An epidemic and social taboos

Dangerous Pregnancies

University of California Press, 2010 392 pp., hardcover, $29.95 9780520259034 | ISBN: 978-0-5202-5903-4

Perhaps the most accurate view of current events is through the 'retrospectoscope,' for those who live through them often do not perceive their long-term importance. At least that thought came to mind while I was reading Dangerous Pregnancies by Leslie Reagan. The author is a historian who writes about the repercussions of the rubella epidemic that struck the US in 1964–1965. At the time, I had just returned from the UK to open a laboratory at the Wistar Institute in Philadelphia, expressly to work on rubella. Two preceding events had opened the way for me: the isolation of the virus in tissue culture by Thomas Weller, and separately by Paul Parkman and his associates and my clinical experience of the disease, which was frequent in the UK during the spring of 1963. By that time, the discovery by Norman Gregg of the teratogenic power of rubella virus in infected pregnant women was two decades old and common knowledge.

Soon, I was immersed in the laboratory performing two separate tasks: viral diagnosis in exposed pregnant women and attenuation of the virus to develop a vaccine. The vaccine strain eventually developed is the one used today throughout the world, which has resulted in the elimination of rubella from the Western Hemisphere and Scandinavia, and in its control elsewhere. However, my experiences on the diagnostic side were more poignant. Women were referred to my lab because at the time viral diagnosis was primitive and not readily available, yet physicians and mothers had to make decisions about pregnancy termination, as rubella infection causes, among other, ocular, auditory and cardiac abnormalities in the fetus. The anguish that accompanied those decisions was apparent, and, as one sympathetic to a woman's right (and a couple's right) to medical abortion, I was glad to help. However, it seems I failed to appreciate the significance of the epidemic to society as a whole.

Dangerous Pregnancies describes the history of rubella, considered to be a minor rash disease, from its early description in the eighteenth century by German physicians (hence the English eponym 'German measles'), through its importance in differential diagnosis of eruptions in the nineteenth century and to its recognition as an agent of fetal defects in the middle of the twentieth century. The author acknowledges the mothers of infants with cataracts whose discussion about the rubella they had in early pregnancy was overheard by Gregg, but she doesn't give him sufficient credit for making the mental leap to convert gossip to scientific fact. Reagan also exaggerates the early opposition to Gregg's hypothesis about rubella being teratogenic, which was simply scientific skepticism pending confirmation by other workers.

However, Reagan well describes the fierce opposition in some quarters to medical abortions given to women who were diagnosed with rubella during pregnancy. She recounts several legal battles that arose from abortions done or abortions refused and how they resulted in relaxation of abortion rules before the Roe vs. Wade decision of the US Supreme Court in 1973 at last struck down all barriers. I had forgotten that, in California in 1968, several physicians were convicted of malpractice in a suit brought by the state attorney general. Fortunately, that decision was reversed. In another instance, a physician from Minnesota who purposely precipitated a 1970 criminal case by performing a medically indicated abortion was mercilessly prosecuted and lost her license.

Reagan gives the rubella epidemic a major role in the liberalization of abortion laws in the US. She points out that in the early 1960s medical abortion was essentially illegal in the US, and few physicians were willing to take the risk of performing one. However, the wide distribution of thalidomide in Europe raised the subject of fetal abnormalities caused by the drug, therefore heightening awareness of possible environmental effects on fetuses, and the threat of congenital rubella, which posed a problem for families of all races and economic levels, created pressure to legalize abortion. The book also describes how some physicians minimized the risk of congenital rubella syndrome to avoid performing abortions, although Reagan does not take into account the uncertainty about the precise level of risk before virologic diagnosis was available to confirm rubella infection in the mother. Studies performed during the epidemic eventually showed that the risk of fetal abnormality after confirmed infection in the first trimester is between 50% and 90%, but much lower figures were advanced earlier.

The essence of Reagan's thesis is that, as noted in the book, “the fear of disabilities opened up the first respectful public conversation about abortion in the United States that listened to women telling why they believed they needed an abortion.” She also contends that congenital rubella improved positive attitudes toward people with disabilities, which seems somewhat contradictory. More convincingly, Reagan argues that the rapid acceptance of the rubella vaccine was a first because vaccination was primarily aimed at indirectly protecting fetuses rather than the vaccinated women, girls and boys.

The book would have been strengthened by interviews of some of the people who were involved in the events described, rather than being restricted to archival research, and to me some of the passages verge on parody of political correctness, such as when Reagan inveighs against campaigns to stop pregnant women from smoking and consuming alcohol on feminist grounds. However, the key points relating to the role of the rubella epidemic gave me a new understanding of events that occurred long ago and are useful reminders that disease and vaccination have social impacts as well as medical significance.

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Correspondence to Stanley A. Plotkin.

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Plotkin, S. An epidemic and social taboos. Nat Med 17, 1177 (2011). https://doi.org/10.1038/nm.2509

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