Vaccine Nation: America’s Changing Relationship with Immunization by Elena Conis (review)

During the last few decades, social historians of medicine have turned to antivaccination as a fascinating phenomenon for their analysis. In contrast to the simplistic ways that resistance to vaccination is usually presented, both by the medical establishment and the media, historians of medicine and public health such as James Colgrove, Nadja Durbach and others, presented its multi-faceted and dynamic aspects, including the rich dialogue that exist between those who support and resist vaccination.¹ Elena Conis’ excellent book in many ways is complementary to these studies, but its starting point is different: despite all the recent media coverage emphasizing antivaccination sentiments, children today actually are being vaccinated at higher rates than ever. Conis suggests that we should not take these high vaccination rates for granted: “Vaccine controversies may have grabbed Americans’ attention at the start of the twenty-first century, but the broad acceptance of vaccination deserved just as much scrutiny” (p. 2). According to Conis, two core lessons emerge from the social history of vaccination in the United States over the past half-century: “First, we have never embraced the mass vaccination of children for strictly medical reasons. Second, new vaccines create imperatives to vaccinate, largely by triggering the transformation if their target diseases into diseases in urgent need of prevention” (pp. 253–54). As much as the rise of various diverse social movements such as environmentalism, feminism, and new age were related to resistance to vaccination, Conis shows how other important social and political events, such as the Cold War, the growing value of children in our society, the HIV/AIDS outbreak, and global immigration, were very influential in broadening and strengthening vaccination programs.

The book starts and ends with two major reforms: The Vaccination Assistance Act of 1962 and the Affordable Care Act of 2010. Conis’ analysis shows how these two reforms marked the growing involvement of the U.S. federal government in creating unified vaccine policies, and even more important—creating the basis of universal vaccine coverage. Interestingly, the relatively “narrow” epidemiological perspective, based on the need to control and even eradicate infectious diseases, helped to promote a universal vaccination coverage perspective, avoiding the usual political hurdles surrounding the debates of universal health coverage. Without achieving herd immunity, control of infectious diseases by the use of vaccination would not be efficient and might even create unintended consequences, such as delaying the age of clinical infections. The epidemiological need for universal vaccination demanded policymakers and politicians to look for better ways to finance vaccinations in a fragmented U.S. medical system. Promoting universal access to vaccines to all parts of society, poor and rich alike, became an imperative in a way that was much less controversial than for any other pharmaceutical intervention. The fact that these programs were targeting children helped. For President Kennedy, this was part of his larger focus on promoting children’s welfare, including the welfare of children with disabilities, at a time when polio vaccines were central to the image of scientific advancement.

The book tells a fascinating story of how—between the 1960s to the first decade of the twenty-first century—fears, debates, and the risk perceptions of diseases had changed dramatically within a dynamic historical, political, and social context. If during the 1960s the poor were blamed as the main cause for spreading infectious diseases, later such blame turned toward government and the fragmented medical system, moving to greedy pharmaceutical companies, social media, or new age influences. Throughout the book, Conis shows how often the designation of a health “threat” occurred upon the appearance of a vaccine itself: “Neither mumps nor chickenpox nor cervical cancer were defined as top U.S. public health priorities . . . before their vaccines were licensed to use. But they were treated as such afterwards” (p. 251). Many agents were responsible for these changes: from scientists, public health authorities, and pharmaceutical companies to parents and politicians. Conis’ work eloquently...