As measles cases crack 1,000, a look at what to do
Powell: Is there something about this moment that makes measles among the unvaccinated U.S. population more likely?
Bloom: Every outbreak but one has been attributed to someone who came from abroad. And the one exception is a direct child-to-child transmission.
Juliette Kayyen: What we haven’t seen before — or at least it’s much more intense now — is the extent to which a foreign power, Russia, is utilizing the sense of division in our country, using social media, websites targeting low-information communities, isolated communities, to propagate an unhealthy status for Americans.
It’s disinformation, not unlike what we saw during the presidential campaign. But the idea that the Russians come out only every two years is nonsense. They’re waging this effort and we’ve seen it move from the election — the politics space — to the public-health space.
It’s not new. During the Ebola outbreak, there were more than hints of this. But we’re seeing it now because we’re looking for it.
Powell: So, this has been going on, potentially, for some time?
Kayyen: With the Ebola outbreak, there was a campaign launched by Russia and others to create skepticism about health care workers and their objectivity. This has always been a concern. I think what’s unique in this instance is that it targets U.S. citizens in outbreaks that are already ongoing.
But it’s not like the anti-vax movement is new, just in the same way racism isn’t new. The Russians have a way of being able to bring out the worst in us.
Powell: And the anti-vaccine movement has been traced back to a particular — discredited — study, linking vaccines to autism?
Bloom: The first anti-vaccine association or society was created in England in 1866 and they’ve been doing great mischief ever since. So the anti-vaccine movement is hardly new.
There was this dreadful paper in 1998 by [British gastroenterologist Andrew] Wakefield that is famous for making an association between the measles, mumps, and rubella vaccine and autism. How that paper got published is totally unclear to me.
The subjects were a dozen kids attending a birthday party at his house, eight of whom were selected at some level and were probably autistic to start with. Then it was shown that Wakefield had selected and falsified data and had a financial interest in the insurance claims from that set of injuries.
The other thing unexplained is why it took The Lancet 15 years to retract the paper and for Wakefield to lose his medical license — only to appear in Texas and at every anti-vaccine rally that he could muster the travel fare to get to.
Powell: It seems that there was fertile ground waiting for the anti-vaccination message. What is it about vaccinations that puts certain people off or about a portion of the American character that is willing to believe these sorts of things? Or is it just the luxury of the success of vaccines over recent decades?
Kayem: Since these outbreaks began, the vaccination rate in some of these communities has gone up — voluntarily — by 40 percent, suggesting that their ideological belief is only strong when it doesn’t matter. It’s just crazy. This is where I get so angry.
The public-safety side has a very different approach to this and a lot of people don’t like it. I grew up in California, where there’s always pockets of this wacky mysticism [and] where there are lower vaccination rates than in Sudan. These are not low-information communities. These are self-centered communities, these are people who have access to the best information.
The other thing, at least more recently, is the sense that big, bad pharma exists only to make money. That’s what’s clearly animating at least some part of the anti-vax movement.
Powell: So, there’s anger there?
Kayyen: They think, “It’s a hoax, fake news.” It’s this idea that “two plus two doesn’t equal four anymore, no matter what you tell me.”
They think this hoax is being led by pharma and big, bad government. That’s clearly what’s animating parts of this.
Then, of course, there’s an incorrect assumption by people on the outside that some religions prohibit vaccinations, and that’s not accurate. Religious communities have been very, very good about trying to push back against all of this stuff.
Bloom: There is a fundamental-values issue that we should take seriously. And we have to take the anti-vaccine people and parents who are hesitant seriously.
Because when we say vaccines are safe — and they are extraordinarily safe — there are always some adverse effects, as there would be with aspirin or any other medical intervention.
There’s a feeling that there are three sets of enemies. One is the government, which doesn’t respect individual freedoms. The second, as Juliette has said, is industry, manipulating people solely for profits and exploiting children in the process. And there’s a third group of enemies, which is us, experts.
One of the questions I spend a lot of waking nights worried about is how you answer the question: “How can you scientists and experts be so sure of everything that you say?” And that’s really hard.
The FDA tries to look at a vast number of studies, at many, many trials of these vaccines, and to get them to the level of one adverse event per million. That would be ideal. Some have somewhat more adverse events than that, but none is anywhere close to being a high-probability event.
Powell: The flip side of that question, then, is to what extent do we all need to recognize that we’re part of a community and need to do things that benefit that community?
Kayyem: Every society sets rules about acceptable behavior to protect the greater good. Israel has universal conscription — everyone’s making a sacrifice.
Here, seat-belt laws were passed because your freedom to fly through your windshield if you get in an accident should be limited because we, as a society, are going to have to clean it up.
So, even assuming that there’s some risk to vaccination, whatever risk I’m willing to put my child through is for the greater good, including that of the anti-vaxxers and the anti-vaxxers’ child.
Bloom: Massachusetts is at the center of critical decision-making on the issue of individual rights versus the public good.
One of my favorite cases that has nothing to do with vaccines had a connection to Massachusetts: Schenck v. United States, in 1919. The judge who wrote the decision is an old Harvardian named Oliver Wendell Holmes. The issue was anti-war anarchists publishing stuff that was detrimental to the war effort. In a two-page decision, the court ruled that even the First Amendment — and other amendments, in principle — has limitations. In this case, public safety trumped an individual’s right to say whatever he wanted. And that’s where the famous quote came from where you cannot yell “Fire!” in a theater.
A second case, Jacobson v. United States, in 1905, was an anti-vaccine case. It was the first classic case where a person refused to accept vaccines and the court decided that the public safety and security preempted the individual right to do that. That allowed mandatory vaccines before entry to schools, now the law in all 50 states, and it’s been controversial ever since.
Powell:That was in the case of smallpox, wasn’t it?
Bloom: That was in the case of smallpox vaccination, the world’s greatest killer up to that time, and now eradicated globally since 1977.
Powell: Today, people might say, “Oh, that was smallpox. Everybody should get vaccinated for smallpox. But measles …”
Should the state have a limit on its power based on the nastiness of whatever it is you’re vaccinating for, or can the state say, “Everybody needs a flu shot”?
Bloom: That’s the dilemma: What is the limit of protecting the public good?
As Juliette pointed out in talking about Ebola, the four cases that occurred in the U.S. were not a lot of cases.
But if you don’t do anything, it’s not four cases — it’s 40, or 400, or 4,000. And then the ability to deal with that is very different. The example for that, right in front of our eyes now, is Ebola in the Democratic Republic of the Congo.
We have a vaccine for Ebola. It has been proved to be close to 90 percent protective. But because of distrust of government and breakdown in security, the disease has now gone endemic. It’s there, in a form that has the potential to spread almost no matter what you do. It will be continuing for some time.
Alvin Powell is a Harvard staff writer. This interview is published courtesy of the Harvard Gazette, Harvard University’s official newspaper
