The Vaccine Narrative

by Jacob Heller

Overview

The Salk vaccine seemed like a miracle to parents whose children were threatened with the scourge of polio. With its protection from polio, came also a story line-there were heroic researchers who would use science to protect us from epidemics and perhaps even eradicate disease. For most people, vaccines have become the magic bullets for dealing with dangerous diseases. The continuing quest for new vaccines, including an HIV/AIDS vaccine, despite technical, epidemiological, and social obstacles, suggests the abiding power of this narrative.

The author examines four cases that span the twentieth century—diphtheria, rubella, pertussis, and HIV/AIDS. Each case challenges the reader to examine how the values we attribute to vaccines influence their use. Diphtheria vaccination brought laboratory science into an existing narrative based on earlier vaccines. With rubella vaccine, researchers efficiently responded to an epidemic of birth defects while subtly changing the relationship between vaccination recipients and beneficiaries. Opposition to pertussis vaccine from average Americans created a narrative crisis, in which faith in vaccination as a whole seemed to be at risk. With more recent vaccines, including a hoped-for HIV/AIDS vaccine, the persistent cultural narrative continues to encourage vaccine development and use.

Product Details

ISBN-13:	9780826515902
Publisher:	Vanderbilt University Press
Publication date:	07/11/2008
Pages:	216
Product dimensions:	6.10(w) x 9.00(h) x 0.80(d)

About the Author

Jacob Heller teaches sociology at SUNY Old Westbury.

Read an Excerpt

The Vaccine Narrative

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By Jacob Heller

Vanderbilt University Press

Copyright © 2008 Vanderbilt University Press
All rights reserved.
ISBN: 978-0-8265-9241-5

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CHAPTER 1

Diphtheria Toxin-Antitoxin The Birth of the Modern Narrative

A Sanitary World

Perhaps the most feared disease of the nineteenth century was cholera. A gruesome disease that killed quickly, horribly, and randomly, without any seeming rationale, cholera was immortalized in Thomas Mann's Death in Venice as a way to show the depth of love for beauty and truth. For those of us lucky enough never to have seen a cholera epidemic, it is difficult to imagine the nature of the gesture that Aschenbach makes when he willingly stays in Venice to die of cholera. This brief description of the symptoms suggests how extreme such a sacrifice would be:

Over 90% of cases are of the so-called Cholera gravis type.... The first stage, which lasts for three to twelve hours is of sudden onset with painless diarrhma and vomiting ... soon followed by agonizing cramps first in the limbs and then the abdomen.... [In] the second stage the signs of collapse increase. The surface of the body becomes colder and assumes a dusky blue or purple hue, the skin is dry and wrinkled ... the pulse at the wrist is imperceptible.... In this condition, death often takes place in less than one day, but in epidemics ... the collapse is [sometimes] so sudden and complete as to prove fatal in one or two hours. (Thomson 1969, 193)

Faced with a cholera epidemic, there was nothing to do but flee. But during the 1854 cholera epidemic in London, in one of the simplest and most elegant episodes of scientific inquiry, Dr. John Snow decided not to flee. Instead, he conducted a simple controlled study to test his idea that contaminated water was spreading the disease. By removing the handle from the Broad street pump, he prevented people from accessing the water in that well, proved that cholera spread by contaminated water, and effectively ended the epidemic (Goldstein and Goldstein 1980). In this simple gesture, Snow not only demonstrated the value of empirical experiment, but the preventive power of sanitary medicine—the idea that clean air, clean water, and clean living could prevent disease. Cholera is no longer a public health problem in areas of the world where clean water is readily available.

At the time of Snow's cholera discovery, many of medicine's ideas still came from ancient texts. Aristotle's ideas, that sound health was the result of balanced humors, elements, and tendencies, survived the Middle Ages and persisted into the Industrial Revolution. That kind of holistic view of health persists, in forms, to this day. Of course we now know that germs cause disease, but most of us still believe that moderation and cleanliness are crucial to keeping disease at bay. People who believed in sanitary medicine—or hygienic medicine, as it was sometimes called—were able, like Snow, to effect sweeping improvements in public health without identifying the cause of disease beyond "filth" or unspecified products of still-mysterious processes. This meant that fresh air, clean water, and wholesome diet (variously defined) were of primary importance to good health.

By the late nineteenth century, a new recognition began to take hold that disease came from standing water (miasmas) or the fermentation process (zymotic disease). Behavior and environment were the most important factors, and the association between notions of cleanliness and health resulted in a hygienic revolution in health care. Rather than mystical or religious explanations for epidemics and seemingly random disease outbreaks, hygienic health theories reconstructed the causes of disease as the result of human filth, improper plumbing, and contaminated food and drink (Tomes 1998). In this view, health was a natural state that societies and individuals could maintain by simple adherence to good sanitary practices. As one sanitarian and an early advocate of a low-carbohydrate "fruitarian" diet put it, "Health is the undeviating expression of animal (indeed of all organic) life, always concomitant where the conditions natural to the animal are undisturbed" (Densmore 1892, 7). This kind of view of health and illness inspired public health programs that advocated better living conditions, indoor plumbing, and the clear separation of waste water (sewage) from drinking water.

Sanitary interventions were not, at least initially, conceived in small scale. The discovery that cholera could be transmitted to an entire community through its water supply made the transformation of water and waste systems imperative. This involved expensive and complex changes in the way large numbers of people lived, and substantial public investment. Moreover, the recognition that the environment was crucial to good health reached into all aspects of public and private life: housing-construction standards had to change and personal behaviors like bathing and cooking practices became subject to painstaking, expensive, and intrusive monitoring of people's everyday living. An outbreak of disease could trigger significant state action, in which quarantine and isolation measures often overruled individual preferences in the name of the public health.

For the first time, Western medicine had a guiding principle with a sound empirical basis as well as concrete recommendations for averting or alleviating the spread of disease. The belief in the importance of sanitary practices provided a set of guidelines upon which public health advocates could act, and those actions appeared to produce results. Rates of morbidity (sickness) and mortality (death) from diseases declined over the nineteenth century. Quarantine, which segregated the sick, slowed epidemics. The practice known as "stamping out" (isolation or hospitalization of patients, combined with disinfection) also proved to be of important use in mediating epidemics (Hardy 1993). By the end of the nineteenth century, it seems clear that most American physicians subscribed to the hygienic model of disease prevention—many held to these ideas well into the twentieth century. This was at least in part because sanitary medicine's general principles allowed for relatively easy adaptation to new information. When germs began to gain recognition for their involvement in disease, some sanitarians smoothly incorporated the idea, but did so in the context of a kind of behavioral quarantine: keep the germs away. Many sanitarians, however, rejected bacteriology altogether.

In addition to the general philosophy behind sanitary medicine and public health, other interventions were in common use and sometimes appeared to work. They ran the gamut from violent purgatives and radical surgery to small-dose homeopathic remedies and innovative treatments that involved, for example, the application of electricity to the body or massive quantities of water. Among these, one intervention gained special status—vaccination against smallpox.

Vaccines Work

By the 1890s, new developments in medicine and public health promised great things for the future, and Americans had already seen some important accomplishments. Vaccine successes—most notably smallpox—had made an enormous impact. Unlike other measures, smallpox vaccine prevented or reduced the severity of epidemics over the short term, and appeared to account for the general retreat of the disease. But the basis for that success—how smallpox vaccine worked—remained obscure. Explanations for vaccine effectiveness did not differ very much from explanations for any other remedies employed by doctors earlier in the 1800s, or in previous centuries. Well into the early twentieth century, cures and preventives (including vaccination) remained part of an established view of medicine as a holistic enterprise relating the body, health, and disease (Rosenberg 1979). Traditions of common use helped determine smallpox vaccine's weight and credibility, just as for purgatives, leeches, birthing practices, etc. A broad consensus agreed that mass vaccination against smallpox worked, but its success did not generalize to other vaccines. A narrative that encompassed vaccination in general did not develop until New York City's anti-diphtheria vaccination campaign of the second and third decade of the twentieth century.

Initial acceptance of mass vaccination had come quickly after Edward Jenner's discovery of smallpox vaccine in the 1790s. Based neither on laboratory tests nor on controlled epidemiological studies, acceptance rested on credible individual testimonies and broader subsequent experience that his cowpox vaccine conferred protection during smallpox epidemics. Advocates relied on a wide variety of means to persuade people to accept smallpox vaccination, ranging from admonitory rhymes to legislation, but they had no systematic or causal explanations for its apparent effectiveness; they had only stories of its success. Jenner described his vaccine this way:

may I not with perfect confidence congratulate my country and society at large on their beholding, in the mild form of the cow-pox, an antidote that is capable of extirpating from the earth a disease which is every hour devouring its victims; a disease that has ever been considered as the severest scourge of the human race! (Jenner 1938 [1800], 220)

For a century, the medical profession continued "beholding" smallpox vaccine's success without explaining its function. The notion that vaccines were an antidote, like Jenner's use of the word virus in his papers on smallpox vaccine to describe the thing that caused smallpox, was not technically meaningful. An antidote was simply something that stopped disease; no one had seen or confirmed the existence of anything called a virus; it was at that time just an idea. Like the evidence of efficacy, terms like antidote and virus conveyed little more than a descriptive sense of the vaccine's apparent effect. The most practical aspect of vaccines, however, seemed clear: they were effective at preventing death by smallpox.

Evidence of efficacy was entirely typical of the period: painstaking but not theoretically robust. Unable to explain why vaccination worked, Jenner focused on detailed description of cases when it did work, and instructions for how to introduce the "infectious matter" into recipients. Jenner's initial papers on smallpox vaccine recounted more than a score of detailed, individual successful uses of vaccine without explaining the mechanism by which the vaccine operated. In fact, throughout the nineteenth century, when vaccination established its initial reputation for preventing disease, no one knew what caused smallpox, how it was spread, what the vaccine did, or what the crucial ingredient in the vaccine was that prevented the disease. Physicians and scientists did not develop a coherent explanation for smallpox vaccine's effectiveness until well after it had an established positive reputation. Only during the last third of the nineteenth century did researchers begin to hope for success using vaccines against diseases other than smallpox. This hope came with the development of the germ theory of disease.

The germ theory of disease revolutionized Western medicine, as laboratory researchers isolated and transferred germs—and as little of anything else as possible—and dissected innumerable guinea pigs for proof that disease resulted from specific, causative germs. The theory has become a commonplace: every disease is caused by a specific germ, the disease cannot exist without the germ and the germ has the ability—by itself—to cause the disease. The germ theory quickly began to contend with long-established disease paradigms, most notably sanitary medicine (though it also challenged ideas that disease arose from miasmas, generated spontaneously from filth, resulted from imbalances in the "humors," developed as the result of immoral behaviors, or had zymotic origins). Louis Pasteur's famous experiments in the 1860s disproved spontaneous generation, and his highly (but not unproblematically) public successes with rabies and anthrax vaccines brought widespread attention to him and his discoveries (Latour 1988; Hansen 1998). Further acceptance of the germ theory came in 1876 with Robert Koch's proof that a particular kind of bacteria was the sole cause of anthrax (King 1991), and his isolation of the germ that causes tuberculosis in 1882 (Fee and Hammonds 1995). Despite these laboratory breakthroughs, there were few applications of the germ theory through the end of the nineteenth century.

The outstanding exception was diphtheria antitoxin, which became available in 1895. Antitoxin was not a vaccine in the modern sense, though it did confer some immunity. A dose of antitoxin could cure diphtheria and confer a few weeks of passive immunity, immunity that depended on the continued presence of antitoxin for its strength. Unlike smallpox vaccine, which seemed to simulate the effects of surviving a case of smallpox, and appeared to confer lifelong immunity, diphtheria antitoxin's immunity was powerful, but short-lived. It was also the product of laboratory science—a practical application of the germ theory of disease. In fact, the diphtheria antitoxin program, spearheaded by the New York City Department of Health bacteriology laboratory towards the end of the nineteenth century, is the point at which medical historians mark the beginning of modern scientific immunology (Blake 1948; Starr 1982). For the first time, laboratories used the germ theory to produce an effective treatment. Antitoxin's stepchild, diphtheria toxin-antitoxin, became the first modern, laboratory-tested, bacteriological vaccine to be developed under the germ theory of disease and employed in a civilian population.

When the twentieth century opened, American medicine was-poised on the threshold of modernity. As the new scientific methods of medical research displaced one theory after another, the germ theory promised (or threatened) to shift the ways professionals contended with disease. Not an abstract theory, the germ theory grew out of laboratory research and the reductionist view that reality could (and should) be broken down into its smallest parts in order to understand its essential qualities. Together with the new bacteriology labs, like the one in New York, the germ theory set the stage for radical changes in medicine and public health practices. Many sanitarians, who had long dominated public health departments and believed in the primacy of clean air, water, and healthful living conditions, initially rejected the germ theory (to their professional disadvantage) and increasingly found themselves marginalized as bacteriological methods came to the forefront.

In 1900, medical education institutions were as eclectic and unregulated as medical practice, and had no standard curriculum. Within two decades, however, reformers began to reorganize American health care to conform to the principles of laboratory science, and the regular (allopathic) physicians began to organize themselves into a powerful profession (Starr 1982). The Flexner Report, commissioned by John D. Rockefeller to map out the future of medical education in the United States, and promulgated and enacted during the second decade of the twentieth century, reorganized American medical education—and eventually practice—around the narrower, scientist-and-university-based system, of the kind used in Germany (Kohler 1979; Berliner 1985). This marked the beginning of the end of legitimacy for traditional (and varied) modes of thinking and practicing for health professionals. Despite these far-reaching changes in the underlying ideas and structures of American medicine, the germ theory had made little immediate impact on the practice of medicine or the prevention of infectious disease. That changed with the development of diphtheria antitoxin, a clear success that came directly out of modern laboratory science. Antitoxin, though highly publicized and widely hailed as a miracle cure, did not by itself directly change other aspects of the practice of American medicine.

A decade into the twentieth century, the same New York City Department of Health that had earlier led the antitoxin campaign, initiated an anti-diphtheria preventive vaccination campaign using diphtheria toxin-antitoxin. This brought together the new theoretical foundation for modern medicine (the germ theory), the single most effective intervention (vaccination), the new institutions of medical and public health research (bacteriology laboratories) and the modern public health department. The result was a diphtheria vaccine (diphtheria toxin-antitoxin) designed to wipe out diphtheria. Diphtheria toxin-antitoxin failed to achieve that goal, and Americans would have to wait until the early 1940s, and the acceptance and widespread use of diphtheria toxoid (a form of toxin neutralized with formalin, instead of with antitoxin), for a preventive vaccine that conferred immunity and prevented healthy carriers from transmitting diphtheria. New York's diphtheria toxin-antitoxin vaccination campaign did, however, transform the American vaccination narrative by bringing bacteriological science firmly and irrevocably into the vaccine story. Between 1910 and the mid-1930s the experience of and publicity about the toxin-antitoxin campaign became the template for the vaccination story we know today. That story was based in laboratories, the prevention of childhood disease, and an unimpeachable scientific provenance for vaccination.

(Continues...)

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Excerpted from The Vaccine Narrative by Jacob Heller. Copyright © 2008 Vanderbilt University Press. Excerpted by permission of Vanderbilt University Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Acknowledgments     vii
Introduction     1
Diphtheria Toxin-Antitoxin: The Birth of the Modern Narrative     31
Rubella (German Measles): The "Cultural Provenance" of Vaccination     57
Pertussis Vaccine: Resisting the Narrative     84
HIV/AIDS Vaccine Research: Science and Ethics Confront the Narrative     112
Conclusion     143
Notes     157
References     165
Index     199

Editorial Reviews

The Vaccine Narrative tells the specific story of vaccines, but does more. This well researched book focuses on vaccines but tells us much about the stories of medicine in America: the stories that medicine — as a discipline, as an institution and as an industry — tells us, and the stories we tell each other about medicine.
—Barbara Katz Rothman, Professor of Sociology City University of New York.

From the Publisher