In many a fantasy, a time traveler goes to the past, makes an adjustment and alters the present. In many a fantasy, a time traveler goes to the future, sees chaos and alters the present to safeguard the future. In real life, we—individually and collectively—can time travel and alter the present based on the past for the good of the future. To go to the past, we have history; to go to the future, we have computerized assumption algorithms for potential outcomes.
Today, the availability, efficacy, rationale and practice of COVID-19 vaccination are the fabric of daily recommendations, conversations and societal movements, as well as the determinants of life and death, national and personal economics, freedom of action, and violence. Can past history and future projections help us choose the most rational and optimal of the alternatives before us? Can we as surgeons, as physicians, as scientists, lead the way to fulfilling the Hippocratic credo of “Where the art of medicine is loved, there is also a love of humanity.”
The Past
Bubonic Plague
Before vaccination, there was the bubonic plague, commonly called the Black Death. It is caused by the bacterium Yersinia pestis, carried by fleas and spread by small animals, primarily rats. There have been three major recorded pandemics of bubonic plague. The first—the Justinian plague, 541-542, with recurrences to 750—destroyed the Byzantine Empire, with a death toll of 25 million to 100 million. The second was the Black Death, 1346-1353, which decimated Europe, with a death toll of 75 million to 200 million—one-third to one-half of Europe and Eurasia. The third started in Yunnan, China, about 1894 and surfaced in the United States in 1900, and periodically reemerged until 1959, with a death toll of 15 million. Other episodes of bubonic plague have occurred worldwide to the present day.
As a bacterium-caused disease, bubonic plague today is susceptible to antibiotic therapy, with a reduction in mortality from 90% to 10% (not quite acceptable by modern standards). The Black Death led to the initiation of public health measures of quarantine, social distancing and masking for health care providers—the famous Plague Doctors of the 14th century with their bird-like beak masks of leather with eyepieces of glass filled with scented herbs that acted as a filter against airborne spread of infection.
Vaccines against Yersinia pestis have been developed from time to time with serious flaws in safety and efficacy. If there is another pandemic outbreak of bubonic plague, no recommendable vaccines are available. In essence, our vaccine weapon against such a pandemic would be nonexistent. We would, as a global community, be no better equipped to arrest the pandemic than we were at the outset of COVID-19.
Why did the major bubonic plague pandemics end? We are not sure. The infectious agent could intermittently lose its potency to attack humans. More likely, herd immunity contributed, or the mass death toll of the disease depleted a primary vector for dissemination. Certainly, over time, public health measures of sanitation and vermin control had a major impact. Today, the squalor and poverty, lack of sanitary facilities, and crowding engendered by the mass migrations of refugees in South and Latin America, and in the Near East, have provided the social milieu for the breeding of rats and fleas in close proximity to people.
Smallpox
True vaccinations started with smallpox, a disease caused by a virus with two variants—Variola major and Variola minor. The death toll of the infected population was 30%. The World Health Organization (WHO) certified the global eradication of the disease in 1980. The cause of this unique victory over smallpox was vaccination.
Smallpox is an old disease with visual evidence of its presence dating back to the mummy of Ramses V, who died in 1157 BC. It is estimated that 400,000 people died annually from smallpox in Europe in the 18th century, and 500 million died in the 100 years prior to its eradication. Yet, it was halted and eliminated by vaccination everywhere, from East to West, South to North, in the rich and the poor, in all races, creeds and religions. Smallpox, we hope, is forever gone.
Variolation immunization with live smallpox virus started in China in the 10th century AD. Lady Mary Wortley Montagu promoted the procedure in England in 1718. George Washington, who survived smallpox in his youth, in 1777, as commander-in-chief of the Continental Armies, ordered all of the troops to be immunized. The variolation approach could, however, lead to active, contagious smallpox with a 0.5% to 2.0% mortality rate.
In 1796, Edward Jenner produced smallpox immunity with a cowpox preparation and coined the term “vaccination” from the word “vacca,” for cow. The source of vaccine became Vaccinia virus in the 19th century, a genetically distant relative of cowpox and variola. The vaccine was 95% effective, with an 0.1% incidence of non–life-threatening side effects and a fatal response in 0.000198%. Vaccination against smallpox spread rapidly and soon was made mandatory by many nations. Between 1843 and 1855, the individual states of the United States required smallpox vaccination for all of their citizens. Because humans are the only natural hosts for smallpox and there is no zoonotic reservoir, herd immunity was facilitated. As global immunity became universal, smallpox vaccinations were discontinued in the 1970s.
Polio
I do not need a time machine to visit the polio era. I was there. It is stored in my memory. Polio season started in the summer and was at its most contagious during the hottest mid-summer. In New York City in the 1940s, before window air conditioners became common, there were two refuges from the heat where mothers sent their children: municipal swimming pools and the movie matinees in an air-cooled theater. As polio infections increased, both of these outlets were less frequented and at times closed. The movie matinees, when available, occupied children the entire afternoon. They consisted of three full-length features, two short features, at least two cartoons and always the news of the day. After the encouraging stories of our armed forces winning World War II, this feature traditionally showed the “fortunate” children with withered legs, receiving hot packs and massages at the Sister Kenny Institute in Minneapolis; President Franklin D. Roosevelt taking the baths at Warm Springs, Ga., to sooth his polio-decimated legs; and row upon row of children in iron lungs, negative pressure ventilators, smiling from the steel cages that compensated for the loss of their respiratory muscles.
One afternoon, I was playing ball with a close childhood friend when he declared that he was tired. We went to his apartment. We played a board game. I ate dinner with his family. My friend was very tired and went to bed; I went home. The next morning, I called to see how he was. His father answered the phone and told me that he had died during the night from bulbar polio.
The next summer, I was vacationing with my family at a farm. One day, I was extremely tired and had a headache and fever; the next day, my legs would hardly move. I spent the following week in bed, only able to go to the bathroom with help. As I slowly recovered, my granduncle, concerned about me, came out to the farm to take me for daily walks in the woods—first one mile, then a mile and a half, and so on. I was fortunate; I made a full recovery. My family doctor assured my mother throughout that I did not have polio, which was a term dreaded as much as “cancer” at the time. I believed then that I had polio, and I certainly believe it now.
Polio, or poliomyelitis, is caused by the poliovirus and primarily affects the nervous system, resulting in a flaccid paralysis, most commonly of the legs. It occurs mainly in children, with a 5% mortality rate; if it affects an adult, mortality can be as high as 30%. The virus is limited to humans and generally is spread by the oral or fecal route. Polio paralysis is depicted in ancient Egyptian steles of 1402-1365 BC; however, major polio epidemics are relatively recent 20th-century phenomena. The 1940s and 1950s epidemics paralyzed or killed 500,000 people annually. Type 2 wild poliovirus was declared eradicated by the WHO in 2015, and type 3 wild poliovirus in 2019. Type 1 wild poliovirus is still endemic in Pakistan and Afghanistan.
How has nearly worldwide control of polio been achieved? How have American summers become free of the dread of polio infections, death, lifetime crippling? Vaccination!
The first polio vaccine was developed by Hilary Koprowski at the Lederle Laboratories in 1950, based on a live attenuated virus. The inactivated poliovirus was developed by Jonas Salk at the University of Pittsburgh, in 1955. The injectable inactivated poliovirus (IPV) preparation required three doses to achieve 99% immunity. In 1961, Albert Sabin, at Cincinnati Children’s Hospital, developed the three-dose oral vaccine, with 95% immunity for all three polioviruses. The oral Sabin vaccine was selected for standard global use in developing countries. On rare occasions (one in 2.7 million), however, the virus multiplied in the gut and caused paralytic polio. Since 2000, the United States returned to the IPV given in four separate doses. Vaccination against polio is mandatory for children entering public schools in all 50 of the United States, in addition to vaccination against diphtheria, pertussis, tetanus, influenza type B, measles, mumps, rubella and chickenpox.
The Future
For essentially any combination of test variables for artificial intelligence computer modeling of community incidence of mortality or morbid events, based on known COVID-19 data, vaccination will statistically significantly predict a favorable outcome. A simple example not requiring computer modeling is the calculation of probable events based on the percentage of the United States population having been vaccinated: There have been about 40 million COVID-19 cases reported in the United States, essentially all in unvaccinated people, with about 2.7 million (7%) hospitalized and about 632,000 (1.64%) dead. One adjusted data analysis for age, etc., predicts a 37-fold excess (29-fold unadjusted) in hospitalizations in unvaccinated patients versus vaccinated patients, and a 67-fold adjusted (15-fold unadjusted) excess in deaths. About 50% of the U.S. population is fully vaccinated. If the other 50% were to be vaccinated, and if protection after the delta variant was 65%—not the original 95%—then using these adjusted statistics, only 14 million, instead of 40 million, cases would be reported in the future, with 73,000, instead of 2.7 million, hospitalizations, and less than 10,000, instead of 632,000, dead. That would still be tragic for those afflicted, but it would be a national triumph for public health.
The Present
Our time travel to the past and future must reach the conclusion that vaccination is rational, it is most successful when mandated, it is the best means to achieve herd immunity and it is the only hope for disease eradication.
Yet, so many people have opposed vaccination in the past and so many continue to do so in the present. In 1802, the British cartoonist James Gillray published a depiction of cowpox vaccination with cows emerging from different parts of young women’s bodies. In the 1800s, there were anti–smallpox vaccination leagues in England and the United States. Today’s COVID-19 anti-vaxxers cite for justification of their opposition the infringement of personal liberty, religious beliefs, conspiracy theories of government microchip implantation, and political party motivations.
Whatever their stated reasoning, they are in opposition to the fundamental law and order necessary for a society to function. The basis of community law is to safeguard life and minimize risk for death or harm. Anti-vaxxers make a decision not only for themselves but for their neighbors, fellow citizens and families; they violate the underpinning of public safety and basic societal responsibility. Ironically, they bring disease, hospitalization and death, most of all to their fellow anti-vaccination advocates.
Conclusion
Yes, we can time travel. We can go to the past for its history, and to the future using algorithms, and alter the present. We, as physicians and scientists, must lead the way to implement vaccination against COVID-19. Some people may be able to be persuaded by scientific data, some by logic, some by their religious belief that preservation of life is sacred, some by economics, some by ensuring the most rapid return to schools and other mass assemblies without masks and without fear, some by love of country, and some by self-preservation.
As health care advocates and providers, although frustrated and fatigued, we cannot give up trying to educate and to persuade. Hippocrates said it all: “Where the art of medicine is loved, there is also a love of humanity.”
Dr. Buchwald is a professor of surgery and biomedical engineering, and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery (emeritus), at the University of Minnesota, in Minneapolis. His articles appear every other month.
Editor’s note: Opinions in General Surgery News belong to the author(s) and do not necessarily reflect those of the publication.
This article is from the October 2021 print issue.
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