Booster Shots, book by Adam Ratner
This splendid little book (202 pp. not counting the notes) is ostensibly about measles, but it covers a lot more, not least how we are probably unprepared for the next pandemic. I learned two main things: Vaccines do not prevent disease; vaccinations prevent disease. And successful campaigns against contagious diseases contain within them the seeds of their own destruction. The first of these is perhaps obvious; the second, perhaps less so, but once a disease is eradicated or nearly eradicated, people forget, become complacent, possibly exaggerate the side effects of immunization, and sometimes tragically fail to get their vaccinations. Later in the book, the author discusses the libertarian conceit that individual rights take precedence over obligations to others.
But first things first. The book is Booster Shots by Adam Ratner, a specialist in infectious pediatric diseases at New York University’s Grossman School of Medicine. He is also, judging by the contents of his book, a good historian and a talented writer.
History first. I was fascinated by the story of Peter Panum, a Norwegian doctoral student (!), who was sent with his fellow student August Manicus, to the Faroe Islands in 1846 to study an outbreak of measles. The Faroes had never suffered from measles and were sparsely populated. The two facts together made them a “natural laboratory” and enabled Panum to, in effect, invent the science of epidemiology and also show that measles was a contagious disease and not caused by a “miasma,” or bad air, as from a swamp. Panum went on to a distinguished career and according to Ratner contributed to immunology, physiology, nutrition, and binocular vision, as well as integrating Scandinavian medicine with European medicine. He worked about a decade before John Snow, who found the origin of the cholera epidemic in London, but Panum is not well known, at least in the United States.
Ratner’s detailed history also brought home that measles is not a childhood disease. When the population is dense, however, everyone who is not a child has already had the disease and is immune or has died from it, so children are almost the only ones who contract the disease today. Contrary to what many think, measles is a serious disease with a mortality rate of a few per thousand cases. In the early twentieth century, the disease was exacerbated by the architecture of the tenements in which the urban poor typically lived. Even today, mortality in the industrialized nations is higher among the poor than among the rich.
The eradication of smallpox is well and widely known, but Ratner’s telling is nevertheless interesting. Cotton Mather, whom Ratner calls “ostensibly a man of God,” lost much of his family to measles, but then promoted variolation to prevent smallpox. For his pains he was sent a Molotov cocktail (fortunately, a dud) along with a note, “Cotton Mather, You Dog, Dam you: I’ll inoculate you with this, with a Pox to you.” Anti-vaxxers have a longer history than I ever imagined.
Jonas Salk and Albert Sabin developed polio vaccines based on the work of John Enders and colleagues. Polio was virtually wiped out in the United States. Why not measles, for which Enders developed a vaccine that was licensed around a decade after polio? It is complicated, but I well remember how frightened parents were during the polio epidemic, whereas measles (and mumps and whooping cough) were considered “just” childhood diseases. Also, says Ratner, there was no plan for purchasing and distributing measles vaccine. There were two measles vaccines, and it was unclear which one was preferred. Ratner’s lessons:
that messages matter, that policy decisions about vaccine availability and recommendations matter, and that early confusion on the part of parents and pediatricians can prove difficult to overcome….
We still have not learned all those lessons with regard to Covid.
Even so, we eventually came close to wiping out measles, but then the anti-vaxx movement hit and combined with our collective amnesia to result in a substantial number of unvaccinated children.
Why do people fear vaccination (Ratner politely calls them vaccine-hesitant)? He tells us early on: “fear of vaccines and minimization of the real dangers of the diseases that those vaccines protect against.” Ethical lapses, such as the infamous Tuskegee experiment, also did not help. Ratner stresses, correctly, I think, that the vaccine-hesitant are not fools, and their concerns need to be taken seriously and addressed sympathetically.
I will not go into detail, but Ratner describes the situation in Texarkana, a city that straddles the border between Texas and Arkansas. The two halves of the city are evidently completely integrated, but Arkansas required vaccination for measles, whereas Texas did not. You can guess what is coming next: in a measles outbreak in 1970, 96 % of all cases in Texarkana were found among people who lived in Texas.
Ratner is almost unfailingly polite; remember, he advised approaching vaccine-hesitant patients sympathetically. He shows no sympathy for Robert F. Kennedy Jr. who, he says,
traveled to Samoa to meet with the prime minister and local activists, ghoulishly spreading unfounded anti-vaccine messages in an attempt to ensure that no tragedy would go to waste.
The book was almost certainly submitted for publication before Kennedy lied to a congressional committee and set about destroying the National Institutes of Health and other agencies under his purview.
Ratner worries that we made mistakes letting measles back in. We similarly made mistakes with Covid, but these were more mistakes of ignorance than of omission. He worries that we will not be ready for the next pandemic, whatever it is and wherever it strikes. He is, however, optimistic that we can eliminate measles if we put our minds to it.