The Prime Minister, Boris Johnson, is reported to be concerned about the falling level of Measles, Mumps and Rubella (MMR) vaccination in the United Kingdom. The country has now lost its measles-free status, just three years after this was recognized by the World Health Organisation. He has asked social media companies to block the spread of information from groups opposing vaccination (see previous post on this topic) and called a summit to discuss how they can promote positive information. The NHS website will also be used to address misleading claims and GPs asked to offer catch-up vaccinations.
These are all worthy efforts, but a little-known episode in the history of UK public health shows how wide of the mark they are likely to be.
In 1938, nearly 3,000 children died from diphtheria in the UK. By 1945, against the background of the Second World War, the number of deaths had been reduced to about 720. The number of cases had been halved from about 50,000 per year in the 1930s. How did this happen? Mainly through the introduction of a national vaccination programme in 1940.
Diphtheria immunization was a well-established intervention in other parts of the world. It had been used in parts of the US and Canada since the early 1920s, but only began in the UK during the 1930s. In 1937, less than half of local authorities had vaccination schemes and by 1939, only around 8 per cent of children in England and Wales had been immunized. The Ministry of Health became concerned about the risk of a major epidemic developing among families sleeping in congested air raid shelters and being spread through the crowded conditions under which people travelled. In December 1940, the Ministry decided to fund all local authorities to deliver vaccinations, supported by national publicity.
The propaganda campaign involved advertisements and editorials in print media, despite the strict rationing of paper, radio broadcasts, information films shown in cinemas and by mobile units, leaflets and posters. The scheme was evaluated in 1942. Among parents whose children were vaccinated, 45 per cent had come to hear about diphtheria immunization from their GP, health visitor or infant welfare clinic – 25 per cent had noticed the publicity. Among parents whose children had not been vaccinated, 26 per cent had never noticed the publicity, whole 57 per cent were aware of it but not motivated by it. Other studies at the same time underlined the importance of direct approaches, particularly by health visitors. The national publicity campaigns were abandoned and the focus shifted back to personal engagement between health visitors and mothers.
This case is well-documented in the official history of the Second World War but has been largely forgotten. It is, however, important for two reasons.
First, having a vaccination available does not guarantee that it will have any impact on public health. The vaccines will only reach their targets if the delivery is paid for and organized – and the people who would benefit are persuaded to come forward. Brilliant scientific and technological innovations require a parallel effort in evidence-based public policy and service delivery – or they are useless.
Second, this case underlines the importance of direct engagement with the people who are being asked to accept the vaccinations. The decline in MMR vaccination rates strongly correlates with the decline in health visitor numbers in England since 2015, when they were transferred to local authorities from the NHS. Investment in health visiting had been a priority for both the 1997-2010 Labour and the 2010-15 Coalition governments. By 2015, there were almost 12,000 health visitors in England. In January 2019, there were only 7, 694. As caseloads increase, the personal contact between health visitors and parents decreases. Many areas are struggling to deliver the five contacts between birth and age 2.5 years that local authorities are expected to achieve.
Bashing social media companies may make good headlines. It is, however, a distraction from the decline in public investment in child health services. If we really want to turn around the trend in MMR vaccinations, local authorities need the resources and political will to employ a sufficient number of health visitors, supported by children’s centres, to build the personal trust that is critical to accepting the minimal risks involved. This will necessarily cost rather more than giving lunch to a few representatives of the media and generate fewer headlines. It is, however, rather more likely to work.
About the author: Robert Dingwall is a consulting sociologist and Director of Dingwall Enterprises Ltd. He has had a varied career in the sociological study of medicine, law and science and is currently a part-time professor at Nottingham Trent University. He is also on twitter: @rwjdingwall