In Christine Holmberg's introductory phrase, new vaccine after new vaccine had at first been hailed as "the best solution for [anything]". Time will tell whether her original word, "everything", is exaggerated. Not surprisingly, therefore, vaccination's history of disappointments and occasional disasters and triumphs is peculiarly rich in ramifications. For a conference of such geographical, chronological and virological breadth to achieve any consistency of focus is something of an achievement. To label preliminarily: four papers were on smallpox, four on HPV, one on MMR [combined Measles, Mumps, Rubella-vaccination]. Though four further ones were wider, three enjoyed considerable empirical foundation. Despite the richness of ramifications, three areas can be discerned: the strategic, the political and, recently of perhaps growing virulence, the economic/institutional.
Within five years of Jenner's announcement of vaccination, at least one German doctor was proclaiming the "extermination" of smallpox. He was, of course, a mere 178 years ahead of the W.H.O.. But, with him and many others, vaccinal optimism was manly – despite Jenner being alerted by milk-maids to the role of cow-pox. It ranked also as Enlightened. This, too, was one-sided. We can now recognise vaccination as arriving generations ahead of its scientific base. At the time, to hail it as vindicating established, i.e. "scientific", medicine was a matter of instinct, at best. But such optimism had the virtue of degrading one's opponents to uneducated "empirics" or superstitious traditionalists. It thus eased the conflation of non-vaccination with anti-vaccinationism. Particularly before vaccines could be mass-produced speedily, the idea was seldom admissable that parents and other adults might, rather than shunning the vaccinal paradigm, try to balance within it the risk of the operation to the individual against a seemingly abstract danger to the collective.
Optimism and controversy also characterised some other major immunisations. Here, no recital is needed of the ambiguous sagas of Koch's tuberculin or of Professor Sir Almroth E. Wright's more numerous claims. By contrast, one conferencee could describe BCG as "the most widely-used vaccine in world history". Yet that vaccine's ambiguity extended way beyond the deaths of seventy-six little Luebeckers during 1930-31. Ethically ambiguous, the line between trials and applications was often blurred. BCG was tried out with, to us, suspicious frequency on African soldiers: for Albert Calmette and colleagues, these had the advantages of military discipline, geographical remoteness and (despite official myths of France's "mission civilisatrice") racial expendability. Anyway, Calmette (the 'C' in 'BCG') found himself (as had Wright from 1908) under bombardment from the British medical statistician Major Greenwood on grounds both logical and empirical (CHRISTIAN BONAH, Strassburg). Yet, as if despite recent comment that BCG's effectiveness lay "between 90 percent and zero" (quoted, ILANA LÖWY, Paris), the vaccine was in international use again from the late 1940s.
Into the 21st century, over-use (never mind over-hype) may be occurring in a very different field: HPV. Findings that, untreated, it can trigger cervical cancer were almost bound to drown out any uncertainty over the durability of vaccinal immunity against it. This logic seems to have swayed the relevant committee (the STIKO) at Germany's Robert Koch Institute into recommending it for every girl in Germany aged between 12 and 17. In the, even nowadays, far more market-impregnated USA, mothers of the same agegroup were targeted too. There at least, another factor in the level of hype was the limited durability of vaccine-patents. One reason for the female focus -- grotesquely reminiscent of Victorian blaming of women for VD/STD -- was that trials on males had given, at best, mixed results: gender-balance would depress profits. In both countries as in many others, company PR and the media screeched about "vaccinating against cancer" (GOTTLIEB, MAMO). Such claims were not echoing around the vaccinal field for the first time (LOEWY). Again, wherever death is feared, puritans of all denominations congregate. Their line received (presumably satirical) summary in the leftwing "tageszeitung": "Sex is stupid: it gives you cancer" (SABISCH).
The chronology of the enforcement and relaxation of smallpox-vaccination differs from country to country. So does its interaction with that of national centralisation. This can make straightforward correlation slippery.
In post-Napoleonic Germany, still a fragmented region, enforcement began around 1820 in some states, including some larger ones, but lagged in others. By contrast, the new German Reich, its foundation-year pock-marked by an epidemic deriving from little- or badly-vaccinated French POWs (whose own, just-exploded, Second Empire had hardly been a paradise of medical localism either), took a mere three years to arm itself with nationwide compulsion. But the latter was in some ways not so draconian as that in self-consciously "free" Britain.
Correlations between compulsion and national political self-image are therefore no less slippery. At an extreme, there is the physical coercion of the Amish, not under Hohenzollern or Romanov despots (the word favoured by many 19th-century "free-born" Anglo-Saxons for continental rulers), but rather by the State of Pennsylvania in 1979 (PAUL GREENOUGH, Iowa City). Again, polarities attempted for many continental states seldom fit developments in England, surely the oldest of all nation-states, where vaccinal compulsion, locally enforced, began decaying from the 1880s, thanks partly to a widened franchise which gave 'antis' power in far more localities than before.
A rivetting exception to surely any generalisations over the history of smallpox vaccination comes from the then East Pakistan, where from 1958 the autonomist and soon separatist Awami League did much to make itself into the ideological power-house for an independent Bangla Desh, by bypassing the Punjabi-dominated health-bureaucracy so as to lead a mass civil-society mobilisation. In this, tens of thousands of lay-people, not least women and secondary-schoolgirls, received rough-and-ready instruction in the use of equally basic, indeed highly variable, vaccinal methods before being let loose on millions of villagers. Mostly, the less welloff were immunising the very-badly-off. Militant amateurism, whether vaccinist or 'anti', has always triggered contemptuous apoplexy among most professionals. Over the value of this particularly broad campaign, however, disagreement extended up to the very top of the W.H.O.. (GREENOUGH).
Politics was articulated variably with broader ideology, according to opportunity. Against BCG vaccination during the late 1950s, those Indians influenced by the retired sanitary engineer A.V. Raman emphasised the superiority of their own traditions, whereas those led by the veteran Gandhian Chakravarty Rajagopalachari used critiques of BCG long available from "Western" specialists to complain that Indians were being jollied along with methods already rejected in wealthier, whiter countries: Indian children were, for reasons of poverty or un-/conscious racism, being used as guinea-pigs.
Political and medical perceptions aggravated each other in Britain over MMR vaccination. The years around 1990 had left long memories of sloth and smugness under a Conservative government over BSE/vCJD. A decade later, these memories were revived, rather than flattened, by a 16-volume official Report on the episode. Under New Labour, Tony Blair responded to the 2001 outbreak of Foot and Mouth Disease by ordering what became the slaughter of millions of animals. This lasted months and was gruesomely televisual. The alternative policy of local-slaughter-plus-ring-vaccination, such as Holland or Germany successfully adopted, was rejected. Cynicism crystallised when Blair and his wife (widely scorned as medically 'loopy') refused to say whether they were practising what he was preaching at any other parent: had their youngest child received an MMR jab, or not? His inconsistency further heightened the visibility of Dr Andrew Wakefield's 1998 "Lancet" article, which had linked that vaccination to autism and irritable bowel syndrome. Parents felt encouraged to exercise their own judgement by perceptions that British governments became unhinged and dishonest over epidemics, and that Blair himself was a dangerously hyperactive hypocrite, medically as much as (for many) in foreign policy. (ANDREA STÖCKL, Norwich) When uptake of MMR fell, vaccinists' level of panic was heightened by ignorance of their own history: they could have steadied themselves, had they been remotely aware that smallpox-vaccination had been at a far lower level between 1914 and 1947 (when compulsion had been accorded long-overdue burial).
If Britain's MMR stalemate was partly political, other vaccinal difficulties may have no directly political roots, at least at first. Thus the scandal over HIV-contaminated blood-plasma during the 1980s was hardly unique to France. (Many in Britain raged at even a partial switch from completely voluntary, unpaid blood-donorship to purchase of plasma derived from American drug-addicts and prison-inmates). But the passions it generated weakened attempts during the 1990s to vaccinate school-children against hepatitis-B, and these cumulative problems weighed further, in turn, on the diffusion of HPV vaccines which was anyway further affected by recent difficulties in implementing a national screening-programme for cervical cancer (LÖWY).
A little more generally still, the degree of obtrusiveness of government health-advice, whether in- or far outside the vaccinal field, can vary independently of its content. Responses to a screaming baby which were prescribed to parents of one generation have, in many countries, been the opposite of those prescribed to those babies by the time they themselves were undergoing the joys of parenthood. Whether or not most countries have during the last few decades suffered "more surveillance ... by an increasing number of [health] professionals" (SIGNILD VALLGARDA, Kopenhagen), we will have to wait before seeing whether intrusiveness declines under the sudden marketisation now threatening at least the British health-system. Sometimes at least, lay employees of American health-insurance firms make phone-calls whose intrusiveness would dumbfound any patient under the still (2011) fiscally funded National Health Service.
Economically, the greater the impact of globalisation in one country, the greater the pressure it may exert within others. Without doubt, it is an increasingly obvious motor of much recent change in vaccinal relations. Not that all aspects of this are new: a century and more ago, the chemical giant Hoechst was considerably funding Koch's research into diphtheria, for example. But Big Pharma now intervenes more fundamentally and powerfully at every stage of research-design and product-licensing. Whether in financial speculation or in medical, the states' regulatory bureaucracies which, at least in North-West Europe, used to seek some distance from market pressures by maintaining career-distance from private firms, are now governed much more by the principle of the revolving door. Some recent alleged goings-on at the STIKO and even on the Committee for the Medical Nobel Prize may be relevant here.
Once-divergent national health-systems are converging on a market model. This is exemplified in the recent H5N1 scare. Previously, governments could react flexibly, both to their own and to public perceptions of an epidemic threat, thanks to a system of public laboratories able to develop and produce vaccines. But, against H5N1, they were reduced to making inflexibly vast contracts with Big Pharma, while being damned for whatever they did or did not do (CHRISTINE HOLMBERG, Berlin). Vaccination-fatigue ("Impfmuedigkeit") may be as old as vaccination (EBERHARD WOLFF, Zürich). But governments are increasingly blamed for it, to some extent precisely because their vaccinal power is shrinking.
A classic example of this is occurring in the Netherlands, where successive governments have till very recently tried "to maintain a competence in vaccine development and production within the public sector" (STUART BLUME / JANNEKE TUMP, Amsterdam). In this, they have held out for an approach which has been relinquished by nearly all countries since mid-century. Any vaccine-development has always involved a trade-off between effectiveness and side-effects, and this has long been aggravated by the need to choose between inactivation and attenuation. During recent decades, however, these familiar uncertainties have combined with growing pressures from pharmaceutical companies and from E.U. and other governments, themselves subject to the same company pressures. The result has been the sidelining of Dutch public institutions' expertise, subsequently its undermining and now its destruction.
Globalisation's tendency to gut and to disempower local expertise may seem new in 'advanced' countries and to their professions. It is more familiar elsewhere and to the formally unqualified everywhere. It is anyway subsidiary to a far broader tendency to gut states themselves. Privatisation of health-care (including of vaccination) is all too subsidiary to broader processes.
Conference overview:
Christine Holmberg/Marion Hulverscheidt: Introduction
Session 1 The meaning of the development of a population-based national policy for the implementation of medical practices ? the smallpox vaccine as stabilizer of the population of the nation state
Eberhard Wolff, Zürich: Smallpox vaccine: example of modern culture in prevention?
Marion Hulverscheidt, Berlin: The development of the smallpox vaccine in the nation state in the 19th century.
Axel Hüntelmann, Bielefeld: The biopolitical development from 1848 to Wilhelmine Germany.
Commentary (Volker Hess, Berlin)
Session 2 The demarcation and establishment of national identity ? introducing a vaccine to counter tuberculosis
Christian Bonah, Strassburg: Evidence and implementation: BCG vaccination strategies with human beings in France, Germany and Great Britain, 1905- 1960
Niels Brimnes, Aarhus: The unwanted vaccine - opposition to BCG vaccination in India 1948-1958'
Arnd Bauerkämper, Berlin: The Transfer of Knowledge and the Twisted Road to a Transnational Civil Society. Recent Research and Perspectives of Scholarship in Historical Perspective
Commentary (Christoph Gradmann, Oslo) and Discussion
Session 3 Globalization and liberation ? Vaccination becomes success strategy and disease extinction the goal of international policy
Paul Greenough, Iowa City: Vaccination, Liberation and Extinction: Response to the Smallpox Epidemic in East Pakistan 1958
Stuart Blume/Janneke Tump, Amsterdam: The development and introduction of new vaccines in the Netherlands, 1960-2000
Andrea Stöckl, Norwich: The MMR debate ? the state, its citizens, and public health
Session 4 Neoliberalism and Health Prevention
Signild Vallgarda, Kopenhagen: Governing technologies and governing ambitions in public health policies. Continuity and change
Samantha Gottlieb, San Francisco: Manufactured Uncertainty: Merck and the commodification of choice
Laura Mamo, San Francisco: Risky Girlhood? how the HPV-vaccine became the right tool for U.S. cancer prevention
Session 5 Development of medical practices in light of sociopolitical changes
Katja Sabisch, Bochum: „Hopelessly infested“: the discursive infectiosity of the Human papillomavirus in German media, 2006-2009?
Ilana Löwy, Paris: "Because of the risk": Debates on HPV vaccine in France and in Brasil
Susanne Bauer: Commentary
Marion Hulverscheidt/Christine Holmberg: Final discussion with the development of new, joint research projects