Vaccination has greatly diminished death, illness and suffering in the world. But no other medical technology has been so dogged with controversy. The book chronicles the development of the key lifesaving vaccines since the 18th century. It tells the stories of great scientists and their discoveries, of the protests and pain along the stumbling path of progress. This is the first book to tell the whole story of vaccination for a general audience. In light of controversies about flu vaccine and autism, it will be of particular interest to parents, pediatricians, public health workers and anyone fascinated by medical history. Read More>>

Also Available: Table of Contents and Index

Arthur Allen is a Washington DC-based journalist who has written on vaccine issues in The New York Times Magazine, the Washington Post Magazine, The New Republic, Atlantic Monthly, Salon and Slate.

CONTACT

Journal of the Royal Society of Medicine

JRSM v. 100 (M a y 2 0 0 7)
By Michael Fitzpatrick

In his comprehensive survey of vaccination controversies
past and present, Arthur Allen quotes US vaccine chief
Walter Orenstein’s recollection that ‘for those trained in
pediatrics in the 1970s, Hib (Haemophilus influenzae type b)
was a horror.’ It was indeed. I recall a mother whose infant
died of Hib meningitis, secondary to an apparently trivial
otitis media, within minutes of arriving in hospital. Already
at an advanced stage of her second pregnancy, she promptly
went into labour and had an uncomplicated delivery. The
way her grief at the loss of one child overwhelmed her joy
at the arrival of another is my enduring memory of the
horror of Hib, which was still killing 60 children every year
in Britain in the 1980s.

Thanks to the introduction of routine Hib immunization
in 1992, this disease has now become a rarity. Yet, as
Orenstein points out, when the immunization was
introduced there was much uncertainty about its impact
on the ecology of Haemophilus and the long term
consequences. As he observes, some things are ‘only
knowable in the long run;’ in the meantime, ‘we have to
take our chances and then follow up.’ One of the themes of
Allen’s book is that this courageous and enterprising
approach to vaccination policy—vindicated by its historic
achievements in the conquest of disease—is now threatened
by the contemporary climate of risk aversion.

Allen does not ignore the history of vaccine disasters.
He includes the fiasco in the US military in 1942, when
yellow fever vaccine contaminated with hepatitis B caused
100 deaths, and the mass vaccination against smallpox in
New York in 1947 that caused six deaths (four more than
the outbreak itself). In the Cutter incident in the 1950s,
inadequately inactivated polio vaccine caused 164 cases of
paralysis and 10 deaths. While acknowledging these failures,
Allen pays tribute to immunization authorities—such as
Henry Kempe and Bob Chen—who have campaigned to
improve vaccine safety.

The great irony underlying current vaccination controversies
is that, as vaccines have become more effective
and safer than ever before, an anti-vaccine world view,
reflecting a combination of nostalgia and cultural pessimism,
has become more prevalent. Allen reports how one family
with an autistic child described ‘going down the rabbit hole’
into a ‘spooky realm of herbalists and populist mavericks
and—not to put too fine a point on it—conspiracy kooks,
who view America as a toxic hell.’ Recognizing that
parents’ anger and inclination to blame vaccines reflect
difficulties in coming to terms with their children’s
disabilities, Allen has himself bravely challenged antivaccine
campaigners who have had such a damaging impact
on the world of autism.

Allen concludes with Orenstein’s prescient warning that
a precautionary approach, reflecting corporate concerns
about a low profit, high risk area of investment and
government sensitivities to public anxieties, ‘could
paralyze’ innovation in vaccines.

Competing interests MF is the author of MMR and
Autism: What Parents Need To Know (Routledge, 2004. ISBN-
13: 978-0415321792. £18.99).
Michael Fitzpatrick
Barton House Health Centre, London N16 9JT, UK
E-mail: fitz@easynet.co.uk

The Lancet

The Lancet 2007; 369:1421-1422

Perspectives, Book
Vaccines: life savers and controversy makers
By Stanley Plotkin

Vaccines occupy a peculiar place in medicine and society. That they prevent disease is incontrovertible; ample evidence for their effects is obvious in the industrialised countries and increasingly so in the developing world. Only clean water has had a greater impact on infectious diseases. Molecular biology now permits the development of more vaccines, perhaps even some against non-infectious diseases. Yet vaccination has been controversial from its inception in the primitive practice of variolation against smallpox to its latest avatar in the form of purified pseudoparticles composed of single papillomavirus proteins that prevent cervical cancer. Objections to vaccination have evolved from early theological concerns that it countered God's will to the belief in certain circles today that for a healthy immune system disease is preferable to vaccines.

This paradox is explained by two factors: first, that vaccines are usually given to healthy people, and reactions to vaccines may make some of those healthy people ill; and second, that vaccination is often made compulsory by governments because of the state's interest in protecting children and in maintaining the herd immunity provided by vaccines. On one side, society insists that refusal to be vaccinated is an act that threatens the community, whereas on the other side, libertarians insist that vaccination should be done only with consent. Thus, we live in a time when vaccines have never been more effective and when vaccine science has never been more promising, but when opposition to vaccines is, nonetheless, flourishing.

The events that brought us to this pass are described by journalist Arthur Allen, in Vaccine: The Controversial Story of Medicine's Greatest Lifesaver. Allen begins with detailed historical description of the early discoveries that led to the eventual eradication of smallpox, follows with a middle section recounting the development of vaccines that were produced in the past 150 years, and concludes with a description of the controversies regarding alleged causation of encephalopathy by whole-cell pertussis vaccine, and of autism by measles-mumps-rubella vaccine or by mercury-containing preservative.

Allen has done considerable documentary research and spoken to many people, including scientists and laypeople, which enables him to give a balanced and well referenced account. The book is a useful chronicle of the subject, and I learned a few things about old and recent history. I might have recounted some stories differently, but then personal memory is fallible and aside from a few mis-spelled names and technical errors (such as denying that pneumococcal conjugate vaccine has decreased the incidence of invasive pneumococcal disease), the book is accurate.

Both the triumphs and tragedies of vaccination are perceptively described, although emphasis is given to the latter. Allen shows how the personalities of scientists figure importantly in the choices made to follow one or the other leads in vaccine development, and how in science one can only do what current methods allow. The development of successful vaccines is, however, made to look simpler than it is, and the many failures and byways that make the process last an average 15 years from start to finish are given insufficient emphasis. Allen is clearly most interested in the controversies that surround vaccination. He gives insight into the dilemma that although vaccines give more benefit than harm, there will always be the risk of reactions, which come in three varieties: real, false, and uncertain. The real ones, such as paralysis after oral polio vaccine, are discovered after licensure and result in revised recommendations or withdrawal; the false ones, such as the claimed consequence of multiple sclerosis after hepatitis B vaccine, are disproved by studies and disappear into urban legend; but the ones that are uncertain, because of their rarity or the difficulty in designing studies, remain to agitate sincerely concerned individuals and conspiracy enthusiasts.

The problem is that each reaction to vaccines—real, false, or uncertain—needs resources to fund studies, and the results of studies do not convince everyone. Allen describes in detail the controversy over thiomersal, or ethyl mercury, which had been used for many years as a way to prevent contamination of multidose vaccine vials. After the realisation that the total quantity of mercury administered to some infants exceeded margin of safety guidelines issued by one of three US government agencies, manufacturers were pushed to eliminate thiomersal from paediatric vaccines. They had already begun to do so before the controversy, but the panic generated in paediatric organisations accelerated the removal, and now no paediatric vaccine in the USA contains more than a trace of thiomersal, with the exception of influenza (for which a thiomersal-free vaccine can be purchased).

At a recent meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, the data on thiomersal in vaccines and autism were presented by an academic investigator. Although none of the epidemiological or ecological data yet available supports an association between the two, and indeed removal of thiomersal has not changed the incidence of autism, representatives of lay organisations at the meeting refused to accept the investigator's conclusions, relying instead on extrapolation of harm from in-vitro toxicology studies. Additional controlled clinical data will be reported in the next year or two, but it is doubtful that all participants in the controversy will be satisfied by them. Allen does a good job of describing the antagonists in this controversy, with their strongly held views that sometimes run counter to the evidence.

Vaccination will never be without controversy and without risk, as Allen emphasises. An example of this was the fate of the rotavirus vaccine licensed in 1998 that rarely caused intussusception in infants, but prevented diarrhoea, dehydration, and hospital admission. Neither the USA nor any other country would accept its use, and the vaccine was withdrawn despite its benefits. It took 6 years and vaccine trials that involved 150 000 children before replacement vaccines came on the market that are not associated with a higher risk of intussusception. During those 6 years at least 2 million children died of rotavirus disease worldwide.

A contrasting example is the US government's smallpox vaccine programme, which was enacted under unrelenting pressure by Vice-President Dick Cheney, only to be halted when unexpected cases of myocarditis were seen in vaccinees. Had there been a real terrorist attack with smallpox virus, the programme would have seemed prudent and prescient, but in the absence of such events those who were vaccinated had assumed an unnecessary risk.

It is this tension between risk of disease and risk of vaccination that animates vaccine developers and vaccine objectors. Allen offers no solution to this conflict, and indeed there may be none, as rational calculation of risk is likely to remain scarce among the critics of vaccination. Nevertheless, the vaccine enterprise is alive and well, largely because technology is improving and new manufacturers from other continents are joining those in North America and Europe.

Stanley Plotkin works for the vaccine manufacturer Sanofi Pasteur and is Emeritus Professor of Pediatrics at the University of Pennsylvania.

The (London) Guardian

A jab in the right direction

Arthur Allen shows how inoculation's successes have led to recent concerns in Vaccine, while Robert Bud charts a very different story in Penicillin, says Mark Honigsbaum

Mark Honigsbaum
Saturday May 5, 2007

Guardian

Vaccine: The Controversial Story of Medicine's Greatest Lifesaver, by Arthur Allen. 512pp, WW Norton, £17.99
Penicillin: Triumph and Tragedy, by Robert Bud. 340pp, Oxford, £30

In March 1947, Eugene LaBar, a rug importer returning from Mexico to Maine by Greyhound bus, collapsed in Manhattan complaining of a fever, rash and headache. Within days LaBar and 11 other New Yorkers had been diagnosed with smallpox, sparking the largest mass vaccination in the city's history. During the following three weeks, six million people were inoculated with the vaccina virus, then as now the only protection. Indeed such was New Yorkers' faith in medical technology and the power of vaccination that clerks and Broadway showgirls queued through the night outside doctors' surgeries in their eagerness to join what newspapers dubbed "the Order of the Itching Arm".

Fast-forward to our own MMR-challenged times, however, and it's a very different story. As the threat of smallpox, measles and other disfiguring childhood diseases has receded, so the balance of power between doctors and patients has shifted. In an era when a list of potential vaccine side-effects is just a mouse click away, few of us itch to have itching arms any longer. Nor do we automatically regard vaccination as a duty to the community, particularly if, as in the case of the HPV vaccine, the disease is sexually transmitted and thus complicated by moralising judgments about "degenerate lifestyles".

According to Arthur Allen, a former AP foreign correspondent with a decade-long interest in the subject, this state of affairs is largely a reflection of vaccination's success. Only a generation of parents that has never experienced the horrors of smallpox - a disease that Macaulay described as "the most terrible of all the ministers of death" and which was thankfully deemed to have been eradicated by the World Health Organization in 1980 - can enjoy the luxury of worrying about autism, a condition that didn't blip on to most GPs' radar screens until 1980. But it also reflects the fact that the question of whether or not to inoculate has always been as much a political as a personal question, and has always attracted zealots on either side.

One of the joys of reading Allen's well-researched but never boring 500-page history is that he pricks both camps, taking a critical look at both the anti-vaccinists' championing of pseudo-science and the medical establishment's repeated tendency to downplay the genuine dangers of vaccine side-effects.

Allen also has a keen eye for the counter-intuitive. For instance, one of the most vocal early American advocates of variolation, as the early 18th-century practice of inoculation was known, was Cotton Mather, the Bible-thumping Massachusetts Puritan and supporter of the Salem witch trials. Despite regarding the pustules of smallpox as evidence of man's innate sinfulness, Mather apparently also regarded smallpox as the "devil's work" and variolation as both a religious and a social duty. Interestingly, his opponents, starting from the same Christian premise, reached exactly the opposite conclusion: it was precisely because smallpox was "God's work" that they argued doctors should let the disease runs its course. Hence the argument of the Swedenborgians that vaccinating a child was "introducing the foul corruptions of hell into innocent life" - a position not that far removed from certain newspaper columnists' rants against the MMR programme today.

In fact, Mather's progressive attitude to vaccination was probably motivated as much by self-interest - he lost several children to smallpox and other diseases - as science. Unfortunately, these days self-interest all too often leads people to ignore the scientific evidence in support of treatment that might serve a greater good, but there was a period when the two happily coincided. Before reading Allen's book, for instance, I hadn't realised that the French superlative "c'est vache" - meaning "excellent" - dates from the early 19th-century Parisian medical practice of corralling cattle on street corners the better to extract fresh vaccine direct from the animals' lymph glands. Nor had I known that such was the enthusiasm for Edward Jenner's cowpox vaccine that Thomas Jefferson personally took charge of its distribution in America, using it to inoculate the last members of the Mohican tribe in 1801.

Present day conservative religious opponents of the HPV vaccine should also note that the reason Jenner's vaccine proved so popular was that it was a lot safer than earlier efforts at variolation in which physicians harvested smallpox directly from patients, many of them infected with syphilis and other sexual diseases. On occasion, however, people have been right to question the prevailing medical orthodoxy, as in 1901 when several children in Philadelphia and other eastern US cities were infected with tetanus as a result of contamination during a smallpox vaccination drive and died agonising deaths from lockjaw despite repeated government assurances that the vaccine was safe.

Allen subtitles his book "the controversial story of medicine's greatest lifesaver", but that is an accolade that Robert Bud, the author of Penicillin, could well dispute, for few drugs can claim to have saved as many lives as Alexander Fleming's "miracle" antibiotic.

Indeed, so closely is penicillin associated with "strong medicine" that Bud, the head of information and research at the Science Museum, argues it could almost be considered a brand, such that "the very writing of a prescription gives hope to the patient and a sense of power to the doctor".

Unfortunately, thanks to the spread of drug-resistant bacteria, the power of penicillin, like that of vaccines, is much diminished these days. The difference is that in the case of penicillin and other antibiotics, this diminution in effectiveness is the result of overuse, not underuse; hence the attempt by doctors to persuade patients to put their faith in vaccination and other medical interventions that have a greater certainty of protecting the health of all of us.

· Mark Honigsbaum's The Fever Trail: The Hunt for the Cure for Malaria is published by Pan

Bookslut

Cotton Mather’s name has become synonymous with Puritanism and hellfire-and-brimstone religion, but he believed both in the absolute rule of an angry God and in the principles and value of scientific inquiry. And so, when smallpox came to Boston in 1721, Mather mobilized the moral weight of religion against the resistance of the medical establishment and fearful members of the public to implement preventive variolation, an early form of smallpox inoculation.

In 1721, smallpox “treatment” consisted primarily of dangerous and ineffective practices like bleeding and large doses of toxic mercury, which caused vomiting, tooth loss, and other side effects. People rightly feared and mistrusted doctors and went to them only as a last resort. Smallpox killed as many as one in four infected, and child mortality from smallpox and other diseases was high. Mather himself lost 13 children, and once said in a sermon that, “A dead child is a sign no more surprising than a broken pitcher or blasted flower.”

Variolation, in which a patient’s arm was lightly scratched and fluid from a fresh smallpox sore rubbed on the wound, was relatively harmless compared to conventional “treatments.” It had long been used effectively to prevent smallpox infection in Africa, Turkey, and other parts of the world outside Europe. Mather learned of the practice from one of his African slaves, while his English counterpart and political opposite, Lady Mary Wortley Montagu, first saw variolation practiced in Turkey.

Both Mather and Lady Mary met with violent opposition, sometimes literally. The history of vaccination is full of politics, contradictions, and, most of all, fear, and has been marked by furious debate since the beginning. In the introduction to Vaccine: The Controversial Story of Medicine’s Greatest Lifesaver, author Arthur Allen writes, “Without fear, history has shown, it was difficult to get people vaccinated.”

Yet fear has also been a primary reason people have refused vaccines; fear of disease and fear of the vaccines themselves have dominated the debate over vaccination for almost three centuries now. We have moved from a world in which often-lethal and crippling diseases killed millions to a world in which vaccines that prevent those diseases are mistrusted by a vocal and growing minority. Allen comes down firmly on the side of public health, but he doesn’t avoid describing the harsh details of the less-than-shining history of vaccines and the medical profession -- or the harsh realities of the diseases vaccines and sanitation have made into little more than clinical descriptions in textbooks to the average Western citizen.

In the first two sections of Vaccine, Allen describes the history of the development of vaccines in a time when there were no clinical ethics boards or informed consent laws and patients often survived despite their doctors’ “treatments,” the defeat of smallpox and polio, and public resistance to widespread vaccination. The history has both triumphs and tragedies.

Religion often supported the side of the anti-vaccinists, believing that disease was God’s punishment and that the Bible prohibited “polluting the blood.” English eugenicists argued initially against vaccines, believing that they would unfairly save the “poor and unworthy,” harming society, but American eugenicists later argued that mandatory vaccination was as important to society as forced sterilization of the “mentally unfit.” Both pro- and anti-vaccinists have always had their share of morally abhorrent, deliberately dishonest supporters.

Vaccines didn’t gain much public support in the United States until World War I and particularly World War II, when the military implemented a mass immunization program against common battlefield killers like typhoid fever, tetanus, smallpox, cholera, typhus, and plague, with great success. Compared to previous wars and to unimmunized foreign troops, U.S. soldiers suffered far fewer illnesses and only a handful of deaths. Soldiers who returned home wanted their children to have the same protection, and the medical profession was respected and trusted to an unprecedented degree. The United States entered a period of public support for vaccines that lasted for several decades.

Allen devotes the last four chapters to the vaccine controversies of the last few decades: the trend towards alternative health, vaccines and autism, and the moral condemnation by religious conservatives of first the Hepatitis B vaccine and now the HPV vaccine. This relatively brief analysis of the modern political debate is not well connected to the first two sections of the book, and it is not flattering in its portrayal of the anti-vaccine movement.

Vaccine presents a well-researched history of both sides of the vaccine wars, warts and all, with unflinching language (and 52 pages of endnotes and references). There’s a lot here to disturb both proponents and opponents of mandatory vaccination, but Allen does support the scientific viewpoint and treats alternative medicine with skepticism. Readers seeking a comprehensive treatment of the vaccine-autism debate or a history of vaccination outside the United States and Europe should seek elsewhere, but readers seeking a solid history of the first two and a half centuries of vaccination will find a lot to think about in Vaccine.

--Melissa Albert, April 2007

City Beat

Unnatural Progress - Jan. 24, 2007

Cincinnati native investigates the history of vaccination

By Stephen Paul Lansky

Cincinnati native Arthur Allen now lives in Washington, D.C. He has become a widely published and respected journalist who covered the war in El Salvador in the 1980s and spent time in Paris and later Germany in the '90s. He has followed stories about ideological and political conflict, including a powerful op-ed piece for The New York Times about Cincinnati's civil unrest in 2001. Since then he's written about public health for Salon and The Atlantic Monthly. His first book, a history of vaccination, Vaccine, is a vast, meticulous exploration of this topical and vital public health policy issue. As an authoritative history, it might serve as a resource to medical professionals while also shaping the public policy debate.

The shades of meaning employed by both sides of a public health controversy chime and wave, as if bells are tolling and flags are being hoisted. Most pointed are the comments concerning how Western political structures interact with the public when military interests shape disease control.

Once the narrative reaches mid-20th century postwar New York, Allen's prose on voluntary mass inoculation rings with patriotism: "Neither parade attendance nor vaccination were duties that could be shirked." Allen's control works behind the reader's eyes, tugging at the bones of the face, pulling muscles long dormant.

Early in the history Allen shares a country rhyme about milkmaids' clear complexions, which seems to contain a powerful grain of wisdom. Edward Jenner's discovery of cowpox and subsequent invention of the smallpox vaccine might have evolved from folklore. In detailing Jenner's 18th-century discovery, Allen's terse, direct delivery puts opposing positions fairly: "Vaccination was unnatural. It was progress."

Yet it's the ongoing saga of compulsory applications of medical science that is discussed recursively. He shares layers of pointed rhetoric, piling up medical officialdom's frustration in contrast with the stamina of the opposing less logical, less persuasive presentations of a strange coalition that has its own reasons for fearing and shunning science at its most compassionate fringe -- a fringe that by stages takes the mainstream -- as the history progresses.

Allen describes the early 20th-century laws swinging back and forth with lives and morality at stake, then he seems to vilify the health food movement, the New Age Luddites and the homeopaths, because the alternative here is better. Allen sees government by majority as a safety valve where compulsory vaccination is concerned.

His views on court decisions are nuanced -- circular logic is unveiled and named. A person cannot always be fully expected to understand medical advancement but can know that sickness is not weakness. Further, sickness does happen to individuals despite their relation to God or even to those who disdain belief.

The development of medical science from the earlier understanding of illness stands in stark relief to this reflection on Cotton Mather's early 18th-century Boston: "Disease, like a spiritual journey, was a passive experience. Disease states, like visions, were visited upon people."

CityBeat recently spoke to Allen about his illuminating new book.

CityBeat: Is there anything good about disease? Arthur Allen:

A lot of natural medicine folks talk about a "healing crisis," and I think I understand that. Sometimes when my son Ike and daughter Lucy got sick as babies, after they recovered they seemed to make a leap in their development. That's purely "anecdotal" and when I've talked about it with some friends they haven't experienced the same thing. But it stands to reason that our immune systems are designed to deal with germs and that the immune system develops, and probably kicks off other developmental processes, as part of the process of illness.

When I asked scientists whether they thought it would be bad if all exposures to germs were avoided, they generally agreed. But that won't happen, they hasten to add. The question is, which is the germ that you need? Smallpox? No. Measles? I don't think so. Polio? No. Haemophilus influenzae type B, which causes meningitis? I don't think so.

Yet every day we are bombarded with dozens of types of microorganisms against which there is no vaccine protection. They continue to prime our immune systems. There's no way that medicine can totally prevent infections, so the question of whether it would be good to avoid all disease is theoretical only. There's no real absolutism here except as a really fascinating philosophical exercise.

CB: When the military and the "military industrial complex" provides a mobilization that is a means to quarantine and inoculate against disease, isn't that a sort of ridiculous paradigm? Saving lives so that killing for some political, economic or religious purpose can be carried out more effectively? AA:

It's another paradox. That's why the chapter title is "War Is Good for Babies." Obviously it's not meant literally. Yet there are ways in which military technology drives improvements in society, vaccines being an example -- not only in that these vaccines were tried out successfully on soldiers, but that the nation's consciousness about trust in medicine was altered by this successful encounter.

CB: When doctors deny and hide their failures, they invite opposition. And when they

Charleston (S.C.) Post and Courier

Journalist Arthur Allen navigates a tremendous amount of research to tell the story of vaccine, perhaps the world's greatest medical achievement.

In this comprehensive work, colorful anecdotes, compelling arguments and historical insights shed light on this revolutionary and controversial weapon against infectious disease. At the same time, Allen tells a parallel history of failure, deadly reactions and the public's confusion over vaccine's efficacy and necessity. He raises complex questions about individual rights versus public good, and the moral ambiguity of sacrificing the one to save the many.

Allen claims the anti-vaccine movement is nearly as old as vaccines themselves, beginning with the Puritans who thought scratching a small amount of smallpox virus into the skin a challenge to God's will. Counted among the most famous detractors, British dramatist George Bernard Shaw and Henry Bergh, founder of the SPCA. And the movement's most unlikely, yet most enduring symbol: the Raggedy Ann doll.

Since the early 20th century, contaminated vaccines, DTP injuries and a purported link to autism have fueled efforts to ban mandatory immunization in America. The most recent controversy stems from efforts to vaccinate preteen girls against HPV, or human papillomavirus, a sexually transmitted virus that causes cervical cancer.

Allen also details public health's role, its early triumphs and failures as it tries to produce safer vaccines and enforce immunization in the midst of smallpox epidemics.

Vaccine's champions also are profiled, beginning with Edward Jenner's 1796 smallpox discovery that formed the basis for understanding immunity. Allen includes Louis Pasteur's work with rabies and cholera and Albert Sabin's and Jonas Salk's polio breakthroughs. He credits the Army's fear of bioterrorism and tropical disease, as well as a polio-stricken president, for ushering in the golden age of immunization in the 1940s.

Small chapters divide in a readable format the discovery of vaccines for nearly forgotten diseases, such as diphtheria, measles, typhoid, typhus and whooping cough.

It's hard to imagine, but according to this history, in the early 20th century, some diseases killed more young American children in one day than SARS has in a year. A sobering thought for parents who ignore their babies' booster shots or complain about school-entry laws.

Informative histories on infectious disease, including a spate of works on the black plague and 1918 superflu, appear to be a publishing trend that mirrors, no doubt, our own current events. "Vaccine," which includes a number of illustrations and photographs, is a commendable companion to these histories.--Victoria Hood, March 4, 2007.

The Independent of London

What is the most important medical advance of the last 160 years? When the British Medical Journal put that question to its readers recently they responded in their thousands. Sanitation topped the poll, followed closely by antibiotics and anaesthesia. In fourth place came vaccines. While a similar poll of lay people might have agreed on the first three, would they have ranked vaccines similarly highly?
It seems doubtful. Vaccines have never had the kind of uncritical support that, say, antibiotics enjoy. Although vaccination has saved hundreds of millions of lives it remains controversial, subject to scares, driven by political imperatives, testing our faith in medical authority and our own judgement.
One of the enduring puzzles of the great MMR scare that gripped Britain for much of the last decade is not how it started - the 1998 Lancet paper linking the triple jab with bowel disease and autism is well known - but how it was sustained. Why did parents - predominantly well-educated, professional people - continue for years to doubt the safety of the vaccine in the face of repeated reassurances from medical authorities and in the almost complete absence of evidence to support claims to the contrary?
At least part of the answer is to be found in this enthralling book. Though it does not discuss the MMR controversy in detail, it demonstrates in case after case how, through its 300-year history, the benefits of vaccination have been oversold and the risks underplayed. The eagerness of the authorities to protect the public health has, too often, blinded them to the true scale of the threat, or to the risks of the vaccine.
In April 1947, New York registered its first death from smallpox in 35 years. A rug importer from Mexico had carried the virus to the city and caused panic. In three weeks more than six million New Yorkers were immunised against smallpox, jamming hospital clinics and queuing for hours - all entirely voluntarily - after the city's health commissioner announced his intention to vaccinate the city.
Yet by isolating and vaccinating each contact the outbreak was contained within days and the disease ultimately infected just 12 people. Meanwhile, six people died from brain inflammation caused by the vaccine and 100 others suffered serious injuries such as encephalitis.
In 1954, huge excitement greeted the launch of the Salk polio vaccine against one of the most feared childhood diseases. But within months it became clear that the version manufactured by Cutter Laboratories was crippling children. The vaccine had become contaminated by live virus which infected up to 220,000 people, made 70,000 ill, and was linked to 164 cases of severe paralysis and 10 deaths.
The Cutter incident inspired major reforms. But while these improved safety they could not prevent vaccination's use as a political weapon. In December 2002, President George Bush rolled up his sleeve to be vaccinated against smallpox - a disease eradicated in 1980. He was launching what was supposed to be a campaign to immunise 10 million police and health workers against the threat of biological warfare.
Yet by 2005, fewer than 40,000 had come forward. Just as the Bush administration had failed to find weapons of mass destruction in Iraq, health workers saw the smallpox campaign as an unjustified attempt to build national consensus by stoking fear.
This is a fascinating, meticulously researched history of vaccination which is admirable for its even-handedness. In this fevered debate it is rare to find an author prepared to examine the arguments without taking sides. Yet the moral of Arthur Allen's story is clear. By eliminating many diseases of childhood, vaccines have become a victim of their own success. Vaccination is no longer seen as a necessary rite of passage but a matter of individual choice, even though each person who vaccinates their child helps protect every other child.
Risks must be set out, but individuals must recognise that complete personal responsibility is unattainable. By accepting vaccination, we all help look after one another, as we must. That, as Allen says, is our social contract.--Jeremy Laurance is health editor of 'The Independent'. March 16,  2007

Library Journal

Vaccines fighting this season's flu strain, cervical cancer, shingles, and childhood inner-ear infections have hit the news, while medical researchers, funded by Gates Foundation dollars, labor feverishly to develop vaccines against the Third World curses of tuberculosis, malaria, and AIDS. The undeniable history of disease prevention via vaccine, however, masks thousands of individual and familial tragedies, the unintended consequences of contaminated vaccines or catastrophic immune reactions. While most parents view routine inoculations as a sacred responsibility, others see a herd of Trojan horses that threaten a beloved child. Noted Washington-based journalist Allen has explored these issues in the New York Times , the Washington Post , and the Atlantic Monthly . Here, he authoritatively and objectively records the miracles, controversies, and tragedies that have accompanied the development of vaccines since Edward Jenner first combated smallpox in the 18th century. A separate chapter explores the alleged relationship between thimerosal, a vaccine preservative, and autism. This compelling narrative of the vaccine's undoubted triumphs and troubling challenges is highly recommended to serious readers interested in medicine and public health. --Kathy Arsenault, Univ. of South Florida at St. Petersburg Lib.

The Oregonian

Over the past two decades, the debate on vaccination has become steadily more rancorous, which is puzzling. After all, vaccines have wiped smallpox from the face of the planet and reduced polio to a ghastly memory. Diseases that once struck fear into every parent's heart -- diphtheria, tetanus, whooping cough, measles -- have become, for most Americans, medical asterisks. But, as Arthur Allen shows in "Vaccine: The Controversial Story of Medicine's Greatest Lifesaver," vaccines are not miracles: They are imperfect drugs with risks and benefits. What's more, he argues, vaccination raises fundamental issues about life, death, illness and the individual's duty to society.

Misgivings about vaccines stretch back to 1721, when Cotton Mather, a Boston minister, promoted inoculation (a primitive forerunner to vaccination) to forestall a smallpox epidemic. Opponents denounced Mather as a misguided crackpot who sought to evade God's judgment through unnatural practices. They also articulated the parental dilemma at the heart of every shot: "I should have less distress in burying many children by the absolute acts of God's providence," wrote one opponent, "than in being the means of burying one by my own act and deed."

The smallpox vaccine proved remarkably successful, so successful it hatched a swarm of imitators. It is somewhat unsettling to read about the haphazard development of these early vaccines, many produced by "guts and guesswork," and tested on soldiers or schoolchildren. In 1942, for example, the U.S. Army, acting on intelligence that the Axis powers might wage biological warfare, injected millions of GIs with a vaccine against yellow fever that was contaminated with hepatitis B. Some 100 soldiers died and 50,000 others were hospitalized. (Sadly, their sacrifice was meaningless; the intelligence was wrong.)

In a similar vein, the polio vaccine developed by Jonas Salk in 1952 was heralded as a triumph of American know-how. Salk described it as "safe, and you can't get safer than safe." Unfortunately, shoddy manufacturing and inept federal oversight allowed contaminated shots to reach the marketplace, crippling hundreds of children before the vaccine was withdrawn.

As the last century wound to a close, vaccines were safer and more effective than ever, but the political and moral calculus surrounding them had changed. The diseases they protected against were largely abstract. Cases of severe reaction, though exceedingly unusual, were dramatic and easy to demonize. And the era of trusting experts was long gone. These trends converged in 1982, when NBC aired an expose on the diphtheria-pertussis-tetanus (DPT) vaccine, complete with footage of quadriplegic and brain-damaged children. Overnight, the modern anti-vaccine movement was born.

It turns out that the whole-cell pertussis vaccine used in the old DPT shots did indeed cause brain damage in extremely rare instances, and that drug companies had known this for decades but never bothered to introduce a safer alternative. Although the pertussis vaccine has since been replaced, the revelations inflicted tremendous damage to the public trust. Many parents now oppose vaccination in principle and blame shots for a horde of maladies from autism to asthma.

"Vaccine" is at least 100 pages too long, and some chapters meander. But Allen really shines with his perceptive analysis of the anti-vaccine movement and his calm examination of the evidence linking vaccines and autism (he is a skeptic). His greatest achievement is to inject a dose of reality into a debate that has become distressingly doctrinaire.  Oregonian, Feb. 18, 2007. By Chris Lydgate.

San Francisco Chronicle

At first glance, the title of Arthur Allen's "Vaccine: The Controversial Story of Medicine's Greatest Lifesaver" seems a little contrived. I mean, how controversial can vaccines really be? A few Band-Aids and lollipops when we're kids, and polio disappears. But in this far-reaching work, Allen, a Washington journalist who has written about the subject for the New York Times, the Washington Post, the New Republic and the Atlantic, shows that those tiny syringes actually represent centuries worth of science, religion, politics and war.

In a world of hyper-specialized medicine, Allen's account of the early days of vaccine discovery has an enjoyable, "greatest generation" feel. He dusts off characters from grade-school history class to conjure a time when giants roamed the earth and wiping out all disease was seen as a noble and attainable goal. Unfortunately, the nostalgia is quickly replaced by the disquieting knowledge that the good old days weren't that good.

"Vaccine" is an exhaustive, and at times exhausting, account of seemingly every religious figure, scientist, politician, school principal and anti-vaccine activist who ever held an opinion on the matter. The book's real value lies not in its details, however, but in the difficult philosophical questions it raises, questions as relevant today as they were when Benjamin Franklin fought over them almost 300 years ago.

What is the individual's duty to society? As Allen points out, vaccination is the first obligation the state imposes on our children; unless a legal exemption is obtained, they can't enter school without them. Most people would agree this is a good thing -- that the individual risk of vaccination is small compared with the overall improvement in quality of life it provides. But, in order to help your neighbor, should the government pressure you to ingest a substance to which you may be morally opposed?

And does immunization constitute an attempt by the government to influence our morality? This question recently came to the fore with the U.S. Food and Drug Administration's approval in June of a vaccine against human papilloma virus -- a sexually transmitted virus with certain subtypes causally linked to cervical cancer -- but it was also an issue when the government was deciding whether to make the vaccine against hepatitis B -- a virus linked to liver cancer that is also spread through blood and bodily fluids -- part of the required schedule of vaccinations.

The argument that a teen girl should not be given a simple shot that may prevent her from getting cervical cancer later in life because it might promote promiscuity is as absurd as saying seat belts should be removed from vehicles because they promote reckless driving. But what if the government made the vaccine, or a similar one, mandatory for people based on sexual orientation? Or a woman was told she couldn't receive government assistance without receiving it?

Like most topics having to do with health and behavior, there are no easy answers. Allen clearly doesn't have much patience for the pseudoscience and predatory zeal with which many anti-vaccine activists use grieving parents of autistic children to push their agendas, but he presents a fair analysis of why the anti-vaccine movement has been so successful.

He rightfully points out that mainstream medicine doesn't do a good job of giving meaning to illness, something people desperately need when there is no explanation or cure. As a mother of a child who died of sudden infant death syndrome says, "If someone dies, there's a reason," and the holistic approach of anti-vaccine proponents provides that reason. Whether or not the trace amounts of mercury in vaccines contributed to her child's death, her conviction that it did has a real impact on the health of her community when she persuades others not to get vaccinated.

"Vaccine" makes it painfully clear that science is very malleable and that people tend to shape the facts to conform to their worldview rather than the other way around. Is President Bush's making a photo op out of getting vaccinated against smallpox in 2002 -- thereby using dubious germs of mass destruction to support his case for war against Iraq -- any more or less shameful than the people in Colorado who frame their anti-vaccine beliefs as a simple "alternative lifestyle choice" while they trigger pertussis (whooping cough) outbreaks that kill children?

Odds are that you'll finish "Vaccine" with more questions than answers, but Allen's detailed lessons in history, statistics, immunology and cultural theory will give you the tools to tackle them. Even more important, they'll cause you to ask some new ones you've never thought of before.

--John Vaughn is a writer and physician in Columbus, Ohio.