Indigenous smallpox had been eliminated from Britain in the 1930s, reducing its threat to the day-to-day lives of British people. The public had, however, come to fear a new disease which first reached epidemic proportions in 1947 – poliomyelitis. From that year onwards, regular outbreaks occurred during the “polio season” each summer. No cure was ever found. The only thing authorities could do was provide treatment for acute symptoms and continue research efforts into a preventative vaccine. By the end of the 1960s, the number of annual cases could be counted on one hand, but the vaccination programme that achieved this decline did not eliminate polio overnight; nor was it without significant financial and logistical difficulties.
This chapter focuses on the theme of demand. This was not unique to polio. As has been seen in previous chapters, the British public had come to demand health and other welfare protections from the government, particularly since the 1940s. There was active demand for emergency vaccination during smallpox epidemics. What set polio apart is that we see clear evidence of public demand for a coordinated routine immunisation campaign. In part, this was because of higher levels of anxiety about polio than about other diseases, but it was significant that the specific solution to this problem would be vaccination. The anti-diphtheria, pertussis and smallpox programmes offered a template; and new vaccine technology made this possible. Initially this involved the mass polio vaccination of all children and priority groups. Later it would evolve into a programme for all young children as they became old enough to be eligible, and specific campaigns to vaccinate young adults to protect them from the disease.
It is clear from contemporary media coverage and internal government files that the British people wanted protection from polio. As in many Western countries, large charities solicited donations to polio research and care and there was extensive interest in the massive field trials of a new vaccine being developed in the United States in 1954 and 1955.1 Even when the vaccine became available, many of these charities continued to provide aftercare and support for affected children and adults – and while the majority of publicity for vaccination would come from health authorities, the climate of concern around polio stimulated discussion and demand. Such was this demand that during the period from the introduction of the UK polio vaccine programme in 1956 to the switch to oral poliomyelitis vaccine in 1962, the government faced significant criticism for being unable to provide vaccine to all who wanted it, due to acute and chronic supply shortages. And yet the Ministry of Health also worried that certain sections of the public were too apathetic towards the new technology and needed to be convinced of the benefit both to themselves and to the wider population.
Demand appears in two main contexts throughout this chapter. First, it could be a statistical artefact – a measurement of how many people had requested polio vaccine. Demand could be measured through the registration system established in 1956 as well as the various requests from local health authorities for vaccine supplies when there were surges of requests in any given area. In these cases, demand could be compared with expected or actual supply; and, indeed, demand could be predicted based on past trends, advertising campaigns and the demographics of priority groups under the scheme. Here, demand could be interpreted as an administrative issue. When demand was too high, supplies had to be augmented through more orders for the vaccine from pharmaceutical companies. When demand was too low, either relative to the programme's goals or the amount of available vaccine, it was stimulated through local and national advertising efforts. This administrative balancing act occurred throughout the period, not always successfully, as this chapter will demonstrate. The second context of demand was more subjective. The public in general believed that the government ought to provide polio vaccination to its people. Universal polio vaccination was a symbol of a modern, rational state. Politically, therefore, the vaccination programme was created and expanded not entirely due to administrative or epidemiological measurement, but on what various branches of government believed would be popular with the wider public. Similarly, there was nothing inevitable about the negative political, media and public attention directed towards the various supply crises across the 1950s. Delays in vaccination represented wider concerns, particularly among the public, with governmental administration than simply the immediate benefits to direct beneficiaries.2
This chapter begins by outlining the development of the polio vaccine up to the mid-1950s. This was a result of international cooperation and charitable donations, resulting in one of the iconic scientific discoveries of the early Cold War era. However, a high-profile laboratory accident severely dented the reputation of this new technology. Traditionally cautious, British health authorities created their own version of the vaccine. After outlining this British variant and the difficulties it caused, the chapter explores the development of the poliomyelitis vaccine campaign. This was continually affected by supply problems. Partly, this was because of the demands placed on the system by the public. A greater problem was the inability to either produce or source enough vaccine, especially when there were surges in demand. Two incidents in particular are highlighted: an epidemic in Coventry in 1957; and the death of the professional footballer Jeff Hall in 1959. The chapter ends with the introduction of oral poliomyelitis vaccine and the end to these long-running supply issues.
As well as covering demand, the rhetoric around polio vaccine exposes other themes that we have already encountered in the 1950s and 1960s vaccination programmes. The general climate of demand was welcome, but the government was consistently worried about pockets of apathy shown by parents with regard to polio vaccine, and made significant attempts to convince the public to register themselves for the scheme. The public did not act in unison, much to the government's chagrin. Similarly, the nation is an integral part of understanding why the British government chose to prioritise British-made vaccine, even though it was more expensive and difficult to produce than its American equivalent, and even when the resulting supply shortages caused the government significant embarrassment.3 With the polio vaccine programme finally established, however, the modern post-war vaccination schedule as we know it today had become firmly entrenched in British health care.
Poliomyelitis and the vaccine
While much has been written about polio, it is worth taking some time to explain the context for the new vaccine that became available in the 1950s. In particular, this context explains why parents had come to fear the disease – a subject which has received significant attention from historians.4 Poliomyelitis is caused by poliovirus, of which there are three types.5 It is spread through the gut, most commonly through traces of faecal matter entering the mouth. It is asymptomatic in around 70 per cent of infections, but can cause limb weakness or even paralysis in a minority.6 Despite the higher death rate among infected adult patients, the crippling effects it could have on children gave polio the reputation as a childhood disease. Indeed, it was often called infantile paralysis, although by the post-war period poliomyelitis – or simply polio – became the preferred nomenclature.7 Given how widespread natural poliovirus was in England and Wales, this led to an average annual case load of acute poliomyelitis of 524 for the five years to 1946, and 5,197 for the five years including and after the first widespread epidemic of 1947 (Figure 3.1). Although there is evidence to suggest that polio has infected humans for millennia, the first full-scale epidemics of the disease were not seen until the late nineteenth century, in American and Scandinavian cities. For this reason, it has been described as a ‘virgin soil infection’ by J. N. Hayes – one that was shocking to the public because of its apparent novelty and a lack of medical or lay experience with regard to its spread and control.8 It appeared to affect rich and poor communities with the same force, unlike other infectious diseases such as tuberculosis. A cure has never been found, although a series of therapies were developed across the twentieth century to deal with the acute problems of paralysis and the chronic rehabilitation required to restore some function to affected parts of the body. The most iconic of these was the iron lung, both a symbol of modern medicine's ability to fight against death and a fearful reminder of the severity of the disease. The sight of crutches and callipers on survivors also represented the permanent impairment and disability left in the wake of an outbreak.9 The only defence against polio would therefore be prevention of infection, which was, paradoxically, more difficult in more economically developed nations. The prevailing hygiene thesis is that most children in countries with poor sanitation are exposed to poliovirus at an early enough stage that they retain some immunity from their mothers; most therefore develop mild or asymptomatic polio and lifelong immunity. In communities with fully functioning sewerage systems and a culture of handwashing, children and young adults are exposed much more infrequently, and so are more likely to develop a more acute version of the disease later in life. This can explain in part why cases became widespread enough that polio became a notifiable disease in the early twentieth century, although it does not fully account for why Britain was affected by epidemic polio much later than many other nations.10
Figure 3.1 Poliomyelitis notifications, 1939–69. Paralytic cases separated from overall notifications from 1950 only. Source: Public Health England, ‘Notifiable diseases: historic annual totals’, 28 November 2016. www.gov.uk/government/publications/notifiable-diseases-historic-annual-totals (accessed 5 May 2017).
Across the Western world during the early twentieth century a number of organisations were established to raise funds for research into polio and a potential cure. The most high-profile of these was the National Foundation for Infantile Paralysis, also known as the March of Dimes. Established by Franklin Roosevelt in the United States in the 1930s, it received millions of dollars from the American public and helped to fund the research which would produce the first commercially available vaccines. In the United Kingdom, where epidemic polio had begun much later than in the USA, the National Fund for Poliomyelitis Research was established in 1952.11 When the US team led by Jonas Salk announced at a press conference in 1955 that it had successfully developed an inactivated poliomyelitis vaccine (IPV), the world's press and television attended. The US government licensed it for use within hours.12 It was an archetypical example of the new, coordinated “big science” of the mid-twentieth century, reliant upon large budgets and teams of scientists and institutions focused on a single problem.13 The polio vaccine trials were among the biggest medical experiments ever conducted, becoming a model of randomised controlled trials for researchers and pharmaceutical companies around the world.14
The Ministry of Health knew that the Salk announcement would stimulate interest in Parliament and in the media. Newspapers had covered the trials as they were being conducted, and regularly reported from international conferences on polio and immunisation.15 The National Fund for Poliomyelitis Research had contacted all the major news outlets to direct their attention to Salk's results (and to publicise its own work), and the MRC was within a fortnight of being able to release its own data.16 In the House of Commons, Minister of Health Iain Macleod took a series of questions on the announcement and pledged to move as quickly as possible to bring IPV to the British public, subject to proper testing.17
Despite this positive publicity, the American IPV programme suffered a major setback almost as soon as it had begun. A batch of the vaccine from the Cutter Laboratories had not been inactivated properly, leading 120,000 children to be injected with live poliovirus. Subsequently, 260 cases developed, of which ten were fatal.18 While this caused governments across the world to reassess their commitment to IPV, the British were particularly cautious.19 Authorities in the United Kingdom had historically been risk averse toward new vaccines, often insisting on a higher burden of proof for their safety than other high-income nations did – most notably in the cases of BCG and anti-diphtheria immunisation.20 The MRC was keen to ensure that any vaccine used in Britain was as safe and effective as possible. Trials using the Salk vaccine were suspended, and the MRC sent a delegation to the United States to ascertain what had occurred.21 Through the course of its research and new trials, the MRC recommended that a British vaccine should replace the Mahoney type-I strain of poliovirus in the American vaccine with a less virulent strain; this not only would reduce the risk of another Cutter incident, but would also be more effective in conferring immunity.22 The MRC was confident that, when combined with the longer and more rigorous testing period demanded by British authorities, the United Kingdom's IPV would be safer and more potent than the American Salk. It advised the government not to use Salk vaccine at all in Britain.23 The Ministry of Health and the Scottish Office established an advisory body, the Joint Committee on Poliomyelitis Vaccine (JCPV), to guide British health departments on the medical and administrative issues surrounding vaccination.24 After securing assurances that Glaxo and Burroughs Wellcome would produce the vaccine, on 19 January 1956 Robin Turton (the Minister of Health) announced to a large press conference that children under the age of ten would be eligible for polio vaccination. Parents would register their children, and local authorities would distribute the vaccine as supplies became available.25 Initially, children were to receive two doses of IPV by injection, but this was extended to three doses in 1958.26
The speed at which the scheme was initiated indicated that the Conservative government thought polio vaccination would be a popular move.
There is something peculiarly distressing about poliomyelitis … Not only does it kill especially the young, but of those who survive 10 per cent remain severely paralysed and a further 20 per cent retain throughout their lives a degree of paralysis. [Turton] was confident that every father and mother would wish God's speed [sic] to the new plan.27
Yet the way in which the scheme was initiated caused a number of problems which had long-standing consequences that would not be fully resolved until the following decade. First, the use of local authorities under Section 26 of the National Health Service Acts meant that administration of the scheme was carried out by councils and MOHs. This caused great variation in the registration and uptake rates for vaccination across the country, as MOHs had different priorities and capacities within their local authorities (as was seen earlier with diphtheria and smallpox immunisation). In two cases, local scepticism even saw local authorities opt out of the scheme altogether. The health committee and MOH of Burton-on-Trent, Staffordshire believed that the national programme was in effect a giant experiment. They also objected to central government guidelines and control. Initially, therefore, the council refused IPV, arguing that more proof was needed that it was safe and effective.28 By April, Burton had reversed its decision under pressure from pro-vaccine parents. It was considered wrong to deny parents the opportunity to consent to vaccination if they were informed and wanted to take the risk. Moreover, as the Deputy Mayor asked, ‘has Burton the right to tell the rest of Britain they do not know what they are doing?’29 In Wakefield, West Yorkshire the council held out even longer, although by the end of 1957 it had agreed to administer the scheme. Here, the local MOH believed that natural immunity against polio was high in the town, owing to its poor levels of sanitation. Besides, even if polio vaccination could help Wakefield, the MOH argued that the government's approach was inadequate. The council also remained critical, proposing that the scheme should not be implemented until every child could be guaranteed a third dose (as was the norm in the United States).30 In each of these cases, there was demand for protection from polio. Neither Burton nor Wakefield appeared to be anti-vaccine, or even anti-IPV, in principle. Rather, their concerns stemmed from the administrative arrangements and evidence base around the vaccination programme during the early months of its operation.
The second – and more politically sensitive issue – was that of supply. In changing the formula of the vaccine from American to British IPV, pharmaceutical companies were unable to produce large quantities of the vaccine in time for the beginning of the programme. Burroughs Wellcome had significant delays getting its plant online and so, for long periods of 1956 and 1957 Glaxo was the sole producer.31 Moreover, in response to the Cutter incident and to maintain public confidence in the safety and potency of British IPV the government had mandated that each batch had to be analysed by the MRC before it could be used on the population. This procedure took around three months. Due to limited laboratory capacity, one batch had to complete the entire testing process before testing could begin on another. Thus, the British IPV supply was released to the public through a narrow “pipeline”, with several stages along the process limiting how quickly it could be made available.32 All this was complicated further by the suspension of vaccination during the polio season.33 The diphtheria immunisation campaign had also been suspended in the summer months, as there was a suggestion that injections could exacerbate paralysis in the limbs of patients who were subsequently infected with poliovirus.34 The restriction on vaccinating during summer months was subsequently lifted following re-examination of the medical evidence, but, even so, it was difficult for British firms to produce IPV promptly enough to meet demand.35
To manage these stresses, the Ministry initiated a registration scheme. Parents would sign their children onto a register with the local authority, which would then distribute IPV as it became available. This started with two priority groups: children aged 12 months to 4 years; and those aged 5 to 9 years. Initially, the plan had been to vaccinate everyone in this cohort, but the supply problems meant that the government and MRC used this as an opportunity to compare the effectiveness of the vaccine in younger and older children by prioritising children born in specific months.36 This had been one of Burton's objections – that central government would dictate who received the vaccine rather than allowing local authorities to exercise their discretion. The registration scheme was unlike for other vaccines, where parents could present their children to the clinic and have the procedure done. Nevertheless, it created a framework which could be extended to other cohorts as new vaccine became available and as the backlog of patients was cleared. Each year, children over the age of 6 months were added to the scheme. Further, children up to the age of 14 became eligible in 1957; young adults up to the age of 26 in 1958; and older adults up to the age of 40 in 1960.37
The Ministry had warned local authorities that ‘disappointment may be inevitable’, and the registration system would provide for only a proportion of the children whose parents demanded it in the first year.38 Before the programme even began senior civil servant Dame Enid Russell-Smith warned that ‘there may be a considerable danger that parents may react adversely’ or become ‘intensely emotional’ to ‘a method smacking of the village raffle applied to something which might be so important for their children’.39 Even so, the degree and nature of supply shortages was an embarrassment. Glaxo continued to have production difficulties, caused by the technical nature of vaccine production and a shortage of available monkeys for testing.40 When a vial of vaccine changed colour in early 1957, possibly because of bacterial contamination caused by improper storage during transit, the entire batch had to be withdrawn, causing significant delays.41 An editorial in The Times summed up the mood:
The frustrating series of official announcements can give rise to nothing but concern … What should be made abundantly clear is that these delays are in no way the fault of the MRC or [Glaxo]. … What seems to have happened is that the Minister took a gamble and announced the probable date on which vaccine might be ready, knowing full well that no one could give any guarantee.42
The British Medical Journal also admonished the Minister for his press conference in the “American” style, which seemed more about gaining political capital than good public health policy.43 The Ministry had been advised against the press conference because the media were ‘extremely sensitive on the subject of poliomyelitis and have been inclined to treat it sensationally’. The programme should have been ‘presented in a sensible and unemotional manner’, lest it ‘evoke embarrassing reactions from the millions of parents who will be involved’.44
Many of these problems were of the government's own making. The choice to use British IPV exclusively placed the programme in a vulnerable position. Production was complex, reliant upon new technologies and expertise that were difficult to procure. Glaxo continued to negotiate with the Ministry of Health on the price and quantity of vaccine which it could supply.45 Manufacturers were also well aware that the profit-making window for the technology was likely to be small. There was a large market in the short term, as the government planned to vaccinate every child and young adult in the country; but unless suppliers were allowed to export their stock, the demand for vaccine in Britain would eventually dwindle to the annual birth rate. Manufacturers were therefore reluctant to invest massive amounts of capital into producing the vaccine unless the Treasury was willing to compensate them for inevitable future losses. Of the vaccine that they did produce, the government was also keen to allow British companies to export a proportion of it to other nations. It especially wanted British IPV to be used in the Commonwealth, as it would raise the profile of the pharmaceutical industry and ensure that the economy as a whole remained a global player in these new technologies of the Cold War (and, very shortly, post-Suez) world.46 If it did not, there was a danger that American companies would gain a monopoly.47 The British political classes were already anxious about Britain's status as a fading power, with science and technology a potent symbol of this decline in the nuclear age. While the Soviet Union launched Sputnik, Britain had no space programme to speak of.48 The pharmaceutical industry was one area where Britain might be able to compete.
Not all of the limited British supplies therefore went to the “front line”, and because of the economic and political incentives to buy British, the government refused to import the American Salk vaccine at all for its programme in 1956, even when there were major shortages.49 While the insistence on British supplies was defensible on medical grounds, the government had committed to a programme that required far more vaccine than it could realistically produce. That the government would persist with the press conference and the introduction of the programme, despite the warnings from its medical civil service and other commentators, is indicative of the perceived demand from the electorate for vaccination. Polio vaccine was emblematic of modern, technical and scientific medicine. The potential conquest of polio was heralded by commentators and the public as one of the great achievements of the modern world.50 For any advanced nation that wanted to do so, the risk of polio could now be managed.51 Seeing itself as an advanced nation, Britain wanted the vaccine. The Conservative government had made pledges to fund polio research in its 1955 manifesto.52 The specific timing of the polio programme was born of pre-emptive demand on the part of the party-political side of the government. But it also reflected years of research and preparation by staff within the Ministry of Health and co-opted advisory groups such as the MRC. Private industry in the form of Glaxo and Burroughs Wellcome was also part of this process, to say nothing of the coverage afforded to the topic in the press. The issue was that in attempting to placate a potential or inferred demand for polio vaccination in the short term, the government had committed itself to a course of action that it was not yet materially prepared for.
American IPV and the Coventry polio epidemic
These difficulties were exposed further in the summer of 1957 in the wake of a polio epidemic in Coventry, Warwickshire.53 The city's MOH, Thomas Morris Clayton, had requested extra supplies of vaccine to help deal with the epidemic and clear the backlog of registrations that had built up in the city.54 The Ministry of Health refused. There was no stockpile of IPV (since there was still a waiting list), so IPV was distributed batch by batch as soon as it passed MRC testing. John Vaughan-Morgan, the acting Minister of Health, explained that each local authority would continue to receive a percentage of new batches of vaccine, as they became available, relative to the number of people in each district who had registered for the programme. The decision to continue vaccination over the summer months from 1957 onwards meant that this would (theoretically) allow all authorities to provide for those still waiting to be vaccinated; for the Ministry, it was more important to keep the national programme intact. The MRC was still in the process of collecting statistics to evaluate the potency of IPV, and the government was mindful of the political disaster that could follow the redirection of supplies from an area that subsequently developed an epidemic.55 For the people of Coventry, however, vaccination appeared to be a common-sense solution to an epidemic of infectious disease. Just as towns had seen queues outside doctors’ surgeries for smallpox vaccine during local outbreaks, it seemed logical that the newly discovered IPV could provide a similar public health function. The cause was taken up by the media-savvy Member of Parliament for Coventry North, Maurice Edelman. He telephoned the Ministry to ask for more supplies of the vaccine, and told the press that the government was about to send more vaccine to Coventry, constituting a policy U-turn.56 Internal documents suggest that Edelman was, at best, mistaken, possibly as the result of a miscommunication about the timing of the next batch of vaccine. (Coventry was about to receive a new delivery of vaccine, but not over and above what it would ordinarily have received as part of its quota.)57 When the Ministry clarified its position the following Monday morning, it appeared as if government policy was muddled and inconsistent. Over the following weeks, Vaughan-Morgan and Clayton both explained to the people of Coventry and the rest of the country that IPV was not a useful prophylactic in a mass vaccination campaign. It took six weeks to confer immunity, meaning it could provide lasting protection for individuals and communities only as part of a routine vaccination programme, established before epidemic polio reached a particular location.58 The local press continued to ask for more help, arguing that even with a six-week delay it could help the city by the end of the summer if supplies were available immediately; however, the national press appeared to broadly accept the Ministry's arguments with regard to domestic IPV supplies.59
Public demand for the vaccine in Coventry may not have been entirely compatible with epidemiological knowledge or public health professionals’ experience with IPV, but it was entirely consistent with the process for immunisations against other diseases. As seen in the previous two chapters, clinics were opened when there were local outbreaks of smallpox and diphtheria, as those vaccines worked relatively quickly and could act both as a long-term preventative and as a short-term prophylactic. In Coventry, the local and national media stopped demanding IPV to help end the current epidemic. Public responses through the newspapers appeared to show that the general population also bowed to medical expertise, demonstrating an understanding that IPV was a technology unlike smallpox or diphtheria immunisation.60 What the public found less explicable or excusable was why, eighteen months after Turton's announcement, British IPV manufacturing capacity continued to lag behind demand. Coventry's registration rate was reasonably high – around 40 per cent as compared to the national average for England and Wales of 29 per cent. Scotland's registration rate was slightly higher, at 42 per cent, but even so this represented a fraction of the eligible population that were entitled to vaccination.61 Coventronians’ other major demand was therefore much more difficult to rebuff: why did the government not import extra supplies from other countries to clear its backlog and provide a more comprehensive service?62 Two years had passed since the Cutter incident. The cause of that disaster had been found, and millions of doses of the Salk vaccine had been administered across the world without incident. When Coventry was presented with offers from Denmark, France and the United States to use foreign-made vaccine, these were rejected in no uncertain terms by the Ministry of Health.63 Nevertheless, chronic shortages were beginning to take their toll, and the government became concerned that the entire programme was at risk of losing public confidence if it could not deal with the demands being placed upon it.
Up to this point, MRC guidance had forbidden imports of Salk-formula vaccine, protecting British IPV and the pharmaceutical companies that supplied it. The relationship between the pharmaceutical companies and the public sector had been a key part of the vaccination programme. Burroughs Wellcome had supplied many of the diphtheria and pertussis vaccines during the 1940s and 1950s, for example.64 Stuart Blume argues that these relationships were mutually beneficial, key to ensuring innovation and supply.65 The British government was still keen to maintain the good will and financial stability of a useful resource, but circumstances had overtaken it. Given that British capacity had not improved as quickly as had originally been hoped, the Ministry of Health went back to the JCPV and MRC to ask them to re-examine the question of importation.66 The MRC continued to favour British IPV where at all possible, since it was still the safest and most potent version available. Yet it was unwilling to make political decisions on behalf of the government. Concerned that the Ministry was simply passing responsibility onto its shoulders, the MRC carefully worded its advice so that it would be ministers that made the final decision on how to proceed. The scientific evidence still favoured the British vaccine; but the MRC changed its guidance so that it no longer objected to American imports, provided that these were used only to augment supplies. It would be up to ministers to decide how much to buy, when, and how to use it. This protected the interests of British manufacturers, as their vaccine would form the backbone of the programme and continuing contracts from central government would be guaranteed; but it also meant that if there were problems in the supply chain the stock could be supplemented by foreign imports. As a caveat, the MRC also recommended that parents be informed if they were to be offered the Salk vaccine.67 Although both types of vaccine were considered to be potent and safe enough for use on the British public, the MRC continued to assert that the British one was still the superior product. Provided that parents were informed and willing to take the risk, their children could either be vaccinated immediately or remain on the waiting list until British IPV became available.
As in 1956, the government's immediate problem was that demand had outstripped supply. In that instance, overall registration rates had been higher than the amount of IPV that could be produced, leading to delays of service. The summer of 1957 presented a new challenge: how to deal with the surges in demand created by the immediate fear of polio infection. A vaccination programme based on registration and a gradual rollout was unable to coexist with a public who responded to epidemics by presenting themselves to health authorities to be immunised, following established precedent. Similarly, registration gave the government a more concrete measure of how much IPV it was likely to need. And on this basis, the demand for polio vaccine was actually too low. The Manchester Guardian noted that the public needed to take some responsibility for the acute shortages, given how reluctant they had been to register for the scheme during the previous year. Only with a localised epidemic and the subsequent criticism in the national press did parents appear to present their children for the procedure. The Manchester Guardian used the metaphor of blowing ‘hot and cold’ on the subject.68 Meanwhile the British Medical Journal believed that the health authorities and the medical profession had not done enough to explain the benefits of vaccination to the public, resulting in extremes of reaction that had little basis in epidemiology.69 It was thus the swings in demand that had created political embarrassment and medical anxieties during 1957. The government's attempt to equalise demand across the financial year to prevent surges, through the use of the registration system, had been upset by events out of its control.
Giving parents the choice of whether to take British IPV or the American Salk vaccine had the result of complicating demand. From an administrative point of view, the general demand could still be measured, and there is little evidence that many parents in practice opted en masse to boycott the Salk vaccine. The more subjective side of demand is more difficult to analyse. Clearly, the disquiet over the supply shortage showed that people were upset that they were not able to access the vaccine. But were they demanding British IPV, or simply any form of polio vaccine? Did the surges in demand perhaps suggest that the public looked to the government to protection from a threatening disease and were willing to accept anything that they believed would help? The speed at which the demand for IPV as a form of epidemic control dissipated in the wake of medical evidence supports the view that the public were broadly willing to accept expert opinion and that their demands were driven by other understandings of disease. In any case, it seems that, as with diphtheria and smallpox, the British public broadly accepted that vaccinations were a useful form of disease control. However, the government was unable to control the outside events that triggered people to apply this understanding to a concrete action of registering and presenting their children for vaccination.
Young adults and IPV: the death of Jeff Hall
The ability to import vaccine from the USA took some stress out of the system, but supply problems continued to occur. Registration rates across 1957 increased more quickly than the Ministry had anticipated. In February, the Cabinet Home Affairs Committee discussed suspending the national advertising campaign. Any more increases in registrations would be pointless, given that there would not be enough vaccine to meet the demand.70 The Ministry, on the advice of the JCPV, had expected 50 per cent uptake, but 60 per cent had registered, leaving a shortfall of around 2.5 million doses of IPV. Further production problems with the British manufacturers meant that a new batch of Salk vaccine needed to be ordered immediately so that it could be brought into circulation before the end of the summer. The new Minister, Derek Walker-Smith, was acutely aware that ‘such a situation will greatly intensify the already considerable volume of criticism about the slowness of progress in the vaccination programme’, and so it proved.71 The Times ran an editorial accusing the Minister of misleading the public by consistently making announcements on IPV based on best-case scenarios with regard to British manufacturing. Since this had been a recurring problem, why was the government not more honest? ‘To have raised the hopes of parents … is unpardonable’, The Times argued, ‘and in view of the fiasco last year – which only a low incidence of poliomyelitis prevented from becoming a tragedy – the country is entitled to a clear statement from the Minister.’72 At least one member of the MRC found it ‘difficult to be sympathetic at this stage’.73 The Council had advised the government consistently to ensure that there was a stockpile of British vaccine and that there should be a proper contingency plan in place against the relatively high likelihood of lost batches.74
Orders of American Salk vaccine allowed the programme to muddle through, and even though there were some issues with a batch of vaccine from the US firm Parke-Davis and continued problems with the British manufacturers, the general situation improved.75 Indeed, supplies were considered robust enough that in September 1958 the Ministry made the decision to extend the scheme to young adults under the age of 26; and offered a third dose of the vaccine to everyone else in order to secure greater immunity among the population.76 At the same time, the government became concerned at the low overall registration rate and the variable uptake among local authorities. Only 54 per cent of Scottish under-15s had been fully vaccinated up to the end of August 1958, while rates in England and Wales varied from as high as 87 per cent to as low as 20 per cent. Plans were therefore put in place for a publicity campaign, under the belief that the most of the major supply problems were at an end.77 Ironically, by early 1959 it seemed that there would be too much IPV in circulation. Pfizer's UK branch had begun production of British-style IPV and was planning, in the words of the Ministry of Health, to ‘flood the market’ in an attempt to convince the British and foreign governments to buy their stock. The Ministry was in a bind, since if it did not purchase the IPV in bulk and use it as part of the vaccination programme, Pfizer would market the drug on prescription to individuals outside the scope of the existing scheme. The NHS would cover most of the cost of the prescriptions, potentially costing the Treasury three times more than the public health scheme.78 The Ministry therefore considered extending the scheme even further to encompass all people under the age of 40. However, events beyond the Ministry's control would cause the government to reassess this position.
Demand for vaccination among young adults spiked dramatically following the well-publicised death of England and Birmingham City footballer Jeff Hall. The 28-year-old had been taken ill after a game with Portsmouth on 21 March 1959. He died in hospital sixteen days later, on 4 April.79 That a young, healthy man could be struck down so quickly shocked the British public. Now that adults under the age of 26 were eligible for the scheme, the case served as a ‘fortuitous’ advertisement to raise acceptance rates. Walker-Smith recorded messages to be played at all Football League matches to take advantage of the situation.80 However, the sheer volume of demand overwhelmed local health authorities, and in turn put impossible demands on the Ministry to supply the vaccine.81 It appeared that the government would be embarrassed again: having tried so hard to promote the scheme to young adults and been frustrated at low uptake, it now faced the prospect of the system again having to delay vaccinations due to a shortage of IPV. MOHs in England and Wales were reminded of the importance of registration rather than providing IPV on demand, while Scottish authorities attempted to vaccinate as many as possible before the traditional holiday month of July.82
Once again, the unpredictability of demand hampered the government's ability to plan its polio vaccination programme. The Ministry had felt that young adults had been too apathetic during the initial registration process, leading to under-estimation of how much IPV would be needed for the coming financial year. In the wake of a high-profile case, demand had then surged to the point that local and national authorities were unable to cope. The government's frustrations at its inability to control and spread vaccination evenly across the year were expressed by Walker-Smith following criticism in the House of Commons:
There has been no maldistribution on the part of my Department at all. I have already pointed out that both the original requests and the supplementary requests have been met. As for any delays in delivering vaccine, these have been very slight, and those who have had to wait at all for vaccine could have been vaccinated months ago if they had registered when I asked them.83
The public had, as in 1957, blown hot and cold on polio vaccination. The reaction to the Jeff Hall case had again shown the reliance of the system on registration and keeping demand even. The demand following this case was slightly different, however, due to the different demographics involved. The 1957 spike in demand in Coventry had been caused by a local increase in cases that brought home to parents the threat to their children. By contrast, Jeff Hall's was an individual tragic story which resonated with young adults who were making their own decisions about the risks to their own health. To be sure, many young adults would also have been parents, and so a clear distinction between these groups cannot be drawn. This level of demand, though, was both administrative and subjective. In the short term, football clubs got their players vaccinated in front of the press and television cameras. In the slightly longer term, the Ministry tried to push forward its plans to extend the programme to everyone under the age of 40. Part of the Ministry's argument was that Hall, aged 29 at the time of his death, would not have been eligible for the existing scheme. The Treasury was unconvinced that supply problems had been adequately addressed, and initially refused to fund extension of the programme.84 Regardless, the Conservative Party pledged to provide IPV for under 40s in its 1959 general election manifesto, and confirmed the extension in February 1960.85
Oral polio vaccine
The year 1960 passed without any major crises. By 30 June 1960, 77 per cent of children had been fully vaccinated with IPV, as also had been half of young adults in the 16–26 age category.86 While the registration rate remained less than ideal among older groups, the fact that such a backlog of cases had been cleared meant that the Ministry scaled back its orders of IPV for 1960/61, causing Pfizer to gradually withdraw from the British market.87 The long-term future of the programme appeared to rest not on securing IPV supplies, but on whether the time was now right to switch to a new technology being trialled in the Soviet Union – Albert Sabin's live vaccine (or oral poliomyelitis vaccine; OPV).
OPV used attenuated forms of the poliovirus to confer immunity through a similar transmission form as the naturally occurring virus. Taken by mouth, the vaccine entered the gut like the natural infection and could confer immunity much more quickly than IPV. Salk had managed to produce a safe version of IPV quicker than his competitors. The speed and extent to which this was adopted in the American population meant that Sabin and others were forced to test their vaccines in virgin populations abroad. Although based in the US, Sabin had been born in the Russian Empire (in latter-day Poland) and his relationships with Soviet scientists helped him convince the Soviet Union to allow trials of his OPV. These were a success and, despite initial Western scepticism, by the early 1960s the potential advantages of OPV were recognised by the United States and its allies88 As with IPV, the British medical establishment was initially cautious.89 Experiments with Hilary Koprowski's OPV in Belfast in 1956 had been ‘disastrous’, as Lindner and Blume have described.90 The trials, overseen by Professor George Dick, showed that the virus could revert back to an infectious form, and this dented the reputation of OPV considerably in the United Kingdom.91 But by the early 1960s attitudes had softened significantly. Sabin's vaccine held a number of advantages for mass and routine vaccination programmes. First, it was much cheaper and easier to manufacture, promising an end to the supply issues that had plagued the British programme thus far. Second, parents found the use of an oral vaccine, requiring only a drop of vaccine on a sugar cube, more attractive, since it caused less distress for their children and eliminated the need for injections.92 Third, it was fast acting. Because it produced immunity much more quickly than IPV, it could be used on a mass scale as a form of epidemic control. And fourth, although controversially, OPV could theoretically vaccinate other members of the community passively, since it could be spread to people in the same way as poliovirus.93 This led to a number of ethical questions about whether this amounted to vaccination without consent, but by the early 1960s the medical community was largely agreed that OPV offered the best opportunity to truly eradicate polio.94 IPV had worked well in many Western nations, but only up to a point. Infection rates in the United States and Canada were beginning to stagnate, after significant falls since the mid-1950s.95 Questions about OPV's safety – since if the virus returned to virulence, it could potentially spread live polio throughout a community – were answered at a number of international conferences, most notably the Fifth International Congress on Poliomyelitis in Copenhagen in July 1960.96 The United States Surgeon General began to recommend the use of OPV, which influenced the British authorities to purchase some vaccine, initially to control epidemics, but later as part of the routine vaccination programme.97
While international scientific networks may have influenced the advice given by the MRC and JCPV on the use of OPV in Britain, the Ministry was motivated to adopt it for more pragmatic reasons. It was clear that a number of pharmaceutical companies were moving towards OPV production, with Wellcome lobbying the government hard for a contract to begin trials in the United Kingdom.98 Within the IPV programme, a relatively quiet 1960 was followed by a more difficult 1961. Demand for vaccination increased significantly after high-profile epidemics in Ipswich, West Bromwich and Liverpool.99 Infection rates had risen after successive years of decline (see Figure 3.1), reminding the public that polio had not yet been defeated. Demand had also been boosted by a large-scale campaign from the incoming Minister for Health, Enoch Powell. While he was aware that it was impossible to say to what extent the campaign had made an impact on vaccination rates, Powell noted that it was politically difficult for the government to be in yet another supply crisis, after having spent so much effort trying to engender support among the population.100 Even though gross demand for the vaccine was now lower, due to the clearing of the backlog of cases from the 1950s, it was still much higher than the Ministry had been expecting. A number of supply problems then hit the Ministry at once. First, a batch of Pfizer's British IPV failed; then a batch of Canadian IPV from Connaught also failed to pass MRC safety tests. This coincided with a shortage in the United States which led the US government to ban exports of Salk vaccine. The spike in demand created by the epidemics left Britain in a situation where it did not have enough stockpiles to meet demand, nor was it able to import enough in the short term to tide it over.101
The Ministry received a number of complaints via Members of Parliament and local councils.102 The BMA also forwarded concerns from general practitioners who were angry that they were the ones who faced criticism from the public when there were shortages.103 The only way to help this situation was to purchase more IPV once supplies from the USA became accessible again, but the Ministry knew that it would face pushback from the Treasury, which had become increasingly concerned at the lack of accuracy in the Ministry's predictions for vaccine demand. While it understood that demand was elastic and impossible to judge with exactitude, the consistent requests for more money were trying its patience.104 The Ministry had already been asked to set out the scientific case for IPV, and evidence that it had actually worked in Britain, during the negotiations over extending the programme to the under-40s.105 More importantly, the Ministry believed that any request for large amounts of cash to purchase IPV would inevitably lead to questions from both the Treasury and the press about why so much was being spent on the older technology when OPV appeared to be the way forward in terms of both the epidemiology and public acceptability.106
In this situation, the demand for OPV was driven by a number of administrative and subjective factors. Western opinion on OPV had shifted dramatically and quickly over the course of 1960 and 1961. This was further helped when OPV was used to help to deal with an epidemic in Kingston upon Hull, East Yorkshire, in late summer 1961. Hundreds of thousands of people were immunised during the outbreak, and the vaccine's apparent success in containing the spread cemented its reputation.107 The subjective demand for the state to provide protection against poliomyelitis was evident. Even in the absence of an oral alternative, people were still demanding IPV during the summer epidemics. Nevertheless, administrative pressure, driven by public opinion, appeared to be pushing toward OPV in the long term. Despite variations in the exact administrative demand within the programme over time, the issue was not over whether polio immunisation should be provided but over the form that it should take.
In September 1961 a civil servant noted: ‘obviously we have miscalculated [demand for vaccination] … The question is whether the miscalculation is defensible.’108 It seems to be difficult to defend the Ministry of Health's long-term policy on IPV. From the outset it promised to vaccinate many more people than were within its capacity. It began the programme before its major manufacturers were able either to build a stockpile of vaccine or to produce enough en masse to meet even the more limited demand of the first registration wave. It tied its own hands by simultaneously demanding the use of British IPV and either banning or severely limiting the use of American Salk vaccine. When it did allow importation, it waited until supplies were almost gone before ordering more Salk vaccine, rather than anticipating growing demand. There were some mitigating circumstances. The Ministry may have been criticised by the Treasury for under-estimating the amount of vaccine required in any given year, but the political cost of overspending during a period of financial retrenchment was considered even riskier. In late 1958, some local authorities had supplies of American IPV that was about to expire, writing off thousands of pounds’ worth of stock.109 Moreover, the field of immunisation was in a constant state of flux – planning from year to year was difficult, and if the government over-ordered one type of vaccine and suddenly found the next year that it would require a different formula, even more money could be wasted.110 In effect, this had already happened with the last-minute switch from American to British vaccine in late 1955, and the Ministry was mindful of having to do this again.
Demand was thus a very difficult beast to tame. Its negative effects could be exacerbated by events outside the government's control. Administratively, consistent and predictable levels of registration were the easiest to provide for, but in reality they were seldom the case. Either specific scares caused spikes in registration, or a lack of immediate danger led to under-registration (and with it, under-ordering of IPV from suppliers). From a subjective point of view, it was also never entirely clear what, specifically, the public were demanding. Low levels of general registration suggested that the public were not particularly excited by polio vaccination as an abstract concept; yet the surges in demand during epidemics or high-profile cases also suggested that the public expected to have the option of polio vaccine whenever they wanted it. Media coverage of the Salk vaccine trials and the consistent criticisms of government mismanagement of the scheme pointed to a nation that expected a properly functioning service; yet general apathy meant that the public did not register when asked to do so in order to ensure that the service ran as smoothly as possible. These paradoxes may not have been unique to polio, but they became much more evident than they had been with smallpox and diphtheria, due to: the novelty of the technology; the scope of the programme in encompassing young adults as well as children; and the high-profile problems with manufacture and supply.
Regardless, OPV was introduced for those awaiting their first dose of polio vaccine. By 1962, the programme was fully operational, having vaccinated the majority of people under the age of 26 and continuing to provide for new-borns and older citizens.111 This was emblematic of the new status quo in public health. Despite the problems outlined in Part I of this book, as of 31 December 1969, uptake among children born in 1967 was 80 per cent or more in England and Wales for vaccines against pertussis, diphtheria and poliomyelitis.112 This continued to vary by region: several authorities reached 95 per cent for pertussis vaccine, while Halifax achieved only 52 per cent.113 For the most part, however, the system appeared to be working. Parents presented their children for the various injections and sugar cubes that protected their children, and epidemics of these infectious diseases had become much rarer.
By the early 1970s, the childhood vaccination programme had expanded to include immunisations against diphtheria, tetanus, pertussis, poliomyelitis, measles, rubella and tuberculosis – and it had phased out smallpox vaccination. What Jacob Heller describes as the ‘vaccine narrative’ in the United States can be said to apply to Britain by this point. He argues that the public broadly believed that vaccinations are safe, effective and a sign of a modern functioning state. This was cemented through the poliomyelitis programme, which could work only through vaccination, rather than other curative or preventative measures.114 In the United Kingdom, similar successes with polio had led the public, broadly, to support and avail themselves of vaccination services.
Present-day research suggests that such attitudes remain in most nations around the globe. However, confidence in individual vaccinations may be dented by local political factors, faith in medical authorities, attitudes towards specific diseases and the reputation of the vaccine.115 Part II explores two incidents which exemplified this in the British context: the pertussis crisis and the MMR crisis. In both cases, disagreements within the medical community about vaccine safety were seized upon by the press and caused confusion for the general public and government alike. The debates that followed were embedded in the contemporary political climate, and so were manifested in different ways.