Book Review

State of Immunity: The Politics of Vaccination in Twentieth-Century America

N Engl J Med 2007; 356:2117May 17, 2007

Article

State of Immunity: The Politics of Vaccination in Twentieth-Century America
(California/Milbank Books on Health and the Public. 16.) By James Colgrove. 332 pp., illustrated. Berkeley, University of California Press, 2006. $39.95. ISBN: 978-0-520-24749-9

In the United States, the number of diseases that are preventable by vaccines is at a historic high, and the morbidity and mortality from childhood diseases that can be prevented with vaccines remain at record lows. State of Immunity provides an intriguing and entertaining look at how childhood vaccination programs in the United States gradually became mainstream and at how the various social and political forces that drove this achievement at times threatened to derail it.

Spanning the past century, the book proceeds chronologically, from the early smallpox vaccine campaigns to the modern antivaccine movement, focusing on the interplay between the new vaccines of the era and the politics of the day. Each chapter uses specific examples to explore the tensions surrounding the widespread introduction of vaccines, including the protection of children's health versus parental control, local versus national jurisdiction over health issues, the inherent risk of vaccination versus compulsory policies (such as school mandates) to improve vaccination rates, and the use of strategies aimed at behavior modification versus system changes to achieve a public health goal. This book is not about justifying decisions or public sentiment based on the scientific evidence, and a reader looking for that perspective will not find it. Rather, it focuses on stakeholders whose perspectives are critically important to programmatic success and yet whose opinions have often been devalued by the medical and scientific communities. People speaking from a political, legal, public-relations, or marketing point of view were prominent in shaping public health successes and failures.

Colgrove exposes many valuable lessons of the past that remain pertinent to current debates in public health. The issues of quarantine and isolation are highlighted in the sections on smallpox vaccine. The conflicts between public health and individual rights that arose in response to the smallpox vaccine program are analogous to the current discussions surrounding preparations for and recommended responses to an influenza pandemic, for example. Likewise, questions of when and how mandatory school vaccination laws should be used are at the forefront of discussions surrounding the newly licensed human papillomavirus vaccine. Although school mandates were originally intended to control highly contagious diseases, the book discusses the goal of reaching the “hard to reach” and achievement of equitable vaccination rates among socioeconomic classes as justifications for subsequent school vaccination laws. The theme of vaccination as a victim of its own success recurs throughout the book, with examples of public health proponents battling public complacency as vaccination rates increase, morbidities decline, and individual risk–benefit ratios shift.

Because vaccines are one of the few medical interventions that affect nearly everyone, this book should appeal to a wide range of readers. Those with an interest in public health will appreciate the thorough and balanced review of the controversies surrounding vaccination. Historians will enjoy the quotes from newspaper articles, pamphlets, and journals. The role of cultural icons in promoting vaccination, including Elvis Presley being photographed while receiving a polio vaccine and Charles Schulz dedicating a Peanuts cartoon to measles vaccination, add to the general appeal of the book.

Kathleen M. Neuzil, M.D., M.P.H.
Program for Appropriate Technology in Health, Seattle, WA 98107
kneuzil@path.org