between XVIII-XX centuries – Facts or a PoliticalArithmetick?”
MamurjonRahimov
Universityof Illinois at Chicago
Departmentof Economics
“Whoever would understand the political phenomenon knownas ‘The Anti-Vaccination Agitation”- and its magnitude would seem to indicateit as being at least worth understanding – must remember some one or two facts, facts obvious enough indeed, but constantlyforgotten. And chief amongst them this, that every opponent of the practice,every skeptic, without exception, as to its benefits, has in the first instanceapproached the question in a spirit at least of impartiality,and probably all his prejudices strongly in its favor”
Alfred Milnes
Introduction
InOctober of 1979, The World Health Organization (WHO), officially declaredsmallpox, also known as variola, eradicated. The disease that was known tomankind as early as 1122 BC in China, took millions of lives throughout theworld (Britannica.com). We all know that WHO is a branch of the United NationsOrganization, and is dedicated to protect the health of the mankind. However,UN also 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 havebeen announced jointly with, if not all, then at least few other UN branchessuch as World Bank, UNDP, and UNICEF. It would be very unfair for medical mento appropriate this great achievement of mankind all to themselves. Althoughmedical men do not like to mention it too much, they all recognize thateradication of smallpox was not only their merit.
Economichistory has contributed significantly to the formulation of various economictheories. Among the economists who have found history to be an importantsource for their ideas one can cite Adam Smith, Thomas Malthus, AlfredMarshall, John Maynard Keynes, Milton Friedman, Robert Solow, and Gary Becker. For economists it is very important to study population history in order tocome up with policies that decrease mortality and morbidity of the population. Factors like life expectancy, infant mortality are considered to be keyindicators of progress in any country. Longer life expectancy means moremanpower to move the industry, larger consumer base for products and services.
Mypurpose here is to elaborate in theoretical and statistical plausibility ofsmallpox vaccination eradicating the disease based on papers written about thesmallpox disease, and to seek whether the vaccination, if efficient at all,weighed substantially in the light of other forces that caused decline inmortality. It is quite striking to read from Memoirs of Jacques Casanova, acontemporary, that “More people perish at the hands of doctors than are curedby them” in those centuries, and in contrast the common belief that in thosecenturies medical men suddenly came up with “one-size-fits-all” cure for one ofthe most dreadful diseases of all time, which, with little modifications, ifany, continued to be administered worldwide up until the second half of the XXcentury.
Forseveral centuries until now, proponents of vaccination hailed smallpoxvaccination to be a proven wonder weapon in the hands of mankind in eradicatingthe disease in the world, although there have been a number of schools ofthought that, if not disprove, then diminish the role of smallpox vaccinationin fighting the disease to an insignificant level, which is the change in thevirulence of smallpox.
We mustremember from European history that the period in which the most drasticdecline in British smallpox mortality took place coincides with the timeBritain experienced industrial revolution, and thus improved standards ofliving must have played crucial role in reducing susceptibility of thepopulation towards infectious diseases (Krause, 1958). A good example is apaper written by several researchers from the University of Liverpool andManchester that used time-series analysis to study the dynamics of smallpox inBritain in 1550-1800, and found a striking correlation between wheat pricefluctuations and epidemics (Duncan, 1993; also see Helleiner, 1957).
Economistsalmost always try to use models in order to come up with logicalinterpretations of current and past events. One such paper (Mokyr, 1993) thattries to explain decline in mortality in the light of economic forces, usedstandard theory of utility maximization as a starting point: Uj = Uj (Xij…Xnj,Lj) where L is composite family life expectancy variable, subject to the usualbudget constraint ∑XiPi = Y. It further goes on and tries to estimatethe rise in knowledge (in hygiene and sanitation, in particular), relativeprices, public goods (convergence towards best practices), and the like andtheir consequent influence on decreased mortality. Economists agree thatknowledge always has indirectly influenced every single area of man’s life,however the paper attempts to go beyond indirect relationship towardsautonomous causality, and since lion’s share of mortality and morbidity isattributed to smallpox at that period in history, it does seem that a generalrise in the level and scope of knowledge had direct effect on mortality declinethroughout Britain.
Muchhas been said and written about the practice of vaccination in general andsmallpox 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 I am writing this paper, hundreds morenew vaccines are being developed in state-of-the-art medical laboratories andmillions of people, young and old, are being vaccinated, despite the growingopposition from parents, scholars, and doctors against mandatory massvaccination. It is interesting to note that vaccination remains to be the onlymedical practice that has to be enforced by law (NVIC.ORG).
A Remarkable Decline inMortality
Mortalityand morbidity of a population, although closely related, are two differentthings. I do not want to elaborate that in a number of developed countries,including the United States, morbidity of the population has been growing,while mortality has been rather low (NVIC.ORG statistics). In this paper, Itried to focus on falling of mortality rates in Britain between 18thand 20th centuries, and the causes of this remarkable decline. Economic gains from falling mortality can never be precisely estimated, becausehuman life is such the most precious thing one can ever have. Between 1750 and1914 mortality rates went down substantially everywhere in Europe, of coursenot at the same pace and the same extent. For instance, life expectancy inBritain went from 30’s in 1750 to 50’s in 1914, and crude death rate fell fromabout 25 per thousand in 1750 to 14-15 per thousand in 1914. The immediatecause of this dramatic shift is undisputedly decline in infectious diseases inEurope, but deeper causes of this phenomenon have been fueling debates amongthree major overlapping “schools” that have emerged to explain the causesbehind the mortality decline. “Nutritionist” school stresses improvement inliving 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 smallpoxvaccination campaigns on mass level and cleaning of sewage systems. The thirdschool, “exogenists”, claims that the decline in mortality can be explained byreduced virulence of major infectious diseases on microbial level and positivechanges in climate (Mokyr, 1993).
Firstinoculation and later vaccination is cited to be plausible explanation for thisdecline. Inoculation, in primitive and crude way, was practiced mainly in a fewOriental and African countries. Due to the limited scale of inoculation, itsefficacy was not known well. People of England learnt about it in 1721 whenLady Mary Wortley Montagu’s daughter was inoculated in London (Tucker, 1963).
Inoculationmust be formally defined to avoid mixing it with the more recent practice ofvaccination. Smallpox inoculation is the injection of smallpox virus taken fromactual smallpox wound of a patient, whereas smallpox vaccination is theinjection of cowpox virus. The symptoms these two practices produce slightlydiffer, but they are both carried out for the same purpose – developingimmunity in people against the actual smallpox disease. Edward Jenner was thefounder of smallpox vaccination in Britain, and interestingly, it was by hismedical induction that he believed that exposing a person to cowpox wouldrender the person immune to smallpox (1798). Nobody could prove empiricallythat this exactly was the case, and for instance William Hewson was not able toverify through numerous experiments what Jenner supposedly achieved. CharlesCreighton, a learned anti-vaccinator, in his book Jenner and Vaccination(1889), proved that Jenner not only failed to demonstrate, experimentally orotherwise, that cowpox and smallpox were biologically related, but nobody else,until the date Creighton’s own book was published, had done so (Greenwood,1930). Besides, the population, which was subject to various vaccination lawsand acts, stubbornly resisted to vaccination (Milnes, 1897). The City ofLeicester became a center of such resistance, and despite the gloomy propheciesof medical men about huge toll to be paid due to a large unvaccinatedpopulation, it was one of the cities that suffered least from several epidemicsof 19th century (NAVL, 1910).
Legal Side of the Story
In 1840British Parliament passed “An Act to Extend the Practice of Vaccination”, bywhich smallpox inoculation that was used prior to smallpox vaccination toprevent this disease was made a penal offence. Since the practice of smallpoxinoculation dates back to 1721, it turns out this life-destroying practicelasted for a hundred and twenty years!
Thefirst compulsory vaccination law was Lord 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-vaccinal morbidity and mortality cases(Krause, 1958), Britain passed another landmark vaccine law in 1867 — thevaccination law of England, which at once was put in force (Milnes, 1897).
Stakes Behind the Vaccination
Often, if not always,there are huge financial interests behind political goals. Due to mostlyqualitative information concerning the vaccination in the stated period, andinexistence of reliable statistical body for the most part of it, “There is nomeans of accurately gauging the amount paid for treating diseases subsidiary,or arising from vaccination” (NAVL, 1910). However, the below brief table forIreland will illustrate that substantial finances were committed to thevaccination practice.
Table1. 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 withNumbers
Amongall 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 pendid leave few stones unturned, and each time with an economic point of view. Although most of the modern terms were inexistent at his time, he describedthings his own way and often cut to the core of the matter. I had to refer tohis famous book, Wealth of Nations, for many times in the past, and the mostrecent review of it gave me a term that has become an anchor for my paper. That term is “Political Arithmetick”. Adam Smith remarkably acknowledged ‘Ihave no great faith in political arithmetick’ (Smith, Wealth of Nations, I,p.534). In a 1785 letter written from Edinburgh Custom House to GeorgeChalmers, Smith reiterated his sentiment: ‘You know that I have little faith inPolitical Arithmetic’ (Smith, Correspondence, p. 288). There were seriouslimitations in gathering and analyzing quantitative information during theearly introduction of vaccination to England, and no wonder many, like Smith,put little faith in numbers.
Davenantgave a good definition to the term Political Arithmetick: “By PoliticalArithmetick, we mean the art of reasoning by figures, upon things relating togovernment.” (Hoppit, 1996) The golden age of political arithmetick began in1662 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 termitself was devised by Sir William Petty in about 1671 or 1672. The use ofstatistics in policy debate became more prevalent at around the same period. It is up to one’s imagination to count the areas which were influenced byPolitical 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. As another author put it ‘Without medicalarithmetic it is impossible to reach the “grandeur of generality”, the sublimeof medical divination.’(Hoppit, 1996).
Almosta century after Adam Smith’s remark about unreliability of politicalarithmetick, a medical man, Dr. Guy, was presenting a paper on smallpox andvaccination at The Royal Statistical Society, and to the question whethervaccination were a preventive of smallpox, he answered that “there can be noanswer except such as is couched in the language of figures” (Greenwood,1930). An amazing contrast in faith in numbers, isn’t it? Where does it comefrom? The thing is proponents of vaccination then and now had no other way ofproving the efficacy of vaccines, smallpox vaccine in particular, than talkingin the language of numbers. Even though it may sound very odd, medicine had littlerole in proving efficacy of vaccines. The thing is vaccines are injected mostlyto people in near-perfect health, and it would be very unethical to exposecontrol groups to the dreadful diseases in order to prove the efficacy ofvaccines. The proponents of vaccination, people with strong ties in thegovernments and pharmaceutical-medical industry, have been trying to prove theefficacy of vaccines through statistical study of population mortality andmorbidity, often making unbelievable claims. Having reviewed dozens ofhistorical materials about smallpox vaccination, I saw an obvious “play withnumbers” in order to reach “politically correct” conclusions. Medicalhistorians McKeown and Record stated that 'the data (on mortality and natality)are so treacherous that they can be interpreted to fit any hypothesis'(Razzell, 1965).
Fewtables below will illustrate this point:
Table2. Mean Annual Rate of Mortality per million from smallpox at all ages inthree groups of years, selected with reference to optional and obligatoryvaccination (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 infectious diseases, without any exception, decreased during thisperiod, contributing to the falling mortality rates in Britain, a lot of themby larger percentage than smallpox. Moreover, except smallpox, none of thoseinfectious diseases were confronted by any inoculations and/or vaccines. Thebelow table will better illustrate the point:
Table3. Mortality compared, Smallpox with Fever Group (Typhus, Typhoid, and Simpleand 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
Table4. Mortality of Smallpox and Cholera compared, on Average per million, for theTwelve Years 1838-42 and 1847-53, and the Forty-two years 1854-1895 (Milnes,1897).Infectious Diseases 1838-42 & 1847-53 1854-95 Decrease in % Smallpox 408 126 69 Cholera 320 69 78
Hence,with in regards to the above two tables, it becomes clear that there is noground to attribute decline in smallpox mortality to smallpox vaccination,because if that were the case, smallpox must have declined by far largerpercentage compared to other infectious diseases. This is not a conclusion,which has been arrived at recently, on contrary this fact has been suppressedfor political purposes, and has been known from the very beginning.
LateDr. Gryzanovski noted the strange fascination in numbers: “Not only themathematician, and the mystic philosopher, but the artists, the physicist, theeconomist, all feel it alike, and even those who are unable to comprehend thereal nature of numbers, have an instinctive appreciation of their conclusiveness”. Below is a good example how numbers can be misleading if used improperly. During an agitation in favor of compulsory vaccination in Germany at the end of19th century, the learned Professor Kussmaul went into great detailsby citing the occurrence of 3330 cases of smallpox in Marseilles in 1828. According to the statistics that was presented by him to prove the necessity ofmass vaccination, 2289 of the 3330 persons 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 seemsobvious that vaccinated folks were luckier and through saved lives smallpoxvaccination caused an invaluable amount of economic gain, but that is only ifwe presume that data is correct and calculation is without any fault. But nowwe have Dr. Lorinser’s data on Marseilles’ population in 1828, and proportionof vaccinated, 133000 and 33000 respectively. And if now we recalculate usingthe correct denominators, we come up with a completely different picture. Infact, it is the opposite of the initial finding that supported efficacy of thesmallpox vaccination. Mortality level among the vaccinated comes up to be 32per thousand, while mortality level among the unvaccinated is 23 per thousand. This recalculation of the data at hand not only disproves the initial claims ofthe efficacy of smallpox vaccination, but also shows that it was dangerous. Sowho is right in this case? Maybe both men’s conclusions were wrong, but Dr.Lorinser’s statistical methods seem to make more sense. (Gryzanovski, 1906).
Hence,the role of smallpox vaccination in eradicating the disease in Britain seems tobe exaggerated. The first medical tool in preventing smallpox disease,inoculation, was pronounced illegal after being carried out on mass level formore than 120 years. It is interesting to note that from the date of mandatorysmallpox vaccination law in Britain in 1853 till the complete eradication ofthe disease in 1979, almost the same amount of time had passed as in theprevious case. One thing is different though – this time, with vaccination,medical men decided to end smallpox vaccination on a good note… After 1979,smallpox cases were spotted in a few LDCs (less developed countries) of theworld, but the WHO did not re-initiate mass smallpox vaccination.
Conclusions and Directions forA Future Research
Withouta doubt, eradication of smallpox disease was one of the greatest achievementsof mankind. It must be emphasized that this was the merit of combined forcesof various factors, such as economic, sanitary, technological, andeducational. Arduous endeavors of certain groups to continue with inoculationlong after it had been banned in 1840 were mentioned (NAVL, 1910), and thisleads one to think that these groups probably had huge economic and/orpolitical interests at stake. Estimation of economic benefits derived fromsmallpox immunization, both inoculation and vaccination, would shed light onthe special interests behind this practice. In case of inoculation thatpreceded vaccination, it seems to be a very low-cost (both start-up, andoperations) and highly 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 statement that “many gentlemen paid forinoculation of the children of the poor in their own neighborhoods” does signalhuge economic spending on inoculation, but does in no way quantify the amount(Razzel, 1965). The above description of smallpox inoculation resembles thecurrent day Internet get-rich-instantly recipes, which also boast low-cost,huge potential markets, and little regulation.
Vaccinationreplaced the arsenal of medical profession against the infectious diseases, butlittle has changed. Many vaccine batches are found to be contaminated evenduring our days, and there is still no sure way to inspect their quality, fewvaccine manufacturers work as a monopoly. Vaccine manufacturers and doctorswho carry out the vaccination practice are legally freed from liability on anyconsequent damage caused by vaccines (NVIC.COM).
I wasnot able to economically compare the weight of smallpox vaccination compared toother forces, mainly not due to the lack of data on smallpox mortality oreconomic and other developments in Britain between 18th and 20thcenturies, but due to impossibility to measure things with he same units. Howwould you compare sanitation, increased knowledge of safe food preparation,better economic standards of living, higher levels of vaccination, and lowermortality rates? How much is the worth of one human being’s life? If just onechild died after vaccination, and it turns out he was a potential new Einstein,how does that change economic calculations of losses due to post-vaccinemortality? I tried to avoid going deep into analyzing mortality rates alone,because it would become a simple body count, not economics. However, withlittle surprise, I discovered that among all the forces that are believed tohave played role in eradicating smallpox, smallpox vaccination remains to bethe most controversial to the date.
Список литературы
1. Helleiner,Karl. “The Vital Revolution Reconsidered”. The Canadian Journal of Economicsand Political Science, Vol. 23, No. 1. February 1957.
2. M.Greenwood. “The Vaccination Problem”. Journal of the Royal StatisticalSociety, Vol.93, No.2. 1930.
3. Scott,Susan. “The Dynamics of Smallpox Epidemics in Britain, 1550-1800”. Demography,Vol. 30, No. 3, August 1993.
4. Milnes, Alfred. “Statistics of Smallpox and Vaccination, with SpecialReference to Age-incidence, Sex-incidence, and Sanitation”. Journal of theRoyal Statistical Society, Vol. 60, No. 3. September, 1897.
5. Gryzanovski, Ernest. “On Collective Phenomena and the Scientific Value ofStatistical Data”. Publications of the American Economic Association, 3rdSeries, Vol. 7, No. 3. August 1906.
6. Encyclopedia Britannica online. www.britannica.com/
7. Krause, J. T. “Changes in English Fertility and Mortality, 1781-1850”. TheEconomic History Review, Vol. 11, No. 1. (1958).
8. TheNational Anti-Vaccination League. (NAVL) “For and Against Vaccination”. London, 1910.
9. National Vaccine Information Centre. NVIC.COM
10. World Health Organization: Smallpox Vaccination. WHO.ORG