Реферат: “The Role of Smallpox Vaccination in Mortality Decline in the Great Britain through Eradicating the Disease between XVIII-XX centuries – Facts or a Political Arithmetick?”

University of Illinois at Chicago

Department of Economics

“The Role of SmallpoxVaccination in Mortality Decline

in the Great Britain through Eradicating theDisease between

XVIII-XX centuries – Factsor a Political Arithmetick?”

by Mamurjon Rahimov

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Title: “The Role of Smallpox Vaccination in Mortality Decline in theGreat Britain through Eradicating the Disease between XVIII-XX centuries –Facts or a Political Arithmetick?”

“Whoever would understand thepolitical phenomenon known as ‘The Anti-Vaccination Agitation”- and itsmagnitude would seem to indicate it as being at least worth understanding –must remember some one or two facts, facts obvious enough indeed, butconstantly forgotten. And chief amongstthem this, that every opponent of the practice, every skeptic, withoutexception, as to its benefits, has in the first instance approached thequestion in a spirit at least of impartiality, and probably all his prejudicesstrongly in its favor”

-Alfred Milnes

Introduction

In October of 1979, The World HealthOrganization (WHO), officially declared smallpox, also known as variola,eradicated. The disease that was knownto mankind as early as 1122 BC in China, took millions of lives throughout theworld (Britannica.com). We all know thatWHO is a branch of the United Nations Organization, and is dedicated to protectthe health of the mankind. However, UNalso has many other branches dealing with issues like business, economy,culture, education, migration, to name a few, and furthermore, the eradicationof smallpox is believed to be a collaborative achievement of most of thesebranches, both on local and on global level. If so, this eradication must have been announced jointly with, if notall, then at least few other UN branches such as World Bank, UNDP, andUNICEF. It would be very unfair formedical men to appropriate this great achievement of mankind all tothemselves. Although medical men do notlike to mention it too much, they all recognize that eradication of smallpoxwas not only their merit.

Economic history has contributedsignificantly to the formulation of various economic theories. Among the economists who have found historyto be an important source for their ideas one can cite Adam Smith, Thomas Malthus,Alfred Marshall, John Maynard Keynes, Milton Friedman, Robert Solow, and GaryBecker. For economists it is veryimportant to study population history in order to come up with policies thatdecrease mortality and morbidity of the population. Factors like life expectancy, infantmortality are considered to be key indicators of progress in any country. Longer life expectancy means more manpower tomove the industry, larger consumer base for products and services.

My purpose here is to elaborate intheoretical and statistical plausibility of smallpox vaccination eradicatingthe disease based on papers written about the smallpox disease, and to seekwhether the vaccination, if efficient at all, weighed substantially in thelight of other forces that caused decline in mortality. It is quite striking to read from Memoirs ofJacques Casanova, a contemporary, that “More people perish at the hands ofdoctors than are cured by them” in those centuries, and in contrast the commonbelief that in those centuries medical men suddenly came up with “one-size-fits-all”cure for one of the most dreadful diseases of all time, which, with littlemodifications, if any, continued to be administered worldwide up until thesecond half of the XX century.

For several centuries until now,proponents of vaccination hailed smallpox vaccination to be a proven wonderweapon in the hands of mankind in eradicating the disease in the world,although there have been a number of schools of thought that, if not disprove,then diminish the role of smallpox vaccination in fighting the disease to aninsignificant level, which is the change in the virulence of smallpox.

We must remember from European historythat the period in which the most drastic decline in British smallpox mortalitytook place coincides with the time Britain experienced industrial revolution,and thus improved standards of living must have played crucial role in reducingsusceptibility of the population towards infectious diseases (Krause, 1958). Agood example is a paper written by several researchers from the University ofLiverpool and Manchester that used time-series analysis to study the dynamicsof smallpox in Britain in 1550-1800, and found a striking correlation betweenwheat price fluctuations and epidemics (Duncan, 1993; also see Helleiner, 1957).

Economists almost always try to usemodels in order to come up with logical interpretations of current and pastevents. One such paper (Mokyr, 1993)that tries to explain decline in mortality in the light of economic forces,used standard theory of utilitymaximization as a starting point: Uj = Uj (Xij…Xnj, Lj) where L is compositefamily life expectancy variable, subject to the usual budget constraint ∑XiPi= Y. It further goes on and tries toestimate the rise in knowledge (in hygiene and sanitation, in particular),relative prices, public goods (convergence towards best practices), and thelike and their consequent influence on decreased mortality. Economists agree that knowledge always hasindirectly influenced every single area of man’s life, however the paperattempts to go beyond indirect relationship towards autonomous causality, andsince lion’s share of mortality and morbidity is attributed to smallpox at thatperiod in history, it does seem that a general rise in the level and scope ofknowledge had direct effect on mortality decline throughout Britain.

Much has been said and written about thepractice of vaccination in general and smallpox vaccination in particular. If you read a couple articles and books onhow lucky we were to obtain the knowledge about vaccination, you may feel that,if not vaccines, mankind would be wiped out from the Earth by the dreadfulinfectious diseases of all kind. While Iam writing this paper, hundreds more new vaccines are being developed instate-of-the-art medical laboratories and millions of people, young and old,are being vaccinated, despite the growing opposition from parents, scholars,and doctors against mandatory mass vaccination. It is interesting to note thatvaccination remains to be the only medical practice that has to be enforced bylaw (NVIC.ORG).

A RemarkableDecline in Mortality

Mortality and morbidity of a population,although closely related, are two different things. I do not want to elaborate that in a numberof developed countries, including the United States, morbidity of thepopulation has been growing, while mortality has been rather low (NVIC.ORGstatistics). In this paper, I tried tofocus on falling of mortality rates in Britain between 18th and 20thcenturies, and the causes of this remarkable decline. Economic gains from falling mortality cannever be precisely estimated, because human life is such the most preciousthing one can ever have. Between 1750and 1914 mortality rates went down substantially everywhere in Europe, ofcourse not at the same pace and the same extent. For instance, life expectancy in Britain wentfrom 30’s in 1750 to 50’s in 1914, and crude death rate fell from about 25 perthousand in 1750 to 14-15 per thousand in 1914. The immediate cause of this dramatic shift is undisputedly decline ininfectious diseases in Europe, but deeper causes of this phenomenon have beenfueling debates among three major overlapping “schools” that have emerged toexplain the causes behind the mortality decline. “Nutritionist” school stresses improvementin living standards and food consumption as a result of economic growth to bemajor causes, whereas “preventist” school contends that this decline inmortality can be attributed primarily to public policy such as smallpox vaccinationcampaigns on mass level and cleaning of sewage systems. The third school, “exogenists”, claims thatthe decline in mortality can be explained by reduced virulence of majorinfectious diseases on microbial level and positive changes in climate (Mokyr,1993).

First inoculation and later vaccinationis cited to be plausible explanation for this decline. Inoculation, inprimitive and crude way, was practiced mainly in a few Oriental and Africancountries. Due to the limited scale ofinoculation, its efficacy was not known well. People of England learnt about it in 1721 when Lady Mary WortleyMontagu’s daughter was inoculated in London (Tucker, 1963).

Inoculation must be formally defined to avoid mixing it with the morerecent practice of vaccination. Smallpox inoculation is the injection ofsmallpox virus taken from actual smallpox wound of a patient, whereas smallpoxvaccination is the injection of cowpox virus. The symptoms these two practices produce slightly differ, but they areboth carried out for the same purpose – developing immunity in people againstthe actual smallpox disease. EdwardJenner was the founder of smallpox vaccination in Britain, and interestingly,it was by his medical induction that he believed that exposing a person tocowpox would render the person immune to smallpox (1798). Nobody could prove empirically that thisexactly was the case, and for instance William Hewson was not able to verifythrough numerous experiments what Jenner supposedly achieved. Charles Creighton, a learned anti-vaccinator,in his book Jenner and Vaccination (1889), proved that Jenner not only failedto demonstrate, experimentally or otherwise, that cowpox and smallpox werebiologically related, but nobody else, until the date Creighton’s own book waspublished, had done so (Greenwood, 1930). Besides, the population, which was subject to various vaccination lawsand acts, stubbornly resisted to vaccination (Milnes, 1897). The City of Leicester became a center of suchresistance, and despite the gloomy prophecies of medical men about huge toll tobe paid due to a large unvaccinated population, it was one of the cities thatsuffered least from several epidemics of 19th century (NAVL, 1910).

Legal Side ofthe Story

In 1840 British Parliament passed “An Act toExtend the Practice of Vaccination”, by which smallpox inoculation that wasused prior to smallpox vaccination to prevent this disease was made a penaloffence. Since the practice of smallpoxinoculation dates back to 1721, it turns out this life-destroying practicelasted for a hundred and twenty years!

The first compulsory vaccination law wasLord Lyttelton’s Act in 1853. LordLyttelton is quoted to have said, “It is unnecessary for me to speak of thecertainty of vaccination as a preventive of small-pox, that being a point onwhich the whole medical profession have arrived at complete unanimity”. Despite a growing number of post-vaccinalmorbidity and mortality cases (Krause, 1958), Britain passed another landmarkvaccine law in 1867 — the vaccination law of England, which at once was put inforce (Milnes, 1897).

Stakes Behindthe Vaccination

Often, if not always, there are hugefinancial interests behind political goals. Due to mostly qualitative information concerning the vaccination in thestated period, and inexistence of reliable statistical body for the most partof it, “There is no means of accurately gauging the amount paid for treatingdiseases subsidiary, or arising from vaccination” (NAVL, 1910). However, the below brief table for Irelandwill illustrate that substantial finances were committed to the vaccinationpractice.

Table 1. Annual Reports for the Local Government Board for Ireland:

Year Ending 31 March

Fees paid to Medical Officers

Other Expenses in carrying out Vaccination Acts

1905

£ 16, 196 183

£ 1, 893 9 4

1906

10, 168 178

1, 857 143

1907

8, 430 4 6

1, 973 17 5

1908

8, 061 140

1, 938 181

1909

8, 006 0 0

1, 963 0 0

Fascination vs.Repulsion with Numbers

Among all the economists of the history,I admire Adam Smith most of all. AdamSmith’s works have been inspiring many economists throughout centuries, andmany scholars can’t help mentioning him in the course of their work. His pen did leave few stones unturned, andeach time with an economic point of view. Although most of the modern terms were inexistent at his time, hedescribed things his own way and often cut to the core of the matter. I had to refer to his famous book, Wealth ofNations, for many times in the past, and the most recent review of it gave me aterm that has become an anchor for my paper. That term is “Political Arithmetick”. Adam Smith remarkably acknowledged ‘I have no great faith in politicalarithmetick’ (Smith, Wealth of Nations, I, p.534). In a 1785 letter written from Edinburgh Custom House toGeorge Chalmers, Smith reiterated his sentiment: ‘You know that I have littlefaith in Political Arithmetic’ (Smith, Correspondence, p. 288). There were serious limitations in gatheringand analyzing quantitative information during the early introduction ofvaccination to England, and no wonder many, like Smith, put little faith innumbers.

Davenant gave a good definition to theterm Political Arithmetick: “By Political Arithmetick, we mean the art ofreasoning by figures, upon things relating to government.” (Hoppit, 1996) The golden age of political arithmetick beganin 1662 with the publication of John Graunt’s book “Natural and PoliticalObservations upon the Bills of Mortality”, and passing with the death of itskey proponents, Gregory King in 1712 and Charles Davenant in 1714. The term itself was devised by Sir WilliamPetty in about 1671 or 1672. The use ofstatistics in policy debate became more prevalent at around the sameperiod. It is up to one’s imagination tocount the areas which were influenced by Political Arithmetick – social order,military matters, religious affiliation, economic performance, public finances,to name a few. Furthermore, ‘MedicalArithmetick’ was being enthusiastically championed by 1780s, though its originsare rooted in much earlier periods. Asanother author put it ‘Without medical arithmetic it is impossible to reach the“grandeur of generality”, the sublime of medical divination.’(Hoppit, 1996).

Almost a century after Adam Smith’sremark about unreliability of political arithmetick, a medical man, Dr. Guy,was presenting a paper on smallpox and vaccination at The Royal StatisticalSociety, and to the question whether vaccination were a preventive of smallpox,he answered that “there can be no answer except such as is couched in thelanguage of figures” (Greenwood, 1930). An amazing contrast in faith in numbers, isn’t it? Where does it come from? The thing is proponents of vaccination thenand now had no other way of proving the efficacy of vaccines, smallpox vaccinein particular, than talking in the language of numbers. Even though it may sound very odd, medicinehad little role in proving efficacy of vaccines. The thing is vaccines areinjected mostly to people in near-perfect health, and it would be veryunethical to expose control groups to the dreadful diseases in order to provethe efficacy of vaccines. The proponentsof vaccination, people with strong ties in the governments andpharmaceutical-medical industry, have been trying to prove the efficacy ofvaccines through statistical study of population mortality and morbidity, oftenmaking unbelievable claims. Havingreviewed dozens of historical materials about smallpox vaccination, I saw anobvious “play with numbers” in order to reach “politically correct”conclusions. Medical historians McKeownand Record stated that 'the data (on mortality and natality) are so treacherousthat they can be interpreted to fit any hypothesis' (Razzell, 1965).

Few tables below will illustrate thispoint:

Table2. Mean Annual Rate of Mortality permillion from smallpox at all ages in three groups of years, selected withreference to optional

and obligatory vaccination (Milnes, 1897).

Dr. Ogle’s Division

The Historical Division

Period

Mortality

Period Difference

Mortality

Period

1) Vaccination optional, 1847-53

305

82, or 26.8%

117, or 38.8%

305

1) Vaccination optional, 1847-53

2) Vaccination obligatory, but not efficiently enforced, 1854-71

223

109, or 48.8%

39, or 20.7%

188

2) Vaccination obligatory, but not efficiently enforced, 1854-67

3) Vaccination obligatory, but more efficiently enforced, 1872-87

114

149

3) Vaccination obligatory, but more efficiently enforced, 1868-87

Fascinatingly, all other infectiousdiseases, without any exception, decreased during this period, contributing tothe falling mortality rates in Britain, a lot of them by larger percentage thansmallpox. Moreover, except smallpox,none of those infectious diseases were confronted by any inoculations and/orvaccines. The below table will betterillustrate the point:

Table 3. Mortality compared, Smallpox with FeverGroup (Typhus, Typhoid, and Simple and Ill-defined) for the Two periods,1838-42 and 1871-75 (Milnes,1897).

Infectious Diseases

1838-42

1871-75

Decrease in %

Smallpox

576

414

26.4

Fever

1053

575

43.4

Table 4. Mortality of Smallpox and Choleracompared, on Average per million, for the Twelve Years 1838-42 and 1847-53, andthe Forty-two years 1854-1895 (Milnes, 1897).

Infectious Diseases

1838-42 & 1847-53

1854-95

Decrease in %

Smallpox

408

126

Cholera

320

Hence, with in regards to the abovetwo tables, it becomes clear that there is no ground to attribute decline insmallpox mortality to smallpox vaccination, because if that were the case,smallpox must have declined by far larger percentage compared to otherinfectious diseases. This is not aconclusion, which has been arrived at recently, on contrary this fact has beensuppressed for political purposes, and has been known from the very beginning.

Late Dr. Gryzanovski noted the strangefascination in numbers: “Not only the mathematician, and the mysticphilosopher, but the artists, the physicist, the economist, all feel it alike,and even those who are unable to comprehend the real nature of numbers, have aninstinctive appreciation of their conclusiveness”. Below is a good example how numbers can bemisleading if used improperly. During anagitation in favor of compulsory vaccination in Germany at the end of 19thcentury, the learned Professor Kussmaul went into great details by citing theoccurrence of 3330 cases of smallpox in Marseilles in 1828. According to the statistics that waspresented by him to prove the necessity of mass vaccination, 2289 of the 3330persons had not been vaccinated. Out ofthese unvaccinated folks 420 or 18.3 per cent died, whereas the mortality amongthe vaccinated 1041 was only 17 or 1.7 per cent. At first sight, it seems obvious thatvaccinated folks were luckier and through saved lives smallpox vaccinationcaused an invaluable amount of economic gain, but that is only if we presumethat data is correct and calculation is without any fault. But now we have Dr. Lorinser’s data onMarseilles’ population in 1828, and proportion of vaccinated, 133000 and 33000respectively. And if now we recalculateusing the correct denominators, we come up with a completely differentpicture. In fact, it is the opposite ofthe initial finding that supported efficacy of the smallpox vaccination. Mortality level among the vaccinated comes upto be 32 per thousand, while mortality level among the unvaccinated is 23 perthousand. This recalculation of the dataat hand not only disproves the initial claims of the efficacy of smallpoxvaccination, but also shows that it was dangerous. So who is right in this case? Maybe both men’s conclusions were wrong, butDr. Lorinser’s statistical methods seem to make more sense. (Gryzanovski,1906).

Hence, the role of smallpox vaccinationin eradicating the disease in Britain seems to be exaggerated. The first medical tool in preventing smallpoxdisease, inoculation, was pronounced illegal after being carried out on masslevel for more than 120 years. It isinteresting to note that from the date of mandatory smallpox vaccination law inBritain in 1853 till the complete eradication of the disease in 1979, almostthe same amount of time had passed as in the previous case. One thing is different though – this time,with vaccination, medical men decided to end smallpox vaccination on a goodnote… After 1979, smallpox cases were spotted in a few LDCs (less developedcountries) of the world, but the WHO did not re-initiate mass smallpoxvaccination.

Conclusions andDirections for A Future Research

Without a doubt, eradication of smallpox disease was one of thegreatest achievements of mankind. Itmust be emphasized that this was the merit of combined forces of variousfactors, such as economic, sanitary, technological, and educational. Arduous endeavors of certain groups tocontinue with inoculation long after it had been banned in 1840 were mentioned(NAVL, 1910), and this leads one to think that these groups probably had hugeeconomic and/or political interests at stake. Estimation of economic benefitsderived from smallpox immunization, both inoculation and vaccination, wouldshed light on the special interests behind this practice. In case of inoculation that precededvaccination, it seems to be a very low-cost (both start-up, and operations) andhighly profitable field: all kinds of amateurs (from farmers tocustom-officers) carried out inoculations throughout towns and villages, withlittle or no regulation; overseers of the poor paid for their parish to beinoculated. For instance, the statementthat “many gentlemen paid for inoculation of the children of the poor in theirown neighborhoods” does signal huge economic spending on inoculation, but doesin no way quantify the amount (Razzel, 1965). The above description of smallpox inoculation resembles the current dayInternet get-rich-instantly recipes, which also boast low-cost, huge potentialmarkets, and little regulation.

Vaccination replaced the arsenal of medical profession against theinfectious diseases, but little has changed. Many vaccine batches are found to be contaminated even during our days,and there is still no sure way to inspect their quality, few vaccinemanufacturers work as a monopoly. Vaccine manufacturers and doctors who carry out the vaccination practiceare legally freed from liability on any consequent damage caused by vaccines(NVIC.COM).

I was not able to economically compare the weight of smallpoxvaccination compared to other forces, mainly not due to the lack of data onsmallpox mortality or economic and other developments in Britain between 18thand 20th centuries, but due to impossibility to measure things withhe same units. How would you comparesanitation, increased knowledge of safe food preparation, better economicstandards of living, higher levels of vaccination, and lower mortalityrates? How much is the worth of onehuman being’s life? If just one childdied after vaccination, and it turns out he was a potential new Einstein, howdoes that change economic calculations of losses due to post-vaccine mortality? I tried to avoid going deep into analyzingmortality rates alone, because it would become a simple body count, noteconomics. However, with littlesurprise, I discovered that among all the forces that are believed to haveplayed role in eradicating smallpox, smallpox vaccination remains to be themost controversial to the date.

Cited Literature

1. Helleiner, Karl. “TheVital Revolution Reconsidered”. TheCanadian Journal of Economics and Political Science, Vol. 23, No. 1. February1957.

2. M. Greenwood. “The Vaccination Problem”. Journal of the Royal Statistical Society,Vol.93, No.2. 1930.

3. Scott, Susan. “The Dynamics of Smallpox Epidemics inBritain, 1550-1800”. Demography, Vol. 30, No. 3, August 1993.

4. Milnes, Alfred. “Statistics of Smallpox and Vaccination,with Special Reference to Age-incidence, Sex-incidence, and Sanitation”. Journal of the Royal Statistical Society,Vol. 60, No. 3. September, 1897.

5. Gryzanovski, Ernest. “On Collective Phenomena and the ScientificValue of Statistical Data”. Publications of the American Economic Association, 3rdSeries, Vol. 7, No. 3. August 1906.

6. Encyclopedia Britannicaonline. http://www.britannica.com/

7. Krause, J. T. “Changes inEnglish Fertility and Mortality, 1781-1850”. The Economic History Review, Vol. 11, No. 1. (1958).

8. The NationalAnti-Vaccination League. (NAVL) “For and Against Vaccination”. London, 1910.

9. National VaccineInformation Centre. NVIC.COM

10. World HealthOrganization: Smallpox Vaccination. WHO.ORG

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