Contains discussion of death statistics some may find distressing.
Is the proposition 'vaccines are safe and effective' a scientific claim or a political statement? Some contend that because this claim is scientific it is not a political matter at all. But this is a mistake, and a dangerous one at that, for it mistakenly presumes scientific truths circumvent debate, rather than depending upon it. If 'vaccines are safe and effective' is a scientific claim then it rests at all times upon methodically reviewing the evidence for each and every vaccine. The moment this process is disrupted, no scientific statement of this kind is possible, and the political battle between 'anti-vaxxers' and their opponents ceases to entail anything that can legitimately be called science.
To have a breakdown of scientific debate in a time of crisis is distressing. Yet this is the third such collapse in medical discourse in just two years. Institutions who were tasked with ensuring the good health of their citizens have failed in at least one undeniable sense: significant numbers of people no longer trust them. As a result, the very concept of public health is now in danger of collapsing, ironically because a zealous enthusiasm for this cause severed the balance between scientific discourse and political action. Medicine now faces as great an ethical crisis as the creation of the atomic bomb posed for physics. Now as then, our technical power outstrips our moral reasoning about it in troubling ways. As strange as it sounds, we must seriously consider whether the time has come to decolonise public health.
Wherever there is a power differential between cultures, there is a risk of some form of colonialism. Even the most generous gestures may hide this kind of inequity. Consider the Gates Foundation's mission to bring an end to polio. To our minds, this seems like a no-brainer: why wouldn't we want to get rid of a truly horrible disease like polio...? But entirely eliminating a disease is never as simple as distributing an appropriate vaccine - and even getting suitable vaccines is never easy. We still know of no way to create a vaccine capable of eradicating any strain of influenza or coronavirus, for instance. Even when appropriate vaccines can be developed, eradication requires enormous co-operation between countries, and substantial diversion of local medical networks. There are severe costs to the polio eradication project we never even paused to consider.
Eradicating a disease is something we desire disproportionately to its health benefits. After all, we have already eliminated polio from our own countries, yet still we are unsatisfied ('what if it comes back from over there?', we say, in this most colonial way of thinking about other people's countries - as a source of contagion). Committing charitable funds to the eradication of polio seems a lot less magical when we recognise that this objective is in competition with the provision of regional health services. Pursuing this agenda inadvertently usurped primary care in many poorer nations. The same money could have been used to help these nations with their own urgent health problems... but as Dr William Muraskin remarked of this vastly expensive crusade: "Nobody ever erects a statue for those who build primary care systems".
Worse, we pursued polio eradication recklessly. In our own countries, we vaccinate against polio using an injection based upon an inactivated or 'dead' virus. In the eradication crusade, however, we used the cheaper and easier-to-distribute oral polio vaccine, which contains live virus. Although this will inoculate against the disease, it does so by causing a mild infection of the poliovirus, and it is possible for this to mutate and spread. This dreadful risk manifested in 2019 when outbreaks of a new vaccine-originating polio strain struck several African nations, as NPR reported. The following year, these new polio strains had spread to more than a dozen African nations. Nobody is saying we shouldn't aim towards ending polio, but prioritising speed of eradication was a 'luxury' health project driven by the whims and egos of colonial philanthropy. We did not adequately safeguard the people in poorer nations whose safety we compromised to reach our chosen goals. And this is only one small aspect of our medical empire.
When we talk about 'colonial history' we are referring to what was called in French mission civilisatrice, the civilising mission. This is the darker side of the philosophical achievements of the 17th and 18th century. Having determined that our empires had become enlightened, colonial rhetoric inferred that it was only logical to share the triumph of reason everywhere. This swiftly became self-justifying propaganda for occupying land that was rich in natural resources that could be exported for enormous profit by the mercantile classes of the great seafaring empires (France, Great Britain, Spain, and Portugal). Then as now, colonial rhetoric conceals commercial motives.
The French chose admirable-sounding metaphors for their actions. They spoke of how the Algerians or the Vietnamese became évolué (evolved) by being forced to adopt French culture, and also of the moral duty to make this happen, since they were elevating the ignorant foreigners, bringing them 'up' to their level. Race (as in: skin colour) was undeniably a factor in this, but even if those abroad had been white-skinned the differences in culture would still have produced an equivalent prejudice (racism is never solely about skin colour). That the colonised people looked different just made it easier to look down upon them.
Today we do not even bother to make arguments to defend our colonialism. We simply know we are right, and therefore we are entitled to bully the world towards the health goals we happen to desire. Thus we push towards eradicating polio, with its majestic air of permanence. It feels like a titanic achievement to us, a self-evidently worthwhile project. Yet consider that in 2020 there were only 800 cases of polio anywhere in the world, 200 of the wild virus and 600 - three times as many - of the vaccine-derived strain we are responsible for. By comparison, in the same year there were 241 million malaria cases and 627,000 malaria deaths, while 800,000 children under the age of five died of pneumonia, and 1.6 million people died of diarrhoea, most of them infants and young children. These are just three of the causes of death we don't face 'at home' and therefore ignore, despite 3 million people dying each year from these diseases. Eradicating polio could have been pursued in tandem with strengthening primary care in every country, achieving the same goal far more safely while helping to prevent vastly greater numbers of deaths from other causes. But we do not help other nations in the ways they want, because we are still colonialists at heart.
If you doubt you are a medical colonialist, here is a simple test: did you ever invoke the 5.6 million deaths over two years attributed globally to COVID-19 to make a point, or nod approvingly while someone else did so...? Although it is forbidden to say so, those who tragically died from this respiratory infection were overwhelmingly the elderly citizens of the formerly imperial nations and their allies. For the UK, 90% of COVID-19 fatalities were older than 65, with a median age of 83 based on ONS data, while global data suggests an average age of death of 72.9. Every death is sorrowful, but those who died from this specific cause have been given a macabre hallowed status in our politics, despite these deaths representing just 5% of global mortality over this period. What's more, a great many of those that died after infection with SARS-CoV-2 were already in a precarious state, and would still have succumbed to their failing health within these two years, irrespective of this disease. There was never truly a question of saving those particular lives, which is in no way an argument for doing nothing.
Conversely, the six million largely young and overwhelmingly black and brown people who died of malaria, pneumonia, and diarrhoea over those two years could have been saved from death - and had their life expectancy more than doubled - with just a small fraction of the money we squandered on largely ineffective interventions against COVID-19. While it is reasonable to focus on public health problems 'at home', the extreme and ill-considered actions of the last two years that we deemed absolutely necessary achieved almost nothing except exacerbating health harms by disrupting primary care. Saving the lives of those others in Africa and South Asia was entirely achievable but never even considered, let alone considered necessary.
Not only is this politicisation of one cause of death above all others inherently unethical, it is deeply colonial in its spirit. When we invoke 5.6 million dead from COVID-19, we claim to care about global mortality yet deceitfully frame this around the one disease we have chosen for political importance, while wilfully ignoring all those other causes of death that have far greater impact in many of the nations whose dead we are ghoulishly 'borrowing' to make our chosen big number. Even the name 'pandemic' reveals our imperialism once we accept that this was not a disease that threatened all global countries equally. 'No-one is safe unless everybody is safe' certainly sounds humanitarian, yet this policy entails forcing our politically-motivated medical agenda onto other nations, all for a vaccination that cannot ever result in the desired eradication that this motto falsely invokes for its moral impact. Less than one hundredth of a percent of the African population died of COVID-19, so tell me this: why did anyone argue there was an urgent need to vaccinate Africans against this disease, if it was not because we never gave up being colonialists...?
Our public health empire operates globally, but is primarily an export of the United States of America, aided and abetted by European nations and the United Kingdom. Through the enormous influence federal agencies such as the FDA and CDC have upon the World Health Organisation (the US being by far their biggest donor), colonial health policies decided in the United States inexorably spread around the globe. Likewise, colonial philanthropy is dominated by the United States, because wealth disparity is greater there than almost anywhere else on the planet. Just as the empires of sail justified their colonial ambitions in terms of the benefits they brought to the occupied, so the medical empire has strong rhetoric supporting its colonisation of global health. And much like imperial colonisation, there are indeed significant potential benefits entailed. Nonetheless, for historical colonialism, we came to realise that this kind of cultural imperialism was horrifically racist. We have yet to awaken to this horror when it comes to colonial public health.
The bigotry of colonial occupation has become such an embarrassment today that enthusiastic protestors gleefully topple statues representing that era. Iconoclasm is far easier than owning up to our continuing commitments to colonialism, after all. In both cases - colonial invasion and medical empire - the fact that both positive and negative stories can be told clouds the issues through the familiar distorting effects of political factionalism. Yet in both cases, it is the negative consequences we need to pay the closest attention to, since the positive benefits (by definition) don't entail concerns. When we trumpet the gains and brush the loses under the carpets, we are being very human. When we do this to defend our ongoing colonialism, we are being all too human.
Our politicisation of science, the eruption of the state of pseudoscience into one topic after another, means that everyone who took up a banner on unresolved medical questions was blinded. Yet we do not need to get into the specifics of these scientific controversies to acknowledge colonial tendencies in the US health agencies. We can start by accepting that first lockdowns, then community masking, and finally COVID-19 vaccination all entered the state of pseudoscience, where rational debate of the evidence was no longer persuasive. We can admit our failure here without having to settle the truth of these matters, because even if we believe 'we know' while those terrible others 'spread disinformation', we can still see that at least one faction ('them') is clearly not open to rational debate. This acknowledgement opens the door to confronting the errors of colonial medicine.
We are currently prevented from establishing a scientific answer to the question 'are these new vaccines safe and effective?', but the question itself is revealing. Both the CDC and the FDA are committed to claiming that all vaccines are indeed safe and effective. Yet this is evidently a conflict of interests: is the purpose of the FDA to defend the idea that vaccines are safe and effective, or is it to determine which vaccines are safe and effective...? An organisation cannot pursue both agendas without tying itself into ideological knots. The former is a political goal while the latter is a scientific investigation - and as has become increasingly clear, these are not compatible forms of thought, even though they can and must intersect. Whenever a scientific institution seizes upon political goals, it can no longer openly pursue the ambiguities of research, and it risks falling into the state of pseudoscience whereby nothing can be determined scientifically for there is no longer any free discussion of the evidence.
The FDA's decision to grant full authorisation to COVID-19 vaccines in 2021 was a choice to bypass the long-term trials that were previously deemed essential to establishing vaccine efficacy and safety. It is no good claiming that the urgency justified skipping this step: the vaccines already had emergency authorisations. Neither the ethical nor the scientific requirement to complete all the relevant safety trials can be bypassed by a state of crisis - indeed, the emergency conditions make such trial data all the more vital. Yet because critics of these vaccines levelled accusations that they were experimental treatments, the US health agencies rushed to provide full authorisation in order to cry out 'look, they're not experimental anymore!'. This leapfrogging over the established protocols cannot be justified solely in scientific terms. It was clearly politically motivated.
Ironically, the FDA were so insanely desperate to defend the claim that 'vaccines are safe and effective', that they made vaccines less safe in order to more loudly shout 'safe and effective'! They intentionally lowered the bar of what constitutes 'safety', out of fear that people might otherwise distrust vaccination. In so doing, they counter-productively increased the very vaccine hesitancy they hoped to prevent, and made their own agency appear far less trustworthy. Neither is this problem constrained to the health agencies: as the journal Science reported, researchers are now wary of investigating COVID-19 vaccines for fear of driving up vaccine hesitancy. This medical negligence is compounded by the fact that the original trials upon which these vaccines were declared 'safe and effective' are still not fully available for independent review, as British Medical Journal editor Peter Doshi has repeatedly raised concerns about.
We find ourselves in a bizarre world where media corporations can censor anyone who breaks ranks with the mantra of 'safe and effective', despite the fact that those responsible for determining the conditions of safety and efficacy have undermined their own scientific procedures for establishing this. Journalists are now so politicised on these issues that they turn a blind eye to the FDA having torn up the rulebook while still dogmatically insisting that the agency can still act as referee. Neither is safety data the only place where the rules of the game were rewritten on the fly. Moderna's application to the US government asking for reclassification of its mRNA treatments in August 2020 makes it clear this request happened precisely because gene therapy had acquired a bad reputation:
...the classification of some of our mRNA investigational medicines as gene therapies in the United States, the European Union, and potentially other countries could adversely impact our ability to develop our investigational medicines, and could negatively impact our platform and our business.
No doubt Moderna is correct that having to market these treatments as gene therapy would have robbed them of the lustre of the word 'vaccine', borrowing the aura of eradication and community benefit that vaccines like the MMR invoke. But perhaps this would have meant fewer ill-informed colonial health vigilantes strong-arming young people into taking drugs that neither they nor those around them could plausibly benefit from. A disease whose mortality is overwhelmingly skewed towards the elderly will not be impacted by vaccinating those too young to be at significant risk with a treatment never designed to prevent spread. God forbid the long-term trials (if they even happen now) reveal some unpleasant consequences that the FDA, in its zeal to defend the pharmaceutical companies, neglected to investigate...
Critics of the FDA call its lamentable situation 'regulatory capture': an organisation that was expressly intended to establish the safety and efficacy of manufactured drugs has become an advocate on behalf of the very corporations it is supposed to regulate. This is not just a conflict of interest, it is an invitation to collapse medical discourse into the state of pseudoscience. Likewise, on the question of community masking, we do not have to resolve the truth of the matter to see that the CDC's actions were compromised: over the space of two years they commissioned zero random-controlled trials to investigate these interventions, despite the original argument for their adoption depending upon inconclusive evidence. Errors like this make the federal health agencies look either incompetent or duplicitous - and either way, trust in their ability to fulfil public health goals inevitably suffers.
Yet it is not solely the US federal health agencies at fault. They have been spurred on by the anxious political desires of the citizenry. As with the colonial philanthropy of polio eradication, so with the draconian enforcement of community face masking and the mandatory injection of COVID-19 vaccines - our naïve assumptions pre-empted scientific investigations that were absolutely necessary. Still, while the state of pseudoscience blocks debate of the evidence, it does not stop it accumulating. These forbidden zones now include evidence on the predicted poor performance of these vaccines against spread, confirmation of the superiority of natural immunity against reinfection, disturbing side effect data from Israel and Germany, risks of Original Antigenic Sin that might mean these vaccines made some situations worse, and unexplained actuarial data in the US indicating an unprecedented 40% spike in young adult deaths not attributable to COVID-19.
What does it all mean...? Who knows! How can anyone claim to have answers when we are not permitted to even discuss these topics in any public forum! Even pointing out ambiguities in the available data now invites accusations and censorship, and anyone with concerns can be pre-emptively denounced as an 'anti-vaxxer'. Indeed, these dreaded 'anti-vaxxers' now seem to be lurking everywhere, much like those dastardly communists of the 1950s... even once-respectable researchers, doctors, and Nobel prize winners seem to have turned to the dark side. Rather than assessing whether or not these new treatments are indeed as safe and effective as their manufacturers claim, we have been reduced to a blind imperialism where our medical desires are the only ones that matter because 'we know' and those who disagree with us merely 'spread misinformation'. What a catastrophic failure of public health!
Despite the prevalent dogma, it is not unreasonable to ask the question 'are vaccines safe and effective?' There are two essential approaches. Firstly, we can take this as an axiom, or indisputable claim, as those who favour colonial public health tend to do. But if it is our axiom that vaccines are safe and effective, then to qualify as a vaccine a candidate treatment must pass rigorous tests on safety and efficacy, as they used to do back in 2019. As soon as this painstakingly careful process was disrupted, we were at an impasse. For it might well be that 'vaccines are safe and effective' - but we can no longer tell whether any particular treatment is or is not a vaccine. The state of pseudoscience blocks us from establishing the truth.
Alternately, we can admit that some treatments called vaccines are not safe and effective, which is why they always require rigorous scientific testing. This approach is more grounded in fact: some treatments bearing this name did not pass their trials, and were consequently withdrawn, and vaccines previously distributed widely have later come into question, as happened for both smallpox and rotavirus vaccines - not to mention the disastrous backfiring of polio eradication. The difference between this pragmatic approach and the axiomatic path is a willingness to use the name 'vaccine' for something that is later demonstrated to be either unsafe or inadequately effective. Since we have never withdrawn the name 'vaccine' from treatments that failed in testing, this pragmatic account reflects established practices while the axiom 'vaccines are safe and effective' is a new proposition, one entailing severe risks of falling into the premature certainty behind all colonial endeavours.
The political battle between 'anti-vaxxers' and their opponents was always claimed to be about scientific truth, even as both sides devolved into a factionalism that disrupted anyone's ability to determine what that truth might be. In fact, despite the fervour of the zealots, the key question with respect to vaccines is arguably ethical and not scientific. On the one hand is the maxim that one life is too many to lose to a medicine, no matter how many lives it might save. On the other is the maxim that if a medicine saves more people than it kills, everyone must take it. There is a legitimate political debate to be had between these two positions, no matter how much we detest confronting it. Tragically, the entire issue risks becoming meaningless without scientific research capable of assessing the safety and efficacy of each and every vaccine, which our arrogant imperialism has now circumvented.
Resolution of the world's health problems cannot be achieved by the methods of empire without repeating the moral crimes of colonialism. If we want to take advantage of the collective health benefits that responsible vaccination offers, then we cannot afford to undermine trust in those treatments whose safety can be proven. But such proof depends upon rigorous scientific investigations, without which vaccine safety is simply unknown - to dogmatically mandate vaccines about which such ambiguities persist is to demand medical negligence. We not only enacted this shocking policy globally, we then condemned anyone who dared express their horror at what we were doing. Yet to be a public good at all, health topics must be open to debate by everyone, because such questions are always both scientific and political. Alas, because the political destabilises the scientific, we have descended into a grotesque medical empire, where the name 'vaccine' has become something to swear fealty to, and those with doubts are cursed as infidels. Our neurotic fear of our viral cousins has been weaponised to divide us.
I believe in the great people of the United States of America, but my trust in their health agencies is strained to the point of breaking. They have spectacularly failed to uphold the ideals of the medical profession, and if their officers will not now admit their mistakes, they should expect to be held accountable for their tragic errors. Public health depends upon trust in scientific institutions, and the last two years have savaged that trust, reducing nearly everyone to either cynic or zealot, pitting us against one other. Public health cannot be conducted as a war, and when it becomes a battlefield it abandons the claim to be medicine, since the doctor's highest ideal is 'first, do no harm'. If you care about the health of everyone in our world, as I do, if you believe that every cause of death matters, then we have an unavoidable duty to confess this failure, and commit to the greatest medical challenge the world has ever faced: decolonising public health.
The opening image is Color Colonisation by Terry Smith, which I found here. As ever, no copyright infringement is intended and I will take the image down if asked.