By Anthony Robbins, MD, MPA

The Journal of Public Health policy has just published my editorial “The CIA’s Vaccination Ruse” on an open-access basis on the journal’s website. The editorial deals with the CIA’s use of a sham vaccination program as a cover for spying operations in Pakistan. As I have studied vaccines and vaccine policy for almost forty years, The Pump Handle has invited me to provide its readers with some big-picture background on vaccines and vaccination policy in the US and around the world to accompany the link to my editorial.

School Entry Laws
In the 1970s, public health departments in the United States were recommending that all children receive vaccines to protect against tetanus, diphtheria, pertussis, measles, mumps, rubella, and polio.  The vaccines were effective, but coverage was insufficient to prevent sporadic outbreaks of measles, mumps, rubella, polio, and pertussis.  The 1977 National Childhood Immunization Initiative set a target of 90% vaccination of all children. The Surgeon General of the US Public Health Service, Julius Richmond, urged states to require up-to-date vaccinations before children could enter school or daycare. States implemented school entry rules, and with support from the medical community, they had the desired effect of increasing vaccination coverage and reducing the incidence of vaccine preventable diseases.

Swine Flu
In 1975, there were a few cases of influenza at an Army induction camp at Fort Dix, New Jersey. The world was alert to new flu strains following the pandemic of 1968-69.  The Centers for Disease Control became alarmed, because the genome of the virus found at Fort Dix appeared to be identical to the one that had caused the great 1918-20 pandemic (The Spanish Flu). Only a small number of Americans had been alive in 1920, thus there was very little protective immunologic memory in the population.  The good news was that the Swine Flu virus did not spread efficiently in people and the epidemic was not large.  The bad news was that without an organized medical care system in the United States, public health leaders learned that there was no effective way to vaccinate the whole population rapidly even once manufacturers had produced an effective vaccine in sufficient quantities.  As a state health officer, I struggled with this problem twice, first in Vermont until June 1976 and then in Colorado.

Objections to Vaccination
One consequence of a mass vaccination effort, for the 1975 swine flu, was that a small number of vaccine recipients developed a paralysis, Guillain-Barré syndrome.  This was not totally unexpected.  Had these side effects occurred during a deadly global epidemic, Americans would have been pleased to be protected, accepting a few cases of Guillain-Barré as the price to avoid a massive death toll comparable to 1918-20.  With no pandemic, people instead focused on the dangers of vaccines, and vaccine manufacturers demanded and received protection from liability.

As director of the Colorado Department of Health (1976-78), I also encountered related problems while implementing our school entry law.  Under the rules, parents could choose, because of medical contraindications or religious beliefs, not to have their children vaccinated.  Faced, for example, with a measles outbreak in the Southwest corner of the state, we could not order children vaccinated if their parents objected.  One fundamentalist religious community was obstinate in refusing any and all vaccine the Health Department offered. We had little choice but to keep unvaccinated children out of school to protect others.  Even if all the children in a school had received all vaccinations, vaccine is never fully effective.  Children unprotected by the vaccine would still be somewhat protected by herd immunity because the vaccine had worked in enough children to reduce the number of susceptible children and prevent transmission of the disease.  This is why vaccination is a community decision based on weighing costs and benefits, not an individual decision.

Vaccine Development: new and safer vaccines
When I moved to Washington, DC in late 1978 to direct the National Institute for Occupational Safety and Health (NIOSH), I had no reason to think I would refocus on vaccine policy less than four years later.  But my tenure at NIOSH was cut short by the election of Ronald Reagan in 1980, and I found myself working for the House Energy and Commerce Committee.  I spent most of my time there organizing resistance to President Reagan’s budget that proposed to cut public health programs, including immunization, by 25%.

How did I get into vaccine policy? Because at NIOSH I had been a member of NIH’s Recombinant DNA Advisory Committee, Committee Chairman John Dingell asked me to look into environmental risks associated with biotechnology and genetic engineering. I enjoyed catching up on the science.  But it was Phyllis Freeman, my colleague on the Committee staff, who asked the key question: What was biotechnology good for, particularly in the domain of public health?  When she and I looked at how the new science was being applied, we found that commercial applications centered on medications, cosmetics, and products like drain-cleaners. Despite the fact that vaccines seemed to be the perfect application of biotechnology, they received little attention. Bill Jordan and his colleagues at the National Institute for Allergy and Infectious Diseases and Ken Warren at the Rockefeller Foundation agreed.  Antigens in vaccines might be produced in relative purity and in great quantities, in a process not unlike brewing beer.  But in commerce, vaccines did not seem to offer a good return on investment, given the following factors:

1. A growing number of lawsuits from parents who thought their children had been injured by vaccines.  (Initially US industry threatened to leave the vaccine business entirely unless protected from liability.)
2. Prices had come way down.as most vaccines had been around long enough to be off-patent. A vaccine, moreover, was likely to be given but a very few times, compared to a drug that might be taken every day for a lifetime.
3. Lack of vaccine research and development. (Although evidence suggested that the old (1949) whole cell pertussis vaccine probably did cause rare but harmful reactions, manufacturers had put little effort into finding a safer alternative.)

Representatives Dingell and Waxman wanted to write legislation to advance development and use of vaccines. The National Institute for Allergy and Infectious Diseases wanted to convince the leaders of NIH (Building One) to invest in developing new and safer vaccines. NIAID paid for three ground breaking reports from the Institute of Medicine of the National Academy of Sciences (here, here, here.) Witnesses discussed the findings in hearings in the House of Representatives.

In 1986, the Congress enacted Public Law 99-660 which included the National Childhood Vaccine Injury Act of 1986 (42 U.S.C. §§ 300aa-1 to 300aa-34).  The law created a no-fault vaccine injury compensation program.  It also called for a national plan to “achieve optimal prevention of human infectious diseases through immunization and to achieve optimal prevention of adverse reactions to vaccines.” Roy Widdus provides an update on the IOM reports and their effect on vaccine development.

Immunization in the Developing World
In the 1970’s, the World Health Organization was eliminating the last naturally acquired cases of smallpox and preparing to declare the disease eradicated.  In 1974, WHO resolved to take on other vaccine preventable diseases under the Expanded Program of Immunization (EPI), led by an American veteran of the smallpox effort, Ralph Henderson.  EPI concentrated on coverage, helping countries put in place delivery systems with safe needles and syringes, refrigerators, and trained vaccinators. The commonly used vaccines (BCG for tuberculosis; polio, diphtheria-tetanus pertussis (DTP); and measles) were inexpensive. It cost UNICEF about $0.50 to buy vaccine for one full childhood immunization series.

As EPI achieved greater coverage, leaders at WHO and UNICEF planned next steps.  The system they had in place could deliver vaccines against other diseases. Vaccines might be made in oral forms and made stable without refrigeration.  The IOM report on vaccine development priorities for developing countries, suggested the great benefit of developing new vaccines and adding them to EPI.  By the mid-1980s, the picture was changing. James Grant at UNICEF and Halfdan Mahler at WHO, supported by the World Bank, UNDP, and the Rockefeller Foundation, were now committed to both vaccine development and immunization.  Public vaccine institutes and bilateral development agencies joined the effort. Most industrial world commercial vaccine makers became engaged once it was clear that they might be able to charge higher prices in industrial country markets, so-called tiered pricing.

Remaining Challenges
EPI has raised child vaccination coverage for tuberculosis, diphtheria, pertussis, tetanus, polio, and measles to about 79 percent and now includes hepatitis B, Haemophilus influenza B, rubella, and yellow fever in many countries. Polio has been eliminated in most of the world and measles outbreaks are far less common.

WHO had hoped to complete global polio elimination by 2005, but local armed conflicts and rejection by religious fundamentalists slowed polio campaigns in Nigeria and in Pakistan. Vaccinators, often from afar, come into fearful and isolated communities.  Even in the United States, organized groups have opposed mandatory vaccination.  Public health officials struggle to overcome residual distrust.

Given how crucial public trust is to vaccination efforts, I was shocked by the CIA’s vaccination ruse, and perhaps more concerned that no one in the US Public Health Service seems to have complained publicly. It is surely impossible to know how much damage the CIA’s vaccination ruse will cause to the polio campaign or vaccination in general. In my editorial, I recommend the following:

The public health community must not let this awful, and now public, decision pass without being sure that the lessons have been learned and similar errors will never happen again. The intelligence community must consider the health effects of its operations, and if unsure, consult the public health community. The public health community needs to break its silence and never again be silent on matters of public health.

The complete piece is available here.

Anthony Robbins, MD, MPA is co-Editor of the Journal of Public Health Policy.