Michael Dwyer, author of Strangling Angel, discusses Diphtheria, cover-ups and the childhood immunization programme in Ireland.

Strangling Angel was inspired by the work of Dr Jack Saunders, Chief Medical Officer to Cork City, Ireland, from 1929 to 1956. Saunders’ annual reports give a unique insight into the challenges faced by a new cohort of public health doctors on the frontline of health service provision in early to mid-twentieth century Ireland. These records reveal the extraordinary origins of the childhood immunization programme in Ireland and they locate Cork city as the unlikely European frontline of the bacteriological revolution. Saunders’ alliance with the British pharmaceutical giant Burroughs Wellcome gave him access to cutting-edge, yet highly experimental, anti-diphtheria serums which were field trialled among institutional children, and among the wider child population in Cork.

Even close engagement with the statistical record relating to infectious disease in Ireland could not justify Saunders’ radical intervention, nor would it offer any rationale as to why the first home-grown Irish government opted to introduce and actively promote a national anti-diphtheria immunization programme. Despite the distinct absence of diphtheria from the historical record Strangling Angel shows that the disease was a prolific child-killer in eighteenth and nineteenth-century Ireland. The early chapters of the book attempt to rescue diphtheria from obscurity and to re-establish its reputation as ‘the most dreaded disease of childhood’. The ‘strangling angel’ of children, that showed scant regard for status and infiltrated Europe’s royal palaces as well as her slums and hovels. A sinuous disease, diphtheria very often took every child in a household and regularly decimated the child population of entire communities.

The long period of disruption attendant on the First World War, the Irish Revolution and subsequent Civil War left the newly independent Irish state with a seriously compromised system of public health administration and service provision. In 1923, the reconstitution of the Ministry of Local Government as the Department of Local Government and Public Health demonstrated that the incumbent Cumann na nGael administration had set improved health services among their first national goals. When the collection of statistical data relating to infectious disease resumed, it became clear that infectious disease in general, and diphtheria in particular, was endemic throughout the country. A new cohort of public health doctors, trained in modern public health interventions in America, were recruited to take charge of public health administration and service provision in every county.

In New York, William Park and Abraham Zingher had demonstrated the effectiveness of combating high levels of diphtheria among school children by administering anti-diphtheria prophylactic as a preventive measure. Although active immunization found advocates in Europe, a strong anti-vaccination lobby ensured that laboratory interventions were not adopted in Britain. In Ireland, the Cumman na nGael government eschewed the reticence of their British counterparts, took their cue from the American experience and adopted and promoted anti-diphtheria immunization. This is noteworthy. It demonstrates that Irish officials and medical officers readily abandoned traditional sanitarian approaches to disease control and embraced new public health methodologies to protect child life. Furthermore, it demonstrates that when it came to public health, the Cumman na nGael administration were not as conservative as the historiography suggests and did not always adopt the British stance on any given matter.

Before the establishment of a stand-alone Department of Health in 1947, the quality of health service provision depended on the efficacy, or otherwise, of the County Medical Officer. Although the Department of Local Government and Public Health actively promoted anti-diphtheria immunization in a bid to completely eradicate diphtheria the decision to implement immunization schemes rested with the local Medical Officer in each county. The wider medical community in Ireland retained their colonial affiliations and continued to view Britain as their professional compass. Furthermore, the wider and more conservative medical profession viewed the new cohort of public health doctors with suspicion. They saw them as a threat to their medical authority, and to traditional income streams, and did not readily support active immunization. The national childhood immunization programme was not readily accepted by the medical community in Ireland: the necessary components to ensure a successful intervention did not combine organically. They were forged through conflict and tragedy.

The most tragic and disturbing incident centred on the Ring College immunization disaster in 1936 when a routine anti-diphtheria immunization scheme resulted in twenty-four children contracting Tuberculosis and the death of a twelve-year-old girl. The historiography relating to the Ring incident is unanimous in its verdict; that Burroughs Wellcome mistakenly supplied a vial of live Tuberculosis in lieu of anti-diphtheria serum. However, Strangling Angel presents new evidence which strongly suggests that an elaborate cover-up of criminal proportions, designed to protect the beleaguered local doctor Daniel McCarthy, was mounted by his advisors, some of whom were senior medical practitioners. The initial cover-up of the immunisation accident itself left the affected children without the close medical attention which they required, and a child fatality ensued. Attempted criminal interference by McCarthy’s advisors failed to halt a coroner’s inquest into the death of the child, and a concocted verdict exonerating McCarthy and laying the blame squarely on the shoulders of Burroughs Wellcome was subsequently returned by a local jury under the influence of the college authorities.

When the subsequent high court case failed to uphold the charge levelled against Wellcome, or to apportion blame on Dr McCarthy, an ambiguous verdict decimated support for established childhood immunisation schemes in Ireland, and the incident was adopted by the anti-vaccination movement in Britain as a warning against the implementation of immunisation schemes there. Furthermore, the Ring incident was hijacked by the Irish Medical Association to support their monetary claims for increased remuneration for providing immunisation services. When minister Sean T. O’Kelly refused to budge on the matter, the medical association withdrew their immunisation services stating that no clarification had been forthcoming on the issue of indemnity relating to the use of anti-diphtheria antigens. As agreement on indemnity or remuneration could not be reached, the medical union maintained their withdrawal of immunisation services for over ten years: until an intervention by Minister Noel Browne settled the matter in 1948. This whole debacle, a direct result of the Ring incident, impacted adversely on the health and life expectancy of infant and child populations in districts far from Ring College.

In 1941, pandemic diphtheria spread across war-torn Europe. By the time the disease reached Britain and Ireland it had taken over one million child lives. The severity of the infection in Britain forced health officials there to perform a volte face, and to introduce a national programme of anti-diphtheria immunization. In Ireland, diphtheria re-appeared in levels not witnessed since the pre-immunization era. Parents were faced with a tough decision. To expose their children to a rampant and potentially fatal disease or to subject them to a compromised immunization programme. By 1944, mounting diphtheria fatalities focused minds and municipal health clinics were overwhelmed by parents seeking to have their children immunized.

Strangling Angel: Diphtheria and Childhood Immunization in Ireland 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.