Eula Biss is best known for On Immunity, her 2014 book detailing the reasons people decide to vaccinate and why some people don’t. Reading it is still, to my mind, the best way to understand the mentality of anti-vaxxers. And yet over the course of a couple recent conversations with her, I noticed something that surprised me: She never used the term “anti-vaxxer,” not even once. It’s a conscious choice, she told me.
“I think it’s misleading,” she said. For one, it’s not an accurate representation of the problem: The number of people who don’t vaccinate at all is smaller than the number of people who undervaccinate or who don’t vaccinate on schedule. For another, she said, “it suggests the presence of a homogenous group of people who are all of the same opinion, and that’s just not the case.” There is no one reason people decide not to vaccinate, Biss said, which suggests that “there is no quintessential anti-vaxxer” or organized anti-vaccination movement.
This is inconvenient for public-health officials, who already have their hands full. In New York City, for instance, Mayor Bill de Blasio declared a public-health emergency earlier this month in response to a growing measles outbreak in a Brooklyn ultra-Orthodox Jewish community; nationwide, experts worry that low vaccination rates are setting the course to make 2019 the worst year for measles in nearly two decades. But the fact that there isn’t a single cause to the problem of low-vaccination uptake suggests that there also isn’t a single solution. A complicated question demands a complicated answer.
The Cut chatted with Biss about measles, how vaccination reminds us of what we owe to each other, and why she’s ultimately optimistic about getting even the staunchest anti-vaxxers — sorry, I mean the vaccine hesitant — onboard.
Are these outbreaks of measles and other vaccine-preventable diseases really becoming more common? Or does it just seem that way because of panicky media coverage?
It is becoming more common. Before we vaccinated, it was entirely common, everywhere in the world, for pretty much everyone to get measles. Most people got it as children — and thousands of people died, and hundreds of thousands of people were hospitalized, and many people were left with disabilities as a result. But, yes, in the last 20 years, the trend is that these outbreaks are becoming more common. That isn’t imagined.
There are lots of factors, but at least one of the factors is that there’s more vaccine hesitancy and less vaccine uptake. Fewer people are getting vaccinated, and fewer people are getting fully vaccinated. And that’s not limited to the United States — right now, there are measles outbreaks all over the world.
I don’t mean to sound callous, but why should we care about measles outbreaks worldwide?
I hesitate to use the word beautiful. But to me, there really is something beautiful about the nature of infectious disease, in that it reveals our deep interconnectedness. Infectious disease anywhere in the world is a problem everywhere else in the world.
These most recent measles outbreaks are a good illustration of that. There’s a major outbreak in Israel right now, and that’s part of how measles got to Brooklyn. And there’s also a devastating outbreak going on in the Philippines — about 200 children have died there. And that’s another way that measles has come into the United States. And it goes both ways. If we have outbreaks, we can also transmit the disease to other countries.
I was reading recently about the 1918 influenza epidemic, which was a worldwide pandemic of influenza. Even people who lived on remote, isolated islands got that strain of influenza. No matter how isolated we might feel, we really are all bodily connected.
That’s interesting you say that, about isolation, because it’s been reported that many of these recent measles outbreaks have occurred within rather insular communities.
Infectious disease blows apart our assumptions about insularity. It’s true that within the last five years, the majority of measles cases have happened in relatively insular communities — a Somali community in Minnesota, an Amish community in Ohio, an Eastern European community in Washington. And I’ve observed anti-vaccine attitudes in my own insular community, which is “women poets who are highly educated and fairly economically privileged.”
A few years ago, The Hollywood Reporter ran a story about low vaccination rates in very wealthy areas of Los Angeles; one of the observations made in that article was that vaccination rates there were as low as some countries like Chad and South Sudan, countries that have little access to medical care. At one time, I was thinking of vaccination more in terms of privilege. But it’s more that one of the aspects of privilege is that you tend to circulate among other privileged people. There is an insularity to privilege, too.
Within communities where people believe themselves to be living apart from the mainstream — and I’m speaking from my own experience here — you can begin to have the illusion that you really are living apart and that your actions alone may affect your community but won’t reverberate beyond it. When the reality is no such community exists when it comes to infectious disease. A disease, once it’s moving within a community, will never stay solely within that community. What I failed to appreciate, before I started researching this deeply, was the consequences for people who weren’t like me.
What helped you see it differently?
I was on a public playground with my young son, who was vaccinated but not fully, just because he wasn’t old enough yet. And a group of children arrived who were from a nonprofit day care that was dedicated to high-risk kids, who were poor, or victims of abuse, or had developmental disabilities. And as my son was playing among these children, I was thinking about how incredibly wrong it would be if my son passed a disease to one of these kids, who already had all of these life challenges.
This was already on my mind — I was already writing about vaccination, and I was beginning to think about this concept of a “community of contagion.” In my own life, I frequently refer to various communities; I refer to writers as my community, for instance. But the community of contagion is different from some of these more self-selected communities; it’s everyone you come into contact with. And that’s what was illustrated to me on that playground: Oh, this is our community of contagion. These are the people my son would infect were he to be carrying a disease.
For me, there are social-justice issues behind vaccination. But I couldn’t get there until I stopped thinking about it as an individual choice and started thinking about it as a collective responsibility.
And that’s something we’re not always so great at doing in the U.S.
There’s this amazing fact that’s a little mind-boggling to me: You’re more likely to catch an infectious disease if you’re a vaccinated person in a totally unvaccinated community than if you’re an unvaccinated person in a totally vaccinated community. Vaccination is not all that effective if only one person does it, but it’s incredibly effective if nearly everyone does it.
But in order to achieve that affect, we need to reach consensus on vaccination. For a disease like measles that’s highly contagious, the percentage of people who are vaccinated needs to be in the upper 90s.
But how do you communicate that across subcultures and value systems?
Just as there are many different reasons people decide not to vaccinate, there are many reasons people decide to vaccinate. In my case, the fear-based appeals to vaccination don’t have a tremendous effect on me. I was raised by a doctor to feel fairly confident in my body’s resilience, and I’m not hugely susceptible to ways of communicating about vaccination that depend on people being scared of infectious diseases.
But what is an affective appeal for my particular value system is the argument that I could, through vaccinating myself and my child, prevent people who are more vulnerable than me from being exposed to disease. It’s the moral and ethical appeal that is highly effective for me.
The challenge of vaccination has some interesting commonalities with the challenge of addressing climate change. That’s another area where we need consensus in order to effectively address the problem. And as impossible as it might seem, I really do believe that it can happen.
I was in South Africa last year, when Cape Town was approaching their Day Zero — they were going to run out of water entirely. But Day Zero didn’t happen, because the city so effectively reduced their water usage. And that was because of collective action. People were not flushing their toilets, or were flushing them every seven to nine uses and using reserve shower water to flush — so that means catching their shower water in a bucket, and using that bucket to flush the toilet.
One person doing that doesn’t actually make a difference at all, right? Like, I can not flush my toilet, and it will have zero effect. Just as one person vaccinating really doesn’t do anything meaningful for disease worldwide. But everyone in a whole city not flushing their toilets has a real, measurable effect.
But what are the challenges for the U.S. in reaching that kind of consensus? You said our social structures are not set up for it, and I tend to agree.
In the United States, our political structures don’t operate by consensus; they operate by majority. Which means we accept that there will also be a minority opinion — people who feel themselves to be outliers from the majority will behave differently than the people around them. It’s part of our diverse society. But when it comes to something like climate change or vaccination, it’s not functional for us to have a few pockets of people who are not participating.
Years ago already, the research was showing us that there is no homogenous vaccination movement and that the reasons why people don’t vaccinate are quite diverse. And so we need a fairly diverse way of approaching the conversation. Instead of using a blanket strategy for the entire country, it’s communicating to various different communities on their own terms.
And I don’t think that consensus is a utopian ideal, by the way. I think it’s something we can achieve. But it’s going to take a kind of conversation that we’re not yet having.
Right now, the tone the conversation often takes is something you could call the “because science!” argument — it’s condescending, first of all, but it also tends to be fact-based instead of feelings-based. Why might that not be an effective persuasion strategy, simply giving people the information?
People who have an anti-vaccine stance and people who have a pro-vaccine stance are often working with at least some of the same information. I don’t think it’s a problem of misinformation; it’s a problem of analysis.
Recently, I was giving a talk, and a woman in the audience said to me, “Well, in Japan they don’t use the MMR combined vaccine.” And she was using that as evidence of, Another country has determined that we shouldn’t use combined vaccines. I’m not even sure that’s true, I haven’t looked it up. [Ed.’s note: According to the Japan Times, it is the policy of the country’s health department to inoculate people twice with a measles-rubella combined vaccine.] But even if it is true, her analysis has some flaws to it. There could be a lot of reasons why Japan is not using that particular vaccine in combination. You can give the measles, mumps, and rubella vaccines separately — you don’t have to give them together. But there are economic reasons why some countries do combine them.
So that’s one of the problems with just saying “because science says so” — people don’t have access to the rationale behind the public-health policy.
What would be a better approach, then?
The first part is really understanding what people’s motivations are and not working off assumptions. For instance, I’ve heard some people use the term “religious freedom” around vaccination in the Orthodox community. But not vaccinating is not a religious practice. There’s a little bit of an assumption being made there.
When I was examining my own subculture, I found that one reason people have for not vaccinating is the assumption that it’s toxic. To my mind, this concern is a manifestation of a much more general anxiety about pollution in the environment at large. Because when you really look at sources of toxicity in a child’s life, vaccination is just not a major source; resisting vaccination isn’t a legitimate way to resist the encroachment of pollution in our environment. So communicating with this community would mean getting across that notion and talking to people about their feelings about toxicity and pollution and chemicals.
Another concern is about government mistrust, and this is where we get into the tricky, big stuff around vaccination, and why I think the problem is not going away anytime soon. People are totally entitled to feel mistrust around the medical system, as an opioid epidemic is unfolding in front of us. In a lot of ways, this is earned mistrust. That means that in addressing this problem, we also have to somehow build better governance structures that earn and maintain trust more effectively.
When you get really into how the problem gets solved, it becomes a massive problem with a massive solution.
But it sounds like you’re still optimistic?
I am optimistic! Because I’ve seen it. People will act even against what seems to be their self-interest when they understand the magnitude of the issue and they understand their impact on other people.
I’m thinking of a woman I know, with whom I’d had a disagreement about vaccination when I learned she didn’t vaccinate her children. A couple years later, I ran into her again and she told me that a neighbor of hers had a child who was being treated for cancer and had a suppressed immune system — even exposure to something like chicken pox could be extremely serious. She said it had never occurred to her that her unvaccinated children could be dangerous to another child in a situation like that. And that was it — she went straight out and got them vaccinated. As soon as she understood what the ramifications were for her wider community, she reversed her decision.
So I’ve seen people change their minds. And I’ve changed my mind, too.