When the U.S. Environmental Protection Agency in September cited Volkswagen with programming 11 million cars to evade emissions standards and tests, the first thought of author Eula Biss was unusual: “This is going to be really bad for vaccination.”
Unusual for most people, but fairly typical of Biss, a lecturer at Northwestern University who will speak as part of Augustana College’s River Readings series on January 14. Her 2014 book On Immunity: An Inoculation is about vaccination, but it starts with the story of Achilles and touches on vampires, the environmental classic Silent Spring, semantics, Alice’s Adventures in Wonderland, anti-bacterial soap, paternalism and sexism in medicine, Kierkegaard, and New Coke among many, many other things.
The Volkswagen scandal fits right in, because – as Biss explains in the book – fear and skepticism of vaccination are nothing new and are now often rooted in a distrust of government and corporations. So when there’s an instance of corporate malfeasance that government was slow to catch, she said in a recent phone interview, it reinforces concerns that people have about vaccinations.
“I discovered really quickly that part of the reason that conversations around vaccination are so heated is that we’re often not just talking about vaccination when we’re talking about vaccination,” she said. “It’s like that fight between spouses about dishes that is really not about the dishes. ... There are all kinds of conversations about feminism and government and capitalism and the environment going on underneath the surface of this conversation about vaccination.”
Arguments and Empathy
To be clear, Biss chose to vaccinate her son – who’s now nearly seven – on the recommended schedule. (It was his impending birth that sent her down a five-year rabbit hole of vaccination research that became On Immunity.)
And the book strongly argues that mass vaccination is a public good because of what’s called herd immunity. “Any given vaccine can fail to produce immunity in an individual, and some vaccines, like the influenza vaccine, are less effective than others,” Biss writes. “But when enough people are vaccinated with even a relatively ineffective vaccine, viruses have trouble moving from host to host and cease to spread, sparing both the unvaccinated and those in whom vaccination has not produced immunity. This is why the chances of contracting measles can be higher for a vaccinated person living in a largely unvaccinated community than they are for an unvaccinated person living in a largely vaccinated community.”
Biss admitted that her prose style is naturally “associative,” but she takes pains in the book to directly address myriad objections to vaccination.
Sometimes she’s unequivocal, as when she refutes one mother’s concern in late 2009 that a vaccine for the H1N1 flu virus contained squalene. There is no squalene in American vaccines for children, Biss flatly states in the book. (An adult vaccine against the H5N1 flu virus with squalene was approved by the U.S. Food & Drug Administration in late 2013.)
However, she argues that squalene isn’t the sole source of anxiety; it reflects the larger issue of additives used in vaccines: “We regard any exposure to chemicals, no matter how brief or limited, as harmful.”
She also acknowledges that some fears about vaccines simply cannot be allayed with facts or science, as when she discusses the concern of many parents that the measles, mumps, and rubella (MMR) vaccine causes autism. “What vaccines do not cause ... is significantly harder to establish than what they do cause,” she writes. “While a substantial amount of evidence is acceptable as proof that an event does and can happen, there is never enough evidence to prove that an event cannot happen.” Still, she writes, a 2011 report reviewing 12,000 studies of vaccination “‘favor[ed] rejection’ of the theory that the MMR vaccine causes autism.”
But Biss does not present concerns merely to knock them down. Early in On Immunity, she rhetorically asks: “Do we believe vaccination to be more monstrous than disease?” The answer for many people is “yes,” and the bulk of the book explores why.
“Fears of vaccines do not seem easily quieted by an abundance of expert risk-benefit analyses assuring us that the good they do is far greater than the harm,” Biss writes.
And that 2011 report indeed concluded that vaccinations do cause rare “adverse events” including “measles inclusion body encephalitis” (from the MMR vaccine) and anaphylactic allergic reactions. From 2006 through 2014, 2,068 claims were paid through the federal government’s no-fault National Vaccine Injury Compensation Program, which is designed to pay people for serious side effects related to vaccination. In that same period, more than 2.5 billion doses of vaccination were distributed in the U.S.
Yet anxieties surrounding vaccination are far more expansive than the limited harm the government and medical establishment have acknowledged. Biss summarizes: “We fear that vaccination will invite autism or any one of the diseases of immune dysfunction that now plague industrialized countries – diabetes, asthma, and allergies. We fear that the Hepatitis B vaccine will cause multiple sclerosis, or that the diphtheria-tetanus-pertussis vaccine will cause sudden infant death. We fear that the combination of several vaccines at once will tax the immune system, and that the total number of vaccines will overwhelm it. We fear that the formaldehyde in some vaccines will cause cancer, or that the aluminum in others will poison our brains.”
Even the language we use with vaccinations can have an effect. The key concept of herd immunity is already difficult for many of us to understand, and the word choice itself produces a negative reaction. “You really can’t understand the impetus for mass vaccination ... unless you fully grasp what herd immunity is,” Biss said. Yet “there’s something essentially distasteful in that term ... – this idea that they’re following the herd or becoming part of a herd or being herded toward something. And I do believe that the language we use changes the way we think.” (In the book, Biss also notes the bovine origins of the word “vaccine.”)
Despite her pro-vaccination conclusion (to the limited extent that On Immunity can be considered a polemic), a defining feature of the book is Biss’ curiosity about deep-seated fears, and her empathy for those who have them – regardless of whether she believes they’re grounded in fact or science. She dedicated the book to “other mothers,” and she said that “I wanted to write a book ... by a woman addressed to other women with deep respect for their intelligence, because I felt that that was part of the damage that was being done in this wider discussion. Women weren’t being given credit for being thinkers and for being smart.”
Biss said that since the book’s publication, she’s regularly been asked by doctors how to deal with people who are hesitant to vaccinate their children: “‘They really don’t want to trust vaccines or the government schedule or the medical establishment. What can I do?’ The answer they want is the right phrasing, the right way to say it to their patient, so that the patient will be convinced. And the more I get that question and the more I think about it, the more I think there’s very little a single medical professional can do. I think that there’s actually huge systematic reform that needs to happen before you can expect every patient who walks in the door to trust ... the medical establishment and the government both.”
Using the examples of Volkswagen and price-gouging in the pharmaceutical industry, she said: “I think it’s totally reasonable – and logical even – for an individual to think, ‘Okay, I actually probably can’t trust these systems that are producing this vaccine.’”
She continued with a general proposal for increased government regulation: “Vaccines actually are one of the best-regulated consumer products we have. But it’s hard to make someone believe that when they see a lack of regulation in almost every industry around us. ... It won’t be until we have much better consumer protections and regulation in general that people will start feeling comfortable injecting something into a healthy child that they don’t fully understand.”
That’s problematic, however, given that many people who oppose vaccination do so at least in part out of anxiety about government.
Inviting Human Error
On Immunity feels essential to the vaccination debate – a succinct (160 pages of core text in the hardcover edition), provocative, and sometimes poetic examination of the historical, scientific, and cultural context from which myriad contemporary perspectives flow. Biss entered the project with questions and followed where they led, and it’s a rare pro-vaccination work that doesn’t treat those opposed to the practice as crazy or ignorant.
It’s rich and thoughtful and a joy – particularly in seeing just how seemingly far afield Biss will go, and how she’ll relate (often by mere implication) apparent digressions back to her core topic. (Again: New Coke.)
Yet Biss’ prose demands careful attention. On Immunity is accessible and easy to read, but it’s also elusive and hard to digest; the meaning is often found as much in the spaces between paragraphs as in the paragraphs themselves.
I say this to emphasize that the book is many things, and there are many things it is not. I’m skeptical people will change their minds about vaccination because of it. It certainly won’t satisfy those demanding detailed documentation of research to support its assertions, although Biss includes 24 pages of notes and 11 pages of “selected sources.”
And people seeking linear argument (or even linear thought) on the topic of vaccination will likely be disappointed, and the author said that some readers have indeed found the book frustrating and confusing. That’s exacerbated by On Immunity having 30 short sections with no obvious structure.
“It’s set up to be driven by what is to me a kind of logical or intuitive movement between ideas,” Biss said. “So when I was writing the book, I did a lot of rearrangement. ... I was constantly rearranging these sections to try to get to the place where one idea led to another idea somewhat naturally and organically. That’s what produces that sense of stream-of-consciousness, even though it wasn’t written that way. It didn’t all come out in the order that it’s now arranged.”
Biss added that she and her editor had an epiphany while trying to work through whether the approach made sense.
“I always assumed from the beginning that these shorter sections would collapse into one another, and that they would somehow magically become one continuous work,” she said. “And that didn’t happen. And toward the end of the process, I was getting increasingly nervous about that not happening. And my editor was asking me questions that I couldn’t answer. Like ‘Why is this the structure of book?’ and ‘Why don’t these sections have titles?’ and ‘Why haven’t some of them been grouped together as chapters?’ Fair questions to ask when an author is nearing the end of writing a book.”
But they ultimately recognized that the somewhat-challenging formal approach was itself a metaphor for society – and thus the concept of mass immunity. “One of the central ideas and the central arguments in this book is not about vaccination strictly, but it’s about the relationship between us as human beings in a society and our bodies,” Biss said. “And it’s about this idea that we are physically, bodily interdependent. And that idea kind of contradicts a lot of ... our Western training, which is this idea that our bodies are 100-percent independent and unique and individual. ... Yes, we are individuals, but we’re highly interdependent individuals.
“I realized that’s what the structure of the book is mirroring. These sections are each their own highly individual moment. ... [But] none of them can really stand alone. This I found to be true when I tried to publish some of these sections as stand-alone pieces. Editors wouldn’t take them at magazines and journals, because they don’t actually stand alone. The comment that I heard back from editors again and again was ‘This doesn’t feel finished.’ And no one of those 30 sections actually is finished without its companions.”
The book’s density is apparent at the outset, with a contradiction whose inclusion might seem puzzling.
“The first story I ever heard about immunity was told to me by my father, a doctor, when I was very young,” On Immunity begins. “It was the myth of Achilles, whose mother tried to make him immortal.” Yet two pages later, Biss corrects herself: “The story my father told me when I was young was not the myth of Achilles, he reminds me now, but another ancient story.”
The author said she learned of this problem too late in the writing process to correct it, largely because Achilles was a much better fit for her book than that other story. But she also said her mistake was appropriate: “Part of what I wanted this book to explore was ... human fallibility ... . We all know that human error is embedded in everything that humans do, and I think that’s part of the fear and anxiety behind allowing a perfectly healthy baby to be vaccinated – this idea that you’re inviting human error into that baby’s body.”
Trust the Untrustworthy?
Biss said that, among mothers she knows who don’t follow the recommended vaccination schedule, the reasons for that choice vary.
“There’s a good number of people I know who do not vaccinate or selectively vaccinate as a political statement – for purely political reasons,” she said. Sometimes the politics are anti-corporate, sometimes they stem from what’s seen as a corrupt medical system, and sometimes they’re related to the ingredients in the vaccines. Some mothers, she said, are “desperate to try to reduce the amount of toxicity that their children are subjected to.”
Still others, she said, distrust government – whose role in vaccination ranges from regulation of vaccines by the Food & Drug Administration to the Centers for Disease Control & Prevention’s recommended schedule to requirements for vaccinations prior to entering school.
Contemporary concerns about compulsory vaccinations, Biss said, are similar to those in Victorian England: “It was a time and place when people were really trying to work out what the role of government was going to be in people’s lives. And I do think that’s a question that has become attached to vaccination, and that is an ongoing question that we’re going to have to try to continue to figure out ... .”
In the book, she writes: “Debates over vaccination, then as now, are often cast as debates over the integrity of science, though they could just as easily be understood as conversations about power. The working-class people who resisted Britain’s 1853 provision for free, mandatory vaccination were concerned, in part, with their own freedom. Faced with fines, imprisonment, and the seizure of their property if they did not vaccinate their infants, they sometimes compared their predicament to slavery.”
Beyond people with specific concerns, Biss said, many people have an amorphous resistance to vaccinating their children: “What they feel is just a generalized dis-ease around vaccination. This is the person who would come into the pediatrician’s office and say, ‘I just don’t feel comfortable with it.’”
And she said she herself has gotten upset when her son has been vaccinated, despite favoring mass vaccination: “Even though we know what we know and we’re convinced that vaccination is doing good in the world, when we’re actually in the doctor’s office seeing the needle penetrate our child’s body, we feel very emotional.”
Given the varieties and intensities of fears about and objections to vaccination, Biss said, it was important to make her factual and scientific points bluntly – even though it was sometimes an unnatural departure from her normal approach: “I’m still an associative writer ... and you can still see it on the page, but I made some major stylistic changes that were difficult for me as a writer and really challenging because there were places where I could not allow ambiguity. ...
“That was frustrating to me as a writer because sometimes it felt to me less like the kind of writing that I enjoy doing – less lyric, less indulging in that ambiguity that I found beautiful. But part of the project of this book was to think about my own style of thought ... . There were many places where I had to overtly articulate my point, and that is totally painful for me.”
Her normal mode is to knit together disparate elements, and the subject of vaccination lent itself to that, with the foundation for fear and anxiety coming from so many different places: concerns about sexism, corporations, industrialization, government, bodily integrity, impurity, pollution, individualism ... .
“The project of this book,” Biss said, “was to ... unknit those associations and say, ‘Okay, just because you believe capitalism is a bad thing doesn’t mean that you can’t use a product of capitalism to prevent people from dying.’”
And yet Biss concedes that her book ultimately puts too much responsibility on the shoulders of families making vaccination decisions, and not enough on the sources of their discomfort. She said that the essayist Maggie Nelson evaluated the book late in the writing process, and that her criticisms stung: “I knew it was true. And I’m still convinced that it’s true. I just didn’t have time to fully write my way out of that problem in the book. ...
“She felt that I put too much onus on the individual in this book, and too much onus on an individual person to come to terms with [for example] our government and its problems, or with the history of sexism [in medical care], and to just take a leap of trust. ... She said that she feels that the government has done things that actually warrant a total break in trust. And the onus should be on the government to reform to the point where it can be trusted – not on an individual to trust an untrustworthy institution. And I think there’s a lot to that.”
Eula Biss will speak on Thursday, January 14, at 7 p.m. in Augustana College’s Wallenberg Hall (inside the Denkmann Memorial Building).
For more information on Eula Biss, visit EulaBiss.net.