American Scientist

ON IMMUNITY: An Inoculation. Eula Biss. vi + 210 pp. Graywolf Press, 2014. $24.00.

The daughter of a doctor and a poet, Eula Biss was raised with an attention to language and a matter-of-factness about illness. Her mother taught her that poetry was about dwelling in life’s uncertainties, and her father taught her to understand the benefits and limitations of medicine. When she was pregnant and starting labor, even the unknowns of delivery left her unfazed. Overnight, this changed. “By the time my son was born,” she says, “I had crossed over into a new realm in which I was no longer fearless.”

Biss’s book about the vaccination debate, On Immunity: An Inoculation, seeks less to argue the science than to examine the language and stories infusing the discussion. As a new mother, Biss relates to those who seek to protect their children by refusing vaccination. Although she decided to vaccinate her own child, she did not make the choice lightly.

The anti-vaccination movement has a long history, one that has been rekindled in the last decade by a 1998 study linking measles-mumps-rubella vaccination to autism—a study later found to be based on data fabricated in response to a lawyer’s bribe. Although vaccinations are known to prevent disease, no one can be 100 percent sure that they will not harm some recipients. “Risk perception may not be about quantifiable risk so much as it is about immeasurable fear,” Biss writes. “Our fears are informed by history and economics, by social power and stigma, by myths and nightmares.” We fear the unknown, and those fears are shaped by our experiences and culture.

Tellingly, Biss opens the book with the myth of Achilles, whose mother’s attempt to protect him leaves an infamous vulnerability. In many of our stories, parents are tricked into taking a gamble they believe will avert their child’s awful fate but instead create a new one. Vampires, which Biss brings up repeatedly, showed up in our lore around the time the mechanisms underpinning contagious diseases were coming to light. Monsters like Dracula represent not only such plagues but also the transmissible nature of fear.

Biss challenges the reader: “What will we do with our fear? This strikes me as a central question of both citizenship and motherhood.” Over the course of the book, she makes it clear that people acting out of fear can act monstrous. Fear heightens our prejudices and our mistrust of others. But the distinction between self and the mistrusted other can be difficult to define. The author offers as examples formaldehyde, mercury, and aluminum—all substances under scrutiny by vaccination skeptics. She notes that we are exposed to these substances continually through common items and that the amounts already present in our bodies are much higher than the amount received in a vaccination.

“Our breast milk, it turns out, is as polluted as our environment at large. Laboratory analysis of breast milk has detected paint thinners, dry-cleaning fluids, flame retardants, pesticides, and rocket fuel,” Biss writes, noting that if breast milk were sold at the grocery store, some of it would exceed federal limits on DDT and PCBs in food. “We are no cleaner, even at birth, than our environment at large. We are all polluted.”

Public health is a collective venture, Biss argues, and so is a well-informed society. “When one is investigating scientific evidence, one must consider the full body of information. And if the body is large, this becomes an impossible task for one single person. A committee of eighteen medical experts took two years, for instance, to examine 12,000 peer-reviewed articles in order to prepare their 2011 report on vaccine side effects for the Institute of Medicine. . . . We do not know alone.” Every health decision demands a choice in placement of trust.

In addition to her sharp analysis, Biss, a writing professor and author of an acclaimed book of essays on race in America, has a remarkable grasp of language. On Immunity makes connections between the words shrouding the subject of vaccination and what they imply. When we receive a vaccine, Americans get a shot and Brits get a jab. The warlike metaphors do not stop at the act of vaccination. Descriptions of how the immune system works often borrow words from the battlefield; even the vaccination debate is described as a kind of combat.

Scientific understanding of the immune system has advanced beyond a simple zero-sum conflict in which the cells of the self are protected and those of nonself destroyed. There are more microbial cells than body cells inside each of us, and these nonself entities are accepted by the immune system. Only cells marked as dangerous are targeted. When researchers describe the immune system, Biss observes, they typically avoid comparing it to conflict, instead likening it to the solar system, a symphony, or a mother’s watchfulness. “Our understanding of immunity remains remarkably dependent on metaphor, even at the most technical level,” she writes.

The language of alternative medicine routinely embraces a more peaceful tone. “If we feel polluted, we are offered a ‘cleanse.’ If we feel inadequate, lacking, we are offered a ‘supplement,’” Biss writes. “These are metaphors that address our base anxieties. And what the language of alternative medicine understands is that when we feel bad we want something unambiguously good.” The irony here is that vaccination, with roots in folk medicine, is not any more unnatural. “Vaccination is a kind of domestication of a wild thing, in that it involves our ability to harness a virus and break it like a horse, but its action depends on the natural response of the body to the effects of that once-wild thing,” Biss argues. “The most unnatural aspect of vaccination is that it does not, when all goes well, introduce disease or produce illness.”

Throughout the book, Biss exhibits a profound admiration for the process of science. Still, she appreciates that the culture of science and medicine—linked inextricably with heroism, paternalism, sexism, and capitalism—have contributed to the mistrust implicit in the vaccination debate. “Quite a bit of what has passed for science in the past two hundred years, particularly where women are concerned, has not been the product of scientific inquiry so much as it has been the refuse of science repurposed to support already existing ideologies,” she acknowledges. The practice of bleeding came into vogue as an act dramatic enough to justify higher billing, although it killed more often than it cured; obstetricians won over midwives’ patients by slandering traditional practitioners as ignorant and dirty, even though maternal deaths initially spiked because of doctors’ poor sanitation habits.

One of Biss’s important messages is that misinformation spreads when it holds some truth: “Our cynicism may be justified, but it is also sad. That so many of us find it entirely plausible that a vast network of researchers and health officials and doctors worldwide would willfully harm children for money is evidence of what capitalism is really taking from us.” Ultimately, though, this cynicism should take a backseat to ethical considerations when it comes to vaccines.

First among those considerations: Not needing to vaccinate is a privileged position. In the United States, people who refuse to vaccinate their children tend to be white, married, college educated, and have a household income of $75,000 or more. This population is not especially vulnerable to disease, but in the event of an epidemic, this group’s immunity protects vulnerable undervaccinated children, whose parents tend to be black, unmarried, impoverished, and to have moved between states.

“For some mothers I know, a refusal to vaccinate falls under a broader resistance to capitalism,” Biss remarks. “But refusing immunity as a form of civil disobedience bears an unsettling resemblance to the very structure the Occupy movement seeks to disrupt—a privileged 1 percent are sheltered from the risk while they draw resources from the other 99 percent.” Privilege is so rarely brought up as part of the vaccination debate, but Biss presents undeniable evidence that it plays a central role; this argument is one of the most powerful and valuable in the book.

The current rampant mistrust is incredibly sad, yet I found On Immunity inspiring, not discouraging. Rather than addressing arguments head-on and talking past the issues, Biss finds the common ground underlying the full range of individual decisions. In so doing, she gets beyond the polarizing debate and to the heart of what we are really trying to talk about.

Katie L. Burke is an associate editor of American Scientist. She received her PhD in biology from the University of Virginia in 2011.