Book Reviews

Eula Biss, On Immunity: An Inoculation, Greywolf Press, 2014

In On Immunity: An Inoculation, essayist and author Eula Biss has given academics and clinicians interested in the public’s skepticism of vaccines, and of science skepticism more generally, a fresh look at what drives these phenomena. Despite public health’s continued success in maintaining high rates of coverage for vaccines across the United States, recent measles, mumps, and rubella outbreaks in the U.S. (and globally for that matter) have harmed lives and indicate cracks in the vaccine uptake façade. From a public health perspective, it’s all hands on deck to make sure vaccine coverage stays high. Biss’s outsiders’ view of these issues offers bioethicists, public health practitioners, and physicians much to consider as we address ongoing challenges to vaccination.

Do not read On Immunity expecting a scholarly analysis of the state of vaccine refusal and resistance. The book is instead part self-reflection (how Biss samples but rejects anti-vaccine sentiments), part observation (the ways vaccines both capture and reflect popular understanding and anxiety about the body, about germs, and about medicine more generally) and part research (into the history of anti-vaccine thought as well as its contemporary impact).

Throughout the book, Biss’s physician father acts as sort of a scientific straight man, laying out both the joys and challenges of medical and scientific practice. In one of these moments, Biss recalls how her father taught her about blood types, and about how both he and she were universal donors. With type O negative blood, Biss would come to understand her universal donor status “more as an ethic than as a medical concept” (18). This belief in a communitarian ethic runs throughout the book. “If we imagine the action of a vaccine not just in terms of how it affects a single body,” Biss writes, “but also in terms of how it affects the collective body of a community, it is fair to think of vaccination as a kind of banking of immunity.” “Contributions to this bank are donations to those who cannot or will not be protected by their own immunity,” she concludes (19).

For those of us who spend time considering vaccine policy, these are obvious points, as are the conclusions to be drawn from them. But what Biss offers its academic readers is a less jargon-filled and stilted way to talk about the importance and fear of vaccines, and thus provides some insight into what we might do to shore up vaccine coverage. One suggestion Biss has is to abandon the term “herd immunity.” In her analysis, it is a negative metaphor, one that “suggests we are cattle, waiting, perhaps, to be sent to slaughter.” “And it invites,” she continues, “an association with the term herd mentality, a stampede towards stupidity.” In its place, Biss suggests the concept of “shared immunity,” rooting the metaphor instead on natural examples like the cooperation of honeybees and collective problem solving. If the herd assumes we are foolish, the notion of shared immunity roots the nature of vaccine coverage in cooperation (21).

Some have read On Immunity as a weak embrace of anti-vaccinationism, if only to have the reader take a taste of it, understand its essence, and be “inoculated” against its impact (Oppenheimer 2014). But I read this book differently. In fact, this is less a vaccine-world Rashamon, and more of an opportunity for scholars and policymakers to view the challenges and mindset of anti-vaccine thought, through the eyes of a sympathetic yet disapproving observer.

Biss’s chapter on how popular misunderstandings of toxicity have seeped into anti-vaccine thought, for example, is especially relevant as policy makers and ethicists consider how to respond to the threats to herd or shared immunity. Fears of toxicity, which she acknowledges is a loosely defined idea in the public’s mind, can at once refer to the ingredients in vaccines, the accumulation of vaccines in the body, or environmental exposures more generally. Biss argues that such references to toxicity by both anti-vaccine boosters and the Gwyneth Paltrow-set “strikes me as an old anxiety with a new name” (75). While she acknowledges the impact and dangers of environmental pollutants, Biss believes that what the pre-germ theory idea of filth once represented “with its moralist air, the evils of the flesh,” today is now expressed in terms of toxicity. “The word toxic,” she writes, is a catch all term that “now condemns the evils of our industrialized world.” Theories of filth and toxicity “allow their subscribers to maintain a sense of control of their own health by pursuing personal purity” (75). This gets played out in a variety of ways, including our search for the “natural,” as well as in vaccine resistance.

An academic reader of the book may also consider Biss’s failure to correct the misinformation that the anti-vaccine community thrives on as a shortcoming, or even fatal flaw of the book (142). I do not share this concern. This book is not meant for the vaccine doubters or resistors who tout their wares on the internet and at alternative medicine conferences. It is instead meant for us: the ethicists, clinicians, and policy makers who are struggling with the challenges we face in an increasingly vaccine resistant or hesitant public. It may well be that the response to anti-vaccinationism is a question of policy and public health ethics: how much should we limit people’s civil liberties to protect the public health. But when I hear studies and pundits suggest that anti-vaccine skeptics are immovable and that we must institute our most draconian policies to preserve our collective health, I find myself the skeptic and worry that we as a field have given up too easily. At the very least, On Immunity offers a retort to this line of thinking, providing vaccine ethicists and policy makers with both rhetorical and practical ways (see above examples about a communitarian ethic, herd immunity, and toxicity) to view and push back against the anti-vaccine movement.

There is one line in the book that continues to resonate with me. Biss writes that “the belief that public health measures are not intended for people like us is widely held by many people like me” (24). While her thinking here is not surprising, it is perhaps the most fundamental challenge to the current anti-vaccine trend. And it is thinking like this that has given largely white, highly educated, and middle and upper middle class families the rationale to resist or refuse vaccination. It is a position of privilege that threatens the public health, a sense of privilege that is not simply the fault of the non-medical public. It is rooted in class and racial tensions that Biss highlights. In a visit to her son’s pediatrician, Biss questions the necessity of the hepatitis B vaccine. Her doctor tells her that it is a vaccine for the inner city, “designed to protect babies of drug addicts and prostitutes.” “In retrospect,” she recalls, “I am ashamed of how little of his racial code I registered.” “Relieved to be told that this vaccine was not for people like me,” she concludes, “I failed to consider what exactly that meant” (24).

But that failure is not hers alone. It is our failure—in ethics, in public health, and in medicine. If people continue to assume, as Biss puts it, that public health “is for people with less—less education, less health habits, less access to quality health care, less time and money” (24), then we will continue to struggle with this novel strain of anti-vaccinationism and be threatened by public health challenges that lie ahead.

Michael Yudell
Dornsife School of Public Health
Drexel University
Philadelphia, PA, USA


Oppenheimer, Mark. 2014. “This Book Empathizes with Anti-Vaxxers, Who Don’t Deserve Empathy.” The New Republic. September 29. Full article »