Last year saw more U.S. measles cases than in any other year in nearly the last quarter century, and 2015 isn't looking a whole lot better, after someone at Disneyland infected people who infected other people in what has become a seven-state outbreak. Measles vaccines have been around for 50 years, but a vaccine is usually only as good as the percentage of the population that gets it. So how do some people in a country that rejoiced in vaccines for killers like polio wind up wary of them? Emory University historian Elena Conis goes sleuthing in her book, “Vaccine Nation: America's Changing Relationship with Immunization,” finding answers in science, politics and shifting cultural standards about how we vaccinate and what our doubts are. At a moment when, as Conis says, children's participation in public life depends on their immunization status, she favors a nuanced view of our complicated relationship with “the jab.”
You locate the roots of the current vaccine resistance in the women's health movement of the 1960s and 1970s, in the environmental movement and in post-Watergate skepticism about government.
People say, where did vaccine skepticism begin? They say it's because of Jenny McCarthy, or the Lancet study [purportedly linking vaccines and autism] that has been discredited. [Years] before that, an NBC investigative report in 1982 called “Vaccine Roulette” alerted Americans to supposed problems with pertussis vaccine.
I was struck by the gender split [in the NBC report]. All these mothers speaking about their children's vaccine reactions: “I went to the Physicians' Desk Reference, we need to be skeptical.” And all these male doctors: “Vaccines are safe, the mothers don't know what they're talking about.”
Women were doing what health feminists were doing when they looked at risks of birth control pills that they said doctors had known about and hidden. It made perfect sense that they would use the same questions with respect to their children's healthcare. They were also using the language of environmentalism, [which] illustrated that only after we had used new technologies did we realize they had risks.
Things like DDT, lead, asbestos. Skeptics began to say, “What if the same is true of vaccines?” In the 1970s, vaccine schedules for children were being expanded and enforced as never before. Thimerosal was removed [from vaccines after questions about its toxicity]. Some vaccines were taken off the market temporarily.
We put science on a pretty high pedestal and tend to grant it the benefit of the doubt. But there's an argument for giving weight to emotion and intuition. There's something a bit sexist when we disregard women for making, quote, just emotional arguments. Mothers deserve credit for being experts on their own children; at the same time, science gets credit for knowing what may be good for children as a whole.
I don't want to tell a story of science bad guys/parents good guys. Everybody's trying to serve their own families and the public interest in a way most closely aligned with their values.
You don't think the term "anti-vaxxer" is accurate.
“Anti-vaxxer” is appropriate for the 19th and early 20th century. Today there is more vaccine hesitancy or vaccination resistance. In the 19th century, if you were opposed to vaccines, you were opposed to the one vaccine out there, smallpox. Today some are opposed to all vaccines on principle. Many more have questions about certain vaccines but don't dismiss all vaccines out of hand.
We reflexively blame outbreaks of vaccine-preventable diseases on supposedly irrational anti-vaccinationists. In doing so, we often neglect to consider the shortcomings of vaccination and the many reasons children lack vaccinations: age, religious beliefs, medical contraindications, poverty, challenges accessing healthcare, and more. It's not just about philosophical objections.
Angrily blaming so-called anti-vaccinationists simply creates an environment of hostility and aggression, and that's never conducive to achieving public health goals.
You found that creating a vaccine can make milder diseases seem more dangerous than they did before the vaccine.
When we begin to vaccinate against a disease, we fixate on its more serious aspects and complications. Over time, vaccinating turns those diseases into serious diseases that we no longer tolerate, even when those diseases were not public health priorities before their vaccines were developed.
One consequence: As the childhood vaccination schedule has expanded — an ever-longer list of vaccines against an ever more varied array of diseases — support for vaccination in general has, not surprisingly, begun to erode. Trust in the measles-mumps-rubella vaccine, for example, may be a casualty of this historical process.
So some vaccine resistance can be laid to the fact that, unlike polio or smallpox, these diseases have a much lower death or serious complication rate?
That's a big part of the story. Take the HPV [human papillomavirus] vaccine. If it had been a breast cancer vaccine, we probably would have seen a really different cultural response because breast cancer is perceived as a widespread public health priority.
Rewind to the 1950s, when we experienced really frightening polio epidemics, and conquered them with vaccines developed right when we needed them most.
How have the Internet and social media affected the vaccination debate?
They've given people access to information. I mean good, solid, scientific information. I also mean rumor and speculation. I mean access to information from each other. The new media have created communities of like-minded people who have some of the same worries or beliefs. [And] a lot of people go online predisposed to think one thing or another. Maybe the new media enable us to easily find what we need to support what we already think.
For years, getting vaccinated was a hallmark of being educated and middle-class.
The relationship between vaccines and class has changed recently. I'll use measles as an example. Middle-class families got the vaccine in the 1960s. There was faith in the nation's doctors, in the nation's biomedical enterprise, and by the end of the 1960s there was a tremendous class gap in who was protected and who wasn't. [The public health message] was, you don't want to catch the diseases that were prevalent in these [poorer] communities.
A person's vaccine history says so much about where they were born, their parents, class and worldview, how we were thinking about infectious diseases at the time. You can tell quite a bit about somebody just by the antibodies coursing through their veins.
The importance of vaccines has variously been promoted as an individual health benefit and as a wider benefit — "herd immunity." Is the latter appeal weaker in a "bowling alone" culture?
In public health, we've been emphasizing personal responsibility for a long time. We do not have universal healthcare; access to healthcare has been a big problem, and the way we've dealt with some of our biggest health problems is to task individual Americans to “take care of your own health.” We've done that with cancer prevention, heart disease prevention. [Herd immunity] is one of those rare areas where we're issuing a message that's in conflict with much of the other health messaging out there.
Where does the authority come from to require vaccines?
The authority rests wholly with the states. That state power came from two Supreme Court cases, in 1905 and 1922. The court ruled that states do on the whole have the power to enforce vaccines for the good of a community.
What do you make of the current measles cluster?
There have been major outbreaks since we developed the vaccine, but smaller outbreaks like this one have proven how hard it is to keep measles under control via vaccination. We need to look more closely at the disease, the vaccine and our expectations of vaccines.
This interview has been edited and condensed.
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