Vaccine Nation opens in the 1960s, when government scientists—triumphant following successes combating polio and smallpox—considered how the country might deploy new vaccines against what they called the “milder” diseases, including measles, mumps, and rubella. In the years that followed, Conis reveals, vaccines fundamentally changed how medical professionals, policy administrators, and ordinary Americans came to perceive the diseases they were designed to prevent. She brings this history up to the present with an insightful look at the past decade’s controversy over the implementation of the Gardasil vaccine for HPV, which sparked extensive debate because of its focus on adolescent girls and young women. Through this and other examples, Conis demonstrates how the acceptance of vaccines and vaccination policies has been as contingent on political and social concerns as on scientific findings.
By setting the complex story of American vaccination within the country’s broader history, Vaccine Nation goes beyond the simple story of the triumph of science over disease and provides a new and perceptive account of the role of politics and social forces in medicine.
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America's Changing Relationship with Immunization
By Elena Conis
The University of Chicago PressCopyright © 2015 The University of Chicago
All rights reserved.
KENNEDY'S VACCINATION ASSISTANCE ACT
A crush of reporters gathered for a presidential press conference late one afternoon in April 1961. They were poised with pressing questions about the national economy, "Red" China, Communists in Cuba, and the Soviets' recent success launching the first human into outer space. But President John F. Kennedy put their questions on hold to make a brief announcement: "Today is the sixteenth anniversary of the death of President Franklin D. Roosevelt," said the president. "It is also the anniversary of the announcement of the vaccine which has been discovered to prevent paralytic polio." He told the reporters that there was a renewed national effort to vaccinate all Americans against polio, and that he hoped "every parent in America" would take advantage of "this miraculous drug."
It was a succinct but carefully timed and scripted announcement. By mentioning Roosevelt, Kennedy invoked the kind of bold, progressive Democrat he intended to be; Roosevelt also happened to be the nation's most famous polio victim and survivor. By mentioning the "miraculous" polio vaccine, Kennedy invoked the nation's impressive biomedical enterprise and its recent victory against a disease that had gripped Americans with fear in the 1940s and 1950s. As Kennedy went on to field questions from the reporters, he found no further opportunity to mention polio or its vaccine; the nation was no longer worried about polio, and the press was fully preoccupied with the economy and the Communist threat. But even as the president spoke, federal regulators were reviewing the evidence on a newer and more effective polio vaccine. And his administration was crafting a bill that would give the federal government an unprecedented role in supporting and shaping immunization all across the United States, against an unprecedented number of diseases.
That bill was initially conceived as a continuation of an Eisenhower-era program of the mid-1950s that had helped provide the first polio vaccine to tens of millions of Americans. But the Kennedy administration proposed taking things further. The resulting Vaccination Assistance Act of 1962 was a quietly significant piece of legislation. It gave states federal dollars and guidance to protect all Americans from a list of diseases—diphtheria, pertussis, tetanus, and polio—chosen not for the number of lives they took, or for the public attention they commanded, but for the existence of their vaccines. Policy, here, took its shape from existing technologies. Indeed, the act was remarkable because it gave Americans something they hadn't asked for: immunization for all, against all vaccine-preventable diseases.
But why did Kennedy promote legislation that few Americans had asked for, and how did he succeed in getting it enacted? As this chapter shows, the vaccination act squared neatly with the president's domestic policy focus on social welfare and health reforms, and it reflected his predilection for cost-conscious and "compassionate" legislation. It bore the influence of his family's personal interest in children's health, and it helped counterbalance the administration's focus on health care for the elderly—a fact that Kennedy's sister Eunice Shriver was blunt in pointing out. It was propelled through Congress by Cold War fears of disease as a national security threat, a zenith of cultural faith in biomedicine and medical technologies, the nation's recent experience with polio, and widening acceptance of routine medical care and vaccination for children.
Kennedy's act wasn't just remarkable for its time; as subsequent chapters of this book illustrate, it would also turn out to have enduring significance. In fact, the story of vaccination and society in modern times begins with Kennedy's proposal precisely because it laid a new foundation for federal immunization policy and set a precedent for federal involvement in vaccination promotion that subsequent Democratic administrations—such as those described in chapters 4 and 7—would mimic and expand upon. Decades later, health experts continued to refer to it as "one of the most successful prevention programs in public health." To this day, in fact, it remains a "mainstay" of public support for child vaccination—even as it remains a product of the Kennedy administration's priorities and the national preoccupations of the early sixties.
In many ways, today's vaccination enterprise is a legacy of the Vaccination Assistance Act of 1962. And that law, in its own time, was made possible by the nation's experience with polio and the success of a federal polio vaccination act passed in the 1950s. Polio, a viral infection that can cause permanent crippling and fatal paralysis, appeared somewhat suddenly in the United States around the turn of the twentieth century. Roosevelt was struck in 1921 and left paralyzed at the age of thirty-nine. He found some relief at a crumbling mineral springs resort in Georgia, which he bought and turned into a nonprofit institute for polio patients. By the 1940s, the small institute had been transformed into a massively successful philanthropy and fund-raising machine, the National Foundation for Infantile Paralysis, later renamed the March of Dimes. From the 1930s through the 1950s, the foundation inundated Americans with information about polio through ubiquitous and celebrity-studded publicity blitzes. Its campaigns popularized the "poster child," a young patient whose image tugged at heartstrings and helped prompt millions of Americans to give time and money to the cause. They also put polio firmly on the national agenda and made the disease's defeat a national priority (even as heart disease, cancer, accidents, and pneumonia and flu claimed more lives).
The foundation also heavily financed the vaccine research of several scientists, including Jonas Salk and Albert Sabin. In 1954 the foundation financed a field trial of epic proportions to test Salk's killed-virus vaccine in children. With some 1.4 million "Polio Pioneers" participating in forty-four states, it was the largest medical experiment ever conducted. A year later, on the tenth anniversary of Roosevelt's death, the trial results were announced before a bank of reporters and television cameras. The Salk vaccine worked, and the country was jubilant—and then desperate for access to the long-awaited miracle drug. The foundation had arranged to buy the first $9 million worth of vaccine for the country's first- and second-graders, who suffered the highest rates of the disease, but it was not at all clear how and when others would get the vaccine. Rumors spread of black markets and doctors charging exorbitant fees, and panicked health officials, parents, and others turned to Washington for help.
Federal assistance came, but it was hard-won. Representatives of the American Medical Association (AMA) and the American Drug Manufacturers' Association argued that the government had no place determining how to distribute or pay for a vaccine. President Dwight D. Eisenhower himself was a moderate conservative with little tolerance for federal involvement in health care. The Democratic Senate wanted to make the polio vaccine available to all children, but the Republican-controlled House favored a bill to provide the vaccine to needy children only. The lawmakers' partisan dispute made headlines, drew charges of socialism, and at one point forced the House Speaker to demand that legislators take a "cooling-off" recess. The compromise bill, which Eisenhower signed in August 1955, allotted $30 million for states to vaccinate children under twenty and pregnant women—as they saw fit. As the Polio Vaccination Assistance Act was being hammered out, and upon its approval, the press made much of the fact that although a federally devised formula had determined how much vaccine each state received, ultimately the authority remained with each state, and not the federal government, to decide who would get the shots and where. The message was clear: the act was not to be taken for socialized medicine.
By the late 1950s, as historian James Colgrove has shown, the National Foundation for Infantile Paralysis had helped move vaccination from local health departments and medical societies to the national stage. By setting in motion the series of events that prompted passage of the 1955 act, the foundation had also (inadvertently) helped nudge the federal government into the "reluctant" role of director. This new arrangement appeared to be effective. In the year Kennedy entered office, 1961, the United States saw just 1,000 polio cases, down from more than 58,000 cases in 1952. More than half of all Americans had received the requisite three doses of Salk vaccine; many more had received one or two.
But by the early 1960s, health experts had begun to notice a new pattern: infants and adult men were still vulnerable to the disease, a finding that prompted a new national campaign urging that "Babies and Breadwinners" get vaccinated. In the course of the nation's battle against polio, Americans, it seemed, had come to think that vaccines were for schoolchildren, and schoolchildren only.
A CAPTIVE AUDIENCE
The 1950s campaigns of the National Foundation for Infantile Paralysis did much to imprint the notion that vaccines were for children firmly onto the American psyche. School-age children were most at risk of polio, but they were not exclusively at risk, as starkly evidenced by former president Roosevelt's paralytic polio. Nonetheless, the ubiquitous images of poster children, the recruitment of over a million young Polio Pioneers, and the foundation's plan to ration limited vaccine to five- to nine-year-olds placed children at the center of the polio vaccination crusade, and as a result vaccination as a service for adults was increasingly overlooked. But the nation's experience with polio wasn't the only factor driving home the impression that vaccination was for children; it had much to do with the rise of pediatric care, as well.
Pediatrics as a medical specialty had emerged in part from a social movement, originating in the latter nineteenth century, that focused on child health and welfare. This child welfare movement spawned laws governing compulsory schooling for children, child labor laws, delinquency reform, and more. In the 1900s and 1910s, Progressive reformers made schools the site of compulsory medical examinations to test hearing, vision, and dental health, taking the position that schools provided the most expedient means of improving not just children's minds, but their bodies as well. To social reformers of the time, the comprehensive welfare of all children promised a strong future for the state. This same belief inspired increased federal involvement in children's lives in the early twentieth century, dubbed the "Century of the Child" by reformers. The U.S. Children's Bureau was established in 1912 to "investigate and report upon all matters pertaining to the welfare of children and child life," including infant mortality, child labor, orphanages, adoption, accidents affecting children, "degeneracy," and childhood diseases. The Sheppard-Towner Maternity and Infancy Protection Act, passed in 1921, gave states federal dollars to provide health and welfare services for children and their mothers.
Pediatrics took shape in the context of this broader social movement. In the first few decades of the twentieth century, the practice of pediatrics—the medical care of children—was increasingly characterized by regular, repeated medical examinations of healthy children. Children were X-rayed, weighed, and measured, and their blood and urine were tested, all in an effort to ensure their "normal" development and keep them free of illness and disease. This type of preventive pediatrics was initially designed for the working class, as sociologist Sydney Halpern has noted. And originally, the care of the well child (as opposed to the sick child) often took place in health centers supported by the federal U.S. Children's Bureau and public clinics supported by the Sheppard-Towner Act. But by the 1940s, this had changed.
In part, that's because pediatrics had become firmly established as an independent medical specialty in the 1930s. The American Academy of Pediatrics was formed in 1930, and the organization issued its first set of immunization recommendations for children in 1934. Meanwhile, as publicly supported sites for well-child care disappeared (Congress stopped funding Sheppard-Towner in 1929), pediatricians' offices became the most logical setting for all well-child services, including vaccination; a series of shots followed by boosters could be easily administered at the same time as a child's regular barrage of tests and measurements. But as a result of this shift from public clinics to private offices, well-child care—and vaccination—increasingly became the domain of the middle class. Over the next few decades, pediatric care offered a convenient setting for the administration of vaccines, a set of professionals eager to own the practice, and a captive audience—but it was an audience defined by its ability to afford preventive care. As members of Congress considered federal legislation to make vaccines available to all Americans in the 1960s, they remarked on precisely this fact: middle-class children received vaccines as a matter of course, but the same was not true of poor children.
THE VACCINATION ASSISTANCE ACT OF 1962
On June 26, 1962, members of the House of Representatives debated a mass immunization bill that had come directly from President Kennedy's office. The administration's bill proposed to give states grants to carry out intensive immunization programs against diphtheria, tetanus, pertussis, polio, and—as new vaccines became available—any other disease deemed a health threat by the surgeon general. It was a problem, the assembled representatives agreed, that so many Americans were not taking advantage of vaccines to prevent disease: 80 percent of all adults and two-thirds of children under the age of five, the majority of them from "low-income" families, were not fully immunized against polio, diphtheria, pertussis, and tetanus. But as members of the House debated the bill's merits, many made it clear that they saw the president's proposal as an imperfect solution. To Peter Dominick of Colorado and Barry Goldwater of Arizona, the root of the problem was not a lack of facilities, vaccine doses, or dollars, but inadequate communication and education. To Harold Collier of Illinois, the bill was redundant, as states already had access to general public health funds from Washington that they could use to vaccinate their populations. To Representative Dave Martin of Nebraska, the bill was simply a worrisome and unnecessary expansion of federal activity.
The administration's proposal provided for the immunization of all Americans, but it placed special emphasis on preschoolers, as did the House debate and other hearings on the bill. The problem of inadequate immunization was "not confined to children," noted Secretary of Health, Education, and Welfare Abraham Ribicoff, but children were at "greatest risk" from the specified diseases and thus constituted a "community epidemic hazard." The bill did not place special emphasis on poor Americans—of any age—but discussions in Congress returned again and again to the findings of a recently commissioned Public Health Service report that "the lower the socioeconomic class, the lower the level of immunization." Though some of the bill's proponents, like Representative Leonor Sullivan of Missouri, endorsed the idea of providing all children, of all means, with vaccines against any disease, this was not the view that held sway with most members of Congress in the spring of 1962. A House committee narrowed the bill's scope to the four diseases for which vaccines already existed and altered its emphasis to cover children in need above the age of five. In that revised form, the bill passed the House. In October the bill passed the Senate, and on the twenty-third of that month, in the midst of the Cuban Missile Crisis, President Kennedy signed it into law. Its title: "An Act to assist States and communities to carry out intensive vaccination programs designed to protect their populations, particularly all preschool children, against poliomyelitis, diphtheria, whooping cough, and tetanus."
Excerpted from Vaccine Nation by Elena Conis. Copyright © 2015 The University of Chicago. Excerpted by permission of The University of Chicago Press.
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Table of ContentsIntroduction
1. Kennedy’s Vaccination Assistance Act
2. Polio, Measles, and the “Dirty Disease Gang”
3. How Serious Is Mumps?
4. Carter’s Childhood Immunization Initiative
5. A Mother’s Responsibility
6. Tampering with Nature
7. Clinton’s Vaccines for Children Program
8. Sex, Drugs, and Hepatitis B
9. Vaccine Risks and the New Media
10. Sex, Girls, and HPV
Appendix: The Science and Regulation of Vaccines