Vaccination against disease has saved millions of lives, yet controversy about their efficacy continues. Researchers have claimed evidence of a link between vaccines and autism, fueled by studies of the effects of mercury poisoning. They also have speculated that increases in attention deficit/hyperactivity disorder may be associated with the high doses of mercury in vaccines for controlling influenza, for example. That is why a citizens movement developed to challenge the safety of vaccines in the 1990s.

Many people in the United States and in other countries take vaccination for granted. When vaccines work, no apparent misery is endured by the patient. Nothing noticeable happens—except that the person has no symptoms of illness of any kind. No polio. No smallpox. No measles. No scarlet fever. No plague. Millions of people have died from smallpox, diphtheria, mumps, and tetanus, for example. We think of vaccinating ourselves as a sign of progress, a triumph over epidemic diseases.

Yet the real or hypothetical side effects of viruses remain a medical contention. Some researchers and critics shake a finger at organisms that have adapted to antibiotics and rendered them ineffective and viruses that have evolved beyond current treatments (e.g., HIV infection). They blame vaccines for causing the disease strains to mutate and persist.

It has been suggested that the problem with human disease epidemics is related to the way we have organized our society economically and politically. The theory is that if society gives priority to accumulating land, resources, and wealth over public health Page 1650  |  Top of Articleconcerns, this in turn creates problems for those who want to control pandemics. Even the political agendas of some governments play a role in the distribution of vaccines, as was illustrated in recent years in the controversy surrounding the human papillomavirus vaccine.

Scientists are beginning to think that vaccines would work better in protecting children from flu if they included both strains of influenza B instead of just one. Further, researchers are reporting that a novel vaccine strategy using viruslike particles (VLPs) could provide stronger and longer-lasting influenza vaccines with a significantly shorter development and production time than current ones, allowing public health authorities to react more quickly in the event of a potential pandemic.

The quest for a universal flu vaccine continues, but researchers at the Mt. Sinai School of Medicine in May 2010 reported new findings suggesting that the day is near when there will not be a need for seasonal flu shots. There will be one vaccine, and it will guard against all kinds of influenza. Current flu shots are strain-specific, making it necessary to adjust the vaccine each year. A patent application for the universal flu vaccine has been filed. (The new findings were reported in the inaugural issue of mBio, the first online, open-access journal published by the American Society for Microbiology.)

There are two central concerns regarding vaccines. First, there is the problem of suspected contaminants or toxins that accompany the vaccines, and the safety of the vaccines themselves, as vaccines are often made from weakened, inactive, or “killed” viruses.

Second, there are concerns about the efficacy of vaccines: Do they actually threaten the appearance of germs? There is worry about emerging “superbacteria” and rapidly mutating viruses. In the wake of public anxieties regarding ongoing and emergent diseases (e.g., HIV, SARS, resistant strains of TB, and now avian, or bird, flu), one wonders if vaccination programs and public health systems in the United States and abroad are sufficient to meet a real pandemic—a disease moving around the globe affecting millions, maybe billions, of people and the animals they depend on. So it is interesting that some people see vaccines themselves as an emerging problem, whereas others see vaccines as a necessary solution to epidemic diseases. The concern remains that the vaccines, and treatment systems in general, may be inadequate given the natural evolution of microorganisms.

The two problems may be interrelated: those who are worried about government-enforced vaccination programs have some grounds for concern because governments themselves are caught up in contradictory demands from citizens in general on one hand and business concerns on the other.

Historically speaking, epidemic diseases are not inevitable or natural events, such as earthquakes or hurricanes. The notion that collectively humans are in part responsible for what literally plagues them has been addressed in popular nonfiction. Jared Diamond, author of a popular book on the history of civilization, notes the central role disease plays in our history and how our societies have helped our diseases. For instance, there is his discussion of our relationship with domestic animals, including pets. Infectious diseases picked up from pets and other animals are usually small nuisances. But some have developed into major killers—smallpox, TB, malaria, the plague, cholera, and measles, to name just a few.

Many of the diseases that have plagued us began early in the agricultural revolution thousands of years ago. Pests such as mosquitoes—which transmit malaria, anthrax, and foot-and-mouth disease—are among the important examples. Such pests are attracted by us and large groups of animals in close captivity.

The maintenance of a stable society over time, involving hundreds or thousands of people, has often required people to own property, tools, and animals and later other people. So-called crowd diseases that would not have gotten a foothold in hunter-gatherer societies flourished in the increasingly large and dense populations of humans and their domesticated animals. Life spans actually decreased as humans transitioned to agricultural communities, where they were subjected to such new maladies as measles, smallpox, TB from cattle, flu and pertussis from pigs, as well as plague and cholera.

The history of vaccines is indicated in part by the very term. Vaccine is derived from vaccinus, a Latin word meaning “of or from cows.” The English naturalist Edward Jenner, hearing that milkmaids working with cows reportedly were less likely to contract smallpox, eventually developed a theory that exposure to the less virulent cowpox conferred some type of resistance to the often lethal human disease. He used variolation, a procedure whereby some pus or lymph from a pox lesion was introduced into a cut made by a lancet, quill, or other sharp object. He inoculated first a child and then others, including his family, with viral particles of cowpox. His theories may have been flawed, but it is interesting that although cowpox and later smallpox inoculations using this method were effective, there were often terrible side effects similar to the disease itself, and occasionally deaths occurred. It is also noteworthy that there was no informed consent. Seldom were people told what could happen or what the risks were. When an epidemic was threatening Boston, Reverend Cotton Mather was eager to introduce variolation to the colonies. This was met with considerable resistance, and those gentlemen heads of households who were persuaded to try the procedure tended to use it on the slaves, women, and children of the household first. It was often the case that women, children, slaves, and servants were the original test subjects. Perhaps this was one historic origin of the controversies over vaccine safety and the distrust of manufacturers and eventually government health programs in the United States.

The history of vaccines has many dark pages—for example, the U.S. government's rush to inoculate the U.S. population against swine flu in the 1980s and the famous Cutter debacle that introduced a toxic vaccine responsible for thousands of lost lives due to an improperly prepared polio vaccine. (The latter incident was, not surprisingly, responsible for increasing public suspicion of vaccines.)

Although, in the wake of the swine flu vaccine program, the swine flu of the 1980s never became a pandemic, reports began to emerge in late November 1976 of a paralyzing neurological illness. This condition, called Guillain-Barré syndrome, was connected to an immune response to egg proteins in the swine flu vaccine. According to historical accounts, federal courts had 4,000 injury claims. It is not known how many injuries were due to vaccination, but the government had to pay out around $100 million.

Given the history of vaccines, it may not be surprising that there have been responses such as the vaccine safety movement in the United States. Arthur Allen, a self-described vaccine advocate, reports the accidents, debacles, and incompetencies that have haunted the history of vaccination. The swine flu incident during the presidency of Gerald Ford came at a time not only of questioning and distrust of the government—in the wake of Vietnam protests and the Watergate scandal, among other important events—but also of a more general distrust of science. In his book, Allen describes the forming of a movement of citizens resisting vaccination, especially compulsory vaccination. In particular, there was resistance to the diphtheria/tetanus/pertussis (DTP) vaccination given in a series of shots to infants. The vaccine does have side effects, especially stemming from the manufacture of the pertussis, or “whooping cough,” vaccine. Side effects have been mild to severe in some infants. The release of the television documentary DPT: Vaccine Roulette in 1982 provoked a grassroots movement of opponents to compulsory vaccinations.

In a report covering a winning lawsuit against a vaccine manufacturer, a spokesperson for the Centers for Disease Control (CDC) had to publicly attempt to stem fears that the vaccine was related to (or a cause of) autism. (The evidence remains far less conclusive than supporters of the vaccination theory would like it to be.) Sociologist Barry Glassner criticizes the American media and other organizations for helping to create what he calls “metaphoric illness”—maladies that people can focus on instead of facing larger, more pressing issues. For instance, we have given much attention to Gulf War syndrome, rather than looking at the reasons for the Gulf War and its consequences. A focus on DTP (also referred to as DPT) deflects the public's attention from larger concerns, perhaps about the credibility of government itself. The DTP vaccine does have some side effects, however, and a newer version is now being used. Glassner points to a similar scare in Japan, and whooping cough, once responsible for the deaths of thousands of infants, may be making a comeback in Japan and the United States. As Page 1653  |  Top of Articlenoted previously, there is more than metaphoric illness going on, whatever fears safety-movement opportunists maybe amplifying. The history of vaccination reveals that there are relevant concerns, issues, and problems on both sides of the vaccine debate.

Improperly prepared or contaminated vaccines have resulted in sickness and death. Many vaccines comprise weakened or neutralized germs. One method of making them is to grow microbes in chicken eggs. People allergic to egg products are warned about using vaccines before their annual flu shots. Concerns about some vaccines causing disorders such autism, as noted, have led to an increased resistance.

Yet anyone who reads firsthand accounts of smallpox epidemics, the current ravages of HIV, or the limited attacks of bird flu will probably want to receive the latest vaccination, even if there are specific risk factors. Other issues have been raised, however, about the overall impact on society of vaccine use. For instance, there is the recent controversy about inoculating under-age women against the strains of human papillomavirus that are linked to cervical cancer. This cancer causes the deaths of thousands of women each year in the United States and the United Kingdom. Because the virus can be sexually transmitted, some critics believe that vaccinating young people may be sending the message that it is acceptable to have sex while legally a minor or to have sex outside of marriage. It remains to be seen whether the use of such vaccines will contribute to an increase in sexual activity in any age group. Whatever our thoughts on this debate, it is easy to see that vaccination involves ethical as well as medical concerns.

The point of vaccination programs is to prevent sickness and death. What various debates on safety and toxicity overlook (or even obscure) is the social arrangements that often promote epidemics and pandemics. For example, the concern over avian flu has probably spurred historical research into past pandemics and our collective reactions. Further, researchers want to know to what extent human action contributes to pandemics. Would we have had the great flu pandemic that followed the World War I (1914-1918) if we had not had the war to begin with? There are good reasons to think that social and economic organization are causative factors in pandemics and our inability to overcome them. A parallel can be found in treatment responses. Antibiotics were once thought to be a road to the ultimate triumph over bacterial infections. Yet the way they are produced and distributed, combined with the evolution of bacteria, have produced bacteria with resistance to these drugs. In effect, the medical and economic organization of treatment has helped to produce “superbugs” that are far more lethal than their genetic ancestors.

Many people are worried that the influenza strain H5N1, or “bird flu,” will become a pandemic. So far, this flu has been largely contained, although whole populations of pigs and chickens have been eliminated in the effort to contain it. One would think that because treatment for this flu is limited in supply and because it is so potentially lethal, those countries that have outbreaks would do everything possible to contain the disease. Page 1654  |  Top of ArticleThe flu may not appear as such initially, and the countries involved may have insufficient supplies and treatment facilities.

These factors, combined with the increasing demand for chicken and pork, allow for increased exposure between wild fowl and domestic chickens and ducks on one hand (a viral reservoir) and agricultural workers and farm animals on the other. This, in turn, creates the conditions for new strains to develop, including strains that can spread from human to human. If this happens and a pandemic occurs, it will no longer be a “bird flu” except in origin. It will then be a human influenza that can mutate further into something similar to the flu that killed millions worldwide after 1918.

Social influences are also reflected in the fact that drug companies dislike flu vaccines because they are hard to produce, are seasonal, and are subject to variable demand. The production process has changed little over the last half century (since Francis and Salk), and although the newer, safer cell-culture technology would eliminate the contamination risk associated with using fertile chicken eggs, drug companies have not upgraded to this process.

Although numerous observers have pointed to the economic problems associated with pandemics—some blaming “corporate capitalism,” others more general economic problems—Tamiflu, or oseltamivir, the one effective treatment for avian flu, is in short supply in the United States. Only two corporations in the United States were making flu vaccine in early 2004, in comparison with the 37 companies making vaccines in 1976.

The 1968 “mild” influenza pandemic killed approximately 34,000 people in the United States. An HN1 (bird flu) pandemic today would very likely kill many more. Sooner or later, an influenza pandemic will happen, but the timing is open to speculation. Given that, why would supposedly advanced societies not prepare for a pandemic with a more powerful virus?

Even a relatively mild pandemic would pressure the United States health care system to the point of collapse. Far fewer hospital beds are available per capita today than in 1968. Shortages of key items, such as mechanical respirators and stores of antibiotics for secondary infections, would quickly develop. Cutting costs is usually a way to save money and bolster profits for investors, or a response to decreased funding from state and federal sources. Responses to cost-cutting efficiency occur on the level of individual practitioners and group practice as well, in great part because of a managed care system that supplies reimbursements and referrals. (The lymphocytic choriomeningitis virus in a pregnant woman, for example, can cause hydrocephalus in her infant. Very little is known about the prevalence of this virus, but running diagnostics for it can raise a doctor's “cost profile” and cause his or her professional ranking as determined by insurance organizations to drop.)

One other issue about vaccines is philosophical, involving our understanding of the nature of disease and our attitudes toward it. The history of vaccination, along with Page 1655  |  Top of Articlethe history of responses to pathogenic organisms that led to the development and use of antibiotics, involves the presupposition that disease is bad and that health involves the avoidance or prevention of disease. As we learn more about the immune system, the socially constructed character of such a conclusion is called into question. Although no one is going to argue that smallpox is a good thing, the “kill the enemy” metaphor in response to pathogens of all types and sorts rests on very weak foundations. A much more effective and useful understanding comes out of viewing the immune system as one would a system of muscles; properly built up and maintained, the immune system can handle the environmental pathogens that people encounter unknowingly every day. Vaccines then can have a role in building up immunological “strength” as long as they do not overstress the system and cause it to break down.

Vaccination for all diseases and reasons, however, reflects economic and social reasoning rather than a medical or scientific indication. A crucial example of this problem is the use of a vaccination for the varicella zoster virus, or chickenpox. Very few children—at least with healthy immune systems—who contract chickenpox have symptoms serious enough to require hospitalization as long as the disease is contracted early in childhood. If exposure to chickenpox is deferred to the late teens or early twenties, the chances of serious infection, hospitalization, or even death among patients skyrockets. The disease is endemic worldwide; thought to be one of the oldest human diseases, it recurs in older people as the painful, though again not usually deadly, condition called shingles (herpes zoster). Vaccination for chickenpox has been promoted for two reasons: (1) to protect our children from disease (the philosophical rationale) and (2) because of the financial implications of parents or caregivers having to take several days off from work so as to care for their sick children. Nowhere in this equation is the danger acknowledged of a vaccination that has an indeterminate effectiveness over time; perhaps we are merely extending the inevitable infection until a later point in adolescence or young adulthood when the benign childhood disease becomes serious or lethal. (Although losing a couple of days of work is irritating, most parents of young children would likely prefer this to the alternative of having a very sick—or dead—teenager.) The public pressure for the new vaccine, however, particularly when marketing focuses on the philosophical rationale of protecting children from disease, is enormous, and the vaccine manufacturers, naturally, have a vested economic interest in promoting such a rationale.

Given the history of vaccines—the experimentation on vulnerable people without informed consent, the problems with their manufacture and distribution, and the rapid evolution of new strains that our economic activity may be assisting—skepticism about vaccination will continue, especially in times where cost cutting and poor production Page 1656  |  Top of Articleoverride concerns for safety or when corporate economics, rather than public health, drive the research and manufacturing of new vaccines.

Skepticism may also continue in the social response to metaphoric illnesses. Metaphoric illness is a way of dealing with social problems that people are unable or unwilling to face head on, perhaps because of the apocalyptic visions of superbugs that no vaccine or health policy can address. Vaccines involve governments making policy about public health and how to intervene directly in the lives—and bodies—of individuals. The intervention of vaccination occurs across a lifetime, involving knowledge and expertise that most people do not have; that is, they do not understand the history, production, and distribution of vaccines, nor do they have medical professional expertise to administer them. Vaccination encompasses a large system of health care, which has become an industry run by remote corporations and technicians with esoteric knowledge. Vaccination is an intervention in the patient's body by this system; it symbolizes a host of interventions beyond the control and understanding of most people. Failure to address the metaphoric dimensions of anxieties about vaccines, fueled by the inevitable side effects and mistakes of any widespread medical undertaking, fosters a public anxiety that may have little foundation in medical science but is nonetheless influential.