How lessons from the past can help shape future health outcomes

Iron lung respirator from 1937. Museum of Health Care at Kingston. Used with permission.

In 1918-19, influenza swept the globe in deadly waves. It is thought to have started in the American Midwest before spreading to Europe and the rest of the world. Aiding its stealthy – and largely unchecked – advance was the fact that countries were hesitant to publicly acknowledge that they were battling an epidemic at home. Many were participants in World War I and were concerned that enemies would take advantage or that allies would halt trading activities.

Experts reason that the high number of deaths from this event is due, in part, to the long period of silence, which was only broken when non-combatant Spain publicly admitted to having a problem. Other countries followed suit.

“As a result, thousands and thousands of people died from what now is widely referred to as the ‘Spanish flu,’ even though it didn’t originate in Spain,” says Dr. Jacalyn Duffin, a Canadian medical historian and hematologist. “When countries stop communicating with each other, that’s a very dangerous situation.”

International co-operation and immunization

Since then, there have been many examples of health threats spreading across borders. Dr. Duffin, whose new book A history of COVID-19 (McGill Queen’s University Press) is released this fall, believes the recent coronavirus pandemic illustrates the importance of an early warning system and a co-ordinated international response.

“At the end of World War II, we finally got the World Health Organization [WHO] so we could improve outcomes by sharing information,” she says. With the understanding that it is a country’s responsibility to alert others to emerging health events, the WHO can then play a role in intervention, and Dr. Duffin gives the example of smallpox epidemics, where teams would travel to hot spots to help “isolate, quarantine and vaccinate.

“This happened for every single smallpox outbreak between 1949 and 1979,” she explains. “We were able to eradicate smallpox because of international co-operation, and we almost achieved the same for polio.”

Advances in medicine have helped to expand our disease-fighting toolkit, according to Dr. Duffin, who held the Hannah Chair of the History of Medicine at Queen’s University from 1988 to 2017.  “We have antibiotics for infections, respirators and oxygen bottles for breathing, and other medications. We have public health measures like hand-washing, masking and social distancing,” she explains. “But the gold standard for controlling infectious diseases – from smallpox, influenza and polio to COVID-19 – is vaccination.”

A history of better health outcomes with vaccines

Historical data shows that immunizations have had a significant impact on health outcomes through the ages, says Rowena McGowan, curator at the Museum of Health Care at Kingston, where an exhibit titled Vaccines and Immunization: Epidemics, Prevention and Canadian Innovation leverages “the dramatic power of historical example and perspective about the impact of serious, debilitating and deadly diseases in Canada before and after vaccines were available.”

The collection represents a unique opportunity to convey medical history through a “very visceral experience,” says Ms. McGowan. “Seeing the objects is very different from learning from a textbook.”

Picture, for example, a metal chamber attached to an engine and bellows, designed to assist breathing by varying the air pressure in the enclosed space, she says. “People have heard of the iron lung, but when you stand in front of it, you can’t help but imagine being inside this box.”

Being encased in such a respirator, which was state-of-the-art life-support technology in the first half of the 20th century, might seem unpleasant – but the alternative was worse. Polio patients, for whom the apparatus was designed, could experience paralysis affecting the chest muscles that left them unable to breathe unaided.

Polio was considered the most feared disease in industrialized countries at the time. The Museum of Health Care’s iron lung was made in 1937 and used at Kingston General Hospital. “If you were lucky, you would have needed it just for a little while – but this might have been your entire life,” says Ms. McGowan. “I know that in 2019, there was still at least one person in North America living in an iron lung.”

As part of the story of epidemics, the iron lung illustrates the devastation of polio – it can also serve as a reminder of what has been achieved through immunization, she says. “Today, polio is no longer feared in most countries, but the coronavirus pandemic is again causing people to struggle for breath.”

The coronavirus pandemic and rising vaccine hesitancy

When vaccines for COVID-19 became available for use in Canada in January 2021, Dr. Stephen Yates, a former family physician, put his retirement plans on hold to take on the role as clinical lead in four different mass vaccination clinics in the Kingston area.

“Canada had a good plan for vaccinating the frontline workers first, and then, as more doses became available, other members of the community,” says Dr. Yates, who worked seven days a week – and 12 to 16 hours daily – as the vaccination campaign ramped up.

What made the experience “quite enjoyable” was his conviction “that we were making a huge difference.” However, enthusiasm for getting the vaccine waned, and towards the end of 2021, there were occasions when hardly anyone showed up for scheduled immunization clinics.

“The problem was the number of people who didn’t have faith in the health-care system and in authority figures in particular,” says Dr. Yates. “Today, everyone consults Dr. Google, where you can find many things, including unmitigated junk.”

With so much – and often conflicting – information available, “some people find it hard to separate myth from truth,” he explains. “And that’s a tragedy, because there’s no question in my mind that vaccine hesitancy is delaying our successful battle against the virus.”

As a medical practitioner with a strong affinity to “evidence-based practices,” Dr. Yates is convinced of the lifesaving power of immunization. “We’ve reached the ability to vaccinate against so many diseases, and we’re getting better and better at it,” he says. “And evidence shows how safe these vaccines are, both theoretically and in practice, so it’s a bit sad that the safety and side-effects of coronavirus vaccines have dominated much of the public discourse.”

How to encourage vaccine uptake

In Dr. Duffin’s view, the current, often polarized discussion is an indication that “the demand of individuals to have their needs and preferences met often seems to take precedence over group safety.

“With every single vaccine, there are side-effects, which can be unpleasant and sometimes dangerous,” she says. “However, from a public health perspective, when you weigh the side-effects against the number of people who would experience serious illness and die without the vaccine, there’s just no comparison.”

However, history has shown that  vaccine mandates – as effective as they may be – sometimes result in pushback. Take the smallpox epidemic in Montreal in 1885, for example. When the authorities, who were predominantly Anglophone, ordered a vaccination drive in response to the disease’s outsized impact on poorer – and often French and Catholic – populations, “it backfired,” says Dr. Duffin. “There were riots all over Montreal opposing this gesture.”

Instead of mandating everyone to get vaccinated, as at times had been the case in England and Italy, for example, Canada more often tried “gentle persuasion,” such as offering free public education to vaccinated children. Dr. Duffin believes that these measures encouraged vaccine uptake and rising acceptance throughout the latter part of the 20th century.

A reduction in suffering

Yet things have changed. Today, vaccine hesitancy is considered a major health threat by the WHO. Beyond prioritizing personal choices and being exposed to misinformation, Dr. Duffin sees another reason for why people are no longer so eager to get vaccinated.

“We have been successful in dramatically reducing the incidence of diseases like diphtheria, whooping cough and measles with routine vaccination, so people have forgotten how horrible these diseases are,” she says. “With diphtheria, it can look like your child is being strangled to death. With whooping cough, your child would be unable to breathe. And measles can come with excruciating rash and brain fever.”

History shows a pattern where vaccine uptake grew as news of suffering in nearby areas spread, Dr. Duffin explains. “People would hear about an epidemic in the region. They then went to a doctor wanting to be vaccinated. It’s hard to show the impact of vaccines beyond the number of lives saved, since we don’t have a suffering meter.”

That’s where the Museum of Health Care aims to make a contribution. “Our objects can tell a million stories, not just about vaccines but also about vaccine hesitancy,” says Ms. McGowan. “A lot of the discussion that was the backlash against the smallpox vaccine, for example, is not that different from what you hear today. It is really interesting to see this continuity.”

The question then becomes what lessons we are willing to learn, and Ms. McGowan believes that seeing an iron lung, a smallpox vaccination certificate or a poster about wearing a mask during the 1918-19 influenza epidemic can provide an extra incentive for seeking out valid evidence.

“Museums are said to be one of the most trusted sources of information, and we work with a great community of medical professionals and historians to ensure what we offer is accurate and relevant,” she says. “Our hope is that what people see and experience here will help them make informed decisions.”

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To view the full report as it appeared in The Globe's print edition: Vaccines