On Immunity : An Inoculation (9781555973278) (13 page)

My father was vaccinated against five diseases as a child. I was vaccinated against seven, and my son has been vaccinated against fourteen. The proliferation of childhood vaccines has become, for some of us, a kind of metaphor for American excess.
Too many, too soon
, one of the slogans common to vaccine activism, could easily be a critique of just about any aspect of our modern lives.

The smallpox vaccine my father received contained far more immunizing proteins, or active ingredient, so to speak, than any of the vaccines we use today. These proteins are what the immune system is reacting to when it responds to a vaccine. In that sense, a single dose of the smallpox vaccine our parents received presented a greater challenge to the immune system than the total challenge presented by all the twenty-six immunizations for fourteen diseases we now give to our children over the course of two years.

When asked by his colleagues to address the question of whether too many vaccines are given too early in life, the pediatrician Paul Offit set out to quantify the capacity of the infant immune system, which is already known to be quite impressive. Infants are exposed to an onslaught of bacteria the moment they leave the womb, even before they exit the birth canal. Any infant who does not live in a bubble is likely to find the everyday work of fighting off infection more taxing than processing weakened antigens from multiple immunizations.

Offit is a professor of pediatrics at the University of Pennsylvania and the head of the Division of Infectious Diseases at the Children’s Hospital of Philadelphia. He is the coinventor of a vaccine, the author of several books about vaccination, and a former member of the CDC’s advisory committee on immunization practices. He is also, if you believe the Internet, a “Devil’s servant” known as “Dr. Proffit.” He earned this distinction, along with some credible death threats, by being an outspoken advocate for vaccination.

Offit is associated with the devil on a website that also compiles evidence that the Holocaust was a hoax and that anti-Semitism was invented by Zionists as a justification for the creation of Israel. Accusations that Offit is a “vaccine profiteer” are generated by a blogger named J. B. Handley, himself no stranger to profit. Handley, a venture capitalist, is the cofounder of a private equity firm with over $1 billion under management as well as the cofounder of Generation Rescue, an autism advocacy organization.

In his book
Autism’s False Prophets
, Offit explores the problematic history of the theory that vaccines cause autism while detailing the research refuting that theory. The question of whether vaccines cause autism is not, Offit makes clear, the subject of any ongoing scientific debate. And groups like Generation Rescue, he reveals, spend a lot of money spreading misinformation and promoting ineffective therapies. Some parents of autistic children consider this exploitation. Meanwhile, Offit receives e-mail messages reading, “I will hang you by your neck until you are dead!”

“It’s hurtful,” Offit says of the persistent suggestion that his research has been driven by profit. He also finds it somewhat laughable. “Who ever goes into science,” he asks, “thinking,
God, if I could just figure out which of these two viral surface proteins evoke neutralizing antibodies, I’ll be rich beyond my wildest dreams!
” He would have made a much better salary, he observes, if he had gone into private practice as a pediatrician after medical school rather than going into research.

When Offit was an intern, he saw a nine-month-old baby die of rotavirus. He had not realized, until that moment, that children died of rotavirus in the United States. After his internship, he joined a team of researchers who were working toward a potential vaccine to protect against rotavirus, which caused the hospitalization of 70,000 children in the United States and killed over 600,000 children in the developing world every year. This was in 1981, and the chance that their work would result in a vaccine was only a remote possibility at that point.

“It took us ten years,” Offit says, “to answer the question,
How can we give a vaccine that induces an immune response but doesn’t cause disease?
Then we went to a series of companies, because only pharmaceutical companies have the resources and expertise to make a vaccine. In addition, no pharmaceutical company will advance a technology that is not protected. We had to patent it.” Even after the vaccine was patented, there was no certainty it would ever be marketed.

Over the course of sixteen years, the RotaTeq vaccine was tested for safety in progressively larger groups of children. The final safety trial involved over 70,000 children in twelve countries and cost Merck about $350 million. When the vaccine was licensed, Children’s Hospital sold the patent for $182 million. The hospital owns the intellectual property of its researchers, so 90 percent of this money went to the hospital and was put back into research. The remaining 10 percent was divided among the three researchers who had worked for over twenty-five years on the vaccine.

Compared to other pharmaceuticals, vaccines are costly to develop and generate modest profits. “In 2008, Merck’s revenue from RotaTeq was $665 million,” the journalist Amy Wallace observes. “Meanwhile, a blockbuster drug like Pfizer’s Lipitor is a $12 billion-a-year business.” Older vaccines make considerably less money than new vaccines, and vaccine production has not proved profitable enough to keep many companies from leaving the business over the past thirty years.

Why the success of his vaccine should render his expertise in immunology invalid remains baffling to Offit. “It’s not like I invented a better way to freebase cocaine,” he says. But he understands the other source of his infamy. In response to the question of how many vaccines is too many, Offit determined that a child could theoretically handle a total of 100,000 vaccines or up to 10,000 vaccines at once. He came to regret this number, though he does not believe that it is inaccurate. “The 100,000 number makes me sound like a madman,” he says. “Because that’s the image: 100,000 shots sticking out of you. It’s an awful image.”

W
HEN I TOOK MY SON TO THE DOCTOR for his one-year checkup, I was surprised to learn that he would be vaccinated against chicken pox. He had already been vaccinated against Hib, diphtheria, hep B, and rotavirus—diseases I was entirely unfamiliar with. But chicken pox was a disease I knew and remembered well from my own childhood, when all four children in my family had it at the same time. My infant sister was not yet a year old then, I had pox in my nose and throat and ears, and my mother was home giving us baking soda baths while my father worked. I could appreciate what it might have been like for my mother to care for four sick children only after I became a mother myself, but vaccinating against chicken pox still struck me as excessive.

The pediatrician smiled generously when I asked if we could limit my son’s vaccines to those that protected against diseases that could kill him. It was unlikely chicken pox would kill him, she allowed, but there were some good reasons to want to avoid the illness. Since my own childhood, there has been a rise in virulent skin infections resistant to antibiotics. Chicken pox can lead to infection with staph and Group A strep, also known as “flesh-eating” bacteria, as well as pneumonia and encephalitis. And, like most diseases, chicken pox can manifest mildly or dramatically. About 10,000 previously healthy children were hospitalized annually before the vaccine was introduced, and about 70 died every year. This was sufficient to convince me to accept the vaccine, but there was more.

Once you are infected with chicken pox, the varicella virus never leaves your body. It lives in your nerve roots and must be kept at bay by your immune system for the rest of your life. In times of stress, it can return as shingles, a painful inflammation of the nerves. The reawakened virus can cause strokes and paralysis, but the most common complication of shingles is nerve pain that persists for months or years. Immunity produced by disease, in this case, involves an ongoing relationship with the disease.

The vaccine virus that protects against chicken pox can also remain in a person’s nervous system. But being a weakened virus, it is far less likely to reawaken as shingles. And when it does, it is less likely to cause a severe case of shingles. Some parents feel that the immunity produced by the chicken pox vaccine is inferior to immunity by natural infection because it does not last as long. To carry immunity through adulthood, when chicken pox can be quite serious, one must get a booster in adolescence. “So what?” my father says. I am trying to explain the phenomenon of chicken pox parties to him. I say, “Some people want their children to get chicken pox because,” and pause to think of the best reason to give a doctor. “They’re idiots,” my father supplies.

I do not think they are idiots. But I do think they may be indulging in a variety of preindustrial nostalgia that I too find seductive. We used to live among wild things, mountain lions on the ridge and fires raging on the prairie. There were dangers, but they were part of, as Rachel Carson would say, “a natural system in perfect balance.” It is difficult to imagine any type of chicken pox, with its distinctive rash described as a “dewdrop on a rose petal,” as sinister. And it is hard not to suspect, when the two types of chicken pox virus are termed the
wild type
and the
vaccine virus
, that the wild type might be superior.

In 2011, a television news interview with a Nashville woman who was selling lollipops infected with chicken pox led to exposure of a “multistate ring” of parents swapping lollipops that had been licked by sick children. As a federal prosecutor was quick to point out, it is illegal to ship viruses through the mail. The ill-gotten lollipops, priced at fifty dollars apiece, were intended as a service for parents who wanted their children to develop immunity from natural infection rather than vaccination, but infectious disease experts were skeptical of the method. Though it is theoretically possible for lollipops to transmit chicken pox, the virus typically has to be inhaled to cause infection. And the varicella virus is probably too fragile to survive a trip through the mail. But lollipops could be a reliable way to transmit hardier viruses, like hep B, which can survive outside the body for at least a week. In addition to hep B, lollipops licked by sick children could potentially carry influenza, Group A strep, and staph.

Chicken pox lollipops are risky for much the same reason arm-to-arm vaccination was once dangerous—other diseases can be passed this way. A popular alternative to vaccination in the nineteenth century was variolation, the practice of purposefully infecting a person with a mild case of smallpox. Both vaccination and variolation had their dangers. Both could cause high fevers, both could result in infection, and both could pass diseases like syphilis. But variolation, which produced an illness that tended to be fatal in about 1 to 2 percent of its cases, was more dangerous than vaccination. Despite being safer, vaccination did not replace variolation immediately after Edward Jenner popularized the technique. Variolation remained popular in England, Nadja Durbach writes, in part because people preferred “what they considered ‘the real thing.’”

By the time Coca-Cola was marketed under the slogan “It’s the Real Thing” in the 1940s, it no longer contained cocaine. It was not the real thing, and it had never really been the real thing. The pharmacist who developed the combination of cocaine and caffeine as a “nerve tonic” in 1886 claimed that it cured nervous disorders, headaches, and impotence. What it did was deliver an addictive stimulant in a pleasantly flavored elixir. It was an immensely popular tonic, but not because it was healthful.

The introduction of New Coke, a 1985 reformulation, did not go well despite blind taste tests that suggested people preferred it to Coca-Cola. There were lawsuits, boycotts, and public protests. That New Coke could not easily replace a product traditionally marketed on its authenticity should probably not have come as a surprise to the Coca-Cola company. We are wary of imitations, even when they offer improvements. We want the wild type, not the vaccine virus. And we would prefer for our children to have an authentic experience of chicken pox. Part of the appeal of intentional infection with chicken pox is that this form of inoculation does not resemble vaccination so much as it resembles variolation, the real thing. For nineteenth-century practitioners, variolation was a means of “taking immunity into your own hands,” as Anne Moscona, a pediatric infectious disease expert, observes. It was, like our contemporary chicken pox lollipops and swine flu parties, “vigilante vaccination.”

T
HE CONCEPT OF
CLEAR AND PRESENT DANGER
was once used to defend mandatory vaccination in times of epidemic. And the term
conscientious objector
, now associated primarily with war, originally referred to those who refused vaccination. Britain’s Compulsory Vaccination Act of 1853 required the vaccination of all infants, and was widely resisted. After later legislation allowed for resisters to be repeatedly fined, those who could not pay had their belongings seized and auctioned, or were imprisoned. In 1898, the government added a conscience clause to the act, allowing parents to apply for exemption. The clause was rather vague, requiring only that the objector “satisfy” a magistrate that her objection was a matter of conscience. This would result in thousands of cases of conscientious objection, in some places accounting for the majority of all births, as well as a debate over what exactly it meant to possess a conscience.

Before the term
conscientious objector
was written into law, it was used by vaccine resisters to distinguish themselves from negligent parents who had not bothered to vaccinate their children. The word
conscientious
was meant to signal that this was an intentional decision made by caring parents. Conscientious objectors argued that a conscience could not and should not be evaluated, and the magistrates themselves were vexed by the problem of whether or not to demand some sort of evidence to support a claim to conscience. “I don’t understand the Act,” one magistrate said in frustration. “I have seen you, and you have told me you have a conscientious objection; I don’t know whether that is enough.” The word
satisfy
was eventually removed from the conscience clause and a series of memoranda specified that an objector must hold an “honest” belief that vaccination would harm her child but that her belief need not be “reasonably founded.” In debating the law, parliamentarians determined that the conscience was very difficult to define.