Two Public Health Interventions Without Much Public Opposition, if Any

Last week, the New York Times reported on protests by anti-vaccine activists in different parts of Canada over vaccination mandates and the new “vaccine passports” being required to attend different venues:

“A crowd rallying against vaccination for Covid-19 clogged the streets outside a Vancouver hospital this week, haranguing and, in one case, assaulting health care workers, slowing ambulances, delaying patients entering for treatment and disturbing those recovering inside.

Kennedy Stewart, the city’s mayor, was among the many people to quickly condemn its members.



As for the anti-vaccine protesters, there’s no immediate sign that they will follow the advice of Vancouver’s mayor and stay home. But they are probably not who they claim to be. The Ontario Hospital Association said that, contrary to the protesters’ claims in Toronto, it believes “that the majority of participants taking part in these rallies were not health care workers.”

It also made it clear that their protests are unwelcome.

“By denying the effectiveness of Covid-19 vaccines they also inflicted moral injury on health care workers who are working tirelessly on the front lines caring for patients sick and dying from this dangerous virus,” the group said. “It is a bitter irony that should any of these anti-vaccine protesters get sick or seriously ill from Covid, it will be hospitals and front line workers that they turn to for care.””

This got me thinking if there has ever been a public health intervention that has been non-controversial. After all, there are people who are opposed to fluoride in the water for a myriad of reasons. In the early 1980s, only about 14% of Americans used seat belts — which had been required to be in cars well over a decade at that time — and they vigorously opposed laws requiring the use of seat belts. And, if you’re reading this blog post, then you know of the long history of the anti-vaccine movement in the United States and the world.

To my knowledge, there have been two public health interventions that have been implemented with little to no social controversy: fortifying milk with vitamin D and fortifying bread with folic acid.

Here is how the National Dairy Council describes why milk has added vitamin D:

“If you’ve ever looked closely at your milk’s label, you may have noticed that vitamin D is added to milk. Why is vitamin D added to milk, you may ask? The story behind vitamin D and milk actually goes back to the early 20th century.

In the 1900s, rickets, a childhood bone disorder caused by not getting enough vitamin D, impacted a good number of children. In fact, around 80 percent of children in Boston had rickets at that point in history.

Around that same time, scientists began to understand the roles milk’s nutrients play in the body. For example, they learned that milk’s minerals, specifically calcium and phosphorus, were key to bone and teeth development.

In 1922, Dr. E. V. McCollum discovered that vitamin D could prevent rickets, because it was needed to help the calcium to get absorbed, so there was a scramble to get vitamin D into the diets of American children. Because vitamin D is not prevalent in many foods, fortifying milk with additional vitamin D was a natural solution, since it also contained key minerals for bone development.

Vitamin-fortified milk began to appear in the 1920s and became more common by the 1930s. Today the milk found in your supermarket is fortified with vitamin D, which has played a role in making rickets now a rare disease in the United States.”

The history of folic acid in bread is similar. When an embryo is developing into a fetus, the part of the body where the spinal cord develops is open. As the embryo develops, that undeveloped area folds closed, protecting the spinal cord from being exposed. That process was found to be dependent on folate, a form of vitamin B. Without proper folate, the neural tube is left open, and the spinal cord exposed. This is known as a Neural Tube Defect (NTD).

In the 1990s, research studies found that women who supplemented their diet with folic acid (a form of folate) before they were pregnant had significantly less risk of delivering a baby with NTD. As a result, the United States government required that flour be fortified with folic acid as a way to reach women of childbearing age. (It should be noted that supplementation must happen before pregnancy because the neural tube closes in the first 28 days of pregnancy.)

Perhaps it is because these two public health interventions had to do with vitamins — albeit synthetic forms of those vitamins in some cases — that there was not much of a social controversy. Nevertheless, these two interventions have similarities to today’s mandates on vaccination and masking in that they are required and/or funded by the government. Unlike what is going on with COVID-19, neither rickets (poor bone development from lack of vitamin D and calcium absorption) nor NTD are infectious. Then again, rickets and NTD hurt children, and that is something that has historically moved societies to unify and act against the danger.

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