Under the Dome
Physicians must try to understand
vaccine opposition, hesitancy
Why are we here again?
We find ourselves witnessing the resurgence of
diseases that we thought were near eradication.
Indeed, as the 20th century closed, polio, rubella,
invasive Haemophilus influenzae Type B (HiB)
disease, and measles seemed so close to being
relegated to the trash heap of history, like smallpox.
And yet, here we are. In the second decade of the 21st century,
we have seen multiple outbreaks of measles and mumps across
the country, along with more isolated outbreaks of invasive HiB
disease. Rates of vaccine coverage have declined so much in certain
communities that future outbreaks of measles are thought to be
likely, including right here in the metroplex. What factors are
responsible for our society’s increasing regression of preferring the
risk of disease over the benefits of vaccines? And, is there cause for
hope in reversing this trend?
History, it turns out, can teach us a few lessons. “All of this has
happened before, and it will all happen again,” as James Barrie
wrote in the first line of his most famous work, “Peter Pan.” Truly,
the so-called antivaccine movement has been present as long as
vaccines have been around.
The first life-saving vaccine was developed by Edward Jenner in
8 Dallas Medical Journal March 2019
Jason Terk, MD
the 18th century to prevent smallpox. This extremely painful disease
nearly always was fatal and certainly was a well-known and dreaded
infection that was spread by respiratory droplets. Outbreaks
occurred in well-populated areas, leading to many deaths, especially
in children. Smallpox had no cure, and it was universally feared.
The use of a related virus (cowpox) to create an immune
response that was cross-reactive with the deadlier smallpox was a
serendipitous discovery when it was observed that milkmaids with
evidence of cowpox infection seemed protected from infection
with smallpox. By the early 19th century, the British parliament
had awarded Jenner the equivalent of $700,000 to develop an
immunization program for the population. By 1840, vaccination
with the cowpox vaccine became official policy in the UK.
Soon thereafter, resistance to compulsory smallpox vaccination
using cowpox inoculation appeared. Objections included
arguments that vaccination disrupted the natural order as ordained
by God as well as protests that vaccination violated people’s
autonomy. There were even allegations that the proponents of
vaccination were driven by more pecuniary motivations than
the desire to prevent a deadly disease. The London Society for
the Abolition of Compulsory Vaccination was established by
well-respected members of British society who opposed the
government’s enforcement of childhood vaccination against
smallpox.
Does this sound familiar?
Bases for vaccination opposition, hesitancy
Today, we hear again the themes of yesteryear’s movement against
vaccines. Witness the public pronouncements of the contemporary
forces aligned against vaccines: vaccines contain ingredients that
can harm; vaccines are unnatural; vaccine mandates serve only
to enrich the companies that make them; the government and
industry are conspiring regarding vaccine requirements; nobody
should require me to inject something into my body or the body of
my child.
Underlying those contemporary and yesteryear arguments are
what we now understand to be moral foundations. These domains
of innate intuitions lead us to certain emotional reactions (approval
or disapproval) to particular interpersonal events. People make
moral decisions based on emotional responses to these events,
and then come up with post-hoc reasons and justifications for
those responses. The emotional responses are guided by a person’s
primary moral foundations.
Six domains have been proposed to explain how people react
and respond to events such as vaccine requirements for school or
a strong recommendation to vaccinate from a physician. They are
Authority, Fairness, Harm, Loyalty, Purity, and Liberty.
• The Authority foundation often is at work when people
“The Cow-Pock — or — the Wonderful Effects of the New
Inoculation!” etching from 1802 shows Edward Jenner vaccinating
patients, who develop features of cows. Political cartoonist James
Gilray’s etching for the Anti-Vaccine Society sensationalizes the
scene of inoculation. Depicted in the center is Jenner using his lancet
to penetrate the arm of a working woman. Surrounding them is a
crowd of vaccinated patients in states of bovine transformation —
some growing horns and even erupting miniature cows like
smallpox buboes from their bodies.