Books reviewed in this essay:
This review covers two different books that address conflicts around vaccine use. Both books contribute to the literature in two ways: first, by providing a richer cultural context to the debates around vaccines; second, by adding new information from original empirical research. America's New Vaccine Wars: California and the New Politics of Mandates draws on archival research and interviews with stakeholders. Antivax: Reframing the Vaccination Controversy draws on in-depth interviews with vaccine-hesitant, vaccine-refusing, and vaccine-accepting people.
Both books also directly discuss the authors’ points of view and biases, clearly stating where each author is coming from. However, America's New Vaccine Wars does that up front, in the introduction. Antivax, on the other hand, addresses the author's biases much later in the book. That book's author would have done better to state her point of view up front, too.
The books are sufficiently different that beyond these general remarks, I discuss them separately, addressing each book's strengths and weaknesses in turn. In the interest of full disclosure, America's New Vaccine Wars refers in part to my actions and opinions.
America's New Vaccine Wars: California and the New Politics of Mandates
America's New Vaccine Wars tells the story of how California removed the nonmedical exemption to its school vaccination requirements in 2015. The story is rich, compelling, and interesting, worth reading for that alone. Beyond that, the book uses the 2015 reform as a springboard for three interwoven threads. First, the book's general thesis is that the 2015 reform signaled a new and different era of school vaccine mandates, meaningfully different from before. Previous vaccine mandates, the authors argue, addressed access and inertia, aiming to nudge parents, not coerce them. California had exemptions for parents who did not want to vaccinate. The new era moved to coercion. Second, the authors provide institutional context, describing the US health care infrastructure and (limited) social programs. They argue that the turn to school mandates was necessary for increasing vaccine uptake because other policy tools, such as improving access and education, were limited by financial constraints and lack of political will. The authors place this in the context of a problematic history of medical research (targeting racial minorities and other vulnerable groups, such as orphaned children, for sometimes abhorrent practices). They also address the earlier opposition of doctors and their professional association to public programs of vaccination. Finally, the authors address normative issues. Their view is clear: they oppose mandates without nonmedical exemptions, seeing their costs as outweighing their benefits. They provide a careful and thoughtful discussion of the ethical arguments for and against mandates and their role in legislative battles. Against mandates, the authors discuss parental freedom, informed consent, and children's rights to care and education. Supporting mandates, the authors discuss the child's right to be vaccinated and protected from disease, preventing harm to others, and fairness (i.e., avoiding free riding). These are important contributions. I also think the book is on very firm ground when it points out that after the politicization of the pandemic, strengthening school immunization mandates is a political nonstarter in many states.
I am not, however, convinced by some of the book's historical claims. First, the book makes a good case that the mandates of the 1960s and 1970s were designed to have exemptions. But those were not the first mandates. Educational mandates go back to the 19th century, as the book mentions, and as cases show, several of them had no nonmedical exemption (for example, Blue v. Beach, 56 N.E. 89, 155 Ind. 121 (1900)). Furthermore, in some cases parents were convicted and jailed for truancy when they kept an unvaccinated child home because of a vaccine mandate (e.g., Anderson v. State, 84 Ga.App. 259 (Ga.App. 1951)). The authors should, therefore, qualify their argument that mandates without exemptions are new. Mandates without nonmedical exemptions are a change from the 1960s–1970s mandates, but they have a long history in the United States. Furthermore, even in modern times, the ease of getting exemptions varied dramatically across states, so not all parents could have used them (Yang and Silverman 2015).
More importantly, I have concerns about the book's analysis of the jurisprudence around mandates. The authors are, I think, mistaken in suggesting that Jacobson v. Massachussets (page 85 and onward) “played a role in authorizing a broad set of early 20th-century public health measures, many of which enacted oppressive violence on society's most vulnerable members,” and that responses led to protections of conscientious rights that would “make it difficult to re-create the coercive vaccination policies that Jacobson affirmed” (86).
The authors’ analysis is based largely on the reference to Jacobson in the notorious case of Buck v. Bell (1927), which upheld a eugenic state sterilization law. When I teach or write about Buck v. Bell, we discuss how Buck misapplied Jacobson (Reiss 2018: 231–32). The authors see Buck as a direct result of Jacobson and therefore see “horrific Nazi medical abuses” as part of the legacy of Jacobson (87). That is problematic. Buck v. Bell referred to Jacobson in passing, with little application or justification of the connection. And Buck is a stand-alone case; it did not create a general trend of abuses. There were certainly research abuses, as the authors discuss, late into the 1960s and afterward (Rice 2008). But there is nothing connecting these to Buck v. Bell, which was specifically about eugenics and sterilization.
There is a potential argument that modern jurisprudence has moved away from Jacobson (see, e.g., Colgrove and Bayer 2005; Gostin 2005; Parmet 2020; Wiley and Vladeck 2020). But these discussions do not draw on Buck v. Bell as a legacy of Jacobson, nor do they address research abuses. Furthermore, whatever the viability of Jacobson, childhood school mandates stand on very firm legal ground (Reiss 2018).
In addition, the book arguably overstates the focus on mandates in increasing immunization rates. I agree that the United States tends to use coercion rather than fixing broken support systems. But the authors suggest that mandates are the only tool used or the only option given America's “broken health care system” (105). This is partial, because mandates are never used in isolation. In California, the law strengthening school mandates was adopted in response to an outbreak. So was New York's repeal of its religious exemption following a large measles outbreak in 2019 (F.F. v. State, 194 A.D.3d 80 (N.Y. App. Div. 2021)). In both outbreaks, mandates were only one of a range of strategies used. In California, the state and medical associations engaged in extensive education campaigns (Willis 2015). School districts created educational materials, vaccination clinics, and reminders to parents (Liu and Ringel 2015). Beyond outbreaks, attention in the United States is given to both access and messaging, for example, efforts to fix the Vaccines for Children program (Rosenbaum 2022) and state-led education efforts and incentives. Often mandates are used when other tools did not work. In that case, the balance is different; when other tools do not work, the price of not reaching for mandates may be children who are sick, disabled, or dead.
The authors’ contention that in the United States mandates are used to increase immunization rates because of the lack of a functioning health care system is also challenged by the experience of countries with stronger health systems. From 2010, in response to a large measles outbreak, several countries in Europe, including France, Italy, Germany, and others, adopted or expanded vaccine mandates (Kuznetsova, Cortassa, and Trilla 2021). These countries’ health care systems are consistently ranked higher than the US health care system, but when facing outbreaks, they reached for school mandates.
Rather than discussing mandates or no mandates, we should examine what role mandates play in the toolbox for increasing vaccine rates, when should they be used, and what form of mandate with what exemptions is suitable to the problem at hand. That is not to downplay the potential problems the authors highlight or the contribution of a systematic examination of the justification; that examination is crucial to assessing when mandates are appropriate or useful. But it is not a “yes/no” issue. It is a “when and how” issue.
Finally, a major drawback of the book is that after highlighting the fact that mandates have costs and calling attention to challenges in strengthening mandates, especially in the aftermath of the pandemic, the authors say that they “do not see any solution to America's vaccine wars” (154). If the authors mean controversies around vaccines are not going away, they are right. Such controversies go back to the first vaccine and have never stopped (Offit 2010: 105–10). That is even more true of vaccine mandates, which were always controversial. But if the book is suggesting that in the new reality there is no way to increase vaccine acceptance or to broaden mandates, that is unconvincing. In some states, strengthening mandates is a nonstarter, and that has been true for a while. And it is always a battle. But in the right circumstances and ways, it is a winnable battle, as shown by some mandates during the pandemic. And there are other ways to increase vaccine uptake and acceptance, such as improving access by bringing vaccines to people, solving access problems (e.g., providing paid leave to get vaccines), or increasing the range of providers that can give vaccines. Or effectively countering misinformation. The future may be challenging, but it is not the first time there were challenges to vaccine uptake. This is an ongoing battle, and the authors, in my view, give up too easily on it.
Antivax: Reframing the Vaccination Controversy
Antivax argues that if we consider the way facts are constructed and the history of the medical profession and the pharmaceutical industry in the United States, vaccine hesitancy or opposition is rational. The author challenges the belief that vaccine refusal results from denying science and suggests that framing vaccine opposition as science denial is unhelpful since it prevents directly addressing opponents’ concerns. The author also challenges the view that scientific facts are objective, instead suggesting they are constructed, and not everyone will agree with the way they are constructed. To seriously address vaccine refusal, the author argues, policy makers, the media, and others need to meaningfully engage with the way vaccine-hesitant people think, not dismiss them as ignorant, crazy, or plain wrong. The author also points out that many people have good reasons to mistrust pharmaceutical companies or doctors and that it is reasonable for those people to apply that mistrust to vaccines, too.
Chapter 10, a very valuable contribution of the book, draws on the author's empirical research to set out a list of reasons people “are skeptical about or resist vaccination” (213). The reasons provided include “belief in the value of natural illness” and “belief in nutrition as the first defense against illness” (213), experiences with illness not effectively treated by “mainstream medicine” (214), perceived vaccine injury (214), “distrust of mainstream scientific studies of vaccine safety” (214), and others. The author then examines closely the views vaccine refusers have on nutrition, illness, and responsibility to the community. Interviewees, for example, believed that nutrition is the main way to be healthy, with some of them eating controversial diets such as drinking raw (unpasteurized) milk (215–16). They saw diet as a treatment and preventive of illness (217). Interviewees also viewed illness as “natural and beneficial to health” (218). Finally, interviewees consider themselves as responsible community members by staying home when sick, and they rejected views that nonvaccination meant they were not responsible members of the community (220–21).
Although this book makes real and meaningful contributions through its discussion of institutional realities and people's experiences, its drawbacks outweigh its contributions. This discussion highlights three major weaknesses in the book. First, the book's argument against explicitly recognizing denial is unpersuasive. Second, the book accepts blatant science denial and untrue facts as legitimate. Third, like America's New Vaccine Wars, the book offers no solution to vaccine refusal.
The book tries to make two theoretical contributions. First, the author attempts to situate the vaccine controversy in a broader context of problematic pharmaceutical and medical institutions that do not deserve trust. Despite this argument having some merit, the author realizes that on its own this would not be a reason to reject the abundant data on vaccines. The book therefore discusses how facts are generated and argues against using the term “denial,” both in the context of science denial and in the context of Holocaust denial. The author argues that for Holocaust denial, denial is not the actual problem; rather, opponents are concerned about the anti-Semitism of holocaust deniers (106–8). I think the author is wrong in describing opposition to denial as simply a disagreement about how to recognize truth (although that is part of it). What opponents are concerned about is the use of misinformation by deniers to spread their ideology. Holocaust denial is a core aspect of anti-Semites’ efforts to promote their ideology exactly because they would have more trouble recruiting people on the facts as they stand (Bauer 2020). This is a good parallel to antivaccine misinformation: denying established truths, such as the risks of disease or the lack of connection between vaccines and autism, makes refusers’ position more appealing and plausible and thereby attracts people. Downplaying this denial hides the insidious effects of misinformation.
Second, in spite of the author's argument that using language of science “denial” is not useful, the discussion in chapter 10 demonstrates that much of vaccine refusal is, in fact, heavily based in science denial. The author quotes several interviewees who choose to drink raw milk “because they feel that it's healthier” (216). These people are choosing to take a preventable risk of bacterial disease for their children because they believe it is healthy. It's hard to see this as anything but science denial. When the author quotes with acceptance interviewees saying there is nothing wrong with sickness or that it is good for you (218) and that the immune system is “like muscles. If you don't use them, you lose them. And with some illnesses and childhood illnesses, they actually make your immune system stronger” (219) or “if you're healthy, you probably won't get sick as often, but you're able to handle it . . . getting sick is an important of being . . . a child” (220), she is affirmatively quoting someone denying science, or misunderstanding it.
Finally, if a reader's goal is to know how to counter vaccine refusal and increase vaccine rates, they would not find suggestions in this book. The goal of the book is to explain vaccine refusal. In fact, I would go further and argue that the book seeks to legitimate vaccine-refusing attitudes. We do need to understand the reasons for vaccine refusal so we can respond to it, and there is a large literature on that. In-depth discussions of the reasons behind vaccine refusal can be found, for example, in Jennifer Reich's (2016) book Calling the Shots, which covers most of the same ground as this book, respectfully and meaningfully engaging with reasons against vaccines and putting them in a rich cultural context—but without accepting and legitimating denial. Similarly, Saad Omer and his collaborators engage in nuanced cultural discussion of values that affect vaccination without accepting science denial (or vaccine refusal) as correct (Amin et al. 2017; Salmon and Omer 2006).
But this book is not trying to help counter vaccine refusal. It ignores and downplays the role of leaders promoting misinformation that misleads people into vaccine refusal. It tries—unsuccessfully—to present vaccine refusal as rational and not based in science denial.
In short, both books contribute context and empirical research to understanding vaccine refusal. Both have limits, but America's Vaccine Wars is the clear recommendation of the two.
Acknowledgments
I would like to thank Katie Attwell, Mark Navin, Richard Pan, and Joe Smyser for previous input to my comments about the book America's New Vaccine Wars. I am grateful to Andrew Kelly and the JHPPL team for their help in shepherding this review through the system and for their insightful suggestions.
