Vaccine Nation: America’s Changing Relationship with Immunization, by Elena Conis

The history of vaccinations in the US has as much to do with politics as medicine, says Helen Bynum

November 27, 2014

Spots, lumps and whoops. I’ve had them all – the jabs, that is. Instead of suffering measles, mumps and whooping cough, my experience of these once-familiar childhood infections was limited to preventative injections. Elena Conis’ Vaccine Nation made me realise that my complete vaccination record is a code. It reveals roughly when and where I was born. It tells something of my childhood rung on the socio-economic ladder, but less than it might, since I grew up in the UK with the benefit of universal healthcare under the NHS. It records some choices my parents made and their fears and hopes for me. It indicates a willingness to benefit from herd immunity despite the individual risks attached to each dose of vaccine. Put another way, my parents did what their doctors told them, with the medics following national guidelines.

 

It’s a different code from those we meet in Conis’ well-crafted history of prophylactic vaccination. Her territory is the US from presidents Kennedy to Obama. As power shifted between the Democrats and Republicans, federal provision for vaccination could be likened to a roller coaster. Democrats equal the ups and Republicans the downs, but the reasons for each Democratic drive differed. John F. Kennedy was mired in the Cold War, swayed by scientific hubris and driven by humanitarian concerns for America’s children. If the Russians vaccinated their children, the leadership of the Western world could not be found wanting. In the era of “duck and cover”, diphtheria would spread easily in crowded bomb shelters, and soil-contaminated wounds might result in tetanus. Such threats were used to justify more federal involvement in the health of US citizens.

Conis brings out the complexities of the rise of vaccine-safety and anti-vaccination movements in the US with great skill

Jimmy Carter presided over the later 1970s, an age of rocketing oil prices and economic slumps, when the rising cost of healthcare dominated the news. Among the pro-vaccination arguments was a desire to support the US biotechnology industry and a return to “prevention is cheaper than cure”. Vaccination cost less than paying out for disease outbreaks and long-term invalidism, but as a Southern Democrat, Carter wanted it done through local initiatives. Bill Clinton saw vaccination as a means of showing the American public how government could be an effective force in their lives, rather than an unwanted authoritarian. He wasn’t terribly successful in this wider aim, or in expanding healthcare provision.

The Democrats’ vaccination drives reflected wider ambitions for improving national health, but the target groups remained the same: infants and schoolchildren. It is, as Conis wryly comments, their arms that bear the burden. However, there have been a series of subtle shifts in the relationships between the youngsters and vaccination. These are skilfully dissected through Conis’ readings of medical journals, contemporary medical advice, congressional hearings and women’s magazines such as Mothering. Here mothers found a voice for their growing concerns about the adverse effects of recommended vaccines. Later, the internet and social media platforms joined the mix. This focus makes Vaccine Nation a different history from those that concentrate on the laboratory and the biological characteristics of our microbial enemies. The author’s broad concern with a range of vaccinations also complements single-disease histories and allows her to weave these strands together.

Initially, vaccination protected children against serious diseases that could cause death or lifelong disability. Polio led the way. The rhetoric began to change with vaccines against mumps and German measles. Once perceived as trivial illnesses, they were recast as more serious conditions. This risk-heightening exercise referred to the complications that sick children faced, but crucially the emphasis shifted to the effects of these diseases on adults. Mumps can render men sterile and German measles damages the unborn fetus. Fully vaccinated children would protect not only the recipients and their cohort but also the otherwise unprotected adults with whom they came into contact. Everyone stood to benefit, and in ways that increasingly reflected the changing nature of society. Economic productivity mattered, so keeping the workforce healthy was deemed a laudable goal. With an increasing number of working mothers, technologies that reduced the amount of time they had to take off to nurse sick children were welcomed.

The list of available vaccinations grew, and there was also a trend to bundle them for ease of delivery. New acronyms entered the medical and parenting lexicon: MMR (measles, mumps, rubella) and DPT (diphtheria, pertussis and tetanus). There was a commensurate increase in the profits of the companies that developed vaccines. Conis smells more than one rat in the huge sums involved when federal funds bought mandated vaccines. The relationships between the parties were too cosy and the lobbying too powerful.

No book on vaccination can ignore the rise of vaccine-safety and anti-vaccination movements. Conis brings out their complexities in the US with great skill. People have refused to have their children vaccinated for disparate reasons. She ties their concerns even-handedly into some of the broader protests and anxieties of the past 40 years. Out of the feminist rhetoric, for instance, some of which called on women to abandon the traditional roles of homemaker and mother, came an interesting return to “mother knows best”. These were the empowered mothers who felt their children had been damaged by vaccines. They claimed “expert” lay knowledge of dangerous side-effects and opposed the medical experts who failed to listen and/or understand their concerns. One group – Dissatisfied Parents Together – cleverly reused the DPT acronym. They demanded better vaccines and compensation, but not an absolute halt to the concept of vaccination. Others considered vaccination to be polluting and drew links to the insidious effects of DDT on the environment exposed in Rachel Carson’s book Silent Spring (1962). The general idea of foreign matter polluting, corrupting and poisoning the body is an old one, but it gained a new immediacy in the late 20th century. Toxicity fears led to the withdrawal of the mercury-based vaccine preservative thimerosal, although the evidence of harm is equivocal.

Iatrogenesis, the idea that medicine could be flawed and harmful, became a buzzword in the 1970s. Its rise overlapped with a swine flu vaccine that caused serious illness in some of its recipients, was ineffectual and remained unchallenged by an epidemic that failed to emerge. It was a media circus. Conis looks in detail at another event – the role of the print and television media in the unravelling story of autism spectrum disorders and MMR. Succinctly recounting its history, she concentrates on the media’s insidious role in keeping the story running by repeatedly setting up straw men to bring down. The new medium of the internet also played a crucial role, allowing families to communicate with each other and disseminate information, flawed or otherwise.

Vaccine Nation brings vaccine-safety and appropriateness concerns up to date in its concluding look at the contentious human papillomavirus or HPV vaccine. Some strains of the virus cause cervical cancer and male sexual partners can pass it on to women. As Conis recounts, some of the teenage girls prioritised to receive the vaccine were far from being passive recipients; instead, they discussed the vaccination and its promotion directly on social media platforms without the old-fashioned intermediary of parents or medical experts. This is a fine social history of an ongoing story.

Vaccine Nation: America’s Changing Relationship with Immunization

By Elena Conis
University of Chicago Press, 344pp, £19.50
ISBN 9780226923765 and 3772 (e-book)
Published 24 November 2014

The author

A resident of the “well-kept secret” that is Atlanta, Elena Conis shares a home with her husband Justin Remais, “who spent countless hours listening while I worked out what, precisely, was at the root of our collective cultural vaccination unrest”, and “two fully vaccinated dogs, Molly (full name Molecule) and Bailey, who make us laugh on a daily basis”.

She does not, she says, have a favourite city. “But I can name favorite things about a long list of cities: San Francisco for the hills and the way history feels alive there; Atlanta for its trees, food, deep sense of community, and neighborhoods full of bungalows; New York for the bagels and brashness it had when I last lived there, in the 1990s; and Los Angeles for Hollywood stories and palm trees. (But truth be told, if life were long enough, I’d want to live in every US state and a long list of foreign countries, too.)”

Now assistant professor of history at Emory University, Conis was formerly a Los Angeles Times journalist. “I see myself as a full-time academic now, but I’d like to remain one who’s capable of communicating to a public audience. I began to shift away from journalism – and toward academia – because I wanted a career that gave me more time and space to tell complicated stories. But there’s still quite a bit of the journalist in me, interested in the public, truth and unspoken agendas and eager to move from one project to the next without pause.”

Born in Brooklyn and raised on Long Island, she took her undergraduate degree at Columbia University. She observes: “I grew up thinking that New York was the centre of the universe (this is not uncommon among New Yorkers. At the same time, growing up in such a diverse place made me aware of – and curious about – the wider world from a very young age.

“I was also lucky to grow up in a place where it was easy to explore the natural world and develop a fascination with the sciences. As a child, I attended summer camp at the Leeds Pond Science Preserve, where we collected plankton from the Long Island Sound and brought it back to the ‘lab’ for examination under the microscope. I also grew up within reach of the Vanderbilt Planetarium, Brookhaven National Laboratory, and Cold Spring Harbor Laboratory.”

In high school, a teacher took Conis’ biology class to lectures at Cold Spring Harbor Laboratory. “Most may as well have been delivered in Latin for all I was able to understand, but I nonetheless walked away with the feeling that the people at the front of the room were decoding life right before my eyes. I vividly recall a lecture on Huntington’s Chorea that instilled a curiosity about genetics, geography and disease that stuck with me for years.”

She says: “I recall being a reader and a writer as a child. My parents, however, would probably say that they could tell from early on that I was interested in intellectual pursuits. My mother often claims that when I was young I kept her up way past her bedtime on a nightly basis, talking and asking questions about the meaning of life and the ways of the world. I won’t contest this.

“But I would add that as a child, I was also interested in a life of stories. I loved reading stories, writing stories, and telling stories. As I got older, I became interested in analysing and understanding the power of stories, as well as thinking about which stories we choose to tell, which ones we forget, and why. (And what is history but an endless source of stories in need of deeper, more nuanced understanding?)”

Conis says she was “rather torn as an undergraduate. I left high school with a deep curiosity about the life sciences; I was also raised in a Greek American family that viewed college as a ticket to medical (or law) school. So I majored in biological sciences – even though my favourite classes, by far, were my studio art and art history classes.

“I spent hours upon hours on weekends visiting places like the Metropolitan Museum of Art and the American Museum of Natural History, where I sketched and daydreamed about the lives and cultures represented by each painting, sculpture, artifact and diorama. I may have been academically torn, but I was fortunate to have chosen to go to college in a city where education opportunities outside the classroom were endless.”

On the subject of access to healthcare in the US and Barack Obama’s attempts to reform the system, Conis says, “I do believe that other Westerners (and non-Westerners) are right to be perplexed, if not appalled, by the American healthcare system. And I do believe that powerful private industries, including the pharmaceutical and insurance industries, have been allowed to cause as many (if not more) problems than they’ve been able to solve.

“Obamacare has significantly improved access to health coverage (more in some states than in others, but that’s on the states, not on Washington); it also put some truly important insurance reforms in place. But in so many ways we’re still stuck with the same system, which is expensive, convoluted, and marked by perverse incentives, and puts significant limitations on consumer choice,” she adds.

What gives her hope? “It may sound strange, but history gives me hope. I’m no positivist, but if history proves anything, it’s that things were often worse than they are now in some ways (and better than they are now in other ways), and, if you take the long view, that despite all of our mistakes and atrocities over the hundreds of thousands of years we’ve been on this planet, our species is still here and slowly moving toward a more just and inclusive society.”

Offered the gift of any magical power, Conis says she would opt “to be able to travel through time. Is that a completely clichéd answer coming from a historian?”

Karen Shook

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