Andrew Tyler of the London Evening Standard recently told me that the National Health Service pays a substantial bonus to physicians with documented vaccination rates over 70%, and a still higher increment if the figure tops 90% (13. His drift seemed to be that the overly civilized British need only informal pressures and inducements to obey authority, while the more rebellious, outspoken Americans have to be coerced with laws and penalties. If that is true, I can understand why you wanted to fetch somebody from America, and I shall try not to disappoint you.

My interest in vaccination arose out of a "gut" feeling not to do it that I have devoted a considerable part of my career trying to clarify. In this as in so many other ways, the study of homeopathy has helped me to articulate what my heart and soul already seemed to know. To recognize the organism as a totality of symptoms already implies that any more narrowly defined standards of vaccine effectiveness cannot possibly be adequate. Other glaring inconsistencies include enforcing compulsory vaccination laws in the absence of any public health emergency, and waiving the rules of scientific inquiry in their honor.

These special privileges give some measure of the reverence accorded to vaccines in what can on]y be called the "religion" of modern medicine (2). Its theology was admirably summarized by the French physiologist Claude Bernard well over a century ago:

What we call the immediate cause of a phenomenon is nothing but the physical and material conditions in which it exists or appears. The object of the experimental method and the limit of every scientific research is therefore the same for living as for inanimate bodies. It consists in finding the relations which connect every phenomenon with its immediate cause, or, putting it differently, defining the conditions necessary for the appearance of the phenomenon. When the experimenter succeeds in learning the necessary causes of a phenomenon, he is in some sense its master. He can predict its course and appearance; he can promote or prevent it at will.

As a corollary to the above, neither physiologists nor physicians must imagine it their task to seek the cause of life or the essence of disease. That would be entirely wasting one's time in pursuing a phantom. The words "life" and "death," "health" and "disease," have no objective reality. Only the vital phenomenon exists, with its material conditions. That is the one thing that they can study and know (3).

Precisely as Bernard foresaw, the search for identifiable components of human structure and function and for powerful technologies to control them has obscured the need for and even the possibility of any unifying concept of life or health against which to judge them. To be considered effective by present standards, vaccines need only satisfy two statistical criteria, i.e., reducing the incidence of the corresponding acute diseases as low as possible, and demonstrating measurable titers of specific antibodies in the blood.

Vaccines have become sacraments of our faith in biotechnology in the sense that 1) their efficacy and safety are widely seen as self-evident and needing no further proof; 2) they are given automatically to everyone, by force if necessary, but always in the name of the public good; and 3) they ritually initiate our loyal participation in the medical enterprise as a whole. They celebrate our right and power as a civilization to manipulate biological processes ad libitum and for profit, without undue concern for or even any explicit concept of the total health of the populations about to be subjected to them.

I therefore want to reexamine and update the major concerns of my original article from this theological standpoint. Now as then, I have mostly a lot of questions to offer, questions so thorny and difficult that decades of careful investigation will be needed to disentangle them. But they seem so basic and important that it would be reckless indeed to require vaccination of every newborn child without adequate measures being taken to address them. Until then, my position remains simply to make vaccines optional and freely available to all at the discretion of their parents, as is now the rule in the UK and other European countries.

I want to begin with a brief history of the measles vaccine, because its dramatic career highlights so many of the issues pertaining to the others as well.

In its natural state, the measles virus enters the body of a susceptible person through the nose and mouth and incubates silently for about 14 days in the lymphoid tissues of the nasopharynx, the regional lymph nodes, and finally in the liver, spleen, bone marrow, and the lymphocytes and macrophages of the peripheral blood. The illness known as the measles is the process by which the virus is expelled from the blood, through the same orifices that it came in, and involves a concerted and massive effort of the entire immune system. Once specific antibodies have succeeded in targeting the virus, the ability to synthesize them on short notice remains as a coded "memory" of the whole experience, a virtual guarantee that people who have recovered from the measles will never get it again, no matter how many times they are re-exposed.

In addition to conferring this specific immunity, the process of recovering from the natural disease also "primes" the organism nonspecifically to respond promptly and efficiently to other micro-organisms in the future. A crucial step in the maturation of a healthy immune system, the ability to mount a vigorous, acute response to infection unquestionably represents a major ingredient of optimum health and well-being in general.

Finally, measles is about 20% fatal in populations exposed to it for the first time. It has taken us many centuries of adaptation and "herd immunity" to convert it into an ordinary childhood disease, such that, when I first encountered it at the age of 6, nonspecific mechanisms were already in place to help me deal with it effectively. In that historical sense, the permanent immunity acquired by recovery from the natural disease represents an absolute net gain for the total health of the race as well. However the vaccines act inside the human body, true natural immunity or any other qualitative benefit cannot be ascribed to them: their effectiveness is a mere statistic, and the resulting "immunity" a narrowly defined technicality.

Thus, in contrast with the natural disease, the vaccine virus produces no local sensitization at the portal of entry, no incubation, no massive outpouring, and no acute disease of any kind. It can elicit long-term antibody production solely by surviving in latent form in the lymphocytes and macrophages of the blood. But then the vaccinated individual would have no way to get rid of it, and the technical feat of antibody synthesis could at most represent the memory of this chronic infection. Nobody would be foolish enough to argue that vaccines render us "immune" to viruses if in fact they merely weakened our ability to expel them and forced us to harbor them permanently instead. On the contrary, such a carrier state would tend to compromise our ability to respond to other infections as well, and would have to be regarded as immunosuppressive in that sense.

The laws mandating vaccination against the measles were enacted in the early 1960's, when the disease was limited almost entirely to children in elementary school, and both deaths and serf us complications had already reached an all-time low. There was very little public debate, and the decision appears to have been made purely as a matter of policy, almost as soon as the vaccine became available. With very few people requesting exemptions, the compliance rate averaged well over 95 per cent. From an average of over 400,000 cases annually in the prevaccine era, the incidence of measles in the United States dropped to less than 5000 in the early 1980's (4), and it looked as though the disease would soon be eliminated.

In the 1980's, however, this comforting mythology began to unravel, as measles began to reappear even in fully vaccinated populations, and public health authorities began to grapple with the mysterious phenomenon of "vaccine failure."

Thus in 1984, 27 cases of measles were reported at a high school in Waltham, Mass., where over 98% of the students had documentary proof of vaccination (5). In 1985, 157 cases were reported over a 3-month period in Corpus Christi, Texas, and the surrounding Nueces County, despite a vaccination rate of over 99% and significant antibody levels in over 95% (6). In 1989, an Illinois high school with vaccination records for 99.7% of the students reported 69 cases over a 3-week period (7).

In all of these outbreaks, the authors concentrated on the documented vaccination rates of the target populations, and curiously neglected to mention the number of actual cases that had not been vaccinated. But they all implicitly refuted the hypothetical "reservoir" of the disease in the unvaccinated, an argument still popular with health departments for frightening wavering parents into compliance.

As the data from these various outbreaks were collected and analyzed, tentative generalizations were made and new strategies formulated. A survey of over 15,000 Canadian cases in 1985-86 indicated that 60% of the patients had documented vaccination records, with 28% "unvaccinated," and the status of the other 12% "unknown" (8). Since the "unvaccinated" group would also have been identifiable only by their own statements, the category "unknown" presumably refers to those who claimed to have been vaccinated but could no longer prove it.

A comparable American survey (9) of 152 separate outbreaks comprising over 9000 cases in 1985-86 yielded similar results:

1) A large majority of cases (69%) were children of school age, i.e., 5 to 19 years of age.

2) Of these, 60% had been "appropriately vaccinated," i.e., at 15 months or more (the schedule then currently in vogue), and another 20% "inappropriately vaccinated" (at 12-19 months, the schedule recommended before 1979), with the number of unvaccinated cases again omitted.

3) A significant minority of cases (26%) were children less than 5 years old, most of them unvaccinated and belonging to black, Hispanic, or other indigent minorities in urban ghettos.

All of these data indicated a resurgence of the disease mainly in older children and adolescents of high-school and college age, groups with much higher rates of serious complications. The usual explanation was that vaccine-mediated immunity was time-limited, and "wore off" with increasing age, presumably leaving the child otherwise unaffected and susceptible as before. This usually unstated assumption also formed the principal rationale for mandatory revaccination at a later date.

Unfortunately, this assumption had already been disproved by an earlier study, which demonstrated that previously vaccinated children with declining antibody titers responded minimally and for an unacceptably short time to booster doses of the measles vaccine (10).

Another refutation came from a sustained outbreak of 235 cases in Dane County, Wisconsin, over a 9-month period in 1986, although the authors of the study declined to take it seriously. As in earlier studies, they found that the vast majority of the cases were in the school-age group (5 to 19 years), but that only 6% of these had not been vaccinated (11). Their most unexpected finding was that "mild measles," with typical rash but minimal fever, was much more likely in children who lacked vaccine-specific antibodies than in either the unvaccinated or those whose vaccinations had "taken" properly. This apparent reversal suggested some kind of inapparent or latent activity of the virus that had not been suspected before and did not show up on routine serological investigation.

Yet, despite these warnings, none of these investigators dared consider the possibility that the "immunity" conferred by the measles vaccine might not be genuine. Much as in the peak years of the Vietnam War, or the chemotherapy of advanced cancer patients after the initial round has failed, the purely quantitative redefinition of immunity cleared the way for the simple escalation of force as needed to approximate the desired goal.