I.

 

Carmen slumped into the chair across my desk with a deep sigh. As the manager of immunization at the American Academy of Pediatrics, she had just reviewed and updated the Academy’s immunization website, including an immunization schedule dictating which vaccines children should receive and at what age they should receive them based on years of evidence accepted by the medical establishment.

 

She recounted how every time she checked the site, there were more comments from anti-vaccinators who questioned not only the validity of the schedule but of immunization itself. Anti-vaccinators, she explained, had pointed to the inexplicable rise in autism diagnoses and conjectured a connection to vaccines, or, more specifically, the preservatives used in certain vaccines.

 

Deadly diseases were not an abstract concept to either of us. Both of my immigrant parents are doctors who deal with disease as a profession, and both Carmen, the eighth of eight children of Mexican-American parents, and my father, who was born in Bangladesh and migrated to India, had contracted dengue fever; she as a Peace Corps volunteer in Jamaica and he as a medical student in Calcutta.

 

More than ten years after my conversation with Carmen, there was a measles outbreak in the very place that epitomizes American childhood: Disneyland. The episode was like a subplot in a dystopian novel—a warning knell of outbreaks to come. A harmful disease that had long been under control through effective vaccination programs saw a resurgence in many states due to exemption laws that value anti-vaccinators’ personal beliefs over community safety.

 

II.

 

In her book, On Immunity (Graywolf Press, 2014), Eula Biss brings together different strains of thought and varied perspectives—artistic and scientific, personal and philosophical—to examine our society’s fear of contagion and suspicion of vaccines. In order to do this, Biss draws upon her own research and the research of others, including leading physicians and scientists and science historians, and displays brilliance as a thinker and a writer. But probably her most admirable traits in this endeavor are her honesty and vulnerability as a new mother trying to understand how best to protect her young son.

 

As you read On Immunity, Biss introduces you to some of the key concepts and controversies surrounding vaccines. One of the first concepts we’re introduced to is one that is central to the effectiveness of vaccinations: herd immunity, the collective immunity acquired when a certain number of individuals in that community, or “herd,” have been vaccinated against a disease.

 

“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,” Biss writes.

 

Therefore, in order for a vaccine program to be most effective, members of a community must value public health over individual well-being and, ultimately, must prioritize the greater good over personal choice. A prerequisite for any effective vaccine program is to provide vaccines that are much less dangerous than the diseases they protect against.

 

Despite reams of data from countless studies showing that adverse effects of vaccines are rare and minimal, these fears persist, stoked by a few stalwarts at the center of the anti-vaccine movement. They persist even after the movement’s singular study was debunked and its author, the key physician in the movement, was discredited. Why?

 

“Our fears are dear to us,” Biss contends, writing about the historical, cultural, and personal origins of that entrenched emotion. “When we encounter information that contradicts our beliefs … we tend to doubt the information, not ourselves.”

 

In order for someone to value public health over individual health, they have to see themselves as part of the broader public. This is not the case when people view public health programs as programs for people other than themselves, and, more specifically, people “less” than themselves. Biss herself confesses, “The belief that public health measures are not intended for people like us is widely held by many people like me. Public health, we assume, is for people with less—less education, less health habits, less access to quality health care, less time and money.”

 

Another notion that Biss introduces us to in the vaccine debate is the implication that natural equates with purity, and that man-made equates with contamination. “What natural has come to mean to us in the context of medicine is pure and safe and benign. But the use of natural as a synonym for good is almost certainly a product of our profound alienation from the natural world.”

 

As biological agents made by man and administered by physicians, where do vaccines fall? Are they natural or man-made, benign or toxic?

 

Biss explores both the appeal and the peril of applying the notion of natural to vaccines. “Allowing children to develop immunity to contagious diseases naturally without vaccination is appealing to some of us. Much of that appeal depends on the belief that vaccines are inherently unnatural. But vaccines are of the liminal place between humans and nature … The most unnatural aspect of vaccination is that it does not, when all goes well, introduce disease or produce illness.”

 

I was disabused of any romanticizing of the natural from a very early age. First, growing up in an immigrant family, I was among people for whom everyday life was somewhat unnatural, given that they were separated from their homeland. And yet, the abundant opportunities I had were a direct result of this migration.

 

As a child, I received experimental growth hormone treatment because of a hereditary insufficiency, which put me at risk of not reaching puberty and other health complications. So the notion that natural is always better is not one to which I innately subscribe.

 

What’s more, the value of the natural is not universal; rather, this value is arbitrated by forces that outwardly look global, but inwardly seem neocolonial. My household, like many other South Indian households, regarded coconut oil as a staple. We cooked certain specialties in the oil because of the unique flavor and smell it imparted, and we rubbed it into our skin, scalp, and hair as an emollient, especially during New York’s long winters. Similarly, coconut water was an inexpensive treat bought on the side of the road during summers in India from a vendor who lopped off the top of a tender coconut to reveal the nectar within.

 

But within a few years all that stopped. In the 1980s, flawed scientific information made the rounds claiming that coconut oil, high in saturated fat, was extremely harmful to heart health and cholesterol. So, despite their medical knowledge and their cultural understanding of its significance, my parents, like so many other Indian-Americans, all but abandoned coconut oil. Meanwhile, teased at school for my long shiny braids, I stopped using it for hair care.

 

Three decades later, coconut water and coconut oil have come roaring back: they’re all the rage amongst yoga practitioners and hipsters alike. But its current iteration has been relabeled a premium product: at Walmart, it costs nearly twice as much per ounce as orange juice. It seems like every week, a beauty magazine “discovers” the soothing properties of coconut oil, lauding, as Allure put it, “Unexpected Beauty Uses” for the substance. But worse yet are the unfounded claims that it can serve as a natural alternative to medical treatment for everything from hair loss to heart disease.

 

In many ways, popular attitudes towards coconut oil and vaccines are two sides of the same coin: just as devotees of the “natural” lionize coconut oil for unproven health benefits, anti-vaccinators demonize vaccines for unproven toxicities. In the latter case, the consequences are truly hazardous to public health.

 

A recent research review featured in The Journal of the American Medical Association concluded that “A substantial proportion of the US measles cases in the era after elimination were intentionally unvaccinated. The phenomenon of vaccine refusal was associated with an increased risk for measles among people who refuse vaccines and among fully vaccinated individuals.” In reaction to the research review, a pediatric researcher told Reuters, “What this latest comprehensive review illustrates is that individuals who refuse vaccines not only put themselves at risk for disease, it turns out that they also put others at risk too – even people who have been vaccinated before, but whose protection from those vaccinations may not be as strong as it used to be.”

 

However, given that I first learned of the anti-vaccine movement back in 2003 (almost fourteen years ago), I wonder why such a virulent movement has been allowed to exist and grow to the point where herd immunity has eroded, putting at risk those who are vaccinated and those who aren’t. Why are their personal beliefs prioritized by state and national health agencies above the health and well-being of the rest of our citizens?

 

To understand this, I view the anti-vaccine movement through the lens of our societal attitudes on race and class. Biss speaks to our society’s inherent and outsized fear of contagion being brought into our borders from those regarded as foreign, deemed as other. She notes the historical context for this fear: “Avoidance of outsiders, of immigrants, of people missing limbs, or people with marks on their faces is an ancient tactic for disease prevention. And this has fed, no doubt, the longstanding belief that disease is a product of those we define as others.”

 

Biss goes on to underscore the impact of our fear of contagion from “others": “Our tendency towards prejudice can increase whenever we feel particularly vulnerable or threatened by disease … The more vulnerable we feel, sadly, the more small-minded we become.”

 

We have only to look at the response by many, including the media, to some recent events. For example, when children fleeing violence-ridden Central American countries arrived in droves across the American border two years ago, right wing media raised concerns about the diseases they were bringing with them and portrayed them as “anchor babies.” Even mainstream media outlets, like NBC News, referred to these children using such sterile terms as “unaccompanied alien children,” and other outlets like CNN and BBC discussed these children being “caught” and “apprehended” rather than rescued. Similarly, when the Ebola epidemic was rising amongst countries in Africa, many called for a lockdown of flights to those countries, even forgoing sending aid and aid workers, stating that the risk of bringing back the disease was too high. Ebola, but not its victims, saturated our 24/7 media cycle. Our paranoia overwhelmed our humanity. Thankfully, science and compassion eventually won out and our fickle attention span turned to the next crisis, real or perceived.

 

By contrast, the anti-vaccine movement has remained relatively uncovered by the mainstream media for years, hiding in plain sight. Their members have been viewed as more bohemian and eccentric than threatening or harmful. Anti-vaccine moms are cast as misguided but well-meaning rather than neglectful or selfish. Biss provides some useful insight into the demographics of the unvaccinated: “Unvaccinated children, a 2004 analysis of CDC data reveals, are more likely to be white, to have an older married mother with a college education, and to live in a household with an income of $75,000 or more … Unvaccinated children also tend to be clustered in the same areas, raising the probability that they will contract a disease that can then be passed, once it is in circulation, to undervaccinated children. Undervaccinated children, meaning children who have received some but not all of their recommended immunizations, are more likely to be black, to have a younger unmarried mother, to have moved across state lines, and to live in poverty.”

 

What is especially telling about this data is the stark contrast between the race and class of unvaccinated and undervaccinated children. It underscores dual narratives: one of choice, one of circumstance. It also begs the question: would this movement have been allowed to grow, endangering the lives of all children, if it was largely populated by poor families of color rather than driven by middle-class white families? Would its members have been generously perceived as misguided but well-intentioned rather than misinformed and dangerous? Ultimately, these individuals working to undermine the protection offered by vaccinations to our nation’s children have been protected by their own race and class privilege—benefiting from another type of herd immunity.

 

III.

 

As I arrived at the college health center, I was proud at not having gotten lost during my first day on this beautiful but expansive campus. I stepped into the office, pulled my medical and immunization records from my bag, and handed them to a nurse behind a desk. As I waited for her to look them over and approve them, I thought about my class schedule and how ingenious it would be for me to sign up for microeconomics instead of General Chemistry, thereby thwarting my parents’ plans for me to pursue pre-med. Suddenly, her voice interrupted my scheming.

 

“Your immunization records are incomplete.”

 

 

“What?!” I was shocked, even incredulous.

 

 

“According to your records, you haven’t had a TB test and it doesn’t look like you completed your MMR.”

 

 

“Oh! I’ll make sure to get it done over fall break.” I was surprised that my parents had overlooked these holes in my immunization schedule but I wasn’t worried about getting it taken care of during my next visit home.

 

 

“Oh no! I can’t let you register for classes until you get these done. We can do them here, if you’d like, but you’ll have to pay for them.”

 

 

I wanted to object but I knew that resistance was futile. “OK,” I said dejectedly.

 

 

“Take a seat and I’ll call you when we’re ready for you.”

 

As I turned to take a seat in the waiting area, I saw a young white woman in dungarees with untamed curls, the kind I’ve always envied. Her arms were crossed in front of her and her expression captured perfectly how I felt.

 

With nothing else to do, we struck up a conversation. She told me she was from Kentucky and I told her I was from New Jersey. She told me that she was the first person in her family to go to college and I told her about my scheme to not become a doctor. We shared our frustrations at having to get on-the-spot vaccinations, especially since tonight was the Freshman Dance Party. When I asked her which vaccinations she was here to get, she responded, “all of ‘em,” and gave a laugh.

 

Later that night, we ran into each other at the dance party. She showed off all her vaccination marks like they were badges of honor. Over the next four years, we would wave to each other across campus. I lost track of my classmate from Kentucky, but my scheming was successful – I’m the only person in my family who isn’t a doctor. When I think back to that moment, I’m thankful that vaccination wasn’t a choice, because I’ve been able to make so many more.