'Anti-vaxxers: How to Challenge a Misinformed Movement' (excerpt)
Jonathan M. Berman's Anti-vaxxers, argues that anti-vaccination activism is tied closely to how people see themselves as parents and community members. Effective pro-vaccination efforts should emphasize these cultural aspects.
Anti-vaxxers: How to Challenge a Misinformed Movement
Jonathan M. Berman
5 The First Anti-vaccine Movements
Early opposition to vaccination was intimately tied to issues of social class, individual liberties, individual and collective rights, and changing ideas about health and medicine. While many disliked the idea of vaccination in its first decades, organized opposition to the practice of vaccination was not common until the British government began mandating it.
Because the Vaccination Act of 1853 required mandatory vaccination for all infants over four months old, it raised issues of civil liberties and numerous civic and religious concerns—about bearing the costs of vaccination for the poor, about placing material from cows into humans, about preserving the integrity of the body, and about disrupting the "natural order." Those who believed in the power of vaccination to improve human health and well-being and in the right of the state to impose vaccination found themselves in a war of both information and culture.
The philosophy of health for many simply did not include scientific experimentation or analysis. The emerging field of science-based medicine was in competition with "alternative" approaches, such as homeopathy, heroic medicine, and "folk medicine." Absent the rigor of experimental and scientific approaches to understanding disease, such alternative approaches were appealing. Indeed, even those administering vaccines in that era did so in a way that we would now consider to be unsanitary, painful, and sometimes disfiguring. Pus would be taken with a tool called a lancet from a pustule of one vaccinated individual and used to vaccinate the next. Colonial powers would impose vaccination on unwilling populations. Vaccine material would be collected from sores on infants who had recently been vaccinated. These practices possibly transmitted other communicable diseases.
At the time poorer economic classes often did not have access to clean water or wound care, and secondary infections could develop from vaccination. Those who believed that health was maintained through integrity of the body saw compulsory vaccination as an outrageous overreach of the state into personal affairs. Those living in colonies of the era often saw vaccination as just another means for controlling and dominating the population. A person's body was the last battleground, where individual liberties would face off against the growing authority of the state.
During the same century, a series of acts seemed to assert the rights of the state over the bodies of especially the poor and women. The Anatomy Act of 1832—which was intended to prevent the shortage of available bodies for dissection and the study of anatomy—expanded the range of usable corpses from only those of executed murderers to those whose remains were never claimed; and, in the view of many, the act allowed the wealthy to dissect the poor. The Contagious Disease Acts required medical inspection of those suspected of prostitution, in order to look for venereal disease, regardless of their consent.
Much of the prevalent anti-vaccine sentiment of the era was laid out in 1854, when John Gibbs, esquire, published the booklet Our medical liberties, or The personal rights of the subject, as infringed by recent and proposed legislation: compromising observations on the compulsory vaccination act, the medical registration and reform bills, and the Maine laws. He was in favor of neither compulsory vaccination nor short titles.
Gibbs attacked the Vaccination Act of 1853 on several fronts, complaining that it was an intrusion on personal rights, that it was written to benefit the medical trade, that it treated the populous as too stupid to make their own health decisions, that it mandated a practice that was not universally accepted among physicians, and that it had failed in some individual cases. The similarity of his pamphlet's arguments to those made by modern vaccine opponents is striking. Gibbs went on to make a much weaker argument in the light of modern scientific knowledge. He argued that the fundamental nature of human biology (and therefore of disease) changed intermittently and that scientific studies of disease were therefore useless. He argued that vaccination, regardless of its protective effects against smallpox might have "influence generally upon the constitution. … Does it lower the vital resistance and predispose the system to receive or does it introduce it to other forms of disease?" His complaint that vaccination benefited the medical trade may have been related to his own occupation as in hydropathy, a kind of quack medicine that involved treatment by bathing in, drinking, or injecting water and applying it to various parts of the body. Given the hygiene practices of the era, promoting bathing was, perhaps, not the worst idea that he had, but it was not an effective means of preventing smallpox infection. A similar tension exists today. Science-based medicine exerts a monopoly on the treatment of disease, and at its periphery "alternative" practitioners market non-evidence-based approaches to health care.
At the same time as vaccination was developing, so was the new science of statistics. In the modern era, statistics is its own mathematical science with a number of well-understood methods and ways of formalizing results. Statistics started as a way for states to collect information about the populations living in them for analysis. The fundamental problem statistics solves is that it is difficult or impossible to survey every member of a population for every parameter you might want to test. For example, if you want to know how many men wear hats in the United States, you could survey every man in the United States, or you could attempt to get an estimate by surveying a subset of men. Statistics allows us to decide how many men to survey, how likely our results are to represent the entire US population, and how much we should trust our results based on that data.
The development of probability theory allowed for the use of testing hypotheses by statistical means. There is a possibility, for example, that if you pick ten American men at random to survey, you have had the bad luck of picking ten hat wearers, or ten non–hat wearers, by random chance. Statistics allows us to estimate the probability of having a representative sample. It also allows us to estimate the likelihood that two measured groups are different because of random chance, rather than an actual difference. If we sample ten people from New York and ten from San Antonio and find ten hat wearers in New York and only five in San Antonio, statistics will allow us to know if we have sampled enough people from each city to draw a reasonable conclusion.
However, statistics can be deployed badly, or in bad faith. The often complex-looking equations and symbols of statistics can be used to communicate quickly and succinctly between those with statistical training, and they can be used to confuse, befuddle, and bully into belief those without. Gibbs's booklet provides examples of the latter approach. By selecting only data that seemed to support his views, a kind of bias that scientists often call cherry picking, he could imply alarming trends. A rise in death rates due to measles in specific cities can be attributed to vaccination by means of a confusion between correlation and causation. These same means of misrepresenting statistical information are still used today by modern anti-vaccine activists.
To understand the reaction to the Vaccination Act of 1853, we need to consider it in its political context. John Locke's writings on natural rights were still influential at the time. Locke proposed that what he called "natural rights," as distinct from legal rights, were rights belonging to every human that could not be altered by human laws. Locke identified these as life, liberty, and property.
An alternative view, also circulating at the time, was proposed by Jean-Jacques Rousseau in The Social Contract. Rousseau proposed that the right of people to be governed should come from agreement between the government and the governed, rather than from divine mandate. Everyone ought to give up the same rights to government and assume the same duties. Thomas Hobbes supported this line of thought, arguing that if humans are born with the natural rights to take any actions, those rights lead to a "war against all" to compete for resources and safety. Therefore, humans must give up most rights in order to live among other humans.
It was in this background of competing ideas about the rights of individuals and the rights of collectives in the form of government that these early vaccine objections occurred. We still debate the boundaries between individual and collective rights today, and these debates inform our modern political philosophies and motivations.
Setting aside the question of whether the government had a right to impose vaccination, Gibbs brought forth the question of whether vaccination worked, which was easier to answer with the emerging fields of science and mathematics. Success had recently been had in using science to prevent cholera. The Public Health Act of 1848 was created to combat cholera epidemics, by improving sanitation and the supply of water, and establish a General Board of Health to oversee local boards of health. These boards would take over public sewers, purchase private sewers, institute street cleaning, provide public lavatories, and supply water. This process was pioneered by John Simon, a surgeon who was appointed as the medical officer of health for London, chief medical officer of the General Board of Health, and later chief medical officer to the Privy Council. Simon was a strong advocate for vaccination and presented a strong rebuttal to claims by anti-vaccine activists that vaccination did not work. Simon wrote:
Hence, in the middle of the 19th century, the very success of vaccination may have blinded people it its importance. It is so easy to be bold against an absent danger—to despise the antidote while one has no painful experience of the bane.
Simon presented to parliament and the queen papers making an extended argument in favor of vaccination. He detailed the history of its opposition, commenting, "It is wearisome work to read stuff so stupid or so dishonest," in response to claims that vaccines were causing people to become cow-like, burst forth with horns, or behave in a beastly manner. He also pointed out that disagreements in the medical profession tended to amplify dissenting voices, but, by and large, the opinions of the medical profession had been fixed since the earliest part of the nineteenth century. Remarkably, he made a statistical argument, not only that vaccination had reduced deaths by smallpox tenfold to twentyfold (figure 5.1) but that in the exceptional cases where vaccination did not prevent later disease, the severity of the disease was likely to be mitigated. He cited work by a surgeon from a London smallpox hospital showing a fatality rate of 35 percent in the unvaccinated, and 0.5 percent in the vaccinated. Furthermore, he showed that revaccination worked to protect the majority of those who had once again become susceptible. Debunking the idea that vaccination itself was causing harm, Simon showed that the overall death rate had declined in the years since the discovery of vaccination.
However, Simon made a mistake that has become frequent among vaccine advocates. He focused only on the scientific challenges that denialists offered and did not make an effort to address the true underlying reasons for their concerns.
Gibbs and other anti-vaccine activists did not make scientific objections because they had approached the question with an open mind, and through scientific inquiry, they had decided that vaccination was ineffective. They started with a complex network of personal reasons for objecting to vaccination and approached the science as a source of prestige that could be borrowed for their arguments. From this viewpoint no experiment can be well enough designed, no controls adequate, and no evidence convincing. The effectiveness of vaccination was beside the point—a mere rhetorical tool to be wielded by whomever was most convincing. The theme of anti-vaccine advocates reaching their conclusions for reasons other than scientific analysis and not changing their views in the face of scientific evidence is a recurring one.
Simon was a member and founder of the Epidemiological Society of London, founded to "venienti occurrite morbo," or confront disease at its onset. The society had a bold mandate: to use the developing tools of science to study epidemics and come to a better understanding of their origins and causes. This society signaled a shift in belief about disease, from seeing it a mysterious force that was largely outside of human control to seeing it as a natural and mechanical phenomenon that could be analyzed and understood. One of the society's founders, John Snow, famously used statistics in 1854 to study the Broad Street cholera outbreak, which killed thirty-one thousand Londoners. By treating the water with chlorine and removing the handle of the water pump that was the source of the infection, he ended the epidemic. This work convincingly showed that cholera is waterborne and not caused by miasma, and was chronicled in the 2006 book The Ghost Map by Steven Johnson. In the same year, an Italian physician observed small organisms living in cholera-causing water, which he believed to transmit the disease by acting on the intestine. His theory was later proved correct, as was his proposed treatment of injection with electrolytes and water to supplement losses due to diarrhea.
The Epidemiological Society of London was symbolic of two trends, one toward the professionalization of medicine and another toward the development of medicine as an applied science. The distinctions among natural scientists, formal scientists, social scientists, and applied scientists had not yet been made in the minds of most who did scientific work or in the mind of the public. Broadly speaking, a natural science is a science that studies the natural world and seeks to understand its underlying rules and mechanisms, while an applied science applies knowledge gained through scientific methods to solving problems in the world. However, the idea that medicine should be based on only that which can be experimentally verified was novel. Those who claimed to cure and treat diseases practiced without licensure and might use any number of methods and modalities.
The idea of a physician as a member of a professional class was unusual. It seemed to be a way for those with the means to take even more away from common people. In many ways these objections were well founded. In the early nineteenth century, the physicians who would evolve into being members of the medical profession we now recognize were little better than quacks and offered a variety of services and cures that we now recognize as being abject nonsense.
Professionalization provided a means to control not only who could call themselves physicians and administer treatments but also the quality of those treatments and the means of deciding how to use them. When the Vaccination Act of 1853 was being considered, the Epidemiological Society of London had a great deal of influence on its creation. Rather than known community members administering variolation, in an often ritualistic and comforting setting, strangers, asserting the authority of the state, were performing a procedure. Given the condition of the medical profession in the early nineteenth century—riddled with pseudoscience and quack practitioners—a primary motivator of this professionalization was the desire for return on investment. Why pay for medical school if someone with no education could practice just as easily? The Medical Act of 1858 established a council for the education and registration of medical practitioners. This granted medicine one of the central features of a profession: self-regulation. To this day, some see the requirement that healers be educated as an unfair imposition that creates a monopoly. The alternative are treatments that have not met the standards of scientific rigor and reproducibility necessary to being considered medicine.
A side effect of professionalization was the development of professional ethics. Professional ethics is a means by which medical practitioners can exert influence and control over the behaviors of their peers in line with an agreed-upon code of ethics. To this day, medical ethics are influenced by the work of Thomas Percival, who first published Medical Ethics in 1803, where he wrote:
The feelings and emotions of the patients, under critical circumstances, require to be known and attended to, no less than the symptoms of their diseases.
Social and political class divides in the era of Victorian England were stark. Thomas Malthus had published in 1798 An Essay on the Principle of Population, which proposed a troubling idea. In essence he argued that populations tended to grow in size over time. Because populations grow they must consume more resources over time. But given that certain resources are limited, Malthus proposed that so long as population growth continues, the scarcity of resources would cause ever greater poverty, until the incentives to have more children were reduced and the population once again stabilized. In his view populations would oscillate between growth, when new resources became available, and a stable equilibrium, when not. Among Malthus's suggested solutions was the proposal of the elimination of social programs aiding the poor. If the poverty were so miserable that it was not possible to reproduce, he reasoned, fewer poor people would have children.
Malthus's idea was deeply influential, as were those of David Ricardo, published in On the Principles of Political Economy and Taxation (1817), which argued that taxes raised for the relief of poverty reduced funds available to pay wages and encouraged laziness. Another influential thinker was Jeremy Bentham. Bentham was an early advocate for women's rights, abolition of slavery, abolition of the death penalty, animal rights, and gay rights. He was also an atheist, who opposed the idea of natural rights as granted by a divine power and therefore disliked the American Declaration of Independence, which borrowed heavily from Locke's ideas. Bentham's major philosophical stance is known as utilitarianism, which is the view that the moral rightness of an act depends on its doing the most good for the most people. Bentham also believed that free markets should set wages and that collecting taxes to relieve the poor interfered with the free market.
With these new ideas influencing the thinking of legislators, plans were made to alter the way the government dealt with poverty and disease. The Poor Law Amendment Act of 1834 changed how the poor were provided relief. Rather than being given money and allowed to choose how to spend it themselves, those unable to find work would need to go to a workhouse, where manual labor could be traded for food and clothing under what we would now consider to be cruel, prison-like conditions, with harsh discipline that separated families and encouraged child labor. The Poor Law Amendment Act also consolidated local control of poverty relief at that parish level to larger unions overseen by Boards of Guardians. Within a year several of the unions had to deal with riots and significant unrest. Laborers began to organize marches, and officials representing workhouses were assaulted, but the opposition was disorganized and fell apart within a few months. Some, seeing an opportunity, began campaigns to organize opposition. The Reverend F. H. Maberly distributed leaflets and organized meetings with as many as two thousand attendees in an attempt to raise opposition to the new system but ultimately failed to start a sustained movement. However, later in the 1830s, when unions began implementing the new Poor Law in the north, organizers experienced with opposition to factory conditions, who emerged from trade unionism and factory-reform movements, would later become leaders in opposition to vaccination. The leaders who emerged from trade unionism and factory-reform movements would later become leaders in opposition to vaccination.
Given the unrest that followed the Poor Laws, as well as the generally poor understanding of the nature of smallpox vaccination, it should be unsurprising that many who opposed the Poor Laws also opposed mandatory vaccination. Not only did the methods developed in opposing the Poor Laws adapt to opposition to the vaccination act, the act itself was seen by many as another salvo in a war against the poor, taking away from them the last dignity they were afforded: control of their own bodies.
"Alternative" medical practitioners attacked the professionalizing system of medicine, both out of fear of losing market share and because medicine at the time was hardly effective and benefited those elites who could afford advanced education. These practitioners led the early opposition of vaccination—as was the case with Gibbs's pamphlet. The circulation of the pamphlet led to a letter sent to the board of health in 1855, "Compulsory Vaccination Briefly Considered in Its Scientific, Religious and Political Aspects." This pamphlet repeated many of Gibbs's arguments and was widely distributed.
In 1866 the first organized opposition to vaccination formed, the Anti-Compulsory Vaccination League (ACVL), organized by John Gibbs's cousin Richard Butler Gibbs, modeled on previous reform movements. Within a few years, it had over one hundred chapters. The ACVL published journals, issued memberships, and of course accepted donations. Although these organizations claimed to act against vaccination on behalf of the working class, the membership was often decidedly middle-class. A number of similar groups arose and began the work of distributing handbills, pamphlets, photographs, and magic-lantern slides of vaccine wound sites. In 1867 and the early 1870s, a series of additional vaccination acts were passed, in response to the growing anti-vaccination movement. These acts updated the process by which vaccination was to be carried out and reaffirmed that vaccination was to be compulsory.
According to one history of the era, Bodily Matters: The Anti-Vaccination Movement in England, 1853–1907, many Victorians looked on anti-vaccine activists as fringe cranks, lumping it with other contemporary movements. Indeed, anti-vaccine activists found support in trade unions, among religious nonconformists, and among alternative medical practitioners. Vaccination took on a decidedly anti-establishment character.
By the 1880s it became common among anti-vaccine activists to attack and harass public health officials. In 1885 the most massive march of the anti-vaccine movement occurred in Leicester. A particular point of contention was the punishments being enforced against five thousand people who had refused vaccination. Demonstrators came from many towns and cities and may have had up to one hundred thousand attendees.
As in many towns, in Leicester, the growth of the population exceeded the capacity of sanitary arrangements and drainage. After the 1872–1873 smallpox epidemic left over three hundred people dead and the Vaccination Act of 1871 made vaccination compulsory, many saw the practice of vaccination as unnecessary, as it had in their view failed to protect those killed in the epidemic. In the period leading up to the 1885 riots, over sixty Leicester residents were jailed for noncompliance with vaccination. Leicester developed its own methods of dealing with smallpox by isolating the infected; cleaning, disinfecting, or burning clothes and bedding; and similarly isolating those who had been in contact with the sick. Vaccination became an issue in municipal elections, and by 1884 the vaccination rate had dropped to 36 percent from 86 percent in 1873, largely due to the efforts of anti-vaccine activists. In late March delegates from the anti-vaccination leagues of over fifty towns arrived in Leicester. On the March 23 a crowd gathered at the Temperance Hall and marched with flags and banners to the marketplace, where they heard speeches.
In 1879 William Tebb, a prominent British anti-vaccine activist, visited New York City. Soon after, the Anti-Vaccination Society of America was founded, quickly followed by the New England Anti–Compulsory Vaccination League and the Anti-Vaccination League of New York City.21 These groups were successful in repealing compulsory vaccination laws in a number of states. In 1905 the US Supreme Court ruled on Jacobson v. Massachusetts over a five-dollar fine imposed on a pastor who refused to vaccinate. The court ruled that states may restrict individual liberties if great dangers to the safety of the general public are present. A concession was made, however: although states could punish those who refuse to vaccinate with fines or imprisonment, they could not forcibly vaccinate. The ruling also required that a medical exemption be made available for those who for whatever reason were medically unfit to be vaccinated. An analogy was made to periods of wartime, when individual liberties may be reduced in order to protect the larger community. This case marked an establishment of a legal balance between the rights of an individual and those of the collective.
By 1898 in the United Kingdom, a new vaccination act gave victory to anti-vaccine activists in the form of an option for conscientious objectors to avoid vaccination, essentially both handing a victory to the anti-vaccination movement and causing a loss of interest in it.
Other countries handled smallpox differently. The publication of Jenner's research coincided with a time when England was preparing to be invaded. France initially treated vaccination as a military technology, which would allow soldiers to avoid sickness, but did not require compulsory vaccination of the citizenry. Vaccinators did begin the work of vaccination, however, and the fifty thousand to eighty thousand annual deaths due to smallpox in France were reduced to one-tenth of their previous level by 1850.
Anti-vaccine activism was by no means limited to England and the United States. In 1904 Dr. Oswaldo Cruz convinced the Congress in Brazil to make vaccination mandatory. The use of force to enforce the law was not well received. An anti-vaccination league was formed and within five days began recruiting. After ten days violence broke out and riots ensued. Thirty people died, and over one hundred were injured. A general attempted to march on the presidential palace. The government relented, at least temporarily. Nevertheless, in 1908 a smallpox epidemic killed nine thousand people living in Rio de Janeiro.
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