O’Cionnfaola v. the Wellcome Foundation and Daniel McCarthy

Chapter six argues that by the end of 1936, the Irish Free State had come close to incepting an operational national anti-diphtheria immunization scheme. This is a noteworthy achievement, as state-backed anti-diphtheria schemes were not introduced as an intervention against this pressing public health issue in the rest of Europe until 1938 and were only pursued with any vigour when wartime conditions exacerbated the problem from 1940 onwards. If it had progressed unimpeded, the Free State intervention seemed destined to eliminate diphtheria, and to become the first established national childhood immunization programme in Europe. However, the death of Siobhán O’Cionnfaola in April 1937, and the subsequent controversy surrounding the Ring incident, asked serious questions of active immunization and ultimately undermined vaccine confidence among parents, practitioners, and politicians. This chapter will evaluate the impact of the Ring controversy and the social, political and medical implications left in the wake of the incident.

The Ring College Immunization Disaster

Chapter five examines the Ring College immunization disaster, in which 24 children reportedly contracted tuberculosis and one 12-year-old girl died following routine anti-diphtheria immunization. The existing historiography relating to the Ring incident has, without exception, insisted that Burroughs Wellcome Ltd mistakenly supplied a bottle of live tuberculosis in lieu of a bottle of the anti-diphtheria serum toxoid-antitoxin floccules (TAF), even though this charge was not substantiated by a High Court ruling in 1939.This chapter provides new evidence suggesting that liability for the tragedy lay not with Burroughs Wellcome Ltd, but with the local attending doctor and his advisors, who mounted a conspiracy to cover up initial negligence in administering the immunization scheme and subsequent perfunctory medical treatment of the affected children.

Towards a National Immunization Programme

Chapter seven undertakes close analysis of municipal immunization schemes in Cork and Dublin in the wake of the Ring incident and in the face of impaired public health service provision attendant on wartime conditions. It argues that the municipal anti-diphtheria immunization scheme in Cork city was the only intervention mounted in Ireland or Britain to attain immunization rates comparable to those achieved in North America. In Dublin, failure to organize a comprehensive immunization scheme facilitated the recrudescence of diphtheria in numbers not witnessed since the pre-vaccine era, and increased diphtheria mortality left parents with a difficult decision to make: to present children for treatment to a compromised public health service or to expose them to a rampant, virulent, and increasingly fatal diphtheria infection.

Developing Burroughs Wellcome Alum-Toxoid

Chapter four suggests that although the practical application of anti-diphtheria immunization in Cork achieved good results, its success was qualified somewhat by the limitations of Burroughs Wellcome’s anti-diphtheria serum TAM. To reduce the occurrence of post-treatment diphtheria cases – occurrences which undermined public confidence in active immunization – field epidemiologist Jack Saunders introduced an experimental ‘one-shot’ Burroughs Wellcome anti-diphtheria antigen in Cork. This chapter explores the development of Burroughs Wellcome’s Alum-Toxoid anti-diphtheria antigen and the relationships that developed between the British pharmaceutical company and Irish medical officers: the former eager to field trial experimental anti-diphtheria serums unrestrained by restrictive British legislation and the latter eager to embrace any solution, however radical, to leverage a modicum of control over diphtheria and its often-fatal consequences, even if this meant side-lining the rights of vulnerable children residing in state-run institutions.

Anti-diphtheria Immunization in the Irish Free State

Chapter three examines the rollout of anti-diphtheria schemes in the Irish Free State. It argues that a successful – albeit small-scale – anti-diphtheria scheme undertaken in Dundalk, Co. Louth, in 1927 influenced the introduction of new legislation designed to accommodate the rollout of a state-backed national anti-diphtheria immunization programme. An overview of the national picture is complemented by more in-depth analysis of local initiatives implemented by ‘front line’ medical officers in Dublin and Cork. These case studies highlight the dissimilar results obtained by a frugal and limited intervention in Dublin compared with the more comprehensive mass immunization scheme implemented by public health authorities in Cork. This chapter suggests that Cork city was the site of the largest anti-diphtheria immunization scheme ever undertaken in Ireland and Britain, the success of which drew national and international attention

Introduction

Prior to the mass social acceptance of childhood immunization in the 1940s, diphtheria was one of the most prolific child killers in history. The formation of a leathery membrane in the lower airways induced death by suffocation and earned diphtheria the moniker ‘strangling angel of children’. It showed scant regard for social status and infiltrated Europe’s royal palaces as sinuously as her slums and hovels. For parents and children of nineteenth and early twentieth-century Ireland, diphtheria represented the ‘most dreaded disease of childhood’ however, for their modern-day counterparts’ diphtheria has been relegated to a somewhat obscure disease. Few Irish doctors have seen a case of diphtheria, let alone treated one. In Ireland, diphtheria has been consigned to history, and so too have the horrors and mass fatalities once associated with it. But how was this achieved? Was active immunization received with open arms by public health authorities, the wider medical community, and the general public? This book tackles these questions by undertaking the first historical examination of the issues that underpin the origins of active immunization in Ireland. It explores the driving forces that shaped the national childhood immunization programme, and those that opposed them. In addition, it examines the complex social implications attendant on the introduction of this mass public health intervention.

Aetiology of Diphtheria in Pre-independence Ireland

The opening chapter rescues diphtheria from obscurity, offering a rationale as to why Irish health authorities opted to embrace a new and radical public health intervention and why they set the eradication of diphtheria amongst the first of their national goals. A study of surviving statistical data relating to infectious disease in nineteenth and early twentieth-century Ireland does not suggest that such an intervention was warranted. However, despite the distinct lack of diphtheria notifications recorded in this period, this chapter will show that diphtheria was indeed a major child killer.

Conclusion

This book is important as it is the first comprehensive study of the origins of the childhood immunization programme in Ireland. It portrays Irish public health authorities as being progressive regarding their willingness to accept and employ new public health initiatives, and importantly, it highlights how this attitude differed from the sluggish response of their British counterparts. The book explores the radical public health interventions which pitted efforts to achieve communal health against the rights of the individual. It presents a historical precedent where the actions of one medical practitioner undermined public confidence in the immunization process itself. In an era when childhood immunization is increasingly considered more of a lifestyle choice than a lifesaving intervention, this book may bring some historical context to bear on a current public health debate.

Diphtheria ‘Arrives’

Chapter two will discuss how, from the 1880s, diphtheria increasingly became an urban disease in Britain, Europe and America, and it is unlikely that Irish urban centres managed to avoid this ominous trend. The introduction of the Infectious Disease (Ireland) Act in 1906, and the mandatory obligation this legislation placed on local authorities to notify outbreaks of infectious disease, exposed the true prevalence of diphtheria in Ireland. The burgeoning, albeit reluctant, acknowledgement by local authorities in Dublin and Cork that diphtheria was endemic in their districts brought with it realization that a comprehensive public health response was required. Radical reform of public health administration and service provision in the newly independent Irish Free State, meant that Irish health authorities were well placed to take advantage of cutting edge laboratory-based measures to control infectious disease. It examines the development of anti-diphtheria antitoxin and its application as a preventive measure on a mass scale in New York in the early 1920s before considering how this radical public health intervention was received by health authorities and medical professionals in Britain and Ireland. This chapter will show how Irish health officials and medical officers eschewed the reticence of their British counterparts, readily abandoned traditional sanitarian approaches to disease control and embraced new public health methodologies in a bid to protect child life.