle reveals the intensity of the individual, who would later discover the first viruses that infect bacteria and went on to become an entrepreneur intent upon commercializing his discoveries around the world.
A dignified Emil von Behring, around the time of his receipt of the first Nobel Prize in Medicine, discovered antisera (later known to be comprised of antibodies) and led a team of Berlin-based scientists that rivaled their French competitors in Paris.
Though n
o authenticated image of “Jim the milkhorse” exists, this equine hero helped produced gallons of diphtheria antitoxin before himself succumbing to tetanus. The resultant distribution of contaminated antisera in St. Louis, and a related incident in New Jersey, triggered the enactment of legislation to regulate vaccine and antisera in the United States. The horse pictured here is another diphtheria antitoxin provider.
One of history’s more forgotten heroes and overshadowed by Louis Pasteur, Gaston Ramon critically contributed to the discovery of vaccines for diphtheria and tetanus.
Born a preacher’s daughter in Wheaton, IL, Peark Kendrick partnered with Grace Elderling and Loney Gordon to discover a life-saving vaccine against whooping cough.
The investigative journalist Brian Deer, of the Sunday Times of London, began his career as a vaccine skeptic but pioneered investigation that led to the revelation of greed-based frauds that had tainted the reputations of both the DTP and MMR vaccines, schemes that continue to threaten the lives of millions worldwide.
Epilogue
Both the title and my goals for the book have sought to reflect the countervailing forces of hope and fear that have surrounded the subject of vaccines throughout their history. From the standpoint of public health, hope should—and ultimately will—dominate the more negative emotion, because modern science has conveyed practical and affordable means to prevent (and in rare cases utterly eliminate) scourges that have long plagued society, chief among them smallpox. Other successes include the management of myriad diseases that have historically killed or maimed innumerable of our youngest and most vulnerable population, as well as the potential to eliminate polio within the coming years. Similarly, vaccines hold the potential to finally manage pandemic scourges such as bubonic plague and influenza, the latter tending to cut down double- and even triple-digit millions of people worldwide on a recurring basis every few decades. In the United States alone, 30,000–40,000 people die each year from influenza in a “good year,” when vaccine uptake is high, and the vaccine is properly matched with the viruses circulating in the American population. Far worse outcomes arise periodically due to vaccine mismatches with circulating virus strains and, even more rarely, when new influenza viruses arise.
As we have seen, each vaccine success has consistently been met with skepticism and outright hostility. Such fears began with the ostracism of Benjamin Jesty and the broadly-held, early nineteenth century view that subjects receiving a cowpox-based vaccine would sprout horns and ruminate in the field. Jesty’s contemporaries can be forgiven their trespasses because they fundamentally lacked an understanding of the disease, not to mention the concept of vaccination. Indeed, most if not all of Jesty’s contemporaries, even the most highly trained scientists of his day, would likely have raised an eyebrow—if not actively tried to dissuade him—from the bold actions that led him to protect his family from smallpox using his wife’s dirty knitting needles.
Modern-day vaccine deniers no longer have the convenience of claiming ignorance. The facts exist, and it is worth repeating a sentiment expressed by the late Senator Daniel Patrick Moynihan: “Everyone is entitled to his own opinion, but not his own facts.” The facts show that vaccines save the lives of countless millions worldwide each year. Denial of this fact exceeds the boundaries of common sense and would entail malpractice if a decision not to vaccinate were made by a physician. However, it is not. Such decisions to avoid vaccines are made by parents—well-intentioned, perhaps, but exceedingly selfish.
In justifying this venal act, many parents cite the mantra of “herd immunity.” This statement reflects the idea that if more than a certain fraction of a population is immunized, then the selfish few will be protected as well. The facts are that the fraction of the population needed to invoke herd immunity varies from pathogen to pathogen and tends to be very high, often requiring effective protection of more than 99.9 percent of the population. This goal is quite daunting, given additional challenges faced by parents, who mght lack access to health care or the resources to get their children immunized, not to mention the number of children who are not able to be immunized because they suffer from a preexisting malady such as cystic fibrosis or who are undergoing chemotherapy for childhood cancer. Furthermore, certain cultures, such as the Somalis in Minneapolis, have long-standing traditions of vaccine resistance. Adding vaccine deniers to the problem only increases the inevitably that the threshold required for herd immunity will not be achieved. Consequently, we are seeing increased incidence of preventable disease and death, spiking with tragedies such as an ongoing tragedy that is cutting through unvaccinated children in Minnesota.
Compounding the problem, an anti-vaccine movement has already done lasting damage in terms of diluting the efficacy of the pertussis, or whooping cough, vaccine. An overreaction to the side effects of the vaccine, first in Japan and then in the United Kingdom, compelled an efficacious product to be replaced by one we know to be inefficient, often requiring boosts every two years. This weakened form of the pertussis vaccine has therefore rendered millennials and future generations susceptible to the return of a dangerous old enemy. These same children (and a growing number of adults) are beginning to feel the consequences. At the same time, the rates of measles, mumps, and rubella are spiking on college campuses as the children of the anti-vaccinators matriculate into the nation’s universities.
What is to be done?
My own fear for the future of vaccines is swamped by the hope that ignorance, rather than malign intentions, is behind the anti-vaccine movement. Ignorance can be overcome, but this requires diligence. In a population captured by the cult of celebrity, it is far too easy for high-profile vaccine deniers such as Jenny McCarthy and Charlie Sheen to convey their messages. Indeed, the highest-profile celebrity of them all tweeted on March 27, 2014, “If I were President I would push for proper vaccinations but would not allow one time massive shots that a small child cannot take—AUTISM.” This individual is clearly ignorant of the fabricated link of vaccines to autism but currently resides in 1600 Pennsylvania Avenue, where he oversees the National Institutes for Health and Centers for Disease Control and Prevention, among other responsibilities.
As a scientist, I believe ignorance is best countered by facts. The facts need to be delivered consistently, accurately and by trusted individuals. With this in mind, public health officials should consider using every possible venue—from physicians to clergy, teachers, and even hairdressers—as a source of information. These populations could be trained in the facts behind immunization, the real benefits and potential risks (and yes, there is some risk, albeit exceedingly rare). In the same way that the much-needed #MeToo movement was initiated by a celebrity scandal but sustained by a groundswell of brave survivors coming forward and conveying their stories, a sustained movement to convey the dangers of a resurgence in measles, mumps, rubella, and other diseases is needed. From #MeToo we learned that sexually motivated abuse is everywhere in our society, affecting women and girls rich and poor, and of all ethnicities. Pathogens are just as indiscriminate, and it is only by understanding how vaccines are vital for the health of our communities that can we stop the resurgence of the deadly diseases that plagued past generations.
It is critical to remember key decisions about immunization are generally made by young adults, who tend not to have as much worldly experience and are arguably more susceptible to the cult of celebrity. Therefore, a counter-denial program should target venues such as MTV, social events, and, most importantly for today’s youth, social media. Social media outlets should be included in a campaign to educate teens and twenty-somethings about the importance of vaccination BEFORE they become pregnant. In the same way that special vitamins are prescribed for prenatal care, information about vaccines needs to be conveyed to this same demographic.
Overcoming this ignorance should be a comparatively easy task, as the primary population from which the anti-vaccinators are generally drawn is not from the inner city or rural countryside but
rather comprises educated and comparatively wealthy individuals. While composing this book, I have been asked in social occasions about what I am working on and have watched a small fraction of people recoil in horror at the prospect of promoting vaccines. However, it is comforting that a continuation of the conversation generally reveals that a typical anti-vaccinator is unaware, for example, that Andrew Wakefield’s data was fraudulent and that the rest of the anti-vaccine movement is built almost entirely on a house of cards. In these conversations, I happily convey the search terms they can use to check this out for themselves. I frequently use the “white box truck” example that introduced this book to address the inevitable response that “so and so’s child was diagnosed with autism after they were vaccinated” as conclusive proof.
Only by actively engaging, rather than excluding, anti-vaccinators can we hope to convey the actual facts and overcome the ignorance. Indeed, this was the motivation for the book you are reading. It was heartening that the inclusion of a high-profile anti-vaccinator in a televised 2018 New Year celebration triggered a wave of social media responses that related how this same person had not hesitated to have a deadly bacterial neurotoxin injected into her face. I am confident this is a reflection of a growing countermovement that will not only ensure the saving of many more lives but will also dispel the ignorance inspired fundamentally by the same fears that led Benjamin Jesty’s neighbors to be convinced his family would soon sprout horns and run wild through the streets.
Between Hope and Fear Page 36
