Book Review

The War against Hepatitis B: A history of the international task force on hepatitis B immunization

N Engl J Med 1995; 333:1718-1719December 21, 1995

Article

The War against Hepatitis B: A history of the international task force on hepatitis B immunization
By William Muraskin. 248 pp. Philadelphia, University of Pennsylvania Press, 1995. $29.95. ISBN: 0-8122-3267-4

This is the story of the International Task Force on Hepatitis B Immunization and the four men who founded it and led its efforts to introduce immunization against hepatitis B to developing countries where hepatitis B virus is most endemic. As such, the book portrays only one aspect of the war against hepatitis B. It largely ignores the many important earlier battles fought and won by scientists in the laboratory or field that laid the groundwork and provided the technical infrastructure that made the efforts of the task force possible. Nonetheless, the book attempts to provide a view of the labyrinth of issues that surround the introduction of a high-technology, expensive vaccine to poor countries, which can least afford but most need it. This is a worthy effort, since these issues are not limited to hepatitis B but apply to several other vaccines and will be encountered with many new vaccines in the future.

Muraskin has made an impressive effort to investigate original sources and dissect the complex milieu within which the task force was founded and began its operations. He has extensively documented his work with a large number of footnotes, many of which make interesting reading. However, the final product is a human portrait of these four pioneers and their single-minded dedication to worldwide immunization against hepatitis B, painted by a man who himself appears to be deeply involved with the struggle against this virus. The author's own bias emerges early in the book: he decries the absence of efforts to restrict the lives and occupations of potentially infectious carriers of hepatitis B surface antigen (HBsAg) and implies a conspiracy of silence on the part of the American health care community with respect to what he considers to be the “pandemic” spread of this potentially deadly virus. He also roundly criticizes the large commercial vaccine manufacturers for the “exorbitant” price charged for the plasma-derived hepatitis B vaccine at its introduction. On the other hand, he displays almost limitless enthusiasm for the efforts of the task force that led the charge in introducing this vaccine to developing countries.

What one might hope to find in this book, but does not, are dispassionate considerations of the many complex issues surrounding the potential quarantine of HBsAg carriers and the array of forces that result in the prices charged for vaccines by their manufacturers. Also lacking is a discussion of the multi-tiered pricing structure that has developed within the international vaccine market, in no small part as a result of the activities of the task force, and the implications of this pricing structure for future domestic and international development and use of vaccines. The book focuses on the human interactions involved in the task force's activities and provides only a brief description of the plasma-derived hepatitis B vaccine manufactured in Korea by the Cheil Sugar Company, which was extensively promoted by the task force in its early days. The author does not discuss the merits and potential liabilities of this vaccine in comparison with the more expensive vaccines manufactured in the West, although these were important issues at the time. Finally, Muraskin's report is somewhat biased by the primary source of much of the material he presents — that is, the files of the Program for Appropriate Technology in Health, which served as the administrative locus for the task force in Seattle. This has resulted in a somewhat U.S.–centered view of the efforts to introduce hepatitis B immunization to the world, with the result that the efforts of others (for example, the role of the Australian government in supporting early demonstration projects) receive less attention than they should.

Despite these limitations, the book makes an interesting evening of reading. Although it may suffer from attempting to record a chapter of history that is too recent and not yet complete, Muraskin's report should be read by anyone who is interested in immunizing the children of the world against other potentially preventable infectious diseases.

Stanley M. Lemon, M.D.
University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7030