A shot in the arm for preventive medicine

Dr Angus Dawson

Overcoming negative attitudes to mass vaccination is vital if we are to address major threats to public health worldwide, explains Angus Dawson, Professor of Public Health Ethics at Birmingham.

When we hear the phrase ‘saving lives’ in a health care context we might first think about treating people for the disease which they already have. Indeed, such a focus is important, and there are many issues relating to the appropriate way to provide such care, how it is funded, and what our funding priorities might be. However, at least some health care is focused not on treatment but on preventing disease in the first place. Much public health activity, for example, attempts to identity threats to health not just from disease, but also from the social, political and physical environment. Once such threats are recognised, the emphasis often changes to seeking to prevent them.

Much of my own recent work has explored the ethical, legal and policy issues that emerge in this preventive context. There are a large number of important matters to discuss, such as what role does the state have in acting to protect the health of citizens where this restricts the freedom of a minority (e.g. smokers)? What is the appropriate role for surveillance of data about a population’s health? Should individuals always have to consent to their data being used in such a manner? Which, if any, identified health inequalities are important, and what should we do about them? What is the appropriate balance to be struck between prevention and treatment within a health care system?

For the last ten years or so I have been writing about different aspects of vaccination policy. My original interest in this topic arose from becoming a parent and facing the question of whether or not to vaccinate my own children. I have explored a series of general arguments about vaccination policy, such as balancing risks and benefits, ideas about the best interests of the child in this context, how we ought to think of responsibility where harm may be caused to others from a decision not to vaccinate, as well as ideas about solidarity and justice in relation to vaccination policy. 

More recently I’ve become interested in trying to understand in more detail why parents might object to vaccination for their children. One current project that I’m involved in, seeks to explore these issues in relation to polio vaccination in the context of Orissa, a predominantly rural state on the East coast of India. This piece of research is a collaboration with colleagues from Ravenshaw University, the leading state university in Orissa, and is funded by the Wellcome Trust. Poliomyelitis is a disease that is spread in water through the environment. It attacks the nerves and can result in permanent damage to limbs, breathing problems, and death. Two different vaccines were developed and introduced in the 1950s, one that is delivered orally through drops on the tongue, and another via injection. The latter vaccine is now standard in high income countries, but the former is still used in lower income countries, mainly because it is cheaper in terms of the price per dose and delivery costs. 

There is a current global campaign to eradicate polio, led by the World Health Organization and UNICEF, and polio remains endemic in only three remaining countries (Nigeria, Pakistan and Afghanistan). India was recently declared polio free, but the vaccination campaigns will continue until the world is declared polio-free.

Our project has three aims. First, we are situating current policy within its historical and cultural context through an exploration of international, national, state and local archives relating to the polio campaign in India, as well as local newspaper reports about polio cases and the vaccination campaign. Second, we will be conducting a series of interviews with parents, public health officials and community workers to understand more about their attitudes to and beliefs about the polio campaign. Third, this empirical material will then be analysed and discussed, compared and contrasted, with data and arguments from discussions of vaccinations conducted elsewhere. 

On a recent visit to rural Orissa, when we were seeking potential sites to conduct our future interviews, we talked to many different people about polio vaccination. Some of the villagers we met in rural areas were enthusiastic about the polio campaign, and saw it as part of a national mission that they and their children were contributing to. However, we also heard about some other villages where the programme is rejected and vaccinations do not occur. 

Our project will seek to discover and explore these reasons for rejection for three reasons. First, there is intrinsic value in comprehending and representing the voices of a minority of the population that are not heard in discourse about this issue. Second, such work is a means of exploring new and extending existing academic arguments. Third, it may also be a means of improving the implementation of existing and future vaccination policy at local, national and international level, and thereby making a real contribution to saving lives.