Understanding the crisis in immunisation
There is a story that I tell to students about two men on a train in Africa. One of them is throwing powder out of the window to the bemusement of the other who asks him what he is doing. ‘Throwing powder to keep the elephants away’, his friend explains. ‘But there are no elephants’, the first insists. ‘There you are, it works’, comes the rejoinder.
The news that there have been two cases of diphtheria reported in Scotland has added to a concern that has been a regular theme of the media in 2019, and a reminder of the need to maintain constant vigilance against infectious diseases. The truth of the matter is that one of the greatest challenges in public health is in making the invisible, visible, not least when a childhood killer is deemed to be a thing of the past. A vivid memory from my childhood is of my father telling me about an outbreak of diphtheria in the 1920s in my home village of Woolton, now absorbed into the administrative area of the city of Liverpool, in which 11 children died. The outbreak was blamed on stagnant water in the village pond that was drained and is now a car park. This was in the days before the widespread miracle of vaccination against a range of potentially lethal childhood infections became available.
That so many parents have apparently been turning their backs on this wondrous technology has been a source of puzzlement. The received wisdom has been that it has come about as the result of one maverick former doctor, Andrew Wakefield, following the publication of his flawed research findings linking the MMR vaccine to autism in the Lancet in 1998. The reality now seems to have as much to do with the machinations of another maverick, the former Secretary of State for Health, Andrew Lansley, and his reckless reorganisation of both the NHS and the wider arrangements for public health in England.
In October, the National Audit Office published a report on the falling vaccination rates that supports the view that the Lansley ‘reforms’ had a devastating impact on the coverage of measles, mumps and rubella vaccine. The coverage rate for two-year-olds in 2019 dropped for the fifth successive year to 90.3% , well below the 95% target for herd immunity. Only 86.4% of children now receive the second dose by their fifth birthday. A graph in the Audit Office Report shows the ‘Wakefield effect’, which was indeed dramatic, bottomed-out around 2004 – with coverage rates as low as 80%, but that this was followed by a sustained recovery until after the change of government in 2010 and the subsequent NHS changes.
None of this should really come as a surprise to those of us who are familiar with the system we led in the early years of the new century. This system gave us the ability to engage with clinicians across the NHS, our colleagues in local government, schools and the mass media. This coordination enabled us to take on the anti-health forces and deliver a recovery plan almost in the same breath, before those functioning arrangements were wantonly cast aside by a politician on a mission.
So, what are the lessons of this debacle? First of all, that public health is too important to be left to the whims of politicians in a hurry to make a reputation for change; that evolution must be better than revolution when it comes to peoples’ health and wellbeing; and that we neglect the clinical dimensions of public health services at our peril. Finally, that we all have a duty to speak out when public health is compromised by credible charlatans.
Fortunately, the Scottish cases of diphtheria seem to have not been home grown but to have been brought into the country from elsewhere; however, before we become complacent we should make sure our services are sufficiently robust to prevent secondary cases from such an event. At the present time, with the attrition of staff, funding, and morale in public health and the NHS, can anybody put their hand on their heart and guarantee that?
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