Vaccine Anxieties

Global Science, Child Health and Society

Melissa Leach, James Fairhead

• Publisher: Taylor & Francis
• Year: 2012
• Print ISBN: 9781844074167
• eBook ISBN: 9781136549229
• Edition: 1
• Topic: Commerce
• Subtopic: Assurance

This book explores how parents understand and engage with childhood vaccination in contrasting global contexts. This rapidly advancing and universal technology has sparked dramatic controversy, whether over MMR in the UK or oral polio vaccines in Nigeria. Combining a fresh anthropological perspective with detailed field research, the book examines anxieties emerging as highly globalized vaccine technologies and technocracies encounter the deeply intimate personal and social worlds of parenting and childcare, and how these are part of transforming science-society relations.

It retheorizes anxieties about technologies, integrating bodily, social and wider political dimensions, and challenges common views of ignorance, risk, trust and rumour - and related dichotomies between Northernrisk society and Southerndeveloping society - that dominate current scientific and policy debates. In so doing, the book reflects critically on the stereotypes that at times pass forexplanations of public engagement with both routine vaccination and vaccine research. It suggests routes to improved dialogue between health professionals and the people they serve, and new ways to address science-society relations in a globalized world.

1

Introduction: Global Technologies, Personal Worlds

A school teacher in the town of Gueckedou, on Guinea’s border with Liberia sees rebel forces with child soldiers destroy his town in 2001, and worries that children’s vaccination has created a strengthened but more violent generation.

A mother in southern England is taken to the High Court by her exhusband over her refusal to allow their child to have the controversial measles, mumps and rubella (MMR) vaccination.¹

Former guerilla fighters in a village in Mozambique seek vaccinations and are angry that government clinics will vaccinate only children, marginalizing their adult political rivals.

Datti Ahmed, a doctor and president of Nigeria’s Supreme Council for Sharia Law, tells journalists: ‘We believe that modern-day Hitlers have deliberately adulterated the oral polio vaccine with anti-fertility drugs and contaminated it with certain viruses which are known to cause HIV and AIDS.’ ² Polio soon resurges from Nigeria across Africa and beyond, sweeping aside the global polio eradication campaign.

Marlon Brando as ‘Kurtz’ in the film ‘Apocalypse Now’ relates how Viet Cong cut the arms off all the children that the US Army had inoculated with polio vaccine in a Vietnamese village. Yet this fictional refusal of cultural and spiritual pollution by America’s campaign ‘to win hearts and minds’ has a factual base.³

Such scenes, unfolding in places across the globe, reveal how much more there is to vaccination⁴ than children’s health. Vaccination – and especially mass childhood immunization – is acclaimed as the most successful and effective form of public health intervention that there has ever been. It has acquired a special character, symbolizing high hopes of lives saved, diseases eradicated, and the power of medical technology in an apparent triumph of science over nature. Such hopes justify mass actions that appear to rise above politics. From the smallpox vaccination campaigns of 19th-century Europe, to the international community’s growing investments in mass childhood immunization across the world, this technology offers a universal promise of disease control that can appear to trump national and local interests. Wars have been suspended for vaccination. In 1990s Sierra Leone, the United Nations Children’s Fund (UNICEF’s) immunization programmes continued to cross rebel front lines when even food convoys did not. Vaccines lend themselves easily to representation as an incontestable public good.

Vaccines are also special in linking the most global with the most local and personal. Aiming to reach every child on the planet, vaccination technology has a uniquely global character. Vaccines are produced, distributed and monitored within systems that are equally globalized. Yet vaccination reaches from the global into the most intimate world of parenting and care. At the needle point, the most global meets the most personal of worlds. As a technology, it enters the intense social world in which parents⁵ and carers seek to help their children flourish, spanning genders and generations, comrades and communities, and advice givers. These are everyday worlds that vary enormously across the globe, and over time. Within them, some jostle for vaccination. Others jostle against. Through thinking and talking about vaccination, people often express a great deal about what they value, who they are and whom they identify with.

Controversies over vaccines feed cornerstone debates of our time. For while vaccination is easily represented as a universal, neutral good, it is actually deeply bound up with politics: with struggles over status, authority and value, writ small and writ large. Thus as some British parents from the 1990s refused to take their children to receive the MMR vaccination, fearing that it would trigger autism, the debates that swirled through policy, professional, media and popular circles ranged widely. They variously evoked notions of trust in government; of media responsibility; of scientific impartiality; of parental choice; of citizenship rights, and of the appropriate limits of government action and enforcement in a liberal democracy. From 2003, some northern Nigerian parents refused to take their children to receive oral polio vaccination, fearing that it would reduce their future fertility or infect them with HIV as part of a genocidal plot against Islamic Africa. Again debates and commentary expanded into far wider questions of governance. They invoked the relations between local and national government; trust in federal government and its global sponsors; the motivations of US foreign policy; scientific impartiality (Whose science? Whose vaccines?); the value of different health priorities, and, as Nigerian news spread across the airwaves and polio cases reappeared across the region, the role and responsibility of media in a globalized world.

This book is therefore a book about global technologies, governance and their intersection with social worlds. We explore how experiences of vaccination are simultaneously experiences of the body and its health, of social relations, and of wider governance and politics. At the same time, a focus on vaccination draws us into much broader public debates (and professional writing) about science and technology, and about the nature of contemporary society. We explore how debates thrown up around vaccination have animated existing public debates such as to affirm and put into play a range of stereotypes – about modern society, about western society, and about African society. What, we ask, is the validity of these ideas? What are they doing? And what might they be hiding?

A notion of anxiety is a central anchor in current debates and in our exploration of them. Anxiety, though, is a double-edged word. Used in a negative sense, anxiety implies a state of unease, worry or concern. Yet it also has a positive meaning, implying an earnest, focused desire for something, or to do something. Recent policy discussions and social science writing have emphasized the first, negative meaning. ‘Vaccine anxieties’, in this sense, are seen as worries about vaccines. Anxiety easily becomes part of an explanation for instances of public refusal or dissent from vaccination, or for controversies. Thus in the British MMR controversy, a negative sense of anxiety is invoked by commentators attributing vaccine refusal to parents’ overblown sense of risk and loss of trust, whether ascribing this to everyone or to the ‘anxious middle classes’. Some see this vaccine anxiety as a manifestation of a broader ‘age of anxiety’ afflicting contemporary western society (Fitzpatrick, 2004; see also Furedi, 2001). A negative sense of anxiety tends to be manifested differently in discussions of Africa and Asia. Here, commentary has emphasized the role of particular individuals and groups in propagating anxieties, and their easy spread among populations who lack a modern understanding of vaccination. Vaccine anxieties, in this sense, are linked either with anti-vaccination ‘rumours’, or with collective resistance (e.g. Streefland, 2001). In both settings, anxiety is imaged in its negative sense in terms of a departure from an unproblematized acceptance of public health routines, towards greater, if misguided, reflection.

Yet such discussions, and the images of society that they produce, overlook the positive meaning of anxiety, and its implications. Anxiety can imply a striving for something and recognizing this is crucial. First, it attunes us to circumstances in which people are anxious for vaccination. Having a child vaccinated may not, in this sense, be a question of passive acceptance of established, normal public-health routines, but a matter of more active demand (see Nichter, 1995; Streefland et al, 1999). This positive sense of anxiety invites exploration of the issues, values and forms of knowledge underlying such demand, and the extent to which they match (or fail to match) the expectations of public health professionals and policy makers. And it draws attention to the sense of let-down that people may feel when their own expectations of vaccination – its availability or effects – are unmet. Second, a positive meaning of anxiety allows us to recognize that people can be anxious for child health and wellbeing more broadly – and that the place of vaccination in this can be more problematic. Where people dissent from, question or fail to respond as expected to public health messages, a common tendency – using a negative sense of anxiety – is to interpret this in terms of ‘failure to understand’, a ‘breakdown of trust’, and so on. But as we shall argue, it is more productive to ask, in a more positive sense, what people expect and desire around child health and why – and why at times vaccination is failing to match those desires.

Appreciating the positive in the double-edge of anxiety has broader implications for understanding public engagements with science and technology. Many debates about and explanations for controversies over public issues involving science are framed in terms of public (mis)understanding or lack of understanding of science, technology or its risks. In an extension of this ‘deficit model’, the lack may be not just of knowledge, but of trust – in both science itself and in its governance. The emphasis is on the negative – deficits of knowledge, deficits of rationality, deficits of trust – on the part of the public. And in response, scientific institutions are called to respond by winning hearts and minds.

But this well-established set of perspectives, in focusing on what people do not think or understand, misses what they do think and understand. It obscures why what they do think might make sense, as part of their everyday lives and experiences, values and conceptualizations of the issues involved. It misses the opportunity to identify the ‘framings’ – forms of knowledge, value and social commitment – that people bring to an issue, and which shape their anxieties about it, whether positive or negative. And it misses opportunities to identify mismatches between people’s framings, and those of the institutions involved with science or governance. A positive perspective that focuses on the ways in which members of the public frame issues involving science and technology, in turn, suggests that similar questions should be asked of those developing and promoting technologies, or exerting authoritative governance over issues involving science. How, one might ask, do scientific and policy institutions frame the issues, and what kinds of knowledge, social and political values and commitments do these framings embody? This will shed light on why it is that scientific and policy institutions represent the public in the ways that they do.

The relevant question, then, is not how the public understand or engage with science and technology as if it were neutral and universal, but how different framings of a problem – among scientific and policy institutions, and a variegated public – have emerged. Crucially, however, we need to go beyond this ‘symmetrical’ approach (e.g. Jasanoff and Wynne, 1997) to consider how policy and public framings have emerged in relation to each other; how they interact. This is a core emphasis of this book. It is not enough simply to draw a contrast between science/policy and public framings, or between globalized and personalized ones, as if they were part of distinct, separate lifeworlds. Rather, crucial questions concern how these contrasts arise, become manifested and consolidated, and how the social and political interactions they shape themselves play into this.

The Problems with Vaccination

At heart, this book is concerned with some very practical problems. It takes as a starting point the great gulfs that often exist between people’s senses of themselves – the people, in this case, being parents and carers of children in diverse settings in Africa and Europe – and the stereotypes applied to them by health professionals, policy makers and media commentators. These gulfs are unhelpful for everyone. They are unhelpful for public health officials trying to increase immunization coverage, who often find their education and communication efforts ineffective. They are unhelpful for the funders and international organizations promoting large-scale disease eradication campaigns, when they lead to these being derailed, and to diseases once again finding a foothold. They are unhelpful for parents frustrated in their engagements with health services. And they are unhelpful for those children who die as a result.

For many people, the problems of vaccination are not controversial. Rather, they are well-known and long established: getting good coverage through improving supply and infrastructure, and improving uptake through education. The challenges lie mainly in tackling the resource and system constraints that prevent vaccination technology and knowledge being extended to all. This book does not dispute the value of such efforts, but it does expose the limits of this comfort zone.

For others, the big challenges lie at a larger scale: in creating the right vaccines to tackle major and emergent disease problems, and developing cost-effective ways to deliver them. This book does not deny the crucial importance of such vaccine innovation, but it does show why grand challenges need to be matched with attention to how parents will engage with these efforts. It also shows that in a world of aggrandizing and globalizing vaccination programmes, parental understandings sometimes come to include dimensions of the larger political economy of vaccine development in ways that can prove problematic, feeding back to derail the programmes themselves. It is these gulfs which are the focus of this book. They recur in vaccination research, development and delivery; in routine mass childhood immunization and disease eradication campaigns.

Vaccination as Technology and Technocracy

Vaccination is high on both national and international policy agendas. Long-regarded as a highly effective, and cost-effective, public health intervention (WHO/UNICEF, 1996), mass childhood immunization is now receiving renewed international attention. While vaccines protect individuals, high levels of coverage can build up social or ‘herd’ immunity against certain infectious diseases, so personal and social immunity, and possibilities for disease eradication frame public health strategies. A variety of initiatives and investments are focusing on improving access to immunization services, expanding the use of existing vaccines and accelerating the development and introduction of new ones.

As technologies, vaccines are still in their infancy. New generations of ‘DNA’ vaccines are emerging. Needle-free delivery is being perfected. The promises of vaccines grown in plants or introduced into foods are materializing. Nano-science and technology offer as yet uncharted delivery techniques. New combinations of vaccines are constantly being created, offering greater efficiency and coverage as ‘three-in-one’ jabs become four-in-one, or five-in-one.

These technological developments contribute to a powerful vision of technological progress. This vision encompasses vaccines against poverty and vaccines against excess. Thus unprecedented international investments target the ‘killer diseases’ associated with modern poverty. These portray vaccination as a key route to tackling pervasive ill-health in Africa and achieving the Millennium Development Goals to reduce childhood mortality, and as a moral imperative as part of global development efforts (Obaro and Palmer, 2003; Smith and Woodward, 2003). At the same time, solutions to the excesses of northern overconsumption through vaccination are envisaged, through inoculations against obesity, drug addiction and cancer.

In the context of these overall narratives of technological progress and promise, many lament how slow innovations have been for vaccines against malaria, HIV and other hard-to-tackle diseases that primarily affect the global south. They question the limited public funding that has been available for this, and the preference of pharmaceutical companies to focus on profit-generating markets – thus favouring curative drugs over vaccines, and northern over southern settings. To speed up vaccine innovation for development, a variety of new aid and philanthropic initiatives now link with pharmaceutical companies in innovative forms of partnership. These go beyond their common labelling as ‘public–private’ as they involve an array of coalitions between wealthy and poor governments, vaccine manufacturers, non-governmental organizations, research institutes, foundations and international health organizations, often involving protracted negotiations to launch and sustain. The largest of these is the Global Alliance on Vaccines and Immunization (GAVI) launched in 2000, together with its financing mechanism, the Vaccine Fund (Heaton and Keith, 2002; Muraskin, 2004, 2005). The International Aids Vaccine Initiative (IAVI) also brings together developing country organizations and northern research outfits, both public and private, to further HIV vaccine research and wider policy through operations in 22 countries. By 2004 IAVI had raised over $340 million (Chataway and Smith, 2006). The Global Fund to fight Aids, TB and Malaria (GFATM), launched in 2002 following a call by the UN Secretary General and a decision by G8 countries, is a large, international, independent public–private partnership designed to attract and manage significant new sums of money – from governments, foundations and the private sector – to address these three diseases, including through vaccine innovation and delivery.

While the aim is to extend vaccines to every person on the planet, their production has become increasingly concentrated, and is set to become more so as technological sophistication intersects with global regulation and patenting. Debates about intellectual property and generics will affect future production possibilities, including the viability of, for instance, small Asian companies that have been attempting to produce cheap vaccines for the poor.⁶ Some argue that the restrictions on property rights are a real constraint to making them available, or to promoting public – as opposed to private, commercial – values.

In the regulation of vaccines and research into them, as for other pharmaceuticals, national issues encounter a world of global standardization. The trend of the past few decades has been to expand intellectual property regimes globally, and indeed an obligation is to comply with the TRIPS agreement under freetrade rules set by the World Trade Organization (WTO). In this context, the spectre of smaller companies becoming part of outsourcing arrangements in larger networked conglomerates controlled by big pharmaceutical companies seems likely. If such a scenario unfolds, and given the disincentives for large pharmaceutical companies alone to invest in vaccine development, the significance of international public–private–philanthropic partnerships in meeting vaccine development needs for the global south may increase further.

Aid funding in these partnerships is not entirely altruistic. First, the rich can catch the diseases of the poor. In a world of mobile people and microbes, eradicating infectious diseases is increasingly a global public good (Kaul and Faust, 2001) – an agenda of mutual north–south self-interest that has undoubtedly played a role in pushing immunization up international political agendas. In what Fidler (1998) calls microbialpolitik, infectious disease control has become central to international relations, as an international security issue. In this light, it is no surprise that a major funding source for the development of vaccines derives from th...

Table of contents

• Cover
• Half Title
• Dedication
• Title Page
• Copyright
• Contents
• List of Figures
• Acknowledgements
• List of Acronyms and Abbreviations
• 1. Introduction: Global Technologies, Personal Worlds
• 2. Analysing Vaccine Anxieties
• 3. Body, Body Politic and Vaccination in the UK
• 4. Anxieties over Science: Arguing MMR in the UK
• 5. Body, Body Politic and Vaccination in West Africa
• 6. Anxieties over Science: Engaging Vaccine Trials in The Gambia
• 7. Conclusions
• References
• Index