|Year : 2012 | Volume
| Issue : 2 | Page : 133-139
Understanding the syndrome of techno-centrism through the epidemiology of vaccines as preventive tools
Vikas Bajpai1, Anoop Saraya2
1 PhD Scholar, Centre for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
2 Professor, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||21-Aug-2012|
Professor Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi - 110029
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Conquering disease and ill health has been an age old pursuit of man. The scientific and technological revolution of the last century ushered in major and important advances in preventive and curative medical technology which fired a new hope in the fight against communicable diseases. However, the experience over centuries shows that major decline in communicable diseases began much before the advent of modern technology due to advances in the socio-economic and environmental conditions of the people. There has been an attempt by the multilateral and unilateral agencies to supplant the expedient of technological interventions like vaccination campaigns as a substitute to socio-economic advancement in the third world countries. The dividends of this approach have been equivocal and have had an effect of distorting public health priorities in the third world. There seems to be an obsession with technology among the policy planners - a phenomenon that we call as techno-centrism; the latest example of which is the pulse polio campaign. This paper draws upon an epidemiological approach to vaccination programs as a tool to unravel this phenomenon.
Keywords: Epidemiology, Immunization, Infectious diseases, Vaccines
|How to cite this article:|
Bajpai V, Saraya A. Understanding the syndrome of techno-centrism through the epidemiology of vaccines as preventive tools. Indian J Public Health 2012;56:133-9
|How to cite this URL:|
Bajpai V, Saraya A. Understanding the syndrome of techno-centrism through the epidemiology of vaccines as preventive tools. Indian J Public Health [serial online] 2012 [cited 2021 Sep 24];56:133-9. Available from: https://www.ijph.in/text.asp?2012/56/2/133/99904
| Introduction|| |
Conquering disease and ill-health have been an age long pursuit of man. Though spectacular, the achievements of modern medicine cannot over awe the behavior of the pathogenic organisms and ecological conditions in determining the behavior of diseases.
It is well acknowledged that major decline in the infectious diseases had occurred much before the arrival of modern medical tools. Better nutrition, housing, sanitation, hygiene, and improved water supply helped reduce the morbidity and mortality due to infectious diseases. ,,,,
The work of Thomas McKeown has been seminal in foregrounding the role of socioeconomic and environmental factors in improving human health.  Ivan Illich's polemical account presents a tempered view of the achievements attributable to modern medicine. 
Emergence of the germ theory of disease subsequent to discovery of microorganisms undermined the primacy of socioeconomic and environmental factors in fighting communicable diseases. The focus shifted instead to technological medical interventions directed at individuals as against ensuring the overall wellbeing of the people. This tectonic shift articulated with the value system of the ascendant monopoly capitalism of the late 19 th century to pave the way for entrepreneurial medical model of healthcare which emphasized technological tools in tackling health problems. 
The syndrome of "techno-centrism" that dominates health policy today originates from this context. This paper uses the epidemiology of vaccines as preventive tools to elucidate our understanding of techno-centrism in health policy.
| Epidemiology of Vaccines as Preventive Tools|| |
Immunization against the vaccine preventable diseases has come to be viewed as one of the most cost effective methods of improving the health of the masses and reducing the burden of disease. ,
How much did the vaccines contribute to the decline of the infectious diseases?
[Figure 1] shows deaths of children below 15 years attributed to scarlet fever, diphtheria, whooping cough, and measles in England and Whales between 1850 and 1965. 90%
|Figure 1: England and Whales: Deaths of children under 15 years attributed to scarlet fever, diphtheria, whooping cough, and measles. Source: Universal Immunization: Medical Miracle or Masterful Mirage By Dr. Raymond Obomsawin|
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Decline in child mortality from these infectious diseases occurred between 1850 and 1940. The first vaccine however was available against diphtheria only in 40's, whereas the pertusis vaccine came in the 50s and the measles vaccine in 60s. Scarlet fever had no vaccine.  Similar trends have been reported for decline of infectious diseases in United States.  Likewise, in the story of small pox, nearly half the decline occurred prior to the introduction of the WHO's small pox eradication program. 
Thurman has summarized these early achievements thus − "It must be remembered that a given germ is only part of the cause of a disease; there are often many other very important contributing, predisposing, or determining factors. As housing conditions were improved, as the general laws of sanitation, ventilation, and personal hygiene came to be better understood; as we came to insist on individual drinking cups; fresh air in bedrooms, and frequent bathing; as doctors became more proficient in treating the infection so as to prevent its serious complications and sequelae; as boards of health became more efficient in the enforcement of public health laws; as methods of isolation and disinfection were better understood the death rate declined accordingly." 
| Turning the Tables on the Developing Countries|| |
In the case of developing countries however, vaccines became expedient to achieve rapid elimination of the communicable diseases, circumventing overall socio-economic development.
The recipe for such an approach in the developing world was enforced by the developed countries on the pretext that the West had to take the path it took because there were no vaccines to begin with, and now that they are available, the developing countries could benefit from them rather than rely on the long drawn out path of social and economic development. This approach is best epitomised in the paper by Walsh and Warren titled "Selective primary health care: an interim strategy for disease control in developing countries."  Indeed this paper was picked up by different multilateral and bilateral funding agencies like the UNICEF, World Bank, and the Rockefeller Foundation to stage a coup d' teat against the principles of 'Primary Health Care' as propounded in the Alma Ata declaration of 1977 that had held the promise of self reliant, people centric development of health care systems in the developing countries. This led to several ill-conceived international initiatives to launch massive vertical immunization programs. 
| Experience of Immunization Programs in India|| |
There have been a range of immunization initiatives in India. Beginning with BCG immunization against tuberculosis in 1962, which later became a part of the Expanded Program on Immunization (EPI) in 1978. In 1979 oral polio vaccine was included as a part of EPI. This program evolved to become the Universal Immunization Program (UIP) in 1985. Measles vaccine was added to the program the same year.  UIP was rolled out in the form of National Technology Mission for Immunization in 1986 with the target of 90% coverage of pregnant women and 85% of infants by 1990. 
| Epidemiological Basis; the Weak Link of the Immunization Program|| |
The departure point for any disease control program is the epidemiological distribution and behavior of the disease so as to justify the program strategy and develop sound tools for assessing its performance. [Table 1] gives the distribution of causes for mortality in children below 6 years in India. The neonatal causes, diarrheal diseases, and pneumonia accounted for 84% of under five mortality 2000-2003.  Thus, the vaccine preventable diseases do not constitute major cause of under five or infant mortality in India.
|Table 1: Distribution of causes of deaths among children under 5 years of age, India 2000-2003|
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[Figure 2] gives estimated proportion of under five deaths by mortality in sub-Saharan Africa and South Asia; two areas of the world that account for maximum no. of deaths in this age group. In neither of these areas are the vaccine preventable diseases a major cause for under five mortality. 
|Figure 2: Distribution of under-5 deaths by cause, 2000. AIDS deaths are not accounted for, due to lack of studies in the affected areas. Source: International Journal of Epidemiology 2003;32:1041-51|
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The six vaccine preventable diseases would come in the category of ''others'', accounting for approximately 10% of the under five deaths. This knocks the base out of the claims that major reductions in child mortality can be achieved through rigorous implementation of immunization programs. [Figure 3] gives the trends in infant mortality in India since 1910 till 2000. The decline in the infant mortality during this period has been nearly 70%. It is obvious in view of the forgoing that even if all mortality due to vaccine preventable diseases were to be overcome, it could not have resulted in 70% decline in infant mortality. Not only that overwhelming decline in infant mortality has been due to decline in mortality from causes like diarrhoeal diseases and acute respiratory infections, but the vaccine preventable diseases continue to be prevalent inspite of good vaccine coverage against some of them.
|Figure 3: Trends in the infant mortality rate for 1910-2002, India. Source: Arvind Pandey et al. NCMH background papers.|
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[Figure 4] shows the reported cases of measles since 1974 till 2004 and reported/surveyed annual measles coverage.  It is seen that since 1990 in spite of high coverage for measles vaccine (90 to 95%), measles cases refuse to decline discounting the unreported cases because people do not seek medical intervention for measles due to cultural believes.
|Figure 4: Reported/surveyed annual measles coverage and cases India, 1974-2004 Source: MOHFW, GOI.|
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Measles is hardly a problem in healthy children, but its mortality increases 400 times in undernourished children and its incidence and prevalence is directly proportional to overcrowded living conditions. Likewise, availability of adequate protected water supply would ensure that poliomyelitis ceases to be a problem. 
[Figure 5], [Figure 6] and [Figure 7] show the declining trend in the cases of neonatal tetanus, pertusis, and diphtheria since the start of the vaccination programs in India. Though trends for these diseases prior to institution of immunization programs were not available, but what is more likely is that immunization only accentuated a pre-existing secular decline.
|Figure 5: Number of reported cases of neonatal tetanus from 1988 till 2008 Note: *: Figures are Provisional and Incomplete. Source: indiastat.com|
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|Figure 6: Number of cases of pertusis from 1985 to 2008 Note*: Figures are Provisional and Incomplete. Source: indiastat.com|
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|Figure 7: Number of cases of diphtheria from 1985 to 2008, Note*: Figures are Provisional and Incomplete, Source: indiastat.com|
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A closer look at the infant and under 5 mortality gives a better understanding of the impact of immunization programs in India. [Figure 8] gives the trends in infant mortality since 1981  i.e. just about the time when EPI was introduced. [Figure 9] gives the trends in neonatal mortality; all India as also in some of the empowered action group states which have traditionally underperformed in health. 
|Figure 8: Trends in Infant Mortality for India, Urban vs. Rural, 1981-97. Source: World Bank.|
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|Figure 9: Trend in neonatal mortality rate, India and EAG states, 1971-2000. Source: J Biosoc Sci 2008;40:183-201.|
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In [Figure 5], around 1990 there is a precipitous decline in the neonatal tetanus cases. We presume that entire decline took place due to increased coverage of pregnant women with tetanus toxoid vaccination. Neonatal deaths constitute significant proportion of under 5 mortality. Neonatal tetanus has been an important cause of neonatal mortality. However, looking at infant and neonatal mortality rates for the years 1991−92, in [Figure 8] and [Figure 9], there is hardly an appreciable dip in infant or neonatal deaths corresponding to the precipitous fall in neonatal tetanus cases in [Figure 5]. Likewise, there does not seem to be remarkable impact on IMR and neonatal deaths due to rather steep decline in cases of measles, pertusis, and diphtheria seen from respective figures. The IMR and neonatal death trends show gradual and smooth declines which appear more to be a part of secular declines, than revealing a remarkable change consequent to immunization programs.
In the light of the foregoing, it can be said that vaccines are only one of the effective tools against some communicable diseases and have contributed to the decline in childhood morbidity and mortality along with factors like availability of better health care and socio-economic uplift of the people.
Small pox eradication; the foremost success story of the effective application of medical technology happened not in the manner of routine immunization, but through military like campaigns to isolate the cases and contain the outbreaks. Immunization and the resultant herd immunity are just one of the determinants of so-called vaccine preventable diseases. Herd immunity is liable to undergo change depending upon the interaction of the disease agent with factors like overcrowding, sanitation, safe water, weather, migration patterns, and nutrition. Vaccines may take care of a disease agent under a given set of agent, host, and environmental conditions. Any change in this equilibrium may give rise to a new epidemiological situation in which the same vaccine may not be effective.
There are other chinks in the epidemiological rationale of the ongoing immunization programs:
- There is little epidemiological data available on the variation in the incidence of diseases in different parts of the country under varying agent, host, and environmental conditions. 
- Analysis of time trends in the epidemiological behavior of diseases and the possible interventions in their natural history, other than vaccines, has been totally missing. 
- Immunization based strategies, especially the proclivity for intense campaigns may undermine mechanisms for acquiring natural immunity in the target group. However, in the period of lax routine immunization that invariably follows the campaigns, there accumulates a susceptible population of new born children liable to an explosive comeback of the disease;  thus a spectacular immunization effort, followed by a spectacular epidemic; save total eradication of the disease. And there are documented instances of such phenomenon.
| The Specific Case of Pulse Polio Immunization|| |
Nothing epitomizes the syndrome of techno-centrism as much, as does the ongoing Global Polio Eradication Initiative (GPEI); a living testimony to subordinating country's health priorities to the prescriptions of the International agencies, in complete disregard for the under mentioned epidemiological features of polio:
These salient features of Polio virus epidemiology have cast lingering doubts over the feasibility of polio eradication as aimed by the GPEI.
- For every case of acute flaccid paralysis (AFP) between 100 and 1000 persons infected with wild polio viruses may go undetected as the manifestations of polio infections vary from asymptomatic to mild disease, to even death.  Indigenous wild polio virus can keep circulating insidiously, without producing even one case of AFP for as many as 20 years as had happened in Albania.  The oral polio vaccine, being a live virus vaccine, itself is capable of causing AFP from the vaccine virus, known as circulating vaccine derived polio virus (cVDPV). 
- Feco-oral transmission being the major mode of transmission of polio in India, any program aimed at its elimination or eradication ought to emphasize strategies to stop this mode of transmission.
Pulse polio program of GPEI epitomises the costs of ignoring disease epidemiology in immunization programs. By 2 nd December 2009, the cases of wild poliovirus (WPV) infection reported by endemic countries had declined somewhat, but the cases reported by non-endemic countries had nearly tripled. Furthermore, cases of infection with the vaccine-derived poliovirus still occur, and will continue to occur so long as oral polio vaccine is used. Resultantly, several deadlines for declaring India and thereby the world polio free have lapsed and the promise of polio vaccination becoming redundant remains illusionary. 
The new target date for polio eradication is 2013. With only 66 cases of WPV infection in 2005, India appeared poised to eradicating polio; however, the 10-fold rise in WPV infection cases over the following 4 years has put the goal beyond reach. 
The less visible clusters of perpetually unimmunized children in densely populated areas with undernourished children suffering from intestinal infections shall continue to harbor WPV circulation, thus bringing to nought the polio eradication efforts. Netherlands is one country where 97% immunization coverage failed to prevent several outbreaks of polio in clusters of perpetually unimmunized persons.  It is least surprising that such intensive efforts have made people suspicious of the GPEI's motives. 
| Re-Emphasizing the Significance of Socio-Economic Development|| |
The lingering threats of opinions like − "Development is not essential to reduce infant mortality rate in India" expressed by leading public health experts of the country's premier medical institute,  oblige us to re-emphasize the role of socioeconomic development. India's abominable maternal and child health indicators and the principle causes of infant and child mortality, bear ample testimony to this.
In India 23% of children are initiated with breast feeding within 1 h of birth; in 2005−06, only 39% of Indian children suffering from diarrhea received oral rehydration therapy). Lack of sanitation, hygiene, and safe drinking water contribute phenomenally to child mortality. Yet, in 2004, an estimated 700 million people in India were not using improved sanitation facilities. Only 45% of households in the country use improved sanitation facilities.  Three-fourths of the surface water resources are polluted and 80% of the pollution is due to sewage alone. 
For our policy planners, regrettably none of these conditions are amenable to any convenient technological tool which could bypass the need for uplifting the overall wellbeing of the people.
These facts are sobering enough to firmly ground the heady feeling that technology shots often give. Yet, techno-centrism as ordained by the international "philanthropic" cartels like Global Alliance For Vaccines and Immunization and enthusiastically lapped up by their third world acolytes, is the currency of public health policy today.
| Conclusions|| |
Immunization programs have often been cited as examples of what technology can achieve in furtherance for human health. The averments made herein are not to say that immunization is redundant and meaningless as a weapon against infectious diseases. The paper acknowledges the significance of the immunization programs and the role that vaccines have played in control and possible eradication of infectious diseases. Nonetheless, in order that vaccines are able to play their due role in the fight against infectious diseases, the need is to revitalise the day-to-day functioning of health system; only then can a widespread epidemiologically directed routine immunization be ensured. The campaigns while giving a short term sense of achievement have tended to weaken the general health services in the long run. India has burned much of its precious resources in such misadventures. It is time that lessons are learnt.
| Acknowledgment|| |
We wish to acknowledge the critical appreciation and constructive suggestions given by Dr Ritu Priya, professor at the Centre for Social Medicine and Community Health, in the development of this manuscript.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]