Thomas HobbesCitizens assert to honour the rights of others in return for assurances that their own rights will be protected.” Thomas Hobbes

The social contract

Along with his rather fine facial hair, Thomas Hobbes sported some pretty fine thinking. With some other great thinkers like John Locke and Jean-Jacques Rousseau, he helped lay the ground for modern democracies through his discourses on the social contract. A path out of our nasty, brutish and short lives, the social contract described an implicit agreement between people to cooperate to protect themselves and one another. Importantly, this contract necessitated the sacrifice of certain personal freedoms in return for state protection of the rights, security and health of its citizens.

Dark passengers, lurking

At a TEDxBrussels event on April 5th 2012 I spoke about the need for us all to revisit the more specific social contract of vaccination. This need is well illustrated in the progress and setbacks of the Global Polio Eradication Campaign. Polio was driven back by the biggest volunteer army (which includes child soldiers) ever assembled in human history, until by 2006 it was hanging on in only 4 countries. The rest of the world was free of polio. Free of polio. No more callipers or iron lungs, no more fear or stunted futures. Vaccines have driven many diseases from view, but only one, smallpox, has gone forever. The rest are still lurking out there, often below our radars, but they are there nonetheless. These diseases have been travelling with us humans for tens of thousands of years – smallpox probably killed Pharaoh Ramses V in 1157BC – and they are in no hurry to part ways. So if we let down our guard, and stop vaccinating, these dark passengers are ready to rear their ugly and murderous heads again. And when they go viral, it is not measured by number of views or downloads, it is measured in death and illness and disability. This is what happened with polio in Northern Nigeria, where vaccination was interrupted in 2004. Polio reappeared, and had soon travelled to 20 other countries in Africa(flick back and forth between 2008 and 2010 on the BMGF infographic).

Vaccination adoption = access + acceptance

The example of polio was not due to a lack of access to vaccines, it was due to a lack of acceptance. Rumours in Nigeriain 2003 that polio vaccine was a western plot to sterilize Muslims were endorsed by religious leaders. This led to boycotts of polio vaccination in northern Nigeria, and a ‘worrisome’ upsurge in polio transmission. Access is vitally important to this side of the equation, and has been the focus of sensational efforts by organizations such as GAVI. However, acceptance is equally crucial, but has been misunderstood and mishandled. This is likely to be a continuing theme on this blog: public acceptance of vaccination In a nutshell: vaccines work, but not if people leave them in their boxes.

We have failed

Each death from a vaccine-preventable disease is a failure of all who are party to, and benefit from, the vaccination social contract. Those failures rest squarely upon the shoulders of public health authorities, governments, health care professionals, vaccine producers and the public. Whether it is the 8 deaths due to measles in Europe in 2011, or the 10 deaths due to whooping cough inCalifornia in 2010, they are on all our shoulders. So what can we do about it? Well, perhaps we need to have another look at that social contract.

The vaccination social contract

With the success of the smallpox and polio vaccines this contract became accepted by the public. Nothing in life is 100% safe, and vaccines are no exception. The minute – but real – risks of protecting their own children with the polio vaccine were accepted, even as the disease faded from view, because immunisation also protected their society (see Hobbes quote above). When people refuse vaccination they are willingly breaking this social contract. A contract that they no longer see the need for, due in large part to the fact that they no longer see these diseases. Vaccines are indeed a victim of their own success. “There’s no such thing in the world as the right decision” – Jesus Jones

The right decision

The choice to not vaccinate your child may in fact be a good decision. As long as everyone around you continues to vaccinate, your child is protected from disease and any attendant, albeit tiny, risk of vaccination. However, if some of your neighbours start to make the same good decision, that mantle of protection is eroded, and your child may be exposed to disease. And suddenly things are different. Because even with diseases often seen as relatively benign, like measles or chicken pox, if you willingly decide to leave your child unprotected, or indeed if you willingly infect them (chicken pox lollipop anyone?), you are rolling a dice. For measles the dice may roll up encephalitis or pneumonia or death (see above). Furthermore, you are also rolling the dice for others in your community who do not have the luxury of vaccination because they are, for example, too young or immunocompromised. Why then is this clause of the social contract being broken? We have a few clues, but I am going to save them for my next post. However, if you can’t wait that long, check out this video for a sneak preview.

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  1. Christine

    Thursday, May 3, 2012

    I agree that the social contract relies on public acceptance… acceptance that people these days are increasingly more reluctant to agree to. History demonstrates that when people, or even nations, are unified in their goals that they can overcome great obstacles. However, there seems to be so much distrust these days and I worry that people are becoming more self-centered. They are no longer motivated by the social good and they often refuse to make any personal sacrifices. They feel entitled to do things for their own personal gain and disregard the impact their actions may have on society as a whole. Unfortunately, this is a trend we are seeing in immunizations. I’m looking forward to hearing more about why you feel this social contract is being broken. But more importantly, perhaps blogs like this one will spark conversation about how we, as individuals, can help put the “public” back in public health.

  2. Angus

    Thursday, May 3, 2012

    Thanks for your thoughts Christine. The whole point of this blog is to “spark conversation”.

    I will try to outline the social shifts that may underlie the erosion of this particular social contract in my next post.