A couple of years ago, as part of my bid to become a permanent resident of the United States, I underwent a physical exam. In a Brooklyn civil surgeon’s office a nurse drew a small pouch of blood from my right arm, then pumped the same arm with several vaccines. Finally, she injected a button of tuberculin solution just beneath the skin of my left forearm. The results of this exam were to be sealed and delivered to my lawyer’s office, where I had already signed a document swearing that I was neither a former Nazi nor a current or future terrorist. The physical had seemed to me an equally arbitrary part of the application process, though about the matters at hand my flesh, presumably, could not lie.
For two days, I watched the tuberculin bubble for signs of fester. My paternal grandmother died of tuberculosis at 34, just as streptomycin, the first cure, became available. Every year until they were 18, my father and his siblings, who had been exposed to the virus, underwent mandatory chest x-rays. On my return to the doctor’s office, a nurse with a telephone receiver cradled between her ear and shoulder reached through the intake window, swiped a finger down my forearm, and waved me out the door. My body had passed the test.
Such experiences—such compliances—come to mind while reading On Immunity: An Inoculation, Eula Biss’s elegant treatise on how science, story, and fear combine in the concept of public health. They come to mind in part because On Immunity, which explores issues of vaccination through a blend of history, meditation, and critical survey, is very much derived from and connected to Biss’s own experience—that of becoming a mother. On the birth of her first child, Biss was gripped by “by an exaggerated sense of both my own power and my own powerlessness.” Each distortion had its own imperative, and for months Biss shuttled between them, one moment flanking the baby monitor that confirmed her son’s every breath, the next relinquishing his future to fate.
These pages feel carefully distilled from the “late-night research” benders that both soothed and stoked Biss’s first, anxious months of new motherhood. The result is an idiosyncratic work in which clarity is achieved through, and not despite, its vine-to-vine associations—the swinging, sometimes within single paragraphs, between the worlds of literature, philosophy, and scientific study. More than vaccinations, the book is about the undertaking of argument, and demonstrates a deft and literary-minded synthesis of the wastes of information that now boggle clear thought on most every subject, but especially this one. It is about the impossibility of complete or certain knowledge, and the necessity of seeking balanced understanding in its place.
Before and after the dawn of germ theory in the late nineteenth century, and the medical revolution that followed, we have used (and misused) metaphor to make sense of the varying health and sickness of our bodies. This is ground staked by Susan Sontag, who presides over On Immunity as a kind of godmother. Biss weaves Sontag’s thinking on illness—specifically cancer and AIDS—and its metaphors into her consideration of today’s cult of wellness, its false binary of “toxic” versus “natural,” and the “variety of pre-industrial nostalgia” driving, as Biss writes, the manufacture and sale of chicken pox-infected lollipops as a kind of homeopathic vaccine.
A more dramatic presence than Sontag’s in On Immunity is that of Dracula, a text whose metaphors for disease, interdependence, and medical intervention Biss threads throughout. A host of intuitive connections between her subject and Bram Stoker’s serve to highlight those that are more unexpected: Biss’s father, a doctor, suggests that the time has come for a new Dracula, “in which the vampire serves as a metaphor for medicine”; the idea of a monster who “moves through the air as mist and lies dormant in the soil,” as Biss points out, resurfaces in a book like Silent Spring, and indeed anywhere humans brave ordinary life with medical masks strapped to their faces and a bottle of hand sanitizer clipped to their bags.
Such behaviors “allay a wide range of fears, most of which are essentially fears of other people,” Biss writes. As the recent Ebola outbreak confirms, people found in the developing world are to be feared as more other than most. The world’s attention has narrowed onto the nearly 3,000 to die from Ebola this year, almost all in northwest Africa—a number more terrifying because the disease is highly contagious and as yet has no known cure. In August, the World Health Organization ruled as ethical the use of experimental treatments on Ebola patients; the drug’s limited supply (and the high profile rescue of several Westerners) only highlights the enduring ethical question of access. It has been noted that in the same span of time, hundreds of thousands of Africans, mostly children, have died from treatable diseases like malaria and tuberculosis. Despite an increasingly borderless world, any discussion of “public health” draws very specific boundaries.
On Immunity addresses the politics of public health beyond American borders in a limited but effective way. Biss describes the difficulty Western vaccine drives have faced in polio-ridden countries like Nigeria and Pakistan. In the latter case, the Taliban’s charge that vaccine campaigns were a form of American espionage was justified: the CIA had indeed launched a fake hepatitis B campaign in the region, secretly collecting DNA evidence they hoped might lead them to Osama bin Laden. It’s the kind of story that starts the mind wandering—in my case all the way back to my injection of several needles full of I-didn’t-even-ask what. Some, a recent Internet search confirms, opt out of the green card vaccinations, an option I was not aware existed. Exemptions are granted on moral or religious grounds, a clause perhaps descended from that attached to Britain's 1853 Mandatory Vaccination Act: those who refused vaccination were allowed to do so as the first "conscientious objectors," a term, Biss points out, now primarily associated with war. Then as now, reason had no place in the discussion, though the anti-vaccine movement Biss describes is more plainly rooted in political, class, and socio-cultural concerns, a phenomenon of privilege that values the individual over the greater good.
When a public divides against itself, how do we discuss, much less support, public health? Biss’s is a truly moral argument, and in that proves both intricate and somewhat elusive. If the arc she describes is long, it bends toward the greater good, not the greater right or wrong. And lesser rights and wrongs will inevitably mark the way. “If you’re going to get medical care,” Biss’s father tells her, “you’re going to have to trust someone.” On a large scale, that trust involves understanding that the forces, scientific and otherwise, that steward and shape public health will always be in flux. HPV was removed from the green card vaccine schedule in 2009; my blood was tested for syphilis but not HIV, a disease that as of 2010 is no longer cause for inadmissibility into the United States.
I had followed the latter development not only as a prospective permanent resident but as a member of the generation, that “came of age in the shadow of the AIDS epidemic.” This cohort, Biss claims, was left believing “not that we are all vulnerable to disease, but that it is possible to avoid disease by living a cautious life and limiting our contact with others.” I’m not sure if I don’t believe that to be true or just hope it isn’t, if only because it implicitly connects a generation’s hermetic inheritance to the anti-vaccine movement. Biss handles moments like this, and more flammable material, with cool persuasion, an effaced, equilibrant style that makes lucid to the point of translucence stakes well suited to the furies of polemic. Instead the prose has a meticulousness that tends to sustain Biss’s flights of association, and allows her, among other things, to make straight-faced reference to “the activist Jenny McCarthy.”
Irony is perhaps not to be desired in such a discussion. The marvel of On Immunity, and its puzzle, is how well it avoids provocation. Biss makes her pro-vaccine allegiance clear, but describes in thoughtful detail her discomfort with both sides of the debate. Beyond those sides lies the moral, the humanist, and altogether uncontroversial recourse at the center of the book: an appeal to community, to metaphors of interdependence, to admitting to what we don’t know, accepting what we do, and acting accordingly, together, as a social body. “Immunity,” Biss writes more than once, “is a shared space.” To choose to join it is to understand there is no other choice.