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Others had religious or ideological concerns. Adherents of naturopathic or alternative medicine, for example, opposed all traditional medical treatments (many of which were actually toxic), used alternative treatments based on plants or water, and believed in the need to keep the body pure. For this group, vaccination was “just another form of toxic medicine coming into your body,” Durbach said.

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An anti-vaccination caricature from the UK in 1907 shows a doctor vaccinating a patient against smallpox, using a lancet to poke multiple holes in the patient’s face. Quack treatments including a bottle of brandy on the table beside the doctor suggest that vaccination is another quack treatment by physicians of the time.

Still others, meanwhile, were worried that the government was essentially experimenting on them by requiring vaccines. Working-class people, who at the time lacked the right to vote in England, were especially skeptical that the government really had their best interests at heart. “There’s a lot of pushback against the idea that people should have to do something that the government is telling them to do, when they are not actually equal and free citizens,” Durbach said.

Anti-vaccination protests swept the country, with activists waving signs with messages like, “Better a felon’s cell than a poisoned babe.” Vaccine opponents distributed pamphlets with titles like, “Vaccination, a Curse.” Ordinary people engaged in forms of “grassroots subterfuge” to avoid vaccinating their children, Durbach said. Some moved shortly after giving birth so that public health officials couldn’t track them down; others paid doctors to issue false vaccine certificates. Some even tried to suck the vaccine out of their children’s arms after it was administered.

It didn’t help public confidence that the new vaccines, while in theory safer than inoculation, could be dangerous in practice. The vaccine was highly effective, with the smallpox death rate among children dropping by 50 percent in the years after the mandate was passed.

However, the way it was administered could cause its own problems. Public health officials used lancets or scarification devices equipped with blades that “shoot out and make these multiple incisions all at once,” Durbach said. Doctors didn’t yet understand the importance of sterilizing instruments and would often use the same instrument to vaccinate multiple children in a row, leading to infections. “You have kids whose arms are dropping off,” Durbach said. “Kids are dying.”

All of this led to intense anti-vaccine sentiment, both in Britain and in the US. British anti-vaccine activists actually sent representatives to the States, where cities were introducing their own vaccine mandates, to help launch a similar movement there. They found fertile ground, with opposition to organized medicine and a focus on purity and avoidance of “toxins” gaining popularity in the US as well. Similar attitudes spread in France, Canada, and elsewhere; an “international anti-vaccination movement” took shape in the 19th century, Durbach said.

 Smith Collection/Gado/Getty Images
An anti-vaccination caricature from France in 1907 shows a demonic, disheveled doctor using a lancet to vaccinate a young child against smallpox. The illustration bears the sarcastic title “Le Triomphe D’Inoculation” (The Triumph of Inoculation).

Things got better. Then they got worse again.

This movement didn’t last forever. To begin with, government officials in the US and the UK began to introduce exemptions to the mandates. In 1907, for example, the British government began granting exemptions to the smallpox mandate to pretty much anyone who applied for one. “That ends the movement almost overnight,” Durbach said, “because there’s really nothing, at that point, to be able to argue against.”

As the 20th century wore on, meanwhile, many Americans began to have an increased respect for doctors and organized medicine, said James Colgrove, a professor of sociomedical sciences at Columbia and the author of ​​State of Immunity: The Politics of Vaccination in Twentieth-Century America.

The middle of that century was “a high- water mark for trust and respect in medical science,” Colgrove said, thanks to “a whole slew of dramatic medical advances” — not least the polio vaccine, which inspired far less pushback than smallpox vaccines had a century before. These advances did not benefit all Americans equally, and Black, Indigenous, and other Americans of color were often ignored or victimized in health care settings. However, media coverage often extolled the virtues of new drugs and treatments, sending a message of general progress even if that progress wasn’t available to all.

Meanwhile, something else was happening in Britain: the creation of the National Health Service. The UK went from “a society in which working-class people feel targeted by the government and by medicine” to one in which “people are getting medical care for the first time for free,” Durbach said. The creation of the NHS helped usher in a “profound cultural shift” in which “people are much less suspicious of things provided by the government,” including vaccines.

The middle of the 20th century wasn’t a time of unalloyed public health progress, however. In 1932, the United States Public Health Service began the now-infamous Tuskegee experiment, in which researchers monitored hundreds of Black men with syphilis without actually treating their disease. Even after an effective treatment — penicillin — became available in the 1940s, researchers continued the study, only stopping in 1972 after more than 100 men had died from syphilis or complications of the disease.

 National Archives via AP

Men involved in the Tuskegee experiment pose for a photograph in Tuskegee, Alabama, in the 1950s.

The experiment, rooted in the racist idea that Black men’s bodies were fundamentally different from white men’s, is often cited today as an explanation for vaccine hesitancy in Black communities, but it’s more complicated than that, says Karen Lincoln, a professor at the USC Suzanne Dworak-Peck School of Social Work who has studied health disparities.

In reality, Tuskegee was far from the first instance of medical racism targeting Black Americans, nor would it be the last. The history of American medicine is full of examples like Tuskegee, dating back to slavery — for example, J. Marion Sims, known by some as the “father of modern gynecology,” conducted painful and invasive research without anesthesia on enslaved women. Racism in medical settings continues to this day, with discrimination a major driver of the high rates of maternal mortality among Black Americans, along with other health disparities.

Alongside the longstanding racist abuses in the medical system, a number of other events led to a slow erosion of trust in vaccines during the late 20th century, Colgrove said. In the 1970s and ’80s, several highly contested studies suggested that the pertussis vaccine (then called DPT) could cause brain damage. The research received significant media attention, with one TV documentary colorfully titled “DPT: Vaccine Roulette.”

Then, in 1998, British physician Andrew Wakefield published a study of 12 children that purported to suggest a link between the MMR (measles, mumps, and rubella) vaccine and autism. The study has been thoroughly discredited — Wakefield was found to have manipulated his data and lost his medical license, and subsequent research has found no link between vaccines and autism. But as Julia Belluz reported at Vox, media outlets covered the study with excessive enthusiasm and credulity, helping fan the flames of anti-vaccine sentiment.

The Wakefield paper also came out just as the internet was coming into wider use, Colgrove said. It was an unfortunate historical coincidence — a new piece of misinformation being released “at precisely the moment when this new medium for the spread of misinformation and conspiracy theories was really taking off.”

Wakefield’s discredited research and the media coverage and online conversation around it helped kick off the contemporary anti-vaccine movement. That movement grew throughout the 2000s thanks to a combination of factors, including a rise in anti-government sentiment and the emergence of a social media environment that tends to amplify conflict and controversy, Colgrove said.

 Daniel Berehulak/Getty Images

Flanked by supporters, British gastroenterologist Andrew Wakefield and his wife Carmel arrive outside the General Medical Council in London, England, on July 16, 2007. Wakefield was accused of gross misconduct and was believed to have caused a measles epidemic in the UK by claiming that the MMR vaccine made millions of children autistic.

Anti-vaccine sentiment has come to a head again during the Covid-19 pandemic, with protests and rhetoric not dissimilar from the opposition to the smallpox vaccine in the 19th century. Anti-vaccine demonstrators march in cities around the country, carrying signs protesting government overreach or bearing false warnings about the dangers of vaccines. Just like in the 1800s, people who are skeptical of traditional medicine or who embrace natural “wellness” worry that vaccines are unnatural or contain toxins.

Some people even try to “undo” their vaccines after complying with vaccine mandates, much like the parents who tried to suck out their children’s smallpox vaccine 100 years ago. As of January 2022, 16 percent of Americans said they would “definitely not” get vaccinated against Covid-19 or would only get vaccinated if required to, a number that’s remained relatively stable for more than a year.

Public health, though, has come a long way since the 19th century. Gone are the days of vaccinating multiple children with the same dirty knife — vaccination today is very safe, the Covid-19 vaccines have been rigorously tested, and serious side effects are rare. However, just telling people those things is not enough — public information campaigns, though they have had some effect, have not eliminated vaccine hesitancy, according to Goldenberg, the University of Guelph professor.

To combat vaccine hesitancy, we have to understand where it comes from

To reach people who remain unconvinced or uncertain, we may have to turn to the lessons of the past. One key is to look at the root causes of vaccine hesitancy. “The attitudes people have about vaccines generally reflect what they think about the governing structures around them,” Goldenberg said. Anti-vaccine sentiment is often “grounded in some kind of belief that your own interests or your community’s interests are not being well-addressed” by the government.

Think of the working-class Britons who were being told to get vaccinated without being given the right to vote. Those who are distrustful of or outright opposed to vaccines today span demographics and races, and their experiences of government vary widely. However, there may be a similar sense among vaccine holdouts of authorities demanding something without giving much in return. After all, the US doesn’t have a National Health Service like the one Britain established after World War II — many Americans don’t have the experience of the government actually providing for their health care needs.

That’s especially true for Black Americans and other people of color, who have faced discrimination both from government agencies and health care providers. Medical racism in America goes way beyond Tuskegee, and it continues today.

To understand vaccine hesitancy and distrust of the medical establishment in Black communities, you need to recognize that “people today are experiencing being dismissed, being underdiagnosed, being overdiagnosed, being undertreated, having a lack of access, living in pharmacy deserts and neighborhoods where there are no health care providers, where there are no mental health care providers, where the quality is poor, where access in general is low because either the services aren’t there, or the services that are provided have lower quality or have practitioners who lack the competency to really understand and relate and serve African Americans,” Lincoln, the USC professor, said.

 Ron Harris/AP

Baseball Hall of Famer Hank Aaron prepares to receive his Covid-19 vaccination on January 5, 2021, at the Morehouse School of Medicine in Atlanta. Aaron and others received their vaccinations in an effort to highlight the importance of getting vaccinated for Black Americans who might be hesitant to do so.

Changing that requires not just improving health care access but also changing the way health care workers are recruited, supported, and trained, Lincoln said. Establishing a health care workforce that’s actually representative of America will require creating pathways for people to become doctors without incurring enormous debt. What’s more, providers need to be trained to think about health at the level of the community, not just the individual, taking into account and addressing the access issues that may prevent people from following health guidelines.

“Without a broader lens, without focusing on the overwhelming majority of factors that really help us understand variation in health, we’re really going to miss the mark,” Lincoln said.

In addition to addressing the causes of hesitancy and resistance, there are vaccine policy issues to consider. Vaccine mandates, for example, have worked in the past — with smallpox, for example, they did increase vaccination and reduce deaths. However, those mandates may need to be coupled with exemptions in order to stem backlash, Durbach, the University of Utah professor, said.

Exemptions need to be carefully calibrated so that they’re not too easy to get — someone should need to have a firm conviction and be willing to expend some effort to get one. When done right, though, exemptions can be effective because “you’re removing the thing that the conspiracy theories theorists rally around,” Durbach said.

An understanding of the past can also inform the one-on-one conversations that physicians, outreach workers, and others are having every day with people who are unsure about or outright resistant to vaccines.

Patients bring a wide variety of histories to these conversations, from reactions to previous vaccines to “​​their own experiences with health care or with institutions more generally and their background in terms of what their family or community has experienced,” said Aaron Richterman, an infectious disease doctor in Philadelphia. That background can include facing racism in medical settings or being stigmatized for a particular disease or condition. For all too many Americans, “their experience historically with health systems is that health systems are not there to help them.”

It’s important to combat that experience by actually offering help, on the patient’s terms. “It often takes building a real relationship with someone and showing yourself to care about someone and to care about what they care about,” Richterman said. “I have my objectives, but it’s about their objectives.” Helping people meet their own health goals can help a physician build trust with patients, which is crucial when talking about something like vaccines. In order to become a “trusted messenger” on such a potentially difficult topic, “you have to try to understand where people are coming from and meet them where they are,” Richterman said.

Unfortunately, in today’s health care system, many people lack a relationship with such a messenger — the percentage of Americans who even have a primary care doctor has been falling in recent years. Making sure people can actually build a relationship with a provider is crucial to encouraging vaccination. “One of the things that really gets missed in the vaccine conversation in the US is how much it really requires that sort of one-on-one,” Richterman said. “People need to be talked to about it.”

 Charles Rex Arbogast/AP

Dr. Rita McGuire, an obstetrician and infection control specialist at Roseland Community Hospital in Chicago, Illinois, speaks with staff members about taking the Covid-19 vaccine on January 29, 2021. McGuire says countering misinformation and mistrust about vaccinations is a daily battle. Many workers ‘’have not forgotten about those studies where they used us as experiments,’’ she said, including the infamous Tuskegee syphilis study.

It’s not only doctors who can forge these relationships, however. Community groups and businesses, from churches to barbershops, that already have a rapport with people in their area, have conducted successful campaigns of vaccine outreach in recent months. “Looking to community partners who have longstanding relationships in communities is really important,” said Rachel Villanueva, president of the National Medical Association, which represents African American doctors and their patients.

Whether in the 19th century or today, it should be no surprise that vaccines, more than other medical advances, require trust and conversation, and sometimes inspire intense resistance.

“People are healthy when you give it to them, and it’s asking them to accept this to protect them from a danger that may or may not happen to them,” Colgrove said. In some ways, communication around vaccines encapsulates the problem of public health as a field: “The benefits that it promises are invisible,” Colgrove said. “When it succeeds, you’re not aware of it.”

The challenge, then, is to convince people to trust the public health system enough that they will accept a treatment whose benefits they may not see right away — or ever. History shows such trust is possible, but it has to be earned. And when that trust is broken, it may take generations to repair.

Some marine biologists say that big projects to clear the oceans of plastic are a waste of resources. A plastic removal system operated by The Ocean Cleanup, a nonprofit, is shown here. | The Ocean Cleanup

Many scientists worry that flashy efforts to clean plastic from the ocean do more harm than good.

Last month, a group of marine biologists noticed something fishy in a video posted on Twitter by a nonprofit called The Ocean Cleanup. “This is likely a staged video,” Clark Richards, a scientist at the Bedford Institute of Oceanography, wrote. “I call bullshit.”

In the 25-second clip, a large net appears to dump 8,400 pounds of plastic waste, including crates, buckets, and fishing gear, onto the deck of a ship. The Ocean Cleanup, which has raised more than $100 million on the promise to rid plastic from the seas, said the trash in the video was just pulled from the Great Pacific Garbage Patch — an infamous region in international waters, between California and Hawaii, that’s polluted with plastic waste.

Richards and several other marine biologists quickly challenged the group’s claim. On Twitter and in media reports, they said that the plastic looked too clean to have been floating for a while in the ocean. There should have been a more visible build-up of marine organisms like algae and barnacles. In response to those allegations, The Ocean Cleanup explained that water in the garbage patch lacks nutrients that marine life needs to grow and shared other reasons why the plastic looked so clean (which some biologists again rebuffed).

The Ocean Cleanup
The Ocean Cleanup empties a net full of plastic from the Great Pacific Garbage Patch on the deck of a ship.

On its face, The Ocean Cleanup’s approach to solving one of the hardest environmental problems appears to be a worthy one. But the whole squabble raises a bigger question about cleaning up plastic in the open ocean: Is it even a good idea to begin with?

Everyone can agree that plastic waste is a scourge. Between 2000 and 2019, plastic production worldwide doubled, reaching 460 million metric tons — and only a small fraction of that gets recycled. The rest is burned, buried, or ends up in the environment, including the sea. Some estimates suggest that by 2050, there could be more plastic in the oceans, by weight, than fish.

But some scientists think that cleaning up the open ocean is a futile, and perhaps even harmful, endeavor. Several marine biologists told Vox that existing methods, including The Ocean Cleanup’s strategy, are inefficient and often produce pollution themselves. Plus, this approach can kill sea creatures — the very animals these efforts are ultimately trying to protect.

Ocean cleanups also do little to address the core of the issue: our dependence on plastic and the steady stream of waste it produces. “It’s like mopping up the spill when the spigot is still on,” Katie Matthews, chief scientist at the nonprofit advocacy group Oceana, told Vox. “We can’t clean up our way out of plastic pollution.”

With a challenge so large, and at a time when climate change and commercial fishing are also threatening marine life, it might seem unwise to shoot down any ideas that could help. But marine scientists told Vox that there are plenty of other solutions that are far more effective — or at least, less controversial — than open ocean cleanups.

The Great Pacific Garbage Patch isn’t actually a patch

The problem with cleaning up the open ocean starts with a pervasive misconception — that there are enormous blobs of trash floating out at sea just waiting to be scooped up. News stories in the 2000s popularized this idea by referring to the Great Pacific Garbage Patch as an “island” of trash. Even today, a Google search of the “patch” reveals images of large expanses of floating waste.

 The Ocean Cleanup
The Ocean Cleanup mapped the Great Pacific Garbage Patch several years ago. It’s a region of concentrated plastic waste between California and Hawaii.

The so- called patch isn’t so much an island as it is a soup, however, in which broken-down bits of plastic are like pepper flakes. Much of the waste is pea-sized or smaller and floats below the surface. That explains why, when you’re there, “it just looks like ocean,” said Melanie Bergmann, a marine biologist at the Alfred Wegener Institute for Polar and Marine Research in Germany, who last visited the region in 2019. The same is true for a handful of other marine garbage patches, which form around gyres — systems of rotating currents.

This is one reason why ambitious ocean cleanup efforts are often inefficient, said Richards, the marine scientist at the Bedford Institute of Oceanography; the large pieces of plastic are spread out and much of the rest is impossible to retrieve. Plus, only about 1 percent of the plastic we dump into our oceans ends up in these kinds of patches (it’s still somewhat of a mystery where the rest goes). So even if ocean cleanups were more efficient, they wouldn’t make a significant dent in the overall waste problem.

Some scientists are also concerned that ocean cleanups could even make certain environmental problems worse.

Ocean cleanup operations can harm marine life

The Dutch inventor Boyan Slat founded The Ocean Cleanup in 2013, when he was 18. Since then, the organization — which counts Salesforce CEO Marc Benioff and tech billionaire Peter Thiel as funders — has tested a few different devices to retrieve waste from the garbage patch. Most of them didn’t live up to the hype.

Today, the organization collects plastic by dragging a shallow net between two large ships. According to Matthews and Richards, the method is not unlike trawl fishing, and so it faces the same problem of bycatch — marine life caught by accident.

It’s hard to collect free-floating plastics without ensnaring fish, turtles, and other animals, said Bergmann, who did her PhD dissertation on bycatch. These creatures often die, even if they’re thrown back into the water, she added. Some scientists also worry that open ocean cleanups harm the organisms that make up an ecosystem right below the ocean’s surface.

 Getty Images

A sea turtle swims near a discarded plastic water bottle.

Matthias Egger, a scientist at The Ocean Cleanup who has a PhD in marine biogeochemistry, told Vox that the group’s approach is “the complete opposite of fishing.” The net is shallow and moves slowly, so that fish can pass underneath it, and there are escape hatches if they get caught, he said. “The main reason why we do what we do is to help marine life,” he added.

The Ocean Cleanup has consulted fishers to make a system that doesn’t catch sea life, he said, noting that it’s still in the research and development phase. However, the group said it has caught a small amount of marine life in its nets before, including sea turtles (which may have been dead before entering the net).

Some marine scientists also point out that using large ships that run on fossil fuels to drag nets through the water pollutes the air and the climate. Two vessels operated by The Ocean Cleanup, for example, release 600 metric tons of carbon dioxide for a month of cleanup, according to the nonprofit — equivalent to about 130 cars on the road for a year. Egger said The Ocean Cleanup aims to develop a system that doesn’t need to be towed by large vessels. Until then, the group says it will offset its carbon emissions and work with its shipping partner, Maersk, to develop more sustainable fuels.

Ridding the sea of plastic with an approach that burns fossil fuels — which are, themselves, used to make plastic — raises additional questions about efficiency, Matthews said. Why not put that investment into something like beach cleanups? “People walking up and down a beach has no carbon footprint,” she said. “The return on investment is much higher.”

Egger agrees that beach cleanups are valuable, but says that conservation isn’t a zero-sum game. Funding The Ocean Cleanup doesn’t necessarily siphon away money away from other projects, he said. Plus, he added, there’s more value in removing plastic in the ocean, where it’s already harming sea life, than picking it up on the beach.

The real way to clear the ocean of plastic pollution

Ultimately, solving the problem of plastic waste requires that companies produce and use less plastic, experts said. Single-use plastics like bags and takeout containers — which have boomed during the pandemic — should be the first to go, Matthews said. “We have decided to use something that lasts forever for something we only need for five minutes,” she said.

Governments around the world have been making progress. Many US cities, including New York and Chicago, ban or tax plastic bags. The European Union went as far as banning single-use plastics outright last summer. And just this week, delegates of the United Nations began working on a global treaty to eliminate plastic waste. “We have seen tremendous progress on negotiations toward an internationally legally binding instrument to end plastic pollution,” the executive director of the UN environment program, Inger Andersen, said in a February 28 statement.

Even if successful, the most ambitious efforts to limit plastic production won’t happen overnight, so there’s still a place for cleanups. “I don’t think that anyone would tell you that you should never pick up trash,” Richards said.

Most researchers agree that coastal cleanups are effective. In 2020, volunteers removed 5.2 million pounds of plastic from beaches around the world in a single day. Perhaps the most beloved solution, however, is Mr.  Trash Wheel. Floating in the mouth of the Jones Falls river in Maryland, it’s a simple machine that intercepts waste heading for Baltimore’s Inner Harbor. (Mr. Trash Wheel is something of a celebrity in the DC-Baltimore area and part of a “family” of similar trash wheels in the region.)

 Courtesy of Waterfront Partnership of Baltimore
A trash-collecting machine in Baltimore, affectionately known as Mr. Trash Wheel.

“There are lots of low-tech tools that get plastic before it reaches the ocean,” said Miriam Goldstein, director of ocean policy at the Center for American Progress, who studied the garbage patch as a graduate student (and has previously criticized The Ocean Cleanup). “Those are highly effective and efficient and cheap.”

Nicholas Mallos, senior director of the Ocean Conservancy’s Trash Free Seas program, agreed. While there’s “absolutely a role for technology,” he said, the science is increasingly showing that removing plastic from rivers and coastal areas is the best and most efficient approach to reducing plastic waste.

The Ocean Cleanup deploys similar river trash collection systems, but the group still sees a place for cleaning up the open ocean. Even if we rid beaches and rivers of plastic, Egger said, there will still be waste floating out at sea and harming marine life. “We should work together on solving this rather than having these arguments,” he said.

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