May 1, 2021

The Great Escape, the Global Idea that is Vaccination

The Great Influenza Outbreak of 1918 is estimated to have taken 100 million lives. In contrast, roughly three million lives have been lost to Covid-19 on a planet with four times as many people.

After the 1918 pandemic, at a time when a murderous world war was afoot, life span in the United States plunged practically overnight by 7 years, to 47 years. In England, it fell by a decade. India’s average life expectancies fell below 30 years. Imagine you were in Boston watching as they stacked bodies in a makeshift morgue or roaming the streets of Bombay where more than 5 percent of the population died of the flu in a matter of months. What prediction would you have made for the next hundred years? Would you have considered the progress of the previous fifty years a fluke? Would you have viewed the Spanish Flu as a harbinger of an even darker future? Amazingly, this dire scenario did not come to pass.

If we published a newspaper only once in a century, the headline on the latest edition would read, “LIFE SPAN DOUBLES, TRIPLES ACROSS THE WORLD.”

Since 1920, life expectancy has never reversed, except for a brief blip during the second world war. India and China have recorded what must rank as the fastest gains made by any society in history. Today, average life expectancy in India is around 70 years. There are few measures of global human progress more astonishing than this. And yet, it never appears as a headline in a newspaper. This progress tends to be measured not in events, but unnoticed non-events. The smallpox infection that didn’t kill you at two years of age. The accidental bruise that didn’t give you a lethal bacterial infection. The drinking water that didn’t poison you with cholera. In a sense, we are protected by an invisible shield, built painstakingly piece by piece over the last 100 years. This shield became suddenly visible during the last year. We have seen holes in it which we can and will fix in the years to come. We have been reminded of how dependent we are on medical science, hospitals, public health agencies, drug supply chains, storage technologies, and transportation logistics.

How did this doubling and tripling of life span happen?

It is a story that can fill a very interesting book. When history textbooks document health progress, they nod to three critical breakthroughs: vaccines, germ theory and antibiotics. They are presented as presented largely as triumphs of the scientific method. In reality, progress was made as possible by scientists as it was by activists, public intellectuals and legal reformers, who ensured that benefits accumulated to ordinary folks like you and me.

For a good part of human history, life expectancy held pretty much steadily at around 35 years. Mankind spent over 10,000 years inventing agriculture, metallurgy, gunpowder, double-entry accounting ledgers, and other clever things but failed to move the needle on how long the average person could expect to live. Until 1750. That’s when things began to change. Specifically, the life expectancy of the European aristocracy began to rise. The best way to understand this is to review the list of European monarchs killed by smallpox prior to 1750 - Holy Roman Emperor Joseph I, grand dauphin Louis of France, Louis I of Spain, Peter II of Russia, Louis XV of France, and Maximilian Josef of Bavaria. It’s a long list. Before 1750, it didn’t really matter if you were a king or a commoner. Your life expectancy was in the thirties.

How the English aristocracy at first, and then the European elites, extended their life spans is attributed to Edward Jenner’s invention of the smallpox vaccine, a watershed moment in human history. But, life expectancy had already begun to rise among the English elites prior to Jenner’s vaccine. An earlier innovation, which originated thousands of miles from England, called ‘variolation’ was the cause. Variolation is a proto-vaccination procedure that involves direct exposure to small amounts of the virus itself. Some accounts suggest that it originated in India two thousand years prior to the first western vaccine. Like other great discoveries, it could have been independently discovered in various parts of the world. Regardless of its origin, the practice had spread to China and Persia by the 1600s, and to Turkey from where the English elite imported it and put an end overnight to smallpox in their ranks. Frederick, the Prince of Wales, was inoculated at birth and lived long enough to produce an heir, King George III. Most crucially, variolation inspired Jenner’s smallpox vaccine. Jenner’s approach was to inject a less virulent version from the same virus family, which lowered the mortality rate of vaccination compared to variolation. Vaccination was truly a global idea from the very beginning.

Then came pasteurized milk, which triggered what economist Angus Deaton has described as “the great escape,” a genuinely new cycle of positive health trends in human societies across the world. In New York city, only 60 humans survived to adulthood in the 19th century. Today, 99 do. The rise of chlorination is another example of transformational reform. It was the work of chemists no doubt, but equal credit must go to sanitation reformers, local health boards and waterworks engineers, whose ranks comprised industrious men and women working silently to revolutionize the lives of fellow citizens. We might be tempted to think that pharmaceutical drugs formed the cornerstone of the last 100 years of health progress. Truth is much of the benefits accrued from clean water, pasteurized milk and early inoculations. For much of the 20th century, drug discovery was an unorganized sector with a scattershot approach. Fleming’s serendipitous discovery of penicillin’s life saving uses in 1928 marked the starting point of Big Pharma. 30 years after Fleming’s discovery, companies like Pfizer and Merck signed on to develop it, and turned into a “miracle drug,” beginning the age of antibiotics. I will save for another day the remarkable story of how Indian and Bangladeshi scientists collaborated to use “low tech” and eradicate cholera from the Indian subcontinent and eventually Africa and other developing countries.

It took Sweden 150 years to bring its infant mortality rate to under 1 percent. South Korea pulled this feat off in 40 years. India doubled life expectancy in just 70 years. In 1951, the difference in life expectancy between the US and China was twenty years. Now it is just two. On the eve of his first term as President, Thomas Jefferson wrote about removing smallpox from the “catalog of evils.” On December 9, 1979, smallpox was declared to be officially eradicated by a committee of world scientists.

As we live through the present pandemic, and keep in mind the extraordinary progress we have made since the last one, what predictions would you make for the next 100 years? Will the forces that propelled the great escape over the last 100 years continue? Will the rising tide of egalitarian public health continue to lift all boats? Or, will we be washed away by an actual tide?

A century of brilliant progress has created a new, more advanced threat: ourselves. History tells us that scientific and technological progress alone do not guarantee our wellbeing. Social progress must go hand in hand with them. The responsibility to keep alive the momentum of the last century rests squarely on your shoulder and mine. Whether or not we lurch recklessly into a new era of pandemics, or race blindly towards a climate apocalypse depends on how we vote. No longer can we afford mediocrity and low-minded thinking in governance.

Universal, free healthcare is a human right. We must say this out aloud. We must ensure that our political leaders understand this and act with expediency.

Before I let you go, a nugget from history: The 1950s were a bizarre period in America, it appears. While a post-war economic boom fueled prosperity, it was also an era of mistrust of “enemies,” both internal and external. In 1956, Nikita Khrushchev, the Soviet President, declared to America, “Whether you like it or not, history is on our side. We will bury you.” The situation went to Code Red in October of 1957 when the Russians launched the world’s first satellite, Sputnik. The Americans became terrified that the Soviets had beaten them at their own game. They figured that they had to do something big to showcase America’s might to the entire world. So, they decided to, wait for it… NUKE THE MOON! Yes. The idea was to create an explosion on the moon so large that all earthlings would see it and be suitably impressed. Luckily, this project dubbed the A-119 project, never saw the light of day. If it had, it’d have given a whole new meaning to “shooting the moon.”

Stay safe. Have a wonderful week ahead.