Journal of Bioethical Inquiry

, Volume 13, Issue 2, pp 349–351 | Cite as

On Immunity: An Inoculation

Eula Biss, 2014, Graywolf Press (Minneapolis, 978-1-55597-689-7, 216 pp.)
Book Review


Immunization Vaccination Benefits and harms Decision-making 


This award-winning author and academic of a non-scientific background appears to have been conflicted by the immense and diverse amounts of information on the benefits and harms of immunization. She resolved her mixed feelings about immunizing her own child by investigating the topic, forming her own opinion, and writing On Immunity: An Inoculation.

She has researched her subject atypically but thoroughly, using a wide-ranging mix of historical, philosophical, ethical, and scientific perspectives.

Each section, left untitled, covers a different piece of the puzzle about gaining or losing immunity. In her book, anything goes: from mythology, history, and environmental disasters to perspectives from family and her physician father, through pregnancy to childhood, in no particular order.

Anyone who wishes to obtain some different but factual views on immunization should read this book


I am a general practitioner with an interest in immunization, so I have medical knowledge and expertise in the area of vaccination. That said, I have no particular skills in matters relating to literature or philosophy, so it was an interesting experience to read this book, written from such a different perspective to mine or the usual medical literature I read.

The author, Eula Biss, is a highly educated mother without medical or scientific training. As a consequence, she uses a very informed metaphorical and philosophical approach in her exposé of issues surrounding immunization. The book is full of stories about a multitude of issues relevant to any debate about immunization and related health issues. Discussions are presented on the best ways of providing protection to a child from damaging infections.

Historically, both medical and public thinking have been flawed regarding the benefits of targeted immunization, instead of a whole population approach. This is illustrated by specific discussion about the hepatitis B virus, which is transmitted sexually, by injury, or through contaminated blood transfusion, leading to the potential long-term consequences of liver cancer. Biss sensitively confides in the reader about her misconception of her own baby having zero risk of hepatitis B at birth or soon after. As a result, her child missed out on the birth dose of the protective vaccine. However, she clearly recognizes and exposes the flaws in thinking that we can identify all those at risk. Her doctor suggested that vaccination would only really benefit drug addicts and prostitutes and that these populations are the only ones in need of hepatitis B infection control. For Biss, the recognition dawned that the risk of infection can be invisible; in her exploration, she also cites public health experience, which illustrates how such an approach is counterproductive. It is now scientifically proven and accepted that a systematic population approach is needed to reduce the rate of infection across the whole community. (Of note, although this may not be the place to correct this very intelligent and talented author, but she presents one misconception about the birth dose of the hepatitis B vaccine, which can protect newborns if given up to seven days after birth, even though within twenty-four hours is preferable [Lee et al. 2006].)

Additionally, the personal, cultural, and socioeconomic factors that influence our thinking, relating to knowledge, attitude, and behaviour about health seeking, are explored. This is framed from both a personal and community perspective and includes an interesting description of “Dr. Bob” and his dangerously distorted advice on the “protection of the nation” by using his “selective vaccination schedule” that would actually give delayed suboptimal immunity, as well his conflicted interest in promoting a private cord blood bank for personal benefit of the individual only.

There are also explanations about the human desire to acquire perfectly safe and complete immunity to all harms, especially for one’s own children. This is contrasted with the reality of vaccines on offer and their generally minor imperfections. One could say vaccination is a victim of its own success. Vaccines reduce infections and their harms, and this affects their “public reputation” in two ways: one, because of their life-saving impact, modern populations may not have any direct experience with the life-changing infections they keep at bay (and thus may not understand the great need for them), and, two, those very dangerous infections and diseases with which they are associated often have generated fear and distrust going back through history. (One example is the proliferation of vaccination against smallpox in the eighteenth century.) Healthcare practitioners and public health scholars also recognize that vaccine refusal is associated with health literacy and the ability to accurately understand that there is a relative risk from both the infectious disease and the vaccine used to protect against it. Biss acknowledges, interprets, and rationalizes these issues well by using examples—such as reiterating for readers that the research falsely linking the measles, mumps, and rubella (MMR) vaccine with autism has been discredited and retracted and the fact that the relative risk of measles encephalitis diminishes by a factor of more than three thousand following vaccination. She then compares these disproportionate fears to our lack of fear about far more dangerous and common things like driving around in cars.

Biss’s discussion includes different people’s attitudes about the acceptance of minor potential risks of adverse reactions from vaccine additives. The use of additives improves efficacy, enables multi-dose vials, and reduces manufacturing costs, all of which make them more likely to be used in poorer nations.

There also is debate about those who chose not to immunize, individuals who often hail from more affluent sections of higher-income countries and who enjoy higher health status. Biss examines how these non-immunizers are ignoring their role in vaccination programs and that their participation towards “herd immunity” is needed to maximize the benefit for all, including those who may not be able to be vaccinated for medical reasons or who have less economic, social, and/or cultural capital when it comes to their health. In a way this relates to the “inverse care law” first described by Julian Tudor-Hart (1971), describing how those in the higher socioeconomic groups take advantage of their wealth, education, and health by using health resources more than their poor, uneducated, unhealthy counterparts. Although here members of the former group tend to make up the non-immunizers, and thus are choosing in this instance to forgo this health resource, this situation makes clear that health service use is inappropriately distributed and inverse to where the greater benefit would be expected.

To help draw a mental picture for her readers about why immunization is vital, Biss uses a factory metaphor, where viruses take over the machinery in cells to force the cells to manufacture thousands more viruses. She goes on to debate the semantics of other common descriptors in use regarding immunity and infections (for example, those relating to war and battle such as “shots”) that continue to linger in our conversations (rather than talk of balance, strength, and harmony).

Far more unfortunate and extreme war-related examples follow, including infectious disease in politically unstable states, the consequences from receiving polio vaccinations (such as the mutilation of children depicted in Apocalypse Now), or the murder of health workers in Pakistan and Nigeria.

In Conclusion

In this book, it is refreshing that so many more perspectives are raised about vaccines, other than the medical and scientific ones, because they appear just as important in the scheme of things.

As a health practitioner, it is good to be reminded to look at issues in other ways, guided by the insights of a mother who has experienced many things on the journey to motherhood and to achieving the best health for her child. Biss shows great mastery in her research of all the options available.


  1. Hart, J.T. 1971. The inverse care law. The Lancet 1(7696): 405–412.CrossRefGoogle Scholar
  2. Lee, C., Y. Gong, J. Brok, E.H. Boxall, and C. Gluud. 2006. Effect of hepatitis B immunisation in newborn infants of mothers positive for hepatitis B surface antigen: Systematic review and meta-analysis. British Medical Journal 332(7537): 328–336.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Journal of Bioethical Inquiry Pty Ltd. 2016

Authors and Affiliations

  1. 1.Bond University Medical ProgramGold CoastAustralia

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