Transcriber: Imaan Khandwala
Reviewer: Elisabeth Buffard In 2008, I was a speaker at a conference
in Berkeley, California. At dinner one night, one of the conference organizers mentioned that her youngest children
had never been vaccinated. I must have had a look
of astonishment on my face, because the other speaker
broke in quickly, as if to forestall any disagreement
among us, and said, “That’s a personal family decision.” At the time, I thought to myself,
but I did not say, I don’t think
it’s a personal family decision. I think it's a public health decision. Around the same time,
I noticed that colleagues of mine with children born after 2000 were nervous
when their kids got vaccinated. So I wanted to understand
these two phenomena, how people a lot like me, but who had kids
about a decade younger than mine, were nervous about vaccination
in a way that I had never been, and how something that I thought of
as a routine public health measure could be framed
as a personal family decision. Vaccination protects individuals
from illness and communities from spread. When people are protected
from severe disease, both they and their communities benefit. Individuals avoid suffering expense,
personal and family stress. Health systems are not overburdened
and social disruption is minimized. But not everyone agrees that the goal of community protection warrants intrusion
into people’s personal health decisions. For those who champion personal
liberty over the common good, or who believe the common good
is best attained through personal liberty, individual rights present a challenge
to community protection. This conflict between the individual
and the public good is at the heart of vaccination
controversy throughout history. The public good side of the equation
motivates compulsory measures to protect populations. But compulsory measures infringe
on people’s bodily autonomy. And vaccination,
unlike other public health measures like public sewers or clean water, is a medical procedure
that is performed on people’s bodies. As a result, people have protected
their bodily autonomy throughout history by violently protesting
compulsory vaccination. In the 19th century in Britain
and the United States, there were riots
against compulsory smallpox vaccination. We should not imagine that vaccine
resistance in our own time period would be any different, because competing notions
of the good remain. And this is one reason why scientific evidence
will not adjudicate this conflict. Because it is not
primarily about evidence, but about which notion
of the good should prevail. Another conflict
in vaccination controversy pits a view of vaccines as harmful against a view of vaccination uptake
as an ongoing public health crisis. Stories of vaccine harms
and vaccination crisis are both persuasive,
but to different audiences. Vaccine injury is a personal story
of harm experienced for the greater good. It is framed as a harm that is authorized
by the government and meted out on the bodies
of innocent people, especially children. Vaccination crisis, on the other hand,
is a public health story that frames each incidents
of infectious disease as a dangerous outbreak and every drop in vaccination rates
as a dire threat to public health. The language of crisis has become
the automatic go-to rhetoric to communicate the dangers of letting up
on vaccination efforts. But this language of crisis
makes it difficult to see containment of infectious disease
as a public health success. Instead, there’s always a focus
on disease incidence and the dangers of non-vaccination. Heralding containment
as a goal of vaccination programs would allow us to tell a different story
about the public good of vaccination. We could talk about
high enough levels of vaccination that are demonstrated by successful
containment of infectious disease, but the ongoing sense of crisis means that its vaccination rates
are never good enough. They could always be better, and those who don’t vaccinate are represented
as risking everybody’s health, rather than acting responsibly
on their own beliefs. The result: two incommensurable viewpoints, one which sees vaccine harms
for individuals and the other which sees disease harms
for communities and populations. This incommensurability
contributes to a lack of trust. Some people don’t see
the government or public health as having their best interests at heart, and they lack confidence
that health care works in their favor. On the flip side, public health officials
are frustrated with communities that lag in vaccination attainment, just as they are frustrated
with the lack of a shared vision of population health. These two basic conflicts
in vaccination controversy are joined by two more
philosophical issues: one which considers people’s responsibility
toward one another, and the other which thinks of illness
as a constitutive aspect of being human. There are more and more people
with immunocompromising conditions, in part due to new classes
of biological drugs that treat autoimmune diseases by suppressing the immune system, and in part due to increasing use
of chemotherapies that damage the immune system
temporarily or more permanently. Of course, many people
benefit tremendously from use of these medications, but there are social consequences
for communities based on how these medications work
and the expectations that they engender. People who are immunocompromised
are susceptible to infection, and because they often do not respond
robustly to vaccination, they are vulnerable to infectious disease. They can be protected when enough people in their communities
are vaccinated. But this begs the question: what is owed to people
with immunocompromising conditions ? Who decides what risk to the self
is acceptable for the sake of others? This concern about vaccination, that it causes some people
to be responsible for the health of other people whose vulnerability
is caused by treatment, is a concern about iatrogenesis
and medicalization. Iatrogenesis means illness
that is caused by medicine and medicalization describes a world in which people
are increasingly dependent on drugs, doctors, and health care
just to live normal lives. Medications that cause people
to be sick in other ways, through so-called side effects,
are iatrogenic. The requirement
that healthy people be vaccinated in order to protect
those who are immunocompromised demonstrates medicalization. Both the iatrogenesis and medicalization
are resisted by people who think that forms of modern medicine
make us sick rather than well. Resistance to medicalization
can be traced back to the anti-psychiatry movement
of the 1950s, and has been studied in sociology
since at least the 1970s. Vaccine dissent draws on this history, criticizing the enlarging
social authority of medicine and emphasizing
alternative views of health. From this perspective, requiring somepeople to be vaccinated in order to protect the health of those
whose vulnerability is iatrogenic forces those people into processes
of medicalization that are dangerous and risky. In a 1926 essay called On Being Ill, British author Virginia Woolf
used two metaphors to describe the experience
of being healthy and ill: the upright and the recumbent. When one is ill, she wrote, one is removed
from the army of the upright. Those people who go to work
and sustain civilization. When one is ill, one lies recumbent. Perhaps looking up at the sky,
which, she points out, can be illuminating. After all, we don’t look at it
all that often. In other words, getting sick
changes your perspective. It also, she wrote, makes one sympathetic
to the suffering of others. Many people believe that getting sick
and getting better are processes that make one
resilient and healthy. After all, this is a lesson
from basic immunology. A participant
in one of my research studies once described getting sick
as a workout for the immune system. One of my cousins once told me that he would rather get the flu
than a flu shot. He didn’t mean he would rather be
in the hospital on a ventilator than get an influenza vaccine. What he meant was maybe
getting sick with the flu wasn’t such a bad way
to gain immunity from it. Maybe it was better than vaccination. Based on my research,
this is not an uncommon view. The idea that getting sick is part
of what it means to be healthy is linked to the idea that illness
is a part of what it means to be human. From this perspective, to be vaccinated is
to remove the possibility of strengthening the body
through natural illness and strengthening the social body through the sympathetic disposition
that illness imparts. We see this idea expressed
in platitudes like: “what doesn’t kill you
makes you stronger.” as well as in the framing
of disease experiences as journeys. When I ask my students to describe
experiences of childhood illness, they talk about days home from school,
Campbell soup and ginger ale, family rituals, special treatment. While illness is rarely fun,
it is part of our shared story. So when I think back to the conversation
and the concerns that led me to study
vaccination controversy, I see now that the assertion that vaccination
is a personal family decision is just one side
of a long-standing debate. I also see that once the story
of vaccine harms becomes a legible social narrative
of vaccination consequences, makes it easier for parents to see
the potential for harm than the contribution that vaccination
makes to the common good. In the 1990s, several social forces, including an increasing number of vaccines
recommended for children, nudged that discourse of harm
into the mainstream, and then public health
revved up the discourse of crisis because more concerns about vaccines
were being voiced. By the time I started studying
vaccination controversy in the 2010s, this pattern had been fully established. What was also fully established was that people who don’t vaccinate
aren’t following the science. But my research
has taught me to listen for the underlying philosophical issues,
the rhetorical framing, and a disposition toward illness. Focusing on misinformation
as a primary driver of vaccine dissent is distracting. It distracts us
from the existential questions that vaccine resistance points us towards, those fault lines about what risks
individuals are willing to take on, what it means to be
a member of a community, and whether illness is good or bad
for humanity at large, or individuals in particular. Focusing on who's right or who's wrong, or which evidence is true
moves us further into difference, not toward common ground. Addressing those existential questions
could bring us closer. At a time when social rifts are palpable
the most mundane social encounters, a return to those questions
and the values they represent offers an opportunity to consider
how to ensure the public’s health in a pluralist society. Pluralist societies are those in which
people from different backgrounds, different ethnicities,
different religious traditions, different beliefs and perspectives
and opinions live together and govern themselves. Pluralism is a founding principle
and normative goal of the United States. In a pluralist society, assuming that those who disagree
with you are wrong is limiting, because pluralism demands
a heightened responsibility to listen to others,
to learn to compromise, and to live with unresolved differences. And pluralism demands a productive social engagement in order
to make rules about the common good. Given that vaccination controversy
reveals distinct ideas about what constitutes the common good, it is a fitting example
of a social problem that needs people
to come together through difference. It is easy to assume
that the people on the other side the other side are being manipulated
by misinformation. Both vaccine dissenters
and vaccine promoters have their own view of that problem. Pharmaceutical companies can shield
certain kinds of negative data from the public. False claims pervade the internet. These things are true, but focusing on them
does not solve a problem that is rooted in divergent beliefs
about the human value of illness, responsibility toward others, and individual bodily autonomy
in relation to community benefit. Make no mistake, public health
in a pluralist society is challenging. Leaning into difference, at least, has the benefit of identifying
the right problem. It may well be that we would all benefit
from lying down and looking up at the sky, as Virginia Woolf suggested
so many years ago. Thank you.
