Rabies as a Social Justice Issue

In the United States, human cases of rabies are very rare, with maybe one or two cases a year, and several of them resulting from exposures outside the country. Human rabies has been brought under control in the United States through a series of programs to control rabies in domestic pets and wild animals and by ensuring adequate surveillance of cases and vaccine supply. Other parts of the world are not fortunate enough to have those systems in place.

According to the World Health Organization (WHO), there are over 59,000 reported human deaths from rabies in over 150 countries. Most of these cases are from bites by rabid dogs, and about half of the deaths are in children under the age of 15. With that kind of mortality, the years of potential life lost must be pretty high, meaning that productivity and other measures of what those people could have contributed to their societies will be greatly impacted.

A. Human deaths from rabies. B. Rate per 100,000 residents of human rabies. Countries in gray have eliminated canine rabies. World Health Organization, 2007 data.

My Experience With Rabies

When I was six years old, a dog that I did not recognize started barking in front of the house. I went up to the dog with my left hand outstretched. The dog bit my hand and held on tight. In retrospect, the whole thing probably took a few seconds, but the memory of it now makes it feel like a lifetime. The dog pulled me forward and dragged me a few meters. Mom and dad ran out of the house, screaming at the dog to let me go. It did, and it ran off.

What follows is still vivid in my mind because trauma works like that. Dad picked me up and took me inside to wash my hand. He then poured hydrogen peroxide over the wounds, making the lacerations sting. To top it off, he went and got “Merthiolate” (a tincture of mercury) to disinfect the wounds. Then mom held me in her arms as dad drove us through town to what in Mexico are called “anti-rabies centers.” These centers are where animals are vaccinated against rabies (mostly domestic pets) and where people who have an “exposure” are taken to get the rabies vaccine. Dad ran inside and then came back out with a nurse and a physician. They took me from mom’s arms and took me inside. My hand was bloody, but most of the injuries were puncture marks instead of tears, with the physician saying that I didn’t need stitches but would need the tetanus vaccine and the rabies vaccine. “Give him the first dose now,” he said to the nurse and then looked at my parents. “He’ll need four more in the next few days.”

When this happened in the mid-1980s, Latin American countries had a big problem with rabies, and some of them still do. The Mexican government set up the anti-rabies centers to serve the public and to keep rabies at bay in the larger cities. The smaller towns didn’t get those centers, but they did get animals vaccinated through annual campaigns to vaccinate pets and freely available vaccines for horses and cattle for ranchers and farmers. The dog that bit me was found a few hours later and died while in quarantine. It was put into quarantine to see if it developed rabies symptoms. It did, and it was euthanized to perform a necropsy. That only increased my parents’ panic over my condition. They both took turns sleeping next to me in the following nights.

On the one hand, I was unlucky to get bitten by a dog exhibiting signs of rabies. Because the owner — a man living down the street from us — did not vaccinate the dog, the dog lost its life and put mine in danger. On the other hand, I was lucky in that I lived in a place in the world where the rabies vaccine was readily available and free to me. Just a couple of years ago, a family in Utah was faced with a $50,000 bill for an exposure to bats that required rabies vaccination. In the United States, few counties subsidize the rabies vaccine for exposures. Many places depend on the person exposed to have health insurance to pay for it, and — as we know from the COVID-19 experience — access to affordable healthcare in the United States is not equitable.

I remember every shot I received because of where it had to be given. Unlike the modern version of the rabies vaccine given in the United States and most developed nations, the vaccine I received had to be given straight into the abdomen. This was because the volume of vaccine given was high, more than could be given into a muscle in the arm or the leg, and because the attenuated (weakened) virus needed a place where it could be picked up quickly by the immune system. Today, the first injection given is a cocktail of antibodies against rabies, and then a series of rabies vaccine is given in the arms over the next month. By the time I got the last shot a few days later, I didn’t mind it very much. As soon as it was done, dad took me to get ice cream.

A Social Justice Issue

Why is rabies a social justice issue? Social justice is “fairness as it manifests in society.” In terms of healthcare, rabies shows the disparities in how to address a 100% preventable disease in places like India, Ethiopia and Mexico. Why do seemingly developed nations in Eastern Europe still have rabies while their neighbors to the west do not? In essence, the investment that would have to be made to eliminate rabies (though not eradicate it) would have a big return due to the productivity from those young people who would be saved. More productivity means more wealth, and a wealthier country in a global economy is always a good thing, right?

Of course, rabies is not the only preventable disease that shows the inequities between and within countries. Measles, which has been making a comeback even in the United States, also follows a similar worldwide pattern as rabies does. Tuberculosis is also concentrated in the poorest countries. For vaccine-preventable diseases, relatively small investments in disease surveillance/testing and distribution of vaccines would have huge returns on investment, and those returns would go a long way toward alleviating other social disparities.

Author: René F. Najera, DrPH

I am the editor of the History of Vaccines site, an online project by the College of Physicians of Philadelphia. All opinions expressed on these blog posts are not necessarily those of the College or any of my employers. Check out my professional profile on LinkedIn: https://www.linkedin.com/in/renenajera Feel free to follow me on Twitter: @EpiRen