Good Thing Chris Christie Isn’t the Governor of Congo

Poor countries from India to Zambia are making huge gains against preventable killers like measles -- just as rich countries are falling behind.

Laurie Garrett
By , a columnist at Foreign Policy and former senior fellow for global health at the Council on Foreign Relations.

When I lived in the African nation of Zambia in 1979, measles was the No. 1 killer of children under 5 years of age. Their tiny malnourished bodies had been ravaged by the virus. I recall holding a baby suffering from measles, her thin body so feverish that she felt hot, as if she’d been in an oven or baking under the African sun. Her unfocused, vacant eyes were covered in a clear film and her chest seemed not to move as she breathed. As I mentally noted these things I felt the weeks-old baby go limp, and knew that she had just died.

When I lived in the African nation of Zambia in 1979, measles was the No. 1 killer of children under 5 years of age. Their tiny malnourished bodies had been ravaged by the virus. I recall holding a baby suffering from measles, her thin body so feverish that she felt hot, as if she’d been in an oven or baking under the African sun. Her unfocused, vacant eyes were covered in a clear film and her chest seemed not to move as she breathed. As I mentally noted these things I felt the weeks-old baby go limp, and knew that she had just died.

Measles is a killer.

There is nothing trivial about measles, contrary to much of the social media chatter that has surfaced since the Disneyland measles outbreak spread in January; it has now reached 14 states and Mexico, sickening at least 42 youngsters and babies and 61 adults. An individual infected with a strain of the virus currently found in Dubai, Qatar, Indonesia, and Azerbaijan visited Disneyland in December. It is not known who this person was, or whether he or she was an American or a foreign tourist, but health officials have determined that the highly contagious virus spread to other Disneyland visitors, most of whom either had never been vaccinated against measles or had not received their booster shot. From these individuals the virus has subsequently spread over an ever-widening geography, primarily among unvaccinated individuals.

In response to the outbreak, U.S. President Barack Obama sought to underscore the importance of vaccination in his Feb. 2 appearance on NBC News, saying, “The fact is that, a major success of our civilization [is] the ability to prevent diseases that in the past have devastated folks. And measles is preventable. And I understand that there are families that, in some cases, are concerned about the effect of vaccinations. The science is, you know, pretty indisputable. We’ve looked at this again and again. There is every reason to get vaccinated, but there aren’t reasons to not.”

The president’s comments drew partisan responses, with New Jersey Gov. Chris Christie countering, “It’s more important what you think as a parent than what you think as a public official. I also understand that parents need to have some measure of choice in things as well. So that’s the balance that the government has to decide.”

In the United States and much of Europe a debate has unfolded over the last decade pitting population protection versus individual rights, i.e., mandatory vaccination against parental choice. Once a virus that plagued the poor world, causing massive epidemics in places like Southeast Asia and sub-Saharan Africa, measles is increasingly a challenge to rich countries. Global-scale vaccination campaigns have dramatically reduced measles illnesses and deaths in the poorest pockets of the planet, but the richest pockets of humanity are shunning the public health tool. Disease incidence is rising among the rich as it falls among the poor.

* * *

The world has waged an all-out war on measles since 1974, when the World Health Organization (WHO) created its Expanded Programme on Immunization, pushing vaccines worldwide. Between 1980 and 1995, that WHO effort slashed the number of measles cases down from 100 million per year to 44 million, and cut deaths from 5.8 million to 1.1 million. So dramatic were the impacts of measles vaccination that global health leaders resolved in 2001 to completely eradicate the disease, creating the Measles & Rubella Initiative, a worldwide effort that has no formal deadline. By 2012, the work of the initiative had prevented nearly 14 million child deaths.

Measles is one of the most contagious pathogens known to man, with a Reproductive Number (RO) between 12 and 18. To put that number in context, consider that Ebola kills between 60 to 90 percent of the people it infects, but statistically a given Ebola case only transmits the virus to two or three other people, so the RO is just 2 to 3. Measles, in contrast, kills less than 4 percent of the children (mostly infants) it infects, but a typical case spreads from one person to as many as 11 others in rich countries, and up to 18. Worse, the virus is capable of adapting to the genetics of the people it is infecting in ways that can make the disease become more severe. For example, researchers have found that as measles spread through immediate and extended families in West African villages, it mutated to outwit the inherited immune system characteristics of the human clan, producing more rapid and severe illness and higher mortality as it passed from sibling to sibling and cousin to cousin.

So health leaders around the world knew that eradication would be a tall order, as any measles viruses circulating in any population on Earth could threaten a resurgence of the disease in places that had eliminated outbreaks if immunization levels fell below so-called herd immunity levels.

When the measles vaccine was invented and proven effective in 1963, the United States experienced an average of 500,000 cases and 500 deaths a year due to the disease. At that time, well over 1 million children died annually worldwide from measles, and the virus was the leading cause of blindness. The eradication scheme actually commenced with the United States in 1968. Later, an “elimination” strategy was adopted that would have countries eliminate all circulation of the virus among their people, leaving public health authorities with the task of spotting those incidents that came from outside the nation and preventing their spread. The thinking in 1974 was that as countries improved vaccine access and one by one eliminated transmission of measles inside their borders, the planet would see the virus disappear region by region until, by the 21st century, measles would be eradicated.

The strategy hinged on the achievement of herd immunity, meaning the human “herd” had to be overwhelmingly vaccinated in order to stop measles from spreading. In the United States, Canada, and Europe, this meant that 19 of every 20 children had to be fully immunized in infancy. Throughout the 1970s and 1980s the United States, Canada, Mexico, most of Latin America, and Western Europe strived to achieve the elimination of measles. Vaccination rates initially soared across the Americas, but then plummeted in the United States from 1989 to 1991. The dream of American elimination seemed to be falling apart, as vaccination rates among preschool children — which had previously been as high as 98 percent in 1988 — fell as low as 45 percent. The problem: poverty, and the lack of medical services for poor families.

Under Presidents Bill Clinton and George W. Bush, access to immunization for the nation’s disadvantaged was turned around. This was the result of multiple efforts and initiatives that ranged from changes in Medicaid law to federal subsidies to welfare incentives and more. By 2000, the United States achieved the elimination goal. The Pan American Health Organization soon certified that every country in the Americas, from Canada to Chile, had successfully followed suit, despite civil wars, grinding poverty, and enormous logistical challenges, and that measles had effectively been eliminated in the Americas by 2002. By that time the stubborn pockets of epidemics in the world were largely in war-torn regions and acutely poor countries lacking domestic public health capacity.

The task of national elimination of measles in poorer countries in the Indian subcontinent, Asia, and Africa offered far greater challenges, primarily because of the high birth rates in those regions. Babies too young for immunization are extremely vulnerable to measles infection and death when surrounded by other small children who either have not been vaccinated or have not had their booster shot. Preventing the spread of measles in these regions hinged on starting immunization as early in life as possible, and achieving full herd immunity in the slightly older under-5-year-old siblings.

For this part of the world, the year 2000 did, indeed, prove an impossible elimination deadline. In 2003 half a million children worldwide died of measles, most of them in sub-Saharan Africa, southern Asia, and the Indian subcontinent. In Africa the measles death toll was so great that a child died of the disease every minute on that continent. And between 2000 and 2010, measles was the third-biggest cause of infectious outbreaks in the world, with 246 outbreaks over the decade.

But thanks to an all-out global campaign fueled by financing from the Bill & Melinda Gates Foundation, the governments of the United States and United Kingdom, and UNICEF pooled under the GAVI Alliance (formerly the Global Alliance of Vaccinators and Immunizers), cost barriers for access to vaccines plummeted. GAVI negotiated lower prices with manufacturers and purchased vaccines in enormous volumes, then financed the delivery of the products to poor and middle-income countries. Millions of vaccination volunteers were mobilized the world over.

Between 2000 and 2008, the nations of Africa achieved an astonishing 92 percent reduction in measles mortality, and by 2012, an 80 percent decrease in the number of cases. In 2013, an estimated 20 million people contracted measles, which killed 145,700 of them. Measles fell from being the No. 1 cause of child deaths in poor countries to the 14th, and immunization dramatically reduced the overall child mortality rate worldwide.

In one country after another the impact of measles elimination was profound, as child mortality plummeted overall, disabilities decreased, and children thrived. And the countries that felt the change most profoundly were those with large populations of very poor citizens who historically had little access to health care.

One of the greatest success stories was Mexico, which achieved 99 percent immunization of its population — not only for measles, but for all of the key vaccine-preventable diseases by 2012.

In 1980 Mexico had a child mortality rate of hideous proportions, with a statistical average of 51 children out of every 1,000 live births perishing before their fifth birthdays, expressed as a ratio of 61:1,000. Mexico achieved “measles elimination” in 1996, and no cases of the disease have been recorded in the country since, except those imported from the United States by under- or unvaccinated visitors and returning Mexicans who had not been immunized while in the United States. By 2013, after 33 years of national immunization campaigns, Mexico brought the child mortality rate down to 12.9:1,000.

Screen Shot 2015-02-09 at 11.07.00 AM

Screen Shot 2015-02-09 at 11.07.00 AM

In 1991 Mexico created the National Immunization Council, which aggressively coordinated delivery and access for vaccines. By 1995 annual immunization campaigns were reaching Mexico’s most remote populations and by 2010 overall child mortality had plummeted 64.3 percent compared to 1990, mostly due to immunization.

Success on behalf of Mexican children has been realized for all vaccine-preventable diseases and sustained permanently thanks to three national policies put in place between 2000 and 2006. First, vaccination is mandatory and every child, within days of birth, is given an immunization registration card and starts receiving vaccines immediately. Second, vaccines are universally available and free, fully financed by the government. And third, vaccination is viewed as a right and privilege, one that is guaranteed for all.

In 2012, countries where vaccination rates also exceeded those in the United States included Guatemala (93 percent), El Salvador (93 percent), Honduras (93 percent), and Nicaragua (99 percent). Sierra Leone, just three months before its Ebola epidemic began in December 2013, achieved 92 percent measles vaccine coverage. Among the other African countries that have higher rates of immunization than the United States are Algeria (95 percent), Angola (97 percent), Botswana (94 percent), Burundi (93 percent), Eritrea (99 percent), Gambia (95 percent), Kenya (93 percent), Rwanda (97 percent), Seychelles (98 percent), and Tanzania (97 percent).

The tremendous successes witnessed in these developing countries seemed to validate the Measles & Rubella Initiative strategy. It seemed reasonable to dream that eradication would eventually be realized.

Except that a new trend was emerging: vaccine refusal in the rich world.

* * *

On June 2, 2011, tens of thousands of European teens and college students gathered outside Rimini, Italy, for a large, three-day youth football competition. Some of the young sports fans also attended a world kickboxing championship nearby. A few days later a giant outdoor rock festival near Baden-Wuerttemberg, Germany, drew thousands to northern Europe. And by the time public health officials in Italy, Slovenia, and Germany figured out what had happened, measles was spreading all over their countries. The majority of the young adults who came down with the disease were unvaccinated, and the outbreak started with a never-immunized 34-year-old female kickboxing fan from Macedonia. Thirteen German youths got measles, 12 of whom were unvaccinated. Another unvaccinated young adult caught measles in the sports events, went home to Slovenia, was hospitalized, and then infected six health care workers.

This is just one incident of many in Europe, where vaccination rates have slumped since 2000 due to parental refusals. Claims made in the late 1990s connecting measles vaccines to autism by a now-dishonored former physician, Andrew Wakefield of the U.K., slowly took hold in the general public’s imagination. This wave of fear includes objections to so-called GMO food, or genetically modified products, and suspicions linking the pharmaceutical and food industries to a campaign to poison people for profits.

France is one such country. By 2008 vaccination rates had plummeted across France, with up to a third of secondary and college students never having been immunized for measles. Not surprisingly, in the spring of that year, there was an outbreak among unvaccinated students at Catholic high schools that quickly spread to local public schools. More than 20,000 people, more than half of them children and young adults, came down with the disease. Quebecois travelers returned home from France in June 2011, bringing the virus to Canada. Nearly 800 Canadians came down with the disease in 2011 — 79 percent of them had not been vaccinated.

Efforts to slow the French measles epidemic by government health workers were stymied by two mistaken public attitudes. First, false information: Right-wing politicians mistakenly linked the disease to the illegal immigrant Roma population. Racism against the Roma runs high throughout Europe, and blaming them for the disease led to demands for actions taken against the people, not the virus. (In truth, the prevalence of measles among the Roma was about half that seen in native-born French.) The second obstacle was a widespread belief that something was wrong with the vaccines, whether or not they caused autism. In particular, many French believed that giving any vaccines to newborn babies was dangerous because their infant bodies couldn’t tolerate the immune stimulation.

The French epidemic raged from 2008 to 2011, with cases still lingering in some regions today.

Across Europe the French measles problems played out in a series of smaller outbreaks. In every case vaccination rates had plummeted due to parental refusal on similar grounds — “autism,” fragile babies, or just “something is wrong with vaccines.”

In 2011 to 2012, similar epidemics broke out in Bulgaria and Switzerland, and, along with outbreaks in 2011 to 2013 in the U.K., Netherlands, and Belgium, hundreds were sickened, including health care workers who attended to the hardest-hit hospitalized cases.

Measles vaccination rates had fallen nationally in the U.K. to 85 percent by 2007, and remained dangerously below the level necessary to achieve herd immunity. A quality-of-life survey of more than 500 U.K. measles survivors conducted in 2012 and 2013 found that the average amount of time lost from school or work was 9.6 days, that more than a third of the patients suffered serious depression while sick, and that a fifth lost the ability to walk or move.

An international dog show competition in Slovenia in November 2014 spawned another outbreak, eventually sickening 44 people. Because Slovenia’s vaccination rate is 98 percent, most of the measles cases came from other European countries, particularly Germany, and involved individuals who either had never been vaccinated or had failed to get their booster shot.

It’s not a huge leap from the dynamics of measles spread at a Rimini football game or German rock festival or Slovenian dog show to Disneyland. The American rise in measles has mirrored the European experience.

The United States has experienced several small outbreaks of measles since the virus was “eliminated” in 2000, typically starting from an unvaccinated American returning from overseas travel, or the arrival of a visitor from a place such as France, where measles was actively spreading. A 2011 study of 16 small outbreaks across the United States found an enormous cost paid by taxpayers for tracking down cases, educating the public, providing emergency vaccination and conducting the overall measles investigation. The price tag? Each one cost $2.7 to $5.3 million.

Last year the United States suffered its largest measles epidemic in more than two decades. It began in early 2014 with the return of an unvaccinated American Amish missionary who had traveled to the Philippines, where a large measles epidemic was underway, to his home in Ohio. The Ohio outbreak spread into the community and eventually to neighboring states, for a total of more than 600 cases. (In 2013, the vaccination rate in Ohio was 86 percent.) According to the Centers for Disease Control, in the first half of 2014, 69 percent of U.S. measles cases were in people who were never vaccinated and only 10 percent were fully immunized, including having a booster shot.

This graphic from the CDC shows why the measles sufferers had chosen to opt out of vaccination:

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Screen Shot 2015-02-09 at 11.33.16 AM

A newly published study shows that most recent measles outbreaks in the United States have spread within pockets of low vaccination, typically in wealthy and upper-middle-class communities where parents either refuse vaccination entirely, or opt out of the full package of recommended immunizations and boosters. In such settings a single case of a traveler or returning vacationer infected with the virus can spread like wildfire. California is dotted with numerous communities of vaccine opt-outs that have been tied to outbreaks, including the current “Disneyland Measles.” Schools in the state allow children to attend without vaccination if parents cite the so-called “personal beliefs exemption,” an opt-out option available to parents in several states. As these tables from the California Department of Public Health illustrate, parents choosing personal beliefs exemptions tend to have their children in private schools, and to have refused vaccinations on secular (not religious) grounds, in consultation with a like-minded physician.

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Screen Shot 2015-02-09 at 11.10.47 AM

The state of Oregon saw a fourfold jump in personal beliefs exemptions between 2006 and 2009, and now leads the nation in the dubious status of having the lowest percentage of the population vaccinated.

But the overall trend nationwide for the last decade has been greater allowance of opt-outs, typically in the absence of religious objections. Some states require that parents seeking exemptions obtain a letter of support from their physician, and surveys indicate that many pediatricians are reluctant to resist parental demands, providing such letters even when they feel it is wrong to leave the children vulnerable to measles and other diseases. A minority of physicians actively encourage parents to minimize the volume and frequency of vaccinations. The exemptions have been legally challenged, and judges have tended to rule that schools have a right to bar under-vaccinated and unimmunized children from classes during outbreaks.

One of the most outspoken voices of the anti-vaccine movement has been the minor celebrity Jenny McCarthy, who now earns her living as an advertising spokesperson for e-cigarettes. McCarthy long ago claimed her son developed autism soon after being vaccinated, and that she cured him of the disorder. After years of linking autism and measles vaccination, McCarthy published an opinion piece in the Chicago Sun-Times last year saying she had been “wrongly branded” as anti-vaccine. McCarthy wrote that her main concern was that too many vaccines were given to small children, adding, “For my child, I asked for a schedule that would allow one shot per visit instead of the multiple shots they were and still are giving infants.”

Many parents who now decline to vaccinate their children mirror the McCarthy approach, choosing to get fewer shots for their kids, spaced out over a longer period of infancy and childhood. The thinking — which has support among some pediatricians — is that babies’ delicate bodies cannot handle the “assault” of multiple vaccines. These parents in communities like Beverly Hills and Marin County pick and choose the shots for their children, with the result that the youngsters are grossly under-immune, unable to effectively fight off measles infection.

The “fragile baby” notion is hogwash. Newborns come into the world with a primitive immune system and incompletely wired brain. A healthy child is the result of enormous stimulation, teaching the baby’s developing immune system and brain to recognize the world properly. Babies grab everything they can reach, studying the objects, sticking them in their mouths, chewing, and drooling. It’s a baby’s job, as it were, to absorb as much intellectual and biological information as possible.

A growing body of research shows that the human body is filled with far more microbes — bacteria, viruses, and parasites — than human cells, performing functions essential to our survival, such as digestion of food. From the moment a baby is born it is engulfing microbes, filling its body with billions of viruses and bacteria. And the baby’s immune system is primed by interaction with this vast microbial world — “assaulted,” to use anti-vaccine parlance, millions of times every single day. It is these interactions that determine whether the child’s immune system will be strong and healthy, or under-immunized, incapable of properly distinguishing “bad” microbes such as measles from routine environmental exposures such as dust and pollen. A healthy immune system, versus one suffering from asthma or autoimmune diseases, is the result of that essential learning-by-licking that is the job of every infant.

If babies thrive when assaulted by millions of living microbes every day, it is hard to understand how a killed or attenuated vaccine strain can be too much for their fragile bodies to handle.

* * *

For years I have been asked by earnest parents during various speaking engagements about the safety and wisdom of vaccination. I used to tell them that failure to fully vaccinate a youngster doomed the individual to grow up unable to safely travel the world. I would ask, “Do you really think your child is going to say thank you when he or she hits 18 and can’t go with college friends on that African safari?”

But now the tables have turned. That unvaccinated 18-year-old American could now be a measles carrier — the one who takes the virus to Rwanda or elsewhere abroad, endangering the 3 percent of its population that hasn’t been immunized, and the mountain gorillas, which are susceptible to human measles.

It’s a terrible, almost unbelievable irony that the dream of measles eradication hinges not on the poorest people on Earth and their desperate need for Bill Gates’ generous provision of vaccines, but on the wealthiest, best-educated Americans and their crackpot ideas. It may never be possible to determine who was the index case that brought measles to Disneyland in December, but the CDC’s Anne Schuchat recently told reporters that the index case was “someone [who] got infected overseas, visited the parks and spread the disease to others.” And genetic analysis of the measles strain matches it to those circulating in Indonesia, Qatar, Azerbaijan, and Dubai. The issue, however, is not where the virus came from, but why so many Americans co-visiting Disneyland alongside that measles carrier were unvaccinated.

But a backlash is brewing on the home front. Even before the Disneyland measles outbreak began in December, the rising incidence of the disease was making parents angry. An August 2014 Harris Poll found 77 percent of Americans supporting mandatory vaccination, eliminating personal beliefs exemptions and most forms of religious opt-outs. Employers, dismayed by the Disney Corporation’s sorry co-branding with the word “measles” and worried about the safety of their clients, are now asking if they can legally compel vaccination. Public sentiment is of a collective mind to blame the vaccine refuseniks for putting general society at risk. Some parents advocate filing lawsuits against the refuseniks and under-immunizers. Californian Carl Krawitt has taken to the airwaves, asking that opt-out kids not be allowed to attend public school alongside his son, a cancer chemotherapy survivor with a weakened immune system. And some schools are now barring unvaccinated high school students.

On Oct. 24, Kaci Hickox reached the Newark airport en route to her Maine home after weeks spent as a nurse volunteer fighting Ebola in Sierra Leone. Fearing that Hickox posed an unreasonable risk to the people of New Jersey, Gov. Chris Christie ordered the nurse quarantined. The following day Hickox emailed an attorney and eventually me as well, writing, “I’m feeling quite vulnerable and distressed right now. Any support would be appreciated.” But Christie stuck to his guns, and was joined by New York Gov. Andrew Cuomo in decreeing that health workers who traveled to the Ebola epidemic should be quarantined upon return to the United States.

In the case of Kaci Hickox and Ebola, Christie felt that no amount of risk to the general public, no matter how far-fetched, was worth leniency. But in the case of well-to-do New Jersey parents who opt out of measles vaccination, the governor feels there is a “need for balance” between protection of the public and “personal choice.”

Appearing on MSNBC this week, Hickox denounced Christie’s vaccination “choice” statements, saying, “I think the unfortunate thing or the scary thing is that I want a leader who consults experts and thinks about sort of all of the different sides to an issue before making statements and — and policies that are unfounded in science.”

If the backlash against non-vaccinators continues to grow, Christie (and others like fellow presidential candidates Ben Carson, who insists illegal immigrants are responsible for measles, and Rand Paul, who has struggled to balance his libertarian views of free choice against support for public health) may realize they have made the wrong political gamble in playing with public health. A deep, emotional polarization already divides public health advocates and those who dream of global measles eradication versus parental-choice promoters who feel even scant hypothetical vaccine risks are too much burden for their babies to bear. This vaccine polarization has been vociferous and often angry for many years. It would be tragic not only for the children of America, but for the measles-fighting world as a whole, if efforts to achieve American herd immunity against the virus were stymied by U.S. political polarization. Measles infects both Democrats and Republicans, and the vaccine protects the children of conservatives and of liberals equally well.

Today the Philippines is bringing its measles crisis under control, the epidemic has been stopped in Congo, and all over the world the viral disease is disappearing — except in the richest countries. Back when the eradication campaign commenced, the idea of elimination efforts region by region assumed the richest nations would be the first to stop measles. Now, thanks to pockets of public refusal and anti-vaccine sentiments, the rich world may be the last to stop measles. Worse, America could become a global measles exporter, as it already has sent measles to Mexico.

*Correction, Feb. 13, 2015: The WHO first launched its immunization push to eliminate measles in 1974. This was followed in 2001 by the creation of the Measles & Rubella Initiative to further worldwide measles-eradication efforts. An earlier version of this story mistakenly cited 1988 as the date when the WHO began working to eliminate measles. This story has been updated in several places to reflect the correct dates.


Laurie Garrett is a columnist at Foreign Policy, a former senior fellow for global health at the Council on Foreign Relations, and a Pulitzer Prize-winning science writer. Twitter: @Laurie_Garrett

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