COMMENTARY – Variations in Vaccination – Pertussis and the Plain People

By Stanley M. Aronson

MEMBERSHIP in a small religious sect frequently carries unique pleasures but also many singular obligations and burdens.

The Mennonites of the 16th Century, for example, had fashioned a creed which foreswore all hier-archy, indeed all clerical authority except those commandments derived explicitly from the words of the Bible. They repudiated oath-taking as a form of blasphemy and rejected the slaying of humans, under any circumstance, and hence they refused military service. From the time of their origins in northern Switzerland, the Mennonites – named after their religious leader, Menno Simons (1492-1559) – were sorely persecuted, were frequently condemned to death for heresy, and many sought refuge in the Western Hemisphere.

Another Christian sect, later called the Amish, separated themselves from the Mennonites because of certain religious disputes. The Amish (named after Jacob Amin) were also cruelly oppressed, particularly in Germany, and many were martyred. Some, called the Plain People, escaped to colonial Pennsylvania in the 18th Century in response to an offer of asylum by William Penn.

The Amish body of beliefs, crystallized over the years, placed the authority of the religiously abiding family above all other secular powers. Amish taught their children the merits of rigorous simplicity and the contentment of manual work. They allowed their children to attend public school, but only to the eighth grade, which placed them in conflict with many municipal jurisdictions. In 1972, the United States Supreme Court (Wisconsin vs. Yoder) finally declared that it was unconstitutional for state authorities to force Amish children to attend high school.

There are no Amish gatherings remaining in Europe but Amish communities are now established in 19 American states, with the great majority living in Pennsylvania, Indiana and Ohio. The Amish communities are readily identified by their rural locations, their farming skills, their pacifist behavior, distinctive dress, religious creed (with prayer services in the home rather than in churches) and their avoidance of electrical or gasoline-powered machinery. Their children are taught to live close to the soil and not to be influenced by current fashions or frivolities (“Be ye not conformed to the world.”)

There are about 80,000 Amish in the United States, clustered in about 300 congregations. These assemblies are distinguished by both geographic and cultural isolation. And, as a consequence, there is a high degree of intermarriage within these segregated Amish communities.

Long before the dynamics of genetic transmission were clarified, people understood that certain neutral characteristics were regularly inherited, especially when the husband and wife were distantly related. A family, viewing a newborn, might then exclaim: “She has Grandfather Nehemiah’s nose!”

But people also recognized that inbreeding was frequently associated with dismaying characteristics such as developmental disorders in the offspring. Indeed, virtually every religion warns of the dangers of inbreeding and denies its blessings to certain closely inbred unions (such as brother-sister marriage). Admittedly, under certain narrowly defined circumstances, such as within some royal families, sibling (endogenous) marriage has been tolerated, but this exemption rarely extends to the general population.

Each minority population with ample numbers of inbred marriages has its own unhappy profile of rare, recessive, hereditary diseases. These diseases are not necessarily restricted solely to these minority population groups but certainly they are encountered more commonly in them (such as sickle cell anemia in persons of African descent, or Tay Sachs disease among Ashkenazic Jews.) And the Amish are no exception.

The Amish have not been shy about their hereditary burdens. Amish community newspapers frequently carry descriptions of these hereditary diseases written, as letters to the editor, in utterly candid prose. For example, there is a form of inherited albinism, sometimes called xanthous albinism, largely confined to the Amish. The albino trait is not as fully expressed as in conventional albinism, and many of the affected Amish offspring develop bright yellow hair rather than the usual white hair of albinos.

Yet other genetic disorders which are substantially more common amongst the Amish include a form of dwarfism with very short fingers and rudimentary fingernails (the Ellis-van Creveld syndrome). Geneticists have also found clusters of cases, amongst the Amish offspring, of a rare metabolic disorder in which the body can no longer metabolize glutaric acid, resulting in an excess of this substance in the blood stream, with enduring damage to the developing nervous system. Still other genetic abnormalities include anomalies of the fifth finger.

But beyond the unhappy legacies of inbreeding there are yet other problems faced by communities with idiosyncratic beliefs concerning preventive health measures. Amish doctrines do not forbid vaccination, but neither do they actively promote vaccination nor encourage periodic pediatric visits for their offspring. As a result, the children of most Amish communities are less protected from vaccine-preventable childhood infections than the general pediatric population of the United States. A sample survey in one Amish community disclosed that 72 percent of children had no vaccinations (against diphtheria, tetanus, pertussis, polio, measles) and 5 percent had no follow-up booster shots.

The Amish communities are characterized by a robust sense of family loyalty, self-sufficiency and avoidance of such health- diminishing factors as cigarette smoke and alcohol. But the Amish children are nevertheless vulnerable to a tapestry of childhood infections. For example, there is a small Amish community in Kent County, Del. which, last year, experienced an outbreak of pertussis (whooping cough) amongst its children. Of the 1,711 children in the community, 345 (20 percent) came down with pertussis with, fortunately, no deaths. This same community experienced a number of pertussis outbreaks during the previous decade, thus resembling the cyclic endemicity of the disease prior to antipertussis vaccination programs.

Pertussis (as well as measles, polio, diphtheria and other vaccine-preventable diseases), in the United States, is now confined largely to immigrant children and children who are members of small religious communities that discourage vaccination.

Stanley M. Aronson, MD, a weekly contributor, is dean of medicine emeritus, Brown University. E-mail: smamd@cox.net.

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PHOTO: An Amish family near Fennimore, Wisconsin.

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