In her engaging book, Elena Conis shows how the USA became a “vaccine nation”. A child born in 1964 whose parents had the means to pay was able to be immunised against half-a-dozen diseases, almost all of which were known to be real threats. Half a century on, over ninety per cent of all children were receiving thirty-two shots against thirteen diseases, some serious but little known others scarcely a risk at all. As Conis observes, “the burden of upholding the social contract” by which the vaccination of individuals secured the entire community from infectious diseases “has fallen increasingly on the shoulders of children” (11). Still, as she seeks to argue, Americans “have vaccinated as much for non-medical reasons as for medical ones” (253).

One thread in this complicated story is the role of the federal government. It assumed responsibility for licensing vaccines in 1902, and its close interest in mass vaccination grew during the world wars. The menace of poliomyelitis and the creation of the first polio vaccine in 1955 prompted federal involvement for the first time in the production and distribution of vaccine. Federal agencies, especially the Communicable Disease Center (CDC) and its Advisory Committee on Immunization Practices (ACIP), served as a base for medical experts and public health officials ambitious to realise the potential of vaccination. Conis’s study begins with Kennedy’s Vaccination Assistance Act (1964), the first of a series of federal initiatives to ratchet up vaccination. The focus was on the vaccine-preventable crowd diseases, including smallpox, polio, diphtheria, pertussis and tetanus, with vaccines against measles, mumps and rubella also becoming available. In 1977, President Carter announced “an unprecedented ‘high-visibility’ two-year initiative to promote immunization” against the target diseases (91). Despite a limited budget, community activism and enthusiasm achieved some impressive results. Measles cases fell to an all-time low in 1981, making its local eradication appear conceivable. In 1993, President Clinton set forward an ambitious scheme, Vaccines for Children, to recover the loss of momentum during the Reagan years. He presented vaccination as a right of all children and as an investment rather than a cost. Presented and perceived as a trail blazer for a larger federal role in health care, the programme came under strong partisan attack, and the plan for federal universal purchase of vaccine was cut back. Still, the federal government became the largest purchaser of vaccines and was able to use its position to cut down costs. In the broader community, the spectre of HIV/AIDS and further progress in vaccine development made prophylaxis good politics. The profile of vaccination, both in terms of vaccination rates and the number of diseases that were vaccine-preventable, continued to rise. In 2009, President Obama again made vaccination central to a broader reform of health care.

Developments in the disease environment do not begin to explain the dramatic expansion of vaccination. It was not an increase in the severity of the crowd diseases that weighed with the Kennedy administration in the 1960s, but a recognition that making vaccination more available and affordable could increase social justice and national well-being. A key point of Conis’s study is that the availability of vaccine itself necessarily transformed the cultural meaning of a disease. Public health officials as well as the pharmaceutical industry played up the dangers of vaccine-preventable diseases. The development of combination vaccines—diphtheria, pertussis and tetanus, and then measles, mumps and rubella (MMR)—lowered the bar in terms of the severity of the diseases for which children vaccination was recommended. A measles epidemic in 1989–1991, which highlighted gaps in vaccine provision and take-up, helped support Clinton’s case for greater federal support for vaccination. Ironically, the greatest health scare at this time was a disease for which vaccine was not available. Still, as Conis shows, the menace of HIV/AIDS ensured a positive response to the release of a vaccine for the hepatitis B, with which it was connected in the popular mind and promotional material. Technical breakthroughs in relation to hepatitis B vaccines extended and transformed the concept of vaccine. A second vaccine produced from genetically engineered yeast was presented as safer and seemed to offer limitless possibilities for the futures. On the other hand, “biotech” vaccines sharpened the contrast between “natural immunity” and “artificial immunization”. In addition, the ambition of vaccination was growing. Fifty years earlier, children were vaccinated for crowd diseases to which they were directly exposed. Since schools were often foyers of disease, their immunization provided protection to the community at large. Rubella was the first vaccine given to children primarily to protect adults. Hepatitis B likewise was no real threat to the overwhelming majority of school children. Vaccination for HPV (human papillomavirus) raised more issues. It was promoted on account of a correlation between certain HPV infections and cervical cancer. Attempts to mandate the vaccination of prepubescent girls against a sexually transmitted infection were opposed. In this case, too, core understandings of vaccination were being stretched. The vaccine did not protect against cervical cancer, but against a risk factor.

The massive expansion in vaccination was accompanied by a lively debate and some resistance. In charting America’s changing attitudes to vaccination, Conis perhaps gives disproportionate space to explaining the concerns of vaccine sceptics and critics of a procedure that medical experts, public health officials, governments and the overwhelming majority of the population regarded as beneficial. Conis is at her most original in showing how old nineteenth-century concerns about vaccination spreading other diseases and making the body more vulnerable gained traction from the social and cultural trends of the last third of the twentieth century. The counter-culture of the 1960s bred distrust of authority and expertise, not least medical authority and expertise, and nourished suspicion of the nexus between government and industry. The environmental movement played its part in nourishing anti-vaccination sentiment. Its rhetoric “seeped into lay vaccine critiques [of vaccination], giving parents who were just a little bit squeamish about vaccines … a new vocabulary with which to describe their hesitations” (131). Especially interesting is Conis’s argument for the influence of second-wave feminism, with its critique of “organized medicine for its intimidation and mistreatment of women, especially mothers and mothers-to-be” (119). She observes that the appeal to mothers and voluntarism to raise vaccination rates in the late 1970s involved “gendered assumptions” that were not well received in all circles. More sensitive was the rhetoric of Clinton’s Vaccines for Children that acknowledged the cost in time and money to parents when a child was ill and the responsibility of health officials and the pharmaceutical industry to deliver vaccination efficiently and economically. In the controversy over vaccine harm, especially the alleged connection between MMR vaccine and autism, there were elements of the new and the old. Women were to the fore in organising support networks for and lobbying on behalf of parents who felt their children had been harmed by vaccination. The changing media landscape, with multiple channels competing for diminishing audience, welcomed stories about vaccine scares and confrontations between so-called experts and mothers. The Internet democratised information, valorised the “experiential knowledge” of mothers and assisted the mobilisation of opinion. A major strand in the debate over HPV vaccine was played out in the new social media where, for the first time, the young people being vaccinated, in this case adolescent girls, expressed their opinions pro and con. Some were quick to call attention to the double standard: as one puts it, HPV was “an equal opportunity infector” but only girls were being vaccinated (243).

Conis has presented a complex story very effectively. Though there is some overlap and backtracking, the book is very well organised. Since a lot of the interest of the book lies in her exposition of vaccine scepticism and opposition, it comes as a surprise when every now and then she reports the development of new vaccines and the soaring vaccination rates. Although she touches on a number of the factors that help to explain the general embrace of vaccination—like the alarms and anxieties arising from new diseases and immigration—Conis does somewhat neglect this side of the equation. The proposition that Americans vaccinated as much for non-medical reasons as medical ones is perhaps too strongly asserted. Most of the non-medical reasons she cites, including enhancing national security, slowing the rise in health costs, meeting “wellness expectations”, and “out of faith in biomedicine”, seem to be predicated on the perceived medical value of vaccination (253). Still, there is no doubt, as she puts it, that “vaccination was, and is, thoroughly infused with political agendas, social values, and cultural norms” and that “by acknowledging and understanding the divergent reasons” for vaccinating in the past why “we just may ensure the continued success of vaccination in the future” (3). Conis has produced a scholarly and accessible book that deserves the widest audience.