NYU Press, 2016. 336 pages.
A timely intervention into recent anti-vaccination controversies, Jennifer Reich’s Calling the Shots unpacks the logics behind vaccine refusal through interviews and ethnographic studies of parents who refuse vaccinations. Eschewing the reductive stereotyping and dismissive condescension that vaccination proponents like Paul Offit have tended take, Reich adopts a generous approach to these parents by exploring their uniquely fraught experiences of decision-making and risk management on behalf of their children. The central tension animating vaccine debates is between what Reich calls “individualist parenting” and the communal responsibilities of public health. American biomedicine has been increasingly defined by individual choice and personalization, values which often stand in direct opposition to public health’s investment in populations and collective wellbeing. Transformations in American health culture since the nineteenth and twentieth centuries “repositioned expertise as residing within the individual” and refigured bodily autonomy as “synonymous with freedom” (16). Yet, as Reich makes clear, this freedom is not universal, and the consequences of certain individual choices disproportionately affect those who may not have the privilege of such choices at all. At stake in this “uneven landscape of parental choice” is how the individualist paradigm of parenthood that places one’s children first ultimately “overrides a commitment to community responsibility and social justice” (19). As Reich points out, many of the parents interviewed failed to acknowledge “how their personal choice comes at the expense of other children” (234).
Vaccination, a medical technology which requires administration by medical professionals, structures a unique encounter between these professionals and parents who actively reject biomedical expertise in favor of their own forms of knowledge. Parents, particularly mothers, face numerous social pressures to be informed guardians of their children, and as a result, see themselves as the adjudicators of health decisions like vaccinations. Throughout Reich’s interviews, mothers figure themselves as those who “most intimately know their own children, understand their unique health statuses and vulnerabilities, and believe that they can most accurately estimate risk” (70). This exemplarity is further exacerbated by American medicine’s preoccupation with patient autonomy and informed consent, both of which do not require medical training or the same level of expertise as their caregivers. Parental beliefs in the uniqueness of their children and their own singular access to that uniqueness prompts “an individualized risk-benefit calculus for each child” toward the acceptance or refusal of vaccines (81). Reich reminds us that “the choice not to vaccinate is seen in solation from the other strategies parents adopt,” but in truth, it is “one choice among a broad landscape of other choices parents make: about schools, religion, nutrition, neighborhood, youth sports, or discipline in the broader context of their children’s lives” (90). While healthcare providers may offer statistical justifications for the specific benefits of a vaccination, parents often find that information irrelevant or secondary to their own evaluation of their children’s specific needs. Contextualizing vaccination within a larger ecology of parental decision-making reframes vaccine refusal less derisively in terms of “ignorance” or “anti-intellectualism” and more compassionately in terms of the complex process of risk mitigation that parents constantly undergo.
Reich identifies two major justifications for vaccine refusal: vaccines as an unnatural form of immunity and vaccines as tied to the profit-making of Big Pharma. As in the case of Hepatitis B vaccines, parents stressed what they perceived to be the unnatural timing of the vaccine, which violated “newborns’ perfect bodies” and disrupted their “natural” development” (102). Crucial to this perspective is a differentiation between natural and unnatural immunity. Parents in favor of vaccine refusal expressed a preference for disease exposure as an identifiable experience that has precedence in these parents’ own personal histories while vaccines, which are artificially produced by pharmaceutical companies and often require boosters, are “at best a necessary evil to be avoided when possible,” especially when there might be adverse side effects (106). The “natural” body imagined by anti-vaccine proponents is self-regulatory and risks becoming debilitated when subjected to external intervention. This concept of the “natural,” which galvanized celebrity-driven movements like “Green Our Vaccines,” underpins vaccine skepticism about the potential for toxic exposure from vaccine contents and safety claims put out by health organizations like the CDC and the FDA who may be controlled by Big Pharma’s multi-billion dollar corporations. Many parents Reich interviewed instead pursued homeopathic, “natural living” approaches to disease prevention in the form of health supplements and dietary restrictions. Particularly useful for understanding the deployment of the “natural” by anti-vaccine proponents is Reich’s reference to the nineteenth-century concept of “therapeutic nihilism,” which she applies to her analysis of the “Slow Vax Movement” or the movement to rejection of the multi-shot vaccination series in favor of fewer vaccines if at all. The nihilistic belief that “the body is powerful enough to heal itself and also that medical intervention or treatment is generally useless or even harmful—that when it comes to medicine, less is indeed more and better” describes a particular form of minimalism touted by anti-vax parents as a safer, more effective way of protecting their children by embracing their natural capacities for immunological self-protection (106). While Reich rehearses familiar assessments of anti-vax reasoning, she reiterates her important claim that “those who question vaccine safety seem invested in individual children, which from the perspective of individualist parenting, is more trustworthy than claims in support of public health” (144). These claims, for parents, are never entirely as innocent or well-meaning as they purport to be but rather complicit in the violation of individual choice under the guise of communal protection.
Parental anxieties about vaccines have recently centered around the vaccine schedule, which the Advisor Committee on Immunization Practices (ACIP) determines as most likely to reduce vaccine-preventable diseases. Parents have expressed dismay at what they perceive to be an increase in the number of vaccines and in the frequency of vaccines given to children at an early age. For Reich, this yet again exemplifies the tension between who gets to “call the shots” in terms of expertise: “Parents know their own children as individuals, while providers read journals, look at population-level data or empirical research about illness and immunity, and draw on clinical experience caring for other people’s children. These are at core different forms of information and different ways of knowing, but are not equally valued by each side” (166). Interview after interview featured parents who felt deeply neglected, disrespected or distrusted by their own healthcare providers who claimed to be invested in the wellbeing of their families. This fundamental epistemological disconnect continues to animate tensions between parental consumers and health professionals whose perceptions of risk and benefit are based on entirely different, often incompatible ways of knowing.
“What do we owe each other?” Reich asks in the book’s conclusion, which speculates on next steps for finding a middle ground between pro- and anti-vax positions. While remaining mostly restrained throughout her book, Reich calls out in this final section what she sees as the dangerous hypocrisy of vaccine refusers:
Vaccine resistance then represents an individual sense of entitlement to use public resources without shared responsibility to others. As parents claim individual expertise and the right to make their own choices, they do so while continuing to claim that their children are entitledto public resources like publicly funded education or use of public spaces like parks, while opting out of public obligation (237).
For Reich, this selective participation in public life while still expecting access to community resources is untenable and ultimately a violation of the social contract. I was surprised to see so little engagement with this rhetoric of the social contract, which Reich admits that, “outside the vaccine context, there are few places where our social contract with each other is debated so regularly and openly” (238). The relationship between immunity and the social has been the subject of many recent scholarly works in the history and philosophy of science that compose what Andrew Goffey has called the “immunological turn.” Reich’s impulse to “strike a balance” in the way vaccine resistance is discussed by focusing on the perspectives of parents could have been significantly nuanced by intertwining those perspectives with analyses of immunological and public health discourses that are permeated by the social. Because Reich eschews a focus on scientific knowledge-making, she does not trace how the rhetoric of individualist parenting draws from a much longer history of political concept-metaphors underpinning immunological theory (i.e. self/nonself, natural/unnatural).
While Reich goes on to offer practical suggestions that might build trust in vaccines from greater transparency in vaccine production and policy to revising our contemporary culture of parental blame, she misses several opportunities to better historicize the phenomena that she attributes to contemporary parenting like the complex ways in which risk has been imagined and negotiated. Reich’s brief opening section on the “public history of vaccines” gestures toward the ways in which state-sponsored vaccination programs have historically infringed on individual rights, but clarifying how these exercises of state power, particularly compulsory vaccination, challenged the very terms of the social contract would have empowered this assessment of anti-vax hypocrisy. If, as Roberto Esposito has argued, the Western social paradigm is an immunitaryone, the tension between individual and public seems intrinsic to the social contract in its inception, a point that Ed Cohen makes in his genealogy of immunitydating back to political theorists like Locke and Hobbes. “These broader questions of trust, community, individuality, and shared responsibility” on which Reich puts pressure in her ethnographic work merit equally broader conceptualization beyond the contemporary moment.
Travis Chi Wing Lau completed his Ph.D. in English at the University of Pennsylvania and is a postdoctoral teaching fellow at the University of Texas at Austin. His research interests include 18th- and 19th-century British literature, the history of medicine, medical humanities, and disability studies. His academic writing has been published in Eighteenth-Century Fiction, Romantic Circles, Digital Defoe, Disability Studies Quarterly, and English Language Notes. His creative writing has appeared in Wordgathering, Glass, The New Engagement, Nat. Brut, Matador Review, Impossible Archetype, Hematopoiesis Press, and Rogue Agent. His chapbook, The Bone Setter, was recently published with Damaged Goods Press. He currently serves as an editor for The Deaf Poets Society and a reviews poetry for publications like Up the Staircase Quarterly and Tupelo Quarterly.