William J. Oliver, M.D.
2892 Bay Ridge
Ann Arbor, Michigan 48103
(734) 761-5169
e-mail: wjoandmbo@aol.com
Letter to the Editor:
RESPONSE TO PATRICK TIERNEY’S ARTICLE ENTITLED "THE FIERCE
ANTHROPOLOGIST" APEARING IN ‘THE NEW YORKER’ OF OCTOBER 9,
2000
The narrative description of the measles epidemic among the Yanomamö
Indians by Tierney warrants careful re-appraisal against correct facts regarding
the vaccine (detailed in a separate Letter* to the Editor by Samuel L. Katz,
M.D. [co-developer of the vaccine with John F. Enders, Nobel laureate] ) and
true, first hand accounts of the events. The blatant inaccuracies of fact and
use of material out of context are easily evident.
The primary sources of the correct accounts were published by Centerwall
(1968) and Neel (1970), augmented by entries in Neel’s and Chagnon’s
personal field journals. These echo earlier descriptions of the devastation
incurred by introduction of a highly contagious, virulent disease to a population
of nearly 100 per cent susceptible individuals. Efforts to abort the
epidemic by active immunization are carefully detailed. The reports of
Centerwall and Neel also document, as have others, the reduction of morbidity and
mortality by aggressive antibiotic treatment and skillful nursing care. It is
highly pertinent to note that these publications of some thirty years ago
certainly did not anticipate the current vicious attack by Tierney on the actions
of these same researchers. The facts were cleanly presented without
embellishments or omissions.
The true sequence of events can be best considered chronologically:
1. PROCUREMENT OF MEASLES VACCINE FOR THE YANOMAMO:
Previous studies in 1966 of the Yanomamö of Venuezuela indicated a few
had antibodies to measles but most had none. Accordingly, in the fall of
1967, in anticipation of the January 1968 expedition, Dr. Neel initiated requests
to pharmaceutical companies and obtained 2,000 doses of Edmonston B measles
vaccine plus equivalent doses of human gamma globulin from the Michigan
Department of Health. He also consulted with the experts at the Center
for Disease Control on the best way to administer the vaccine. His goal was
to vaccinate as many as possible to prevent or, at least, blunt future
epidemics among this highly vulnerable population.
2. MEASLES OUTBREAK IN BRAZIL:
In November 1967, an outbreak of measles began in the Yanomamö of
Brazil. To aid in stopping the epidemic, Neel diverted 1000 doses of measles
vaccine to Brazil. These were given to the Indians by physicians and missionaries
working in that country.
3. MEASLES OUTBREAK IN BRAZIL:
By chance, as Neel’s group arrived in Venezuela, in Jaunuary 1968,
measles was introduced by a young Brazilian boy to the Yanomamö at the Salesian
Mission of Santa Maria del Ocamo in Venezuela. Exposed susceptible
individuals included both those Indians resident at the mission and
those visiting from outlying villages. As advance members of Neel’s team, the
Venezuelan physician, Marcel Roche, and Napoleon Chagnon were at the
mission at the time the ill youth appeared on January 23, 1968. Roche made a
tentative diagnosis of measles in the boy. Two facts were well known to
Roche and Chagnon. First, measles can be a devastating disease in a virgin
population; second, administration of the vaccine 72 hours or more
before exposure can protect from the wild disease. Vaccine was available but
gamma globulin would arrive with Neel two weeks later. It was concluded that
the wisest course was to give the vaccine. Roche, with Chagnon as
interpreter, vaccinated 31 Yanomamö plus nine Brazilians (page 57 of Tierney’s
article). Of the 21 immunized Indian children, ages two to 12 years, 17 were
brought to sick call when Neel and the full team arrived. Febrile response to the
vaccine was high and, as noted by Neel, "a few had a reaction indistinguishable from moderately severe measles". Importantly, he observed no significant complications and no deaths. At the mission, new cases of wild measles developed in 15 days and also appeared in surrounding villages.
4. NEEL’S ATTEMPT TO STOP OR MINIMIZE THE EPIDEMIC:
Neel arrived at the mission on February 5, 1968, He and members of his
team responded quickly and responsibility in an attempt to halt the
epidemic. Several teams including members of Neel’s group, missionaries, and
medical auxiliaries of the Venezuelan Government were dispersed to villages in
the surrounding territories. The immunizing program used Edmonston B measles
vaccine with simultaneous administration of human gamma globulin. The vaccine Neel brought was later augmented by additional quantities from the Venezuelan Government. There were no deaths or serious untoward events. This observation was expected from the known world-wide experience with the vaccine. Deaths occurred only in Indians suffering from wild measles. Fatalities were usually due to complications of bronchopneumonia in the absence of early and aggressive antibiotic therapy.
The orderly program of vaccination was abruptly interrupted by development of a serious outbreak of measles at Ocamo Mission. In his entry of
February 17, 1968 written at Mavacca village, Dr. Neel describes an urgent request at
2:00 a.m. for help with the emergent situation. Neel and the team promptly returned to the mission that same morning. His notes detail thoughtful deliberations for developing an optimal plan for preventing or minimizing the disease and its complications. Indians not yet ill but late in their incubation phase were given gamma globulin; others given vaccine and gamma globulin. Those ill with measles and its complications were aggressively treated with antibiotics and nursing care. Additional teams were dispatched to other villages to augment those already giving immunizations plus bringing antibiotics for those already ill.
The priority given by Neel for humanitarian assistance is additionally
given in his schedule for the village of Patanowa-tedi. His log notes that the
first activity planned for the Indians of the village is "immunize for measles". Biomedical and anthropological studies were listed for subsequent days.
In his entry of February 25, 1968, Neel gives a summary of the measles
vaccination program. Nine hundred and ninety-three doses of vaccine were given simultaneously with gamma globulin to Indians in 12 different villages. Vaccine was administered without gamma globulin only to the first forty recipients as noted previously. The logistics of getting viable vaccine in a tropical environment to villages widely separated by dense jungle and rivers with varying degrees of navigability to unsophisticated natives with high suspicion regarding foreign medicines should not be underestimated. The accomplishments in face of these difficult field conditions should not be minimized. Again, there were no deaths or serious complications associated with the immunization program, with or without gamma globulin.
5. DEATH OF AN INFANT:
In his article (page 57), Tierney employs a highly dramatic introduction
to his perception of events ending in the death of a one-year old infant. His
report is factually incorrect. Dr. James Neel’s meticulously comprehensive
entries in his personal field journal for February 6, 1968 and February 17,
1968, written 32 years ago, give the true sequence. These are his on site
observations. The summary segment of the entry for February 17, 1968 is titled "Measles at Ocamo" and ends with the phrase: "Story put together with French group at Ocamo on 16 February 1968."
First, it was noted that Vitalino Baltasar was a 21-year old Brazilian, a friend of the boy with the first case of measles, not a Yanomamö Indian. In his formal report of the measles epidemic (Neel [1970], reference 14), he wrote "Both Brazilians (i.e., the boy and Baltasar) were typical ‘caboclos’, probably of mixed Indian, Negro and Caucasian ancestry."
In the entry for February 6th, Neel wrote that Vitalino Baltasar and a 30-year old Yanomamö male sought medical care on the night of February 5th. Dr. Neel and the second physician, Dr. Willard Centerwall, described both to be very febrile (39-40º C.), with intense conjunctival injection (red eyes), and rashes atypical for measles. The diagnosis was not thought to be measles. Both given penicillin by injection. Baltasar was seen two days later by Dr. Poiviere, a French physician working at the mission, still with injected eyes but also with signs of pneumonia. The antibiotic, terramycin, was given.
On February 13, 1968, Baltasar brought his one-year old son, Roberto, to
the Ocamo Mission for treatment. Neel wrote that the infant had a very high fever, intense conjunctival injection, extreme shortness of breath and findings of pneumonia but no rash. He was given penicillin, terramycin, a cardiac stimulant and quarantined in the infirmary. Following a short phase of improvement, his condition deteriorated. He died on February 15, 1968.
There is no record of Vitalino Baltasar or his son receiving measles
vaccine. In retrospect, it is likely that both had wild measles, but atypical for absence of a classical rash.
The Mission was not the only site of wild measles at that time. Chagnon
in his entry of January 31, 1968 recorded that he arrived at Mavaca and the
missionary, Danny Shaylor, was absent. He had become involved in taking the remains (ashes) of a Yanomamö boy, age 17 years, who had died of measles in
the village of Tamatama, near Ocomo mission, back to the boy’s home village.
6. CONFUSION BETWEEN WILD MEASLES AND TOXIC REACTIONS TO VACCINE:
In many villages, the immunizing teams were preceded by Indians
returning to the village after exposure to wild measles. The long incubation of
measles (10-12 days) resulted in asymptomatic travelers returning home and only
then breaking out with the disease. Thus, in villages distant from the mission, simultaneously there could be the presence of wild, virulent measles disease
and the milder but toxic reaction to the vaccine. An understanding of the
distinction between the two clinical pictures might not be apparent to trained observers much less to these frightened Indians. Characteristics of measles, including its transmission by droplet spray, its relatively long incubation period plus appearing as a new disease in the experience of the Indians, all contributed to misconceptions. Far easier to incriminate those giving the vaccine and the vaccine itself as the causes of illness and death than to believe that seemingly healthy Indians could bring a severe and often fatal disease back to the village. This erroneous interpretation would clearly explain the entries in the mission journals of an association between visits of Neel’s immunizing teams and outbreaks of wild measles (page 57 of Tierney’s article).
The total absence of communicability of the vaccine appears to have
escaped recognition by Tierney and those whom he quotes.
7. TREATMENT OF COMPLICATIONS OF MEASLES:
Dr. Neel’s expedition brought in a large quantity of medicines for
dispensing to sick Indians. This was Neel’s standard operating protocol. ‘Sick
call’ occurred daily. Illnesses were always treated prior to any biomedical
studies. In this instance, the aggressive treatment of the Indians with bronchopneumonia complicating the wild measles was successful. However,
the number of cases of pneumonia, exceeding 35 per cent of those with
measles, rapidly depleted the antibiotic supplies of the team. Thus, the request
to Caracas by the radio operator, Rousseau, was logically for additional antibiotics to treat the secondary pneumonia, not for drugs to treat the primary measles (page 58 of Tierney’s article).
8. REDUCTION OF DEATHS FROM MEASLES:
The fatality rate for measles among all the Yanomamö was 8.8 per cent. This
is high by standards of civilized societies, but low in comparison to the usual death rate observed in Indians. The lower rate most likely could be attributed to the intensive antibiotic therapy and nursing care given by missionaries, government auxiliaries and members of Neel’s team. Fatality rates over 25 per cent have occurred in similar epidemics when care was unavailable or given late. In the majority of cases, deaths were due to the secondary pneumonia. In contrast, fatal complications do not occur in association with measles vaccine.
9. CONVERSATIONS DURING FILMING OF MEASLES VICTIMS:
The described exchange between Timothy Asch, the expedition
photographer, and Neel is one blatant example of material taken out of context by Tierney (page 58 of Tierney’s article). This was not a callous comment by an uncaring investigator. It was made in the course of taking movies to document
the impact of a formerly termed ‘childhood’ disease’ of acculturated societies on
all generations of a previously inexperienced group. In this instance, the
conversation focused on Neel’s efforts to confirm extreme examples of the
disease occurring simultaneously in three generations plus the range of illness from extreme to mild. Neel’s comment, "We’re going to document the whole gamut of measles in this group" reflects this goal. Importantly, these films also illustrate the clinical picture confronting those natives not yet ill with the disease. The magnitude of physical misery recorded in these movies helps to explain the Indians usually ill-fated attempts to escape disease by retreating to the jungle.
In summary, the above comments focus on a scant few of the incorrect and distorted statements which characterize the article in the New Yorker by
Tierney. Only a longer response could permit a complete detailing of these blatant untruths which unfairly damage the reputation of James V. Neel and his colleagues.
(A full list of supporting references and sources is detailed on the University of Michigan web site [http://www.umich.edu/~urel/darkness.html].
Sincerely yours,
William J. Oliver, M.D.
Emeritus Chairman of Pediatrics
University of Michigan
(734) 761-5169
FAX (734) 769-5562
e-mail: wjoandmbo@aol.com
*Published New Yorker 10/30/00
Supporting References / Sources:
1. Black, FL, Woodall, JP, and Pinheiro, FDP (1969): Measles vaccine
reactions in a virgin population. Amer. J. Epidemiology 89: 168-175
2. Brody, JA, McAlister, M, Emanuel,I, and Alexander ER (1964)": Measles
vaccine field trials in Alaska. J.A.M.A. 189: 339-342.
3. Chagnon, NA: Entries in persona field journal for January 31, 1968
4. Centerwall, WR (1968): A recent experience with measles in a
"virgin-soil" population. In: Biomedical Challenges Presented by the
American Indian, Scientific Publicaion No 165. Pan American Health
Organization, Wash., D.C., pp. 77-8
5. Katz, SL, and Enders, JF (1959): Experiences with a live attenuated
measles virus. Am.J.Dis. Child. 98: 605
6. Katz, SL, Enders, JF, and Holloway, A (1962): The development and
evaluation of an attenuated measles virus vaccine. Amer. J. Pub. Health
52 Supple: 5-10
7. Katz, SL, and Enders, F, (1965): Measles Virus In: Hosfall, FL, Jr.
and Tamm,I. (Eds): Viral and Rickettsial Infections of Man, 4th Ed., J..B
Lippincott Company, Philadelphia. 784-801
8. Katz, SL ( September 15, 2000): Personal communication to William J.
Oliver (copy appended)
9. Markham, FS, Cox, HR, and Rueseger, JM (1962): A summary of field
experience with live virus measles vaccine. Amer. J. Pub. Health 52
Supple: 57-64
10. McCrumb, FR, Bulkeley, JT, Hornick, RB, Snyder, MJ, and Togo,
Y(1962): Clinical trials with living measles virus vaccines. Amer J.Pub.Health
52 Supple: 11-15
11. Morley, D, Woodland, M, and Martin, WJ (1963): Measles in Nigerian
children. J. Hygiene 61: 115-134
12.Morley,D, Katz, SL, and Krugman, S (1963): The clinical reaction of
Nigerian children to measle vaccine with and without gamma globulin. J.
Hygiene 61:135-141
13. Neel, JV: Entries in personal field journal for 1967-68
14. Neel, JV, Centerwall, WR, Chagnon, NA, and Casey, HL (1970): Notes
on the effect of measles and measles vaccine in a virgin-soil population of
South American Indians. Amer. J. Epidemiology 91: 418-429.
15. Oliver, WJ: Personal observations as participating member of
research teams in field studies in Brazil, Panama, and Venezuela in 1967, 1971,
1972, 1974, 1975, and 1976 and physician responsible for medical supplies on
the expeditions.
- - - - - - - - - - - - - - - - -
[Reference 8:
William J. Oliver, M.D.
2892 Bay Ridge
Ann Arbor, Michigan 48103
[734] 761-5169
FAX: [734] 769-5562
e-mail: wjoandmbo@aol.com
e-mail from Dr. Samuel L. Katz
September 15, 2000
Bill:
I was able to locate James Neel's paper in the American Journal of
Epidemiology (1970; 91: 418-429). Not having previously read it, I found
it very interesting. The reported results are not unexpected. He obviously
was trying to abort a measles epidemic already in progress by administration
of vaccine. A number of comments are due.
First of all, he was using two different Edmonston B vaccines, one grown in chick embryo cell cultures, the other in canine renal cell cultures. The latter was later abandoned as it was more reactogenic than the chick cell material, but it was licensed by FDA.
A number of studies had shown and have subsequently been reaffirmed that
if vaccine is administered within 72 hours of exposure, one can obtain a vaccine response and abort the wild virus illness. Thus he was undoubtedly dealing with a mixture of natural measles and vaccine-induced responses. In the absence of virus isolations and (then unavailable) genomic characterization it would be difficult to segregate the two.
"We" and other investigators had studied previously the responses to Edmonston B vaccine in children in developed nations as well as those in developing lands (Haute Volta--now Burkina Faso, Nigeria, among others) in infants and children with malnutrition, protein depletion, malaria and other underlying problems. Several results were consistently observed: the children responded with excellent antibody levels (often greater than their more fortunate contemporaries in developed nations), although they had febrile responses they remained well and active, there was never anytransmission of vaccine virus to susceptible contacts who were controls receiving placebos. Despite every attempt to domonstrate communicability of the vaccine virus, it has never occurred in any populations of the many studied. Although there was the morbidity described with Edmonston B vaccine (especially when used without gamma globulin)--fever, occasional URIsymptoms, evanescent rash--there were never any severe complications such as those observed with natural measles (especiall bronchopneumonia, gastroenteritis, croup, otitis media, encephalitis, etc.).
Despite the administration of millions of doses of vaccine to childrenthroughout the world, the only deaths known to have occurred were in several youngsters who were under intense therapy for their leukemias and more recently a young adult with AIDS. These patients developed the giant cell pneumonia that has been seen with natural measles.
In summary measles vaccine viruses (Edmonston B, Moraten, Edmonston Zagreb,and any other descendents of Edmonston) have never been shown to
be transmissible from a vaccine recipient to a susceptible contact. Except for
the rare instances noted above they have not been responsible for deaths despite the administration of hundreds of millions of doses throughout the world. Before the availability of vaccine, WHO estimates there were 6 million measles deaths annually among infants and children. WHO's estimate for 1999 with increasingly widespread use of vaccine globally was 800,000 deaths. After the successful elimination of polio, measles is next on WHO's agenda for attempted eradication.
In hopes these lengthy comments assist you in your current endeavors, and
please feel free to contact me if there are further questions--Cheers, Sam
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