July 08, 2004

A Golden Dark Age of Vaccines

I blogged about Vaccines at the CNEhealth.org Blog.

The upshoot of the story was the collision between reading this CNN story and reviews like this - the contrast is stark. On one hand we are seeing declines in vaccination not due to economics or lack of technology but "well-disinformed parents". On the other hand it seems like vaccines are ready to take off and become a far wider range of therapeutic tools than just prophylaxis against epidemic diseases.

To extend my reasoning about the distrust of vaccines: The original fears about vaccination were partially about safety, but also included ethical opposition on the ground that the process was inherently immoral, mixed species and changed the structure of creation. In many ways they mirror current fears of xenotransplantation, where the safety concerns are fuelled by deeper, less often expressed "philosophical unease" (or gut reactions) about the implications.

This is a common pattern in the slow transformation of biotechnology from perversion to practice (and maybe later religion); we see it in the current biotechnology debates, where the narrow discussions abour safety, equity and ethics in the narrow sense are fuelled by a deeper and broader conflict about differing views of nature, humanity and what they should become.

Later opposition was more about the rights of an individual to choose to vaccinate or not to, with a debate about the ethics of public health. Here the debate seems to have ended with a fairly broad consensus that the collective benefits of vaccination outweigh the individual's right to bodily self-determination. Here most collectivist, utilitarian or duty-based moral systems were in agreement, with some libertarian opposition. But even from a libertarian standpoint it is not trivial to determine whether the expected harm to others due to not vaccinating oneself outweighs the small risks/costs/compulsion to oneself due to vaccination. Being myself of the opinion that an act of omission of help to others is not necessarily immoral and that the right to one's body rank very high in the rights hierarchy, I think it would not be immoral to abstain from vaccination. After all, we do not forcibly confine people carrying colds to stay at home, despite the fact that they do infect others and the infections contribute to overall mortality (see also this analysis). It might still be morally commendable and the rational thing to do out of self-interest. It is also potentially something that could be seen as part of a social contract: just as we relinquish certain rights to a government even in the minarchist case (i.e. the legal use of violence) in order to gain a useful social order, we could have a disease control clause in the social contract. But this presupposes (morally) explicit contracts that can be chosen or not, not the current coercive form.

Leaving people to decide whether to vaccinate clearly can lead to under- or un-vaccination. This can occur even in the completely rational and fully informed case; see Chris T. Bauch, Alison P. Galvani & David J. D. Earn, Group interest versus self-interest in smallpox vaccination policy, PNAS, September 2, 2003, 100(18), 10564-10567 for a game-theoretic analysis of voluntary vaccination reaching the conclusion that it would not reach the optimal level.

But I find the trend of ignoring vaccinations due to vaccine scepticism more worrying. Rational non-vaccination can be handled through rational discussion, the construction of suitable institutions or incentives (what about my favorites, the insurance companies? one could find the cost of the non-vaccination risk and use them to have defectors pay it, while using insurance to compensate for the vaccine risks). Lack of information and misunderstandings can be handled through education. But resistance due to risk complacency brought about by a safe environment, risk aversiveness towards mediagenic risks, selective information gathering and powered by traces of an anti-technological, romantic perspective cannot be handled this way. It would be tragic if the only way to reverse the trend would be a widely publicized epidemic killing children (but it would likely work; maybe this is good material for a TV miniseries? For once a scare story could be based on something real). I think the only way of really getting anywhere with this is to re-establish a sense of "scientific belonging": to get people to really know how the vaccines works, their real pros and cons, how their efficacy and safety are tested, how the current controversies are handled and especially show how we belong in the scientific universe. An enormously tall order, as usual (I better go back to asking for Dyson Spheres instead). But helping establish at least some scientific literacy is a good start to get people engaged in making actual risk assessments (e.g. "even if the sceptics are right and MMW vaccine increases the risk of autism, is that risk increase worse than the risk increase to my child (and others) of measles, mumps and rubella?").

As always with me, the "answers" seems to be 1) we need to create flexible, free institutions that help us sustain the benefits of our civilisation without dangerous or immoral concentrations of power, 2) we need to become more aware of how the world around us works. But even if this is just me hitting all problems that look like nails with my solution hammer, I doubt these solutions have any serious side-effects.

Posted by Anders at July 8, 2004 01:26 AM

Just when I thought I could log out, I found this story on New Scientist:
Apparently the old Soviet polio vaccine was infected with the potentially cancer-causing virus SV40 up until the 80's, potentially affecting hundreds of million people.

Another reason to switch to DNA vaccines where there is no risk for this (unless of course the plasmids themselves turn out to be dangerous, but that seems unlikely). But in the short run this will likely just feed the anti-vaccine movement and demands for ever stricter (and more expensive/slow) controls of vaccine production.

Posted by: Anders at July 8, 2004 03:30 AM

"Soviet scientists fuck up, give millions of people cancer. Film at 11."

Wow, now if that isn't the very definition of a "Dog Bites Man" story, I don't know what is.

Aaah, them wacky Soviets - trying to solve problems by putting guns to people's heads and invariably ending up with half-assed solutions that give millions of people cancer.

Oh, and don't forget Lysenkoism!

Posted by: Korgmeister at July 8, 2004 04:14 PM

Yes, Soviet biology was a disaster. Lysenko was not alone in politicing soviet biology and ending scientific disagreements by sending opponents to gulags (see W.B. Gratzer's entertaining "The Undergrowth of Science"). Overall it shows just how important the free exchange of ideas and criticism is, and the danger of getting the government and (heaven forbid!) ideology involved.

But the Soviet vaccine mess is an unusually large mess - over a 100 million people may have been affected. Most likely the virus wasn't that dangerous and the benefits even of the tainted vaccine in terms of human life chances were immeasuably larger, but one shouldn't take chances.

And it brings up the question of how much quality control we want and need. On one hand the Soviet level is too low, it allows potentially risky things through. But the increasingly risk aversive regulators in the west are making medications and vaccines extremely expensive beyond their original cost. One approach would be to allow different levels of quality control, clearly labelled. That way one could find the right balance between cost and safety. But that works best when it is consumers rather than governments who selects the vaccines (or rather, the health consumers get their doctors to buy the right level). In centralized systems the trade-off will be between the government view of safety and cost, and that can diverge enormously from the citizens' views.

Posted by: Anders at July 8, 2004 06:50 PM