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Dr Edward Jenner (1749-1823) performing his first vaccination on eight year old boy James Phipps on May 14, 1796. Painting by E. Board at the Welcome Museum, London. Credit – Bettmann Archives / Getty Images
President Thomas Jefferson wrote a letter to English physician Edward Jenner in 1806. Ten years earlier, Jenner had intentionally infected a boy with smallpox, in order to protect him from the much more terrifying smallpox. It worked. Jenner gathered more evidence, and two years later he published his Investigation of the Variolae vaccinae known as Cow Pox. The news crossed the Atlantic and Jefferson was among the first Americans to recognize the revolutionary potential of vaccination. He praised Jenner in lavish terms: “Medicine has never produced a single improvement of such usefulness.” In fact, Jefferson predicted the end of a disease that was then the deadliest and most feared affliction in much of the world. “Future nations will know only from history that the horrible smallpox existed and that by you was eradicated.”
Jefferson was visionary, but overly optimistic. Smallpox mortality declined precipitously as vaccination spread, but progress stopped and sometimes reversed at the end of the 19th century. Even at the start of the 20th century, there were still thousands of cases of smallpox per year in the United States, and it was not until the late 1920s that the disease was completely eradicated from the country. Overall, progress has been even more hesitant. A massive global health crusade in the 1960s and 1970s finally realized Jefferson’s vision of making illness a thing of the past. The last natural case of smallpox occurred in 1977—171 years after Jefferson’s letter to Jenner envisioned a world without the disease.
The example of the elimination of smallpox is one of many examples that remind us that the control of infectious diseases requires both technical and social adaptations. Jenner’s discovery of vaccination is one of the greatest scientific achievements of all time. But technical solutions alone are never enough. In the United States, the spread of immunization required an effective communication campaign, cultural acceptance of vaccines, and most importantly, changes in the nature and power of the state. Namely, the rise of public health councils and their ability to enforce vaccination was necessary to fully roll back the disease nationwide.
The COVID-19 pandemic was a painful reminder that meeting the challenge of infectious diseases requires both science and social adaptation. The development of several safe and highly effective COVID-19 vaccines in less than a year is a wonderful achievement. And yet, the combination of reluctance to vaccinate at home and vaccine inequality overseas has allowed the pandemic to pick up and linger, with no end in sight. Before COVID-19, the United States was ranked at the top of pandemic preparedness. And yet our response has been an embarrassment and a tragedy, along with a detailed map of our weaknesses, which the enemies of our nation are sure to follow in detail. Our science was ready, but our society was not.
Read more: The history of vaccines, from smallpox to COVID-19
As an infectious disease historian who expected us to face a destabilizing pandemic in our lifetime, I don’t find this pattern surprising. But it is concerning that we are not absorbing the lesson. Last month, the Biden administration released a preview of its future pandemic preparedness plan. The vision is admirably bold. It proposes an investment of 65 billion dollars over 10 years which will be managed “with the seriousness of the objective, the commitment and the responsibility of an Apollo program”. The plan is motivated by the sober reality that another pandemic is inevitable. Indeed, as the plan states, “There will be an increasing frequency of natural – and possibly man-made – biological threats in the years to come. And, as he notes, the next one just might be worse. COVID-19 is a serious and fatal disease, but there are many opportunities for a new pathogen that is just as contagious but more virulent.
The strategy proposed by President Joe Biden offers a lot to like. It promises to make major investments in critical areas where we are not doing enough, from surveillance and early warning systems to real-time monitoring of viral evolution. It paves the way for even faster vaccine development and deployment, as well as fundamental improvements in the treatment of viral diseases. It proposes fundamental improvements in public health infrastructure at national and global levels.
The problem, however, is that almost the entire agenda centers on technical solutions. There are only modest signs of an effort to understand how societies are responding to the challenge of pandemics and how we can work to make ourselves more resilient. The plan calls for “evidence-based public health communications,” which is laudable, but otherwise nothing matches its scientific aspirations with an equally ambitious call to prepare our society to face the next threat with more. of cohesion and strength. So, well done for the vision of Apollo. But pandemic preparedness is a distinctly different project from going to the moon, as success depends on the behavior of more than 300 million Americans and 8 billion people around the world.
It is a disheartening fact that the experience of COVID-19 has made our society less ready for future challenges. The tribalization of our response to masking, vaccines, and other mitigation measures has been swift and extreme, and this represents a serious obstacle to preparedness. The reality is that public health is always political. But he is not always bitterly partisan, especially in a polarized society. On the contrary, we have taken a step back. Compulsory vaccination, for example, has enabled us to overcome smallpox and other threatening diseases, and it has become an integral part of our constitutional order and our social fabric. In 1905, when a Massachusetts man protested a vaccination warrant, claiming that the requirement violated his individual freedom, the Supreme Court ruled 7-2 that compulsory vaccination was a state matter. The majority opinion held that “there are many constraints to which each person is necessarily subjected for the common good …” On any other basis, organized society could not exist with the security of its members. Some of the constitutional idiosyncrasies have changed, but the fundamental issues have not. We are questioning our sense of the common good, at a time when division and mistrust are on the rise.
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The sooner we come to grips with this reality, the better prepared we will be. Evidence-based public health communication is a start, but it is far from adequate. A full-fledged plan should establish an R&D program that draws on social and human sciences; it should put in place the framework, resources and incentives to advance our understanding of the determinants of successful public health initiatives. There is a huge amount of research going on trying to help us understand why countries (and even states) have reacted so differently to COVID-19. It is already evident that this represents a complex issue, involving both seemingly fixable variables like good leadership, but also cultural factors much deeper and rooted in history. A resilience-building plan will have to deal with the tensions between individualistic values and social cohesion, the decline in public trust in institutions, the poison of polarization, the role of social media in shaping attitudes towards society. health and medicine; and the structural inequalities that have been so evident throughout the pandemic. In short, we need a bold and cohesive agenda to advance our understanding of the human side of the equation.
The Biden strategy as proposed earns an A technically, but unless its flaws are corrected, it will fail in its socio-behavioral agenda. We know all too well how this combination has worked – both throughout history and in our present moment.
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