Not far from the hospital in Edinburgh where I work there's a graveyard; it can be a calm, if morbid, place to reflect after a tough shift. Passing it acts as a memento mori on days when I need to be reminded of the value of medical practice—which for all its modern complexity remains the art of postponing death. Benches are set out in the shade of trees, between red-shingle walkways and rows of Victorian tombstones. Many of the stones commemorate dead children, but there's a memorial near the entrance that always stops me short. It's dedicated to Mary West, a woman who died in 1865, at the age of thirty-two—two years before Joseph Lister published his groundbreaking work on antisepsis. The reason for her death is unrecorded. Beneath her own name are listed the names of her six children in their order of death—at ages two, eleven, four, twelve, and fourteen. Only one lived to adulthood.
The death of any child is a tragedy, but to lose so many is now almost unthinkable. In the Victorian period, when infectious diseases were rife, it was routine. I trained in medicine through the 1990s and never saw a case of one of the most virulent, measles, though my tutors told me to learn about it from textbooks. Yet working in the emergency room recently I saw a girl with a rash, fever, conjunctivitis, swollen lymph glands—all classic symptoms of the measles virus. “Do you know if she has had her MMR [measles, mumps, and rubella] vaccine?” I asked her father. He nodded, but something made me doubt his sincerity.
“Are you sure?” I asked again.
He nodded, then broke my gaze. “Maybe she skipped that one,” he said at last.
One in twenty children with measles develops pneumonia. Only about one in a thousand develops the most serious complication, encephalitis (a viral infection of brain cells). About two in a thousand will die. Having to second-guess parents about whether a patient has been vaccinated is new: physicians are accustomed to trusting the parents of the children they see—after all, we both want what's best for the child. But when fears about vaccine safety cause a drop in vaccination rates, cases of serious infectious disease start rising. Parents who decline to vaccinate their children sense a growing opprobrium toward their choices. They have a consequent incentive to lie or, perhaps worse, stay away from the emergency room for fear of having their parenting challenged by medical professionals.
In 2014 Eula Biss examined this crisis of confidence in her book On Immunity: An Inoculation and proposed that we think of infection control as an ecology to be kept in balance rather than a war between opposing sides.1 Writing with the perspective of a new mother who ultimately chose vaccination for her own child, Biss explored the metaphors we use to think about disease and the body. The word “inoculate” has its origin in the care of gardens and orchards, and was originally used to describe the grafting of a bud onto a tree. It's unfortunate that vaccination has come to be seen as an unnatural and dangerous intervention, when in truth it's through “grafting” that the natural power of the recipient's own immune system is harnessed. The testimony of our graveyards is that before public health, clean water, antisepsis, and vaccination, it was perfectly natural that most children died.