How to improve vaccination

By Felix Salmon
January 10, 2013

The NYT is leading its home page right now with a big story about the current raging flu epidemic. The cost of this disease is going to be enormous, both in dollars and in lives, and there’s a limited number of things that anybody can do to slow it down. As Kent Sepkowitz says:

This season’s hyperactivity demonstrates emphatically how critical vaccination is to control of influenza… There can be no greater advertisement for vaccination or a louder call for better vaccines than the great influenza outbreak of 2012–13.

Vaccination isn’t perfect — as we’re discovering right now. Especially with respect to influenza, which comes in a dizzying variety of flavors, a vaccine can’t prevent an outbreak every year. But vaccination has proved itself time and time again as being the most ambitious and effective solution to public-health problems that the world has ever seen. Vaccinate enough people, especially children, and you can eradicate entirely some of the world’s most lethal and devastating diseases.

As a result, it’s hard to imagine a more egregious violation of the Hippocratic oath than doing anything to violate the effectiveness of a vaccination program. Seth Mnookin has a wonderful book explaining how skepticism about vaccines is itself a kind of virus — he calls it the Panic Virus. And athough a panic virus does not need a kernel of truth at its core, such kernels are always incredibly dangerous.

Which brings me to the unconscionable behavior of Pakistani doctor Shakil Afridi, as orchestrated by the CIA:

Agents approached Afridi, the health official in charge of Khyber, part of the tribal area that runs along the Afghan border.

The doctor went to Abbottabad in March, saying he had procured funds to give free vaccinations for hepatitis B. Bypassing the management of the Abbottabad health services, he paid generous sums to low-ranking local government health workers, who took part in the operation without knowing about the connection to Bin Laden. Health visitors in the area were among the few people who had gained access to the Bin Laden compound in the past, administering polio drops to some of the children.

Afridi had posters for the vaccination programme put up around Abbottabad, featuring a vaccine made by Amson, a medicine manufacturer based on the outskirts of Islamabad.

In March health workers administered the vaccine in a poor neighbourhood on the edge of Abbottabad called Nawa Sher. The hepatitis B vaccine is usually given in three doses, the second a month after the first. But in April, instead of administering the second dose in Nawa Sher, the doctor returned to Abbottabad and moved the nurses on to Bilal Town, the suburb where Bin Laden lived.

This is horrible on three levels. First, doctors should treat disease, they shouldn’t allow themselves to be used as pawns in some counter-terrorism game, and they should never be deceptive about what they’re doing. Secondly, and much more importantly, no doctor should ever administer the first dose of a hepatitis B vaccine without then going on to administer the other two doses. That’s the worst thing you can do: it means that the vaccine is utterly ineffective, even as many families think that they’ve now been vaccinated. Thirdly, it’s very easy to draw a direct connection from Afridi’s behavior to the news that eight polio vaccinators have been murdered by militants in Pakistan.

Pakistani preachers have been saying that vaccination campaigns are a western attempt to sterilize Muslims; that’s ridiculous, of course, but the fact that the CIA has indeed used vaccination campaigns in the past, as a way to prosecute its own counter-terrorism campaigns, hardly makes it any easier for organizations like the World Health Organization and Unicef to counter the rumors.

What can the US government do about this? Not a lot, sadly. But there is one small thing, which is quite easy, and could conceivably make a real difference at the margin. Here’s Charles Kenny:

A declaration by the US that public health interventions will not be used to gather intelligence could play a vital role in tipping the balance towards successful polio eradication – and enhance US national security. Such a declaration has been proposed in a letter sent to President Obama this Monday signed by the deans of America’s top public health schools. I suggest this could be modeled on – and inserted into – Executive Order 12333 which mandates that “No element of the Intelligence Community shall sponsor, contract for, or conduct research on human subjects except in accordance with guidelines issued by the Department of Health and Human Services,” and bans engagement in or conspiracy towards assassination and actions intended to influence United States political processes, public opinion, policies, or media.

Kenny would like one extra line added to EO12333:

No person acting on behalf of elements of the Intelligence Community may join or otherwise participate in any activity directly related to the provision of child public health services on behalf of any element of the Intelligence Community.

Adding that line could do no harm, and might, conceivably, do quite a lot of good — saving the lives of children and health workers alike. Given the millions of parents who decide whether or not to vaccinate their children every year, even small things can have large potential knock-on effects. Here’s hoping the White House is listening.


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Even if you concede that this kind of subterfuge is justified in order to capture the world’s most-wanted terrorist, for the life of me I can’t figure out why the CIA allowed this to become public knowledge. Why was this in the papers at all?

Posted by absinthe | Report as abusive

“The cost of this disease is going to be enormous, both in dollars and in lives”

Well sort of, most of the people killed by the flu were likely going to die soon anyway. Influenza doesn’t kill many healthy people in places with even modern medicine.

Posted by QCIC | Report as abusive

“Influenza doesn’t kill many healthy people in places with even modern medicine.”

QCIC, Influenza and pneumonia death rates for those 15–34 years of age in the 1918–1919 flu epidemic were >20 times higher than in previous years (35). Overall, nearly half of the influenza-related deaths in the 1918 pandemic were in young adults 20–40 years of age, a phenomenon unique to that pandemic year.

Source: -0979_article.htm#whydidthe1918viruskill somanyhealthyyoungadults?

Posted by crocodilechuck | Report as abusive

Because the 1918-1919 epidemic has a lot to do with the modern world and the current typical flu season?

Posted by QCIC | Report as abusive

Somewhere in my mind swims the line, “Americans want to know what is going on in the whore-house, but they won’t find out by acting like Mother Theresa.”

In an objective sense what Dr. Afridi did was wrong, but the greater good of fingering the world’s most notorious terrorist must be considered. When I was in college, I was a pacifist, convinced that we should always uphold the highest principles. In the real world, grown-ups need to make decisions in morally grey areas. Sometimes that may mean co-opting a doctor to locate a bad guy.

Societies have the morality that they can afford. The “prisoner’s dilemma” evaluated across cultures makes that clear.

Posted by Publius | Report as abusive

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