Pestilence is in fact very common, but we find it hard to believe in a pestilence when it descends upon us. There have been as many plagues in the world as there have been wars, yet plagues and wars always find people equally unprepared. […] When war breaks out people say: ‘It won’t last. It’s too stupid.’ And war is certainly too stupid, but that doesn’t prevent it from lasting. Stupidity always carries doggedly on, as people would notice if they were not always thinking about themselves.

— Albert Camus, The Plague

DURING A PRENATAL VISIT to her pediatrician, Eula Biss asked about the necessity of the Hep B vaccine because claims — unproven — have suggested it is linked to multiple sclerosis and sudden infant death syndrome. Her doctor told her that her child wouldn’t need it because it was “for the inner city […] to protect the babies of drug addicts and prostitutes.” It didn’t occur to Biss to clarify that her Chicago neighborhood might be the kind he was talking about. “I am ashamed by how little of his racial code I registered,” she writes in On Immunity: An Inoculation. “Relieved to be told that this vaccine was not for people like me, I failed to consider what exactly that meant.”

On the copyright page of On Immunity appears the following disclaimer: “This book is not intended to diagnose, treat, cure, or prevent any disease. It is an inoculation only against maladies of a metaphorical nature.” This wry (no doubt legally necessary) statement strikes at the nature of Biss’s project: to continue in On Immunity, her third book, a conversation she began in Notes from No Man’s Land, her second, about the impact of race and class on American culture.

Published in 2009, Notes from No Man’s Land received a rapturous reception, winning the Graywolf Press Nonfiction Prize and the National Book Critics Circle Award for Nonfiction; therefore On Immunity has been much anticipated, and it does not disappoint. Its somewhat musty title — that academic overtone — alludes to Voltaire’s “Letter XI — On Inoculation,” a short essay produced sometime between 1733 and 1742 by France’s preeminent writer of the Enlightenment, in which he recommends to his countrymen the revolutionary practice of immunization. Biss’s contemporary plea — directed more specifically at her countrywomen — is less introspective, more journalistic, than Notes from No Man’s Land, but no less striking or accomplished. Biss, who describes herself as “an essayist, a citizen thinker,” uses her personal journey through early parenthood as the book’s connective tissue, while chewing the bones of human nature right down to the nub. Indeed, On Immunity may be too reasoned, too intelligent, too thoughtful, too philosophical — and be perceived by those who adamantly oppose its conclusions as too unrealistically altruistic — to be heard above the cacophony of sensationalized quackery that masquerades as debate about immunization (and other scientific issues such as the environment and diet) in our popular media. It is a necessary book — a hefty dose of compassionate rationality prescribed by our contemporary heir to Voltaire — asking us to take a long, hard look at the societal consequences of individual choices. Some may be unwilling to swallow it, though — the idea of preventative medicine being, according to Biss, faintly un-American, because it implies that “the enemy is us.”


Immediately after a healthy pregnancy and the routine delivery of her baby boy, Eula Biss suffered a uterine inversion, a rare condition causing substantial blood loss necessitating a transfusion and invasive surgery. She makes a full recovery, but the experience leaves her shaken, a feeling compounded when she discovers that her son, like herself, suffers from unpredictable allergies. While lifting the new, terrifying weight of parental responsibility, Biss falls down the rabbit hole of contradictory information about infant healthcare. Struggling to balance love and hazard becomes “not a question of whether I would protect him so much as it was a question of whether inoculation was a risk worth taking.”

Anti-vaccination movements in the United States have existed ever since vaccinations began around the time of the American Revolution. Current vaccine opponents raise the same spectrum of political, religious, and philosophical objections cited by their predecessors. Many object due to concerns about vaccine safety, or prefer to rely on “alternative” medicine rather than conventional. Some believe that children develop “natural” immunity to disease and that industrially produced vaccines are contrary to sound environmentalism. Others argue that medical intervention thwarts God’s intentions, or are convinced that our successful eradication of many contagions is due not to immunization but to improvements in sanitation and hygiene. And there are those who see immunization as the prime example of governmental infringement of individual rights. The biggest outbreaks of measles reported in the United States during 2013 and 2014 have clustered in communities that have lower than average rates of vaccination due to those securing exemption for such beliefs.

Biss’s tone throughout On Immunity is reasoned and calm. Wisely, she chooses not to include discussion or examples of such conditions as autism or sudden infant death syndrome in relation to immunizations, understanding that it would be irresponsible to conjecture the causes behind conditions that doctors and scientists are still struggling to understand. Her primary intent is, as she says, philosophical and metaphorical. Immunization is an emotive topic, and she tackles it by keeping emotion under control, refusing to exploit, or extrapolate from, any single family’s tragedy. Her deep and articulate thoughtfulness, which is the defining trait of her narrative style, will probably not propel On Immunity onto the best-seller lists (though I hope to be proved wrong) but does allow the reader to distinguish the wood from the trees.

The first critical takeaway from On Immunity is that Biss debunks, convincingly, the various claims made by leading anti-vaccine advocates, such as Jenny McCarthy and Andrew Wakefield, and skewers some insidious advice offered by the well-known American pediatrician Robert Sears — known as Dr. Bob — author of the best-selling The Vaccine Book, which outlines alternative shot schedules for anxious parents. Much anxiety surrounding immunization derives from fear of preservatives, those markers of the modern industrialized world — what McCarthy terms, “the frickin’ mercury, the ether, the aluminum, the antifreeze.” Neither antifreeze nor ether is used in vaccines, and mercury-based preservatives were discontinued in 2002. However, although Andrew Wakefield, who spawned the hypothesis that the MMR (measles, mumps, rubella) vaccine caused autism, was struck off the medical register in the United Kingdom for “irresponsible and dishonest” conduct, and the Institute of Medicine in the United States released an exhaustive report in 2001 rejecting his theory, one-quarter of the parents who responded to a national survey about vaccines continue to believe him.

“Misinformation that finds a host enjoys a kind of immortality on the Internet, where it becomes undead,” writes Biss, making one of many references to vampires, the fictional personification of germs and debauchery. Even when medical articles are corrected or withdrawn by relevant authorities, faulty information proliferates on the web, that unchecked spreader of disease. The immortality (and I would add the rampant immorality) of misinformation compounds an often-fractious relationship between women and the medical profession. Historically prohibited from practicing medicine and ostracized as witches when they made the attempt, women were identified until the 1970s as “a convenient missing link in germ theory,” for any condition that medicine could not characterize, including schizophrenia (overbearing mothers), autism (cold mothers), and homosexuality (coddling mothers). “If it’s not viral or bacterial,” a psychotherapist quips to Biss, “it must be maternal.”

Not surprisingly, after centuries of being patronized, women are more prone to skepticism about medical advice than men, and it is to women, specifically, that Biss addresses On Immunity, by using the term “mother” rather than “parent” throughout. Furthermore, she hopes to reach those mothers who have access to healthcare and the opportunity to vaccinate but may be dithering over whether or not to do so. Women anti-vaccine advocates tend to be white, economically better off, college-educated, in a marriage or partnership, and with children attending a private school. The mothers of under-vaccinated children are often single parents, living in poorer or immigrant communities with little or limited access to healthcare. (I understand Biss’s desire to share solidarity with mothers, the community to which she and I belong — especially while she is simultaneously poking at some of its assumptions — nevertheless I couldn’t shake the impression that fathers have been marginalized in this debate or were presumed indifferent, as though their presence were reduced to the odd puff of pipe smoke or newspaper rustle from a distant corner of a faraway room.)

We cannot dismiss as irrelevant the powerlessness and despair that parents must feel when a child dies from sudden infant death syndrome, or develops a condition such as autism or epilepsy, for which the current medical knowledge can offer neither a definitive explanation nor a cure. It is natural that grief and rage might send us looking for explanations among the new chemicals and byproducts spawned by our rapidly industrializing world, even without verifiable evidence, and it is right and imperative that such chemicals and byproducts are rigorously tested for health and safety. Nevertheless, Biss is much more compassionate toward sister-naysayers than I am; I want to clonk their heads together for giving credence to bunkum that, according to one lawyer from the US Court of Federal Claims, would require us “to emulate Lewis Carroll’s White Queen and be able to believe six impossible (or at least highly improbable) things before breakfast.” Given that Biss suggests Coca-Cola is probably more harmful to our children than vaccines, what is the root of our irrationality? Do we, she asks, really “believe vaccination to be more monstrous than disease?”

When Biss brought up an article in The New York Times in a discussion about the efficacy of the flu vaccine, other mothers commented that they didn’t like its tone. “They found it insulting for the same reason I found it reassuring — it did not acknowledge any good reason for doubt.” And, heaven knows, reasons for doubt in our modern world abound: unreliable media, inept governments, corrupt financial institutions, hypocritical politicians, illegal surveillance, racial and ethnic profiling, casual pollution, pharmaceutical and biochemical industries favoring profit over ethics. Doubt breeds immeasurable fear, and “our fears are formed by history and economics, by social power and stigma, by myths and nightmares. […] When we encounter information that contradicts our beliefs, […] we tend to doubt the information, not ourselves.” What matters, legal scholar Cass Sunstein tells Biss, “is not whether people are right on the facts, but whether they are frightened.” Our relationship to risk, therefore, is often unscientific and irrational. A person who is scared witless of flying might happily drive across America, even though driving is at least a thousand-fold riskier. The most natural-born killers of human beings are mosquitoes, not sharks, but most folks fear the latter more than the former. Biss admits to sleeping with her baby and using a bicycle, despite some of the most dangerous consumer products being — you guessed it — beds and bicycles. Irrational risk assessments occur not only at the individual level but also on a governmental one, where political and social agendas come into play: as a nation we have decreed it unacceptably risky to give a nine year old a Kinder Egg, but we will happily hand her an Uzi.

Our wonky conflation of risk with personal belief derives from those maladies of a metaphorical nature to which Biss refers in her disclaimer, another symptom being the language of our cultural discourse. Drawing on essays and books by Susan Sontag (Illness as Metaphor and AIDS and Its Metaphors), James Geary (I Is an Other), and George Lakoff and Mark Johnson (Metaphors We Live By), Biss contends that whoever controls the language of our cultural conversation gets to define what is or is not true. We have a war on drugs, a war on terror, a war on women, and a war on disease, and sometimes the war on disease is defined by two warring parties described as “ignorant mothers and educated doctors, […] or caring mothers and heartless doctors […] — sexist stereotypes abound.” Biss interviews scientists who object strongly to the use of military jargon to describe disease as it induces fear in the patient, and simplifies and pigeonholes the complex nature of viruses or bacteria as “bad,” whereas, as Biss’s father (an oncologist) remarks, “not all germs should be put to death.” Such combative language fails to recognize the astonishing “ebbs and flows” of a human immune system “striving for balance and harmony, rather than engaging in armed conflict.” Such language choices pervert the positive attributes of disease prevention; thus the Brits get “jabs” and the Americans get “shots,” and in both cases vaccinations are metaphorically perceived as a violence.

And if the vaccination is to protect us against a sexually transmitted disease, “it seems to become a sexual violence.” The politician Michele Bachmann warned of the “ravages” caused by the HPV vaccine (to prevent papillomavirus), and the journalist Jennifer Margulis saw no need to protect her daughter against Hep B because it was “a sexually transmitted disease she had no chance of catching.” Given that we can’t predict the identity of our children’s future sexual partners, I can only assume that Margulis was suffering from that common delusion that our daughters will never, under any circumstances, have sex at all.


The late Victorians, Biss reminds us, were titillated by Bram Stoker’s Dracula (1897),which exploited their long-held fears of filth, sexual deviance, and female promiscuity. The scar left by the smallpox vaccination resembled, to those with feverish imaginations, the puncture wound left by a vampire. Because vaccination requires transferring organic matter from one human being to another, some religious leaders railed against it, associating it with sin, while the superstitious called it “the mark of the beast.” In this way disease became associated with evil, and with the perverse notion that illness is a punishment for sin, and therefore a sick person is responsible for her or his fate — a prejudice that lingers yet.

Historical revulsion over the comingling of blood and fluids, in real life or fiction, fostered in some people an obsessive admiration for, and pursuit of, “bodily purity,” which led us toward the bone-chilling territory of the eugenics movement, miscegenation laws, anti-sodomy laws, and the hideous consequences of anti-Semitism. Then, in the 1980s, the AIDS epidemic made the very idea of the needle seem dirty. Nowadays, Biss eloquently argues, it is our conviction “that toxins, rather than filth or germs, are the root cause of most maladies,” and “the natural body meets the body politic in the act of vaccination, where a single needle penetrates both.” Thus does Biss weave a fine web linking subliminal cultural assumptions of our past — poverty equals filth equals disease equals sin — into our present day, where good health is in danger of becoming both an economic marker and a status symbol, the humble-brag of the middle- to upper-class lifestyle. To be a healthy person, it is implied, is to be a better person, and we perceive disease as something that is done to us, not something that we have the potential to carry within us; disease is the other.

And speaking of other, the immigration office in Baltimore was packed on the day, a few years ago, that my husband Arthur and I had our final interview for American citizenship. We are Scots and white, and the majority of the people in the waiting room with us appeared to be from India, China, Southeast Asia, or Africa. The women tried to keep their squirming children occupied, restless in their new clothes and fresh haircuts on the uncomfortable plastic chairs. Men clutching thick binders of paperwork looked at the ceiling with expressions comingling panic and distraction. When our turn came, the immigration officer interrogated Arthur at length, trying to catch him out with complicated questions about electrical engineering. Me, she ignored. I began to daydream, my gaze flitting from the massive files (all about us) on her desk to the Stars and Stripes and the portrait of President George W. Bush hanging on the wall behind her, until, suddenly, she turned and asked me the date of our wedding anniversary. I blanked, stuttering. She smiled. After we took the oath, she gestured toward the waiting room and said, “You are exactly the kind of new citizens we like to see.” It shames me to admit that her racial code did register and yet I said nothing. Arthur steered me firmly by the elbow out the door.

Smallpox was once known by many names including “Mexican bump” and “nigger itch,” and since then we’ve had pandemics of various strains — and nationalities — including Spanish, Russian, and Asian, though we’ve yet to experience an American flu. “The concept of a ‘risk group,’” said Susan Sontag, “revives the archaic idea of a tainted community that illness has judged,” and there has always been “the conflation of otherness with disease.” Those who exhibit difference — be it a different religion, a different sexual orientation, a different economic status, or a different race — often trigger societal fears. I would argue that much of the current heated debate surrounding immigration is founded on fear; some politicians talk of people “swarming” over our borders, metaphorically associating immigrants with bacterial infestation. Biss writes in Notes from No Man’s Land, “There is no biological basis for what we call race, meaning that most human variation occurs within individual ‘races’ rather than between them. Race is a social fiction. But it is also, for now at least, a social fact.” When Biss’s doctor implied that Hep B was not something she need worry about, he gave medical advice based on a faulty assumption that certain diseases are contained within race and class lines, which ignores entirely the philosophical foundation behind the notion of “public” health.

Biss and her father have blood type O-negative, making them both universal donors, and Biss uses the metaphor of the universal donor to elegantly demonstrate the lack of a biological basis for race, and as a motivation for immunization. Blood type O-negative can be used in transfusions for any person of any blood type of any race because all blood types cross all races. Nevertheless, racial identity is so conflated with the notion of bloodlines that some of us are thrown when we discover through genealogy, more often than not, that our racial ancestry is mixed. “What integration seems to mean to many white people,” Biss explains in Notes from No Man’s Land, “is that a very small number of other people will be accepted into white communities and institutions, where they will be ‘tolerated.” And “toleration” is a term Biss very much dislikes as it implies other people are simply a nuisance; that diversity is something we “put up with” — the way my husband might put up with a cat — rather than embrace. While looking through children’s books for her son, Biss was perplexed by how many of them were about the same thing: “the problem of ‘us’ and ‘them.’”


In the groundbreaking book Silent Spring (1962), Rachel Carson drew a direct correlation between evil and modern life, and we believed her — often with good reason. Uneasy with rapid technological developments, we gobble everything labeled “natural” or “organic,” convinced, despite evidence to the contrary, that nature is always benevolent. We cleanse and detox. We balk, as Biss does, the first time we give our children water. We want purified air and purified food, and berate those mothers who don’t — or can’t — breastfeed, even though tests of breast milk have revealed “paint thinners, dry-cleaning fluids, flame retardants, pesticides, and rocket fuel.” As Biss points out, there are much larger doses of formaldehyde circulating in our bodies than are contained in a vaccine. Our environment is polluted, therefore so are we; “we are diseased all the time, it is only when it manifests itself that we see it as unnatural.” Although we tend to think in terms of “safe and not-safe,” toxicologists know that it is always the level of the dose that matters. The desire to ensure our children develop “naturally” can spur idiotic acts of vigilante vaccination such as chicken pox parties or infected lollipops mailed through the post, as though a swab taken from the mouth could contain only a single kind of bacteria. Some people believe they need not vaccinate their children provided they feed them a healthy diet of organic food combined with vitamin and mineral supplements, and take them on frequent visits to the chiropractor. The so-called superfoods are very good for you, but I doubt that a blueberry and flaxseed smoothie will stop Ebola in its tracks. It doesn’t seem to occur to some parents that an unvaccinated child with a sturdy immune system can be the carrier of a disease without exhibiting its symptoms — while little Johnny waits in the checkout line at Whole Foods clutching his organic pomegranates and his macrobiotic yogurt, he could be passing on measles or whooping cough to the pregnant mother standing ahead of him and the newborn baby in the buggy behind.

Sometimes our best intentions have unforeseen consequences. Silent Spring led to the formation of the Environmental Protection Agency and proved, correctly, that “our bodies are not boundaries,” yet Carson’s assertion that DDT caused cancer remains unproven. DDT is still perceived to be the most effective pesticide for mosquitoes, but it is banned by most countries although malaria rates are rising, killing one African child out of every 20, a mind-boggling statistic that we would find utterly unacceptable in our own nation but seem willing to tolerate elsewhere. Vaccines, in turn, are perceived to be the very definition of artificial toxicology, yet, Biss states, they are a product of “that liminal place between human and nature — a mowed field,” often involving the manipulation of live, that is natural, bacteria and virus — that is “a kind of domestication of a wild thing.” As the science writer Carl Zimmer observes of humans and viruses, “there is no us and them.”

My brother contracted polio at four years old, most likely from the vaccine, a scenario, thankfully, that is no longer possible due to medical advances. When I was born three years later, I was vaccinated too. Although he made a full recovery, my mother’s courage (and my brother’s courage) seems remarkable to me now, in light of Biss’s book. My mother had an old-fashioned relationship with our family doctor — he delivered all of us — in an age before healthcare became a service industry and patients became clients. Mainly, though, I interpret my vaccination as part and parcel of her larger worldview, shared by the society in which she (and I) was raised: that is, Scottish, working-class, lefty, unionized, collective. She didn’t make a decision to vaccinate me; it simply never crossed her mind not to. Everyone knew there was a risk of contracting polio from the vaccine, she told me, but it was the responsibility of the majority to protect the vulnerable minority, so as far as the risk was concerned — as she put it — someone had to get it.


“All that matters is that he is safe,” Biss writes, recalling a phrase other people used time and again to reassure her whenever she worried about her choices with reference to her son, and she found herself wondering “whether that was, indeed, all that mattered.” After his birth, Biss pondered the precise meaning of trust. “A trust — in the sense of a valuable asset placed in the care of someone to whom it does not ultimately belong — captures, more or less, my understanding of what it is to have a child.” As parents we make decisions on behalf of our children, but our children do not belong to us; when a parent makes a choice not to vaccinate a healthy child, it is the child — not the parent — who carries the risk. Further, our choice to vaccinate cannot be merely personal because it has public ramifications: and yet, there is no federally mandated law that requires vaccination, so “allowing oneself to remain vulnerable to disease remains a legal privilege today.” Dr. Bob once stated that Hep B was an important vaccine from a public health standpoint yet not critical from an independent point of view. “In order for this to make sense,” Biss responds, “one must believe that individuals are not part of the public,” that public health is “not our health.” And by “our health” Biss implies (as does Dr. Bob) the health of middle-class white people, who “have the luxury of entertaining fears the rest of the world cannot afford.” Dr. Bob’s nauseating suggestion that we should not share a decision not to vaccinate with our neighbors lest it affects overall herd immunity bears a disturbing parallel with “a privileged 1 percent […] shelter[ing] from risk while they draw resources from the other 99 percent.”

At the time of writing this review, the Ebola virus in West Africa is predicted to affect around 20,000 people in a matter of weeks. The international president of Médecins Sans Frontières (Doctors Without Borders) has said, “the world had done too little, too late, to try to contain it,” and has condemned wealthier nations for prioritizing efforts to protect their own borders and their own nationals while offering little proactive, boots-on-the-ground expertise to those suffering in Africa. When an American missionary was released from an Atlanta hospital, after being flown home for treatment, he thanked God for his full recovery. I am very glad for him, though how not to wonder why God should choose to spare one white American, while allowing thousands of black Africans to die.


“It is thought foolish not to subject one’s actions to the calculus of self-interest and profitability,” writes Biss (quoting Sontag). In so many of our choices, public and private, we are encouraged to consider what’s in it for me? How ironic, therefore, that some fear vaccination, given that it is, potentially, a win-win scenario, “no altruism required.” More importantly, Biss argues, if economically secure white women like herself (and me) vaccinate our children, we help to protect those who tend to be under-vaccinated, namely the children of younger, unmarried black mothers, living in poorer communities. So even though some doctors (and politicians) would have us believe that public health is not strictly for people like me, “it is through us, literally through our bodies, that certain public health measures are enacted.”

“A child cannot be kept from his fate, though this does not stop the gods themselves from trying,” writes Biss, while considering the role of Greek myths and fairy tales in our collective culture. Mere mortals have tried, too, and with increasing success. Prior to 1900 in the United States, 100 children out of a thousand died before their first birthdays, compared to six out of a thousand today (an impressive statistic though not as impressive as the rest of the industrialized world). Nevertheless, the unspoken target for all age groups is zero. In his poem “Keys to the Doors,” Robin Robertson sums up the parental dilemma of addressing our children’s curiosity about this conundrum:

and I would nod, like some broken-hearted sage,
knowing there would be no answers soon
to all the big questions that were left, to cruelty and fear,
to age and grief and death, and no words either.
And you, like me, will sit and shake your head.
In true life? Yes my sweet, strong daughter, I’m afraid
there is all this as well […]

What we really want is not a vaccine against disease, but a vaccine against death. Death is our Achilles’ heel, and we rail against it, rail against the “other” who would bring it, determined that if and when that bloody bell tolls, it tolls neither for mine nor me. “If disease is a punishment for anything,” Biss argues, “it is only a punishment for being alive.” In Notes from No Man’s Land she wrote about her anger over racial and class discrimination, and

at the extent to which so many of us have agreed to live within a delusion — namely, that we will be spared the dangers that others suffer only if we move within certain very restricted spheres, and that insularity is a fair price to pay for safety.

Fear is isolating for those that fear. And I have come to believe that fear is a cruelty to those who are feared.

When Dr. Bob asks if we can fault parents for putting their own child’s health ahead of that of the kids around him, he means the question to be rhetorical, but Biss stresses that Dr. Bob’s implied answer is not hers; he is deluded if he thinks that we are other than interdependent. All men must refuse to give way to pestilence, argues Dr. Rieux, the central character of Albert Camus’s The Plague, and must “do their best to be doctors.” This “isn’t about heroism,” he says, “It’s about decency. It may seem a ridiculous idea, but the only way to fight the plague is with decency.”

The implication that it is perfectly acceptable to risk my neighbor’s child to protect my own — even though vaccination could protect them both — seems to me to be the very antithesis of decency. When Biss’s wise father (who reminded me throughout this book of Dr. Rieux) was teaching her how to drive, he told her, “you are responsible not only for the car you are driving, but the one ahead of you and the one behind.” Plagues will rise again, warns Camus, and send their rats to our well-contented cities. In the meantime, we could do no better than to hand out copies of Biss’s compassionate, important, and surprisingly optimistic book to every new parent — together with a vaccination schedule. We cannot give our children immortality, but, Biss believes, by embracing the concept of the universal donor, we might secure them longevity and a good quality of life. Or maybe the best we can hope is that we die before them. But not yet, not yet.


Susan McCallum-Smith is the author of Slipping the Moorings, a collection of stories. She was born in Scotland and currently lives in Ireland.