State of Immunity: The Politics of Vaccination in Twentieth-Century America (review)

The advances in bacteriology and immunology near the end of the nineteenth century validated Edward Jenner's discovery of a vaccine against smallpox and initiated the development of protective vaccines against other infectious diseases. Over time, this approach would save more lives than any other contribution of the new scientific medicine. This being true, one might have expected a universal welcoming and broad application of these panaceas throughout the wealthy societies of the West—but nothing is so simple.

In this well-written book, James Colgrove has explored in detail the ups and downs of vaccine use in twentieth-century America. He reviews the public reception of smallpox vaccine, and then of those for diphtheria, pertussis, and tetanus (DPT); and finally he recounts the rest of the century's developments of vaccines against polio, hepatitis B, rotavirus, anthrax, and measles, mumps, and rubella (MMR). Even in the comic strip Peanuts, young Linus wondered whether his pediatrician thought that he was a dartboard!

This is more than a story of "politics," as suggested by the book's subtitle: it is a sociological tour de force involving cultural attitudes, religious and ethical beliefs, socioeconomic stratum differences, and even the conflict between the growing field of public health and the entrenched medical establishment. The issue pitted religious objectors and antigovernment libertarians against city and state officials who claimed that the greater good of society supersedes the rights of the individual. It was argued that childhood immunizations not only protect the individual but, equally importantly, they contribute to the protection of the public at large through "herd immunity."

Each new vaccine was bedeviled in its turn by real or imagined undesirable side effects. The author cites in detail not only the proven cases (such as the Cutter production of infectious Salk vaccine in 1955, and the swine flu vaccine–induced Guillain-Barré syndrome in 1976) but also a steady stream of anecdotal reports of postvaccination problems (such as heart attacks, encephalitis, and even an "epidemic" of autism). Against these was perhaps a less readily demonstrable benefit—the absence of disease. The rights of the individual versus the state led to a series of court battles that sought to define the limits of coercion in a democratic society. In the end, it appears that public education regarding risk/benefit relationships has been far more effective than law enforcement in ensuring a generally effective compliance.

Smallpox has now been eradicated from the world, and polio, rubella, measles, and several other infectious diseases have been substantially banished from the American medical scene. But this has raised new ethical problems: With smallpox vaccination no longer needed, how do we deal with the potential problem of post-9/11 bioterrorism? With some other infections becoming more rare, have the risks of undesirable side effects started to outweigh the benefits of continued vaccination programs? Is it ethical to vaccinate children against the benign childhood disease rubella in order to protect someone else—the pregnant woman whose fetus might suffer a deadly congenital rubella infection? Who pays the injury claims that arise from vaccine accidents and side effects? And how in a democracy do we protect the rights of the individual from the growing power of the state?

This book started by outlining the problems associated with vaccines in the early 1900s—but despite the inexorable progress of scientific medicine, the moral, ethical, and legal situation has changed little one hundred years later. Plus ça change . . .