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Vaccinating Britain

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Vaccinating Britain 4 Pertussis Part II of this book signifies a shift in emphasis for the British vaccina- tion programme. Some of this was due to maturity. By the 1970s, many of the fundamental questions about which vaccines to include and whether the state had a role in protecting the British public had been answered. Citizens had come to accept vaccination for themselves and demand it of others. Other changes were due to political and historical circumstances. Whereas MOHs had played a key role in the admin- istration of immunisation from the 1940s to the 1960s, these func- tions were subsumed by the Department of Health and Social Security (DHSS) in the 1974 reorganisation of the NHS. The DHSS and its pre- decessor, the Ministry of Health, had attempted to exert more central control over and unification of the vaccination programme. This was seen in the surveillance of local authority uptake statistics; a growing role for the medical civil service through bodies such as the JCVI; and national control over the provision and funding of vaccine supplies to the regions. These issues of localism did not disappear. General practitioners took ever greater responsibility for ensuring that their areas met cen- trally determined targets for vaccination rates. However, with a mature programme and a tried and tested vaccination bureaucracy, the major concerns were different. No longer were there regular surges in demand to cause supply issues. Nor was apathy so acute in a system that could better monitor and follow up with parents who did not vaccinate their children. Rather, the key crises for the national vaccination programme came when the new status quo was challenged. This was exemplified in two key incidents in which faith in specific vaccines was damaged. Chapter 5 will examine the MMR vaccine crisis and the subsequent Gareth Millward - 9781526126764 Downloaded from manchesterhive.com at 09/25/2021 10:09:55PM via free access 150 Vaccination crises sociological debates about vaccine confidence and health education at the turn of the millennium. This chapter deals with pertussis. In the mid-1970s, some doctors questioned the safety of the pertus- sis (or whooping cough) vaccine, claiming that it could cause brain damage in young children. Despite protestations from the majority of the medical community, public confidence in the vaccine dropped sig- nificantly. Pertussis vaccination rates fell from 78.5 per cent of children born in England and Wales in 1971 to 37 per cent in 1974.1 As a result, the whooping cough outbreak in the winter of 1978–79 was worse than any since the 1950s. It was not until the mid-1980s that vaccination rates recovered and infection rates returned to pre-crisis levels.2 To counter negative publicity, the government commissioned a report into the science behind the vaccine and embarked on an advertising cam- paign to encourage parents to vaccinate their children. But science and medicine formed only part of the debate. As they had been from the first vaccination programmes, questions about the boundaries and responsibilities of the state were central. In the case of pertussis, public health policy was considered alongside social security and the wider welfare state. If the hazard of brain damage was real, regardless of how small the risk, did the government not have a duty to provide support for the families adversely affected by vaccines? Similarly, if herd immu- nity was a crucial part of a functioning public health programme, did the health authorities not have a duty to ensure that uptake was as high as possible? Citizens demanded that the state should provide protec- tions, but also that citizens should be protected against state actions. This chapter, therefore, is about risk. We have already seen how sta- tistical computations of risk were used in the vaccination programme. The decision to ban imports of Salk vaccine from North America had been taken because it was felt that the British vaccine was less likely to cause damage. Routine infant smallpox vaccination ended when the risk of damage from the vaccine was considered higher than the risk of an unvaccinated population actually catching the disease. Diphtheria immunisation was hailed as a success because immunised children were less likely to contract the disease, and if they did they were much less likely to get a serious form of it. Such statistical calculations had become the foundation of epidemiology and chronic disease management by the 1970s, building on the research that had established the link between tobacco smoking and lung cancer.3 Although elements of these can be Gareth Millward - 9781526126764 Downloaded from manchesterhive.com at 09/25/2021 10:09:55PM via free access Pertussis 151 seen in the chapters in Part II, this chapter focuses more on the socio- logical concept and how it manifested in debates around the pertussis crisis. Studies of risk usually take three forms.4 First, they explore how societies have come to create, identify and manage new risks as they become more technologically advanced. Modern societies have created new hazards – things that can go wrong – with ever greater destructive power (e.g. the potential meltdown of a nuclear power plant). Regula- tory frameworks manage the risk – the statistical likelihood that the hazard will actually occur – so that the benefits of these modern tech- nologies outweigh the dangers.5 Second, risk studies look at the social and cultural conditions that make certain individuals or organisations prioritise certain risks over others. These approaches tend to focus on the meaning and social construction of risk, with a focus on decision- making processes and politics.6 Third, risk can be viewed through a Foucauldian lens. We can analyse how power identifies and manages risks through governance. Risks are managed by the state as well as being internalised by citizens.7 Together, these analyses stress the cen- trality of risk to modern states, especially since the early twentieth century. Thus, we can analyse not just what risks were identified but also how different societies focused on specific risks and how those were integrated into systems of governance. This chapter does not seek to explain why parents chose to eschew whooping cough vaccination during the crisis. Instead, it puts the per- tussis debate in context by showing how it was inherently tied up in wider public concerns over risk. These risks were partly to do with the vaccine. The medical deliberations over the relative risks of vaccine damage and infectious disease were clearly the catalyst for the crisis. More importantly, however, these debates were rooted in anxieties about the role of the welfare state. The most prominent discussions were over the provision of financial compensation to the victims of vaccine damage. This was a product of renewed political interest in groups whose risks of poverty had not been successfully managed by the 1948 welfare state.8 The public demanded protection from the risks of vaccine damage – that is to say, they wanted to prevent damage from happening and to have an adequate safety net for those who became disabled. But they also demanded protection from infectious disease, as evidenced by the queues outside clinics for vaccination when the epidemic broke out. Moreover, the levels of risk and the importance Gareth Millward - 9781526126764 Downloaded from manchesterhive.com at 09/25/2021 10:09:55PM via free access 152 Vaccination crises attached to them varied by constituency. This was a policy debate in which there were multiple actors, including parliamentarians, voluntary organisations, the medical profession, the DHSS, the Treasury and the press. These concerns were an extension of a classic problem in decision making around vaccination: omission versus commission.9 A child who catches a disease when they have not been vaccinated can be said to be a victim of an ‘error of omission’. An act was not taken (whether delib- erately or not), leading to an unwanted event. A child who suffers an allergic reaction to a vaccine may be a victim of an ‘error of commission’. This is the opposite of ‘omission’, since an action was deliberately taken.10 Parents and individuals tend to be better at rationalising acts of omission, where a negative event can be attributed more to chance than to an active, harmful decision on the part of the individual. As this chapter will show, this dilemma was present throughout the pertussis crisis. The potential negative outcomes (or hazards) to individual fami- lies of either brain damage or whooping cough were catastrophic. While medical experts debated the acceptable odds of these events happening (risk), the lay public found it difficult to find a clear answer.11 This debate was fuelled and reflected by the ample press coverage which the crisis received.12 But it was not just parents caught in this bind. As risks became both visible and manageable through technological change, certain obligations were placed upon individuals and organisations to manage them.13 For supporters of vaccination, parents were expected to vaccinate their children as part of their duty towards themselves and their fellow citizens (as seen in Chapter 1).14 For critics, the govern- ment’s slow response meant that it had failed to manage the risks of either vaccine damage or infectious disease adequately. Neither omis- sion nor commission alone would give the DHSS an easy policy option. The risks of continuing to use a vaccine that might prove to be danger- ous were obvious. At the same time, doing nothing about the impend- ing epidemic was also unacceptable. This chapter explores these themes by outlining the key events of the pertussis crisis. It then focuses on the two main areas of debate. First, the passage of the Vaccine Damage Payments Act 1979 was predicated on the idea that individuals who were vaccinated for the good of society should be compensated for taking that risk if things went wrong.
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