“The advantage of the emotions is that they lead us astray.” -Oscar Wilde
It happened over Christmas in 2011. As a gift, my daughter — then just two months old — got a virus: measles. And she probably got it from me. Within the span of just a few hours, we were both covered with masses of crimson blotches. Distracted by the task of keeping this newly-minted being alive, I had been cut off from the news of the outside world, and specifically from the news that a measles epidemic had hit my area — the Drôme region in southeast France — particularly hard. Not that knowing about the epidemic would have made a big difference for my daughter, since the measles vaccine is only offered to children over one year old.
In any event, both of us were seriously sick — but I took comfort in my rational mind: There was no risk of losing my daughter, I reassured myself, because in the developed world, fewer than one in 1,000 people who get measles will die — typically those who are already immune-compromised. Statistically, I had put my daughter at greater risk by taking a car trip to a Christmas party more than 125 miles from our home.
Still, this supposedly benign virus had me stuck in bed, dripping with sweat. I couldn’t tolerate any light at all, and my head pounded, filled with dark thoughts: What if? What if this devil of a virus, which according to the World Health Organization predictions should have been eradicated long before, stole my daughter? I didn’t dare to answer that. My mother thought she remembered having me vaccinated. Was it possible that my immune cells were as distracted as I was? That they’d forgotten what this microbe looked like?
By the early part of the new year, both of us were exhausted but recovered, and I checked my old vaccination booklet. On the “measles vaccination” page, there was a handwritten date: October 17, 1980, but that was it. No vaccine name, no stamp, no doctor’s signature. My mother suggested that maybe that was the date when I came down with the disease? Maybe. Unless that was the date when I was scheduled to get the vaccination but — for whatever reason — it never happened. No way to check. In any case, there was no record of a second shot, which is required for the protection to take effect.
A few months later, I was at a work-related medical appointment. I saw a mocking smile cross the doctor’s face. “Right! We know all about the area around [the French city of] Die and the anti-vaxxers there!” I was annoyed, and responded that I had barely even lived in Die (pronounced “Dee”); I was originally from Grenoble and it was highly possible that I had been vaccinated once, during my first year of life. Still, the doctor’s smile went from mocking to sardonic: During the 2008-2011 epidemic, more than 95 percent of measles cases were in people who weren’t vaccinated at all, or who weren’t fully vaccinated.
During those years, the number of measles cases was crazy. Between October 2010 and April 2011 alone, no fewer than 12,500 cases were reported in France. During the entire 2008-2011 epidemic, more than 23,500 cases were reported. Given that cases are chronically under-reported in France, the actual number is probably about double that: 43,000 cases. A study done on a sample of family practice doctors in southeast France showed that in 2011, only 23 percent of them routinely reported measles cases to health officials. In Die, after a middle schooler was reported to have measles in 2010, the staff of the Rhône-Alpes regional health department investigated further and found more than 50 cases. I was probably one of them, because I was diagnosed by my doctor. But my daughter probably wasn’t, as she was seen by a doctor in another area who didn’t recognize the disease. During this epidemic, more than 1,500 people suffered serious complications, including acute hepatitis, serious pneumonia, and some 30 cases of irreversible neurological damage.
Ten people died. Seven of them were immune-compromised. The immune-compromised population’s immune systems are so weak that they cannot get live vaccines, including MMR (mumps, measles, rubella).
So, what if? This question haunts me. Even today, it takes me down a rabbit hole of thoughts. What if my daughter and I had suffered these complications? What would I have said to my friends and neighbors, who are mostly against this vaccination? No doubt, these children and adults who choose not to be vaccinated are fertile ground for the virus, in an age when most people are vaccinated. Without them, the microscopic virus would be like a tick in Antarctica: It wouldn’t be able to survive if there was no one to infect. But a group of unvaccinated people is like a tropical jungle: Once the measles virus settles into one person’s tissue, it goes on to infect — on average — 15 more. If one of those 15 secondary cases is unlucky enough to have a weak immune system, the virus will beat a path to the vital organs — like the brain. That’s exactly what happened to the 10 people who died, and to hundreds of others who came down with serious cases of pneumonia or encephalitis during the 2008-2011 epidemic.
How can we wrap our minds around these preventable deaths and complications? After all, 10 deaths in three years isn’t a huge deal. More than 70,000 people in France die each year from smoking, 48,000 from air pollution, and at least 10,000 from the flu. From a numbers standpoint, the measles epidemic was nothing at all. But the people whose lives were touched by those deaths clearly feel otherwise. Take the parents of the children who were too young to be vaccinated, or the friends and family of the immune-compromised people. To them, these deaths are impossible to accept. Impossible to rationalize away. From their perspective, their loved ones died because of someone else’s ideology or self-centeredness. Should we pay attention to the logic of numbers on a worldwide scale, or should we look with compassion on an individual scale? The problem with the individual approach is that it can lead us to any conclusion at all, or to the opposite conclusion. It can cause us to defend vaccination to the death, or the other way around.
In December 2016, the results of the citizen dialogue on vaccination — launched by the French Ministry of Health a few months before, to combat French opposition to vaccination — were made public. I remember the discussion that followed. A man stood up to speak, his voice laden with emotion. “I’m immune-compromised. If vaccines like Prevenar or the flu vaccine didn’t exist, I wouldn’t be here tonight.” Applause! A few minutes later, another man spoke. “I’m the father of a child who was sickened by the Meningitec (meningitis C) vaccine. There are 600 other families like us. We’re sick of hearing only about fear and threats.” Hiss! Boo! So, suffering doesn’t matter? That’s why I prefer hard numbers and cold facts over the emotional approach. As Antoine de Saint-Exupéry said in “The Little Prince,” “It is only with the heart that one can see rightly.” But sometimes the heart clouds our view.
To dig deeper into what the numbers mean, we have to think beyond the number of deaths and irreversible complications. Both sides of that equation have their problems. We have to think about morbidity: death. On a societal scale, what do 43,000 measles cases in three years represent? If I extrapolate my own experience with measles to the scale of everyone who got sick, that translates into thousands of courses of antibiotics, thousands of people who couldn’t work for a week, and months of constant fatigue. But it would seem that I got off pretty easily. In France, 22 percent of reported cases required hospitalization; 46 percent of people older than 20 had to be hospitalized. Clearly, the most serious cases were reported. So those percentages might not apply to the estimated total number of cases, but it still represents at least 7,000 hospitalizations. And when you have hospitalizations, you have hospital-acquired illnesses: approximately 5 percent of hospitalized patients contract an infection while they’re there.
A 2011 study of 460 patients hospitalized for measles shows that on average, a measles patient is hospitalized for three days. Given France’s number of hospitals per capita, that’s that many fewer beds for other critical health problems. And 43,000 measles cases represent a tremendous cost. A German study showed an average per-patient cost of $640 for doctor’s visits, hospitalization, treatment, and tests. That would put the direct cost of those 43,000 measles cases in 2008-2011 at about $27.5 million, or an average of $9.2 million per year.
In addition to those direct costs, we also have to look at sick pay, and lost productivity due to missing work. A U.K. study showed that an adult with measles misses an average of 10 days of work, and parents of children with measles miss seven days. If we apply those figures to France, that means more than 300,000 days of lost productivity during the three years of the measles epidemic. A Dutch study tried to assess the direct and indirect costs — lost productivity of course, but also things like child care — caused by the 2013-2014 measles epidemic. The result: nearly $2,000 per case. Those numbers are close to those from an Australian study. France seems allergic to these types of studies on health care economics. But if we apply those average costs to our epidemic, the total cost would be more than $84 million over three years, or $28 million per year — approximately 0.001 percent of France’s GDP.
Of course, these numbers have to be weighed against the cost of universal vaccination. According to a report by the Cour des comptes (France’s Court of Auditors), measles vaccinations cost about $23 per person. The total cost of the two MMR shots was about $16 million in 2013, fully paid for by the French Social Security system since patients are reimbursed for 100 percent of the cost. And we have to add the costs of the vaccine’s side effects. In the U.S., where adverse effects of medications are reported much more often, there are between two and 10 serious complications — such as death or hospitalization — from the measles vaccine each year.
According to various studies of all types of side effects (fainting, convulsions, allergies, fevers, local reactions, etc.) that occurred after a measles vaccination … between 3 and 15 undesirable effects — 30 percent requiring hospitalization — will occur, per 100,000 doses of measles vaccine. In France, that would mean 20 to 120 undesirable effects per year, with six to 36 requiring hospitalization. In any case, that’s well below the hundreds of serious complications caused by the disease itself — approximately 500 per year during the epidemic — and also well below the number of hospitalizations. It’s clear that vaccinating the entire population is less expensive than an epidemic.
One might argue that using data from an epidemic doesn’t represent reality. The truth is, since 2013, France has seen fewer than 350 measles cases per year. But what we now think of as an epidemic is nothing compared to the number of measles cases before 1983, when measles vaccinations became standard for young children. Before that time, a single year might have seen 500,000 measles cases. France routinely saw more than 100,000 cases per year until the early 1990s. So it’s not difficult to see the economic appeal of the measles vaccine for a country. But public health officials never use that argument.
“Get vaccinated, it’s less expensive for us,” is probably a less effective message than, “Get vaccinated, to protect the most vulnerable.”
Lise Barnéoud is a science journalist and author based in France. Her work appears regularly in Sciences et Vie, Le Monde, and Libération, among other publications.