Vaccine Rhetorics

Front matter

VACGINE

RHETORICS

HEIDI YOSTON LAWRENCE

Contents

List of Tables vii Preface: A Starting Point ix Acknowledgments xv Introduction ¢ Retaining Persuasion 1 About Vaccination Controversy 3 Contending with Materiality 7 Considering Vaccine Rhetorics: A Theory of Material Exigence 11 About This Book 18 A Final Note on Materiality 21 Chapter 1 * Doing Disease 25 Material Exigence: Vaccines and the Modification of Infectious Disease 27 Doctors Doing Disease: Vaccination in Medical Practice 34

Diseases, Cures, and Prevention: Material Exigencies of Disease in

Vaccination Discourse 44 Changing Disease: Toward Intervention and Eradication 47 Chapter 2 e Community Immunity and the Promise of Eradication 49 Material Exigence: Medico-Legal Rhetorics and Smallpox Eradication 51 Prevention and the Public Good: Toward Community Immunity 55 Exemptions, Eradication, and the Disneyland Measles Epidemic 62 Medico-Legal Rhetorics and Exigencies of Eradication 72

Index

75 77 86 93 96

97 99 104 115

TABLES

TABLE1 Physicians study interview questions 35

TABLE 2 Vaccination requirements: CDC-recommended schedule compared with Virginia requirements for school and daycare entry 61

TABLE 3 Flu study interview questions 106 vii

Preface

A Starting Point

| BEGAN researching vaccination controversy in 2010 while supporting what would later become the Vaccination Research Group at Virginia Tech. Frankly, I started off relatively agnostic on the issue. I had never gotten a flu vaccine but was otherwise fully vaccinated and didn't have children to vaccinate. I knew that some people refused vaccines, but I honestly didn’t see what the big deal was. Nevertheless, as a dutiful researcher, I dove in, eager to see what it was all about.

I was quickly hooked. Intrigued by the problem, its many passionate and colorful actors, and seemingly intractable path to resolution, I found new questions and opportunities for rhetorical intervention at every turn the research took. Over the years to follow, I completed dozens of presentations, qualitative interview studies, and survey studies and read hundreds of articles about vaccination and its attendant controversies as I completed a dissertation and subsequent publications on the topic.

And then I got pregnant and had a baby boy.

Going into motherhood, I knew that I would vaccinate my child, but I was always deeply ambivalent about rotavirus vaccine,’ which protects against rotavirus infection. Rotavirus is a serious disease. At its best, it is essentially very bad diarrhea. At its worst, it can cause severe dehydration and malnutri-

1. Two vaccines were available against rotavirus during the timeframe under discussion here, Rotarix and Rotateq. I do not know which actual brand my son’s pediatrics office administered. i ix x « PREFACE tion, and even lead to death. So I could see the benefits and necessity of the vaccine. Yet I mostly perceived my son to be at low risk for contracting or spreading it, and I felt confident that my access to resources would make it manageable even if he did somehow get it. It also isn't a required vaccine for school entry in my state, so I knew that by skipping it, my son wouldn't have to “catch up” on the vaccine later. So the risks of the vaccine side effects—a cranky baby, maybe some diarrhea, even the rare chance of intussusception— didn’t quite seem worth it. I reflected on my position toward rotavirus and the vaccine in a 2016 article, which I wrote when my son was six weeks old:

I also planned to refuse rotavirus vaccine entirely. He is breastfed and does not attend daycare or have any interaction with other children, so my reasoning was that his risk of contracting or spreading the disease was low. We also live in a populous area with easy access to a variety of health care facilities. If he did contract it, so my thinking went, any complications like dehydration could be easily and quickly addressed before they became dire.

Then I read Kathleen Hennessy’s “How a Bout of Rotavirus Made Me Appreciate Vaccines,’ and, to my surprise, I felt my position on Rotavirus vaccine slip away. (Lawrence, “Fear” 206)

Hennessy’s narrative in the above-mentioned excerpt describes her child’s back-to-back rotavirus infections. It is a harrowing tale involving sleepless days and nights, endless bleaching of surfaces, and—most worrisome of all— concerns about feeding and weight gain for a sick baby. In response I wrote:

I have read versions of her story before, of course—both clinical and personal accounts about the duration of the disease, the perniciousness of its infectiousness, the undeniable ick factor, and the very real possibility of a baby becoming severely dehydrated and dying. But Hennessy’s narrative made me experience all of those things anew as I pictured myself in her position: desperately trying to feed a sick baby, tensely watching his every breath, and feverishly bleaching surfaces as sleepless days and weeks go by. And then I felt it: fear. (Lawrence, “Fear” 206)

A few weeks later, I got that vaccine for my son. I felt good about it, like I had made the right decision as a parent.

Not long after, he developed a bout of serious gastrointestinal (GI) problems and intolerances, and I grew hesitant as the next rotavirus booster approached. Rotavirus vaccine is an oral vaccine, and after months and months of trial and error trying to figure out what was causing my baby’s GI

PREFACE œ xi problems, things had finally returned to normal. By the time his appointment arrived, I had decided that I wasn't getting the next booster. Although I in no way associated his problems with the vaccine, I just didn’t want to introduce anything that might jeopardize the progress we had made. I communicated my decision to his practitioner as soon as the topic of vaccines came up. She disagreed, citing research that his GI problems made him even more susceptible to rotavirus, noting how devastating it might be to his progress if he were to become severely ill, and describing how safe and effective the vaccine was. I wasn't persuaded.

After leaving the appointment where I refused the vaccine, I made the following voice note to myself on the drive home:

Overall, I think that the most difficult part of it was that it was just deeply uncomfortable. [The practitioner] and I were having this very nice appointment. We were communicating really nicely. Everything was really friendly. She was really excited, talking about how cute [my son] was. It was a very nice interaction.

Then, when I said I didn’t want to do the rotavirus vaccine, it was like things changed, like the dynamic really shifted.

I felt discomfort. I didn't feel irritation. It didn’t feel antagonistic. It felt more just like, “Why are you doing this? We were all getting along so well, and now youre not doing what I say, and now this is a point of tension.”

As it would turn out, this would be the last time I met with that practitioner, since she left the practice soon after. I regretted that this was our last interaction. She meant a lot to me. She had shepherded me through the first few months of new motherhood and been really supportive of breastfeeding. She had helped us through a bad respiratory infection, along with the GI problems. I trusted her and liked her and was thankful for everything she had done. And then this happened, and it just felt like this interaction created a fissure in our relationship, one that I never had the chance to repair.

I share this story for three reasons related to the purpose of this book. First, to articulate my position: I consider myself a vaccinating parent and a provaccine adult. I wholeheartedly support vaccines and vaccine mandates. I know that vaccines are safe and effective and important. I also felt that it was my responsibility to skip a booster that I felt provided uncertain benefit and possible increased risk to my son. All of these things are, to me, logical, internally consistent, and a part of the way I enact what I believe to be good parenting. Yet other stakeholders—parents, practitioners, policymakers alike—might lump me in with “anti-vaxxers,” shorthand for someone who is anti-science, xii e PREFACE stupid, a Jenny McCarthy acolyte, and possibly even a negligent parent who deserves a call to Child Protective Services (CPS) because I refused a vaccine for my child. Pushing back against such rigid, unproductive categorizations and understandings of vaccine skepticisms is one purpose of this book.

Second, I also share my story to outline an experience interacting with a medical practitioner about vaccines in a less than positive way as an example of how rhetoric might uniquely help attenuate existing discord. Although I cannot know how my child’s practitioner felt about my refusal, I do know how I felt—uncomfortable, anxious, questioned in my ability to make good decisions on behalf of my child, and nervous about what that meant for my standing in the practice. I can also read the signs of her discomfort in the events that followed: she walked out of our appointment, retrieved a waiver form that I had to sign, and then left again without another word to me or my child, leaving the nurse to administer the remaining vaccines that he was receiving that day. Again, I cannot know what was in her head, but she seemed angry and disappointed at not being trusted. It really wasn’t about me trusting or not trusting her, though. I didn’t trust the vaccine itself. I knew the risks and benefits. I knew every argument for and against the vaccine. I knew that she was absolutely making the best recommendation she could and that no one would be more surprised than she if his GI problems resurfaced after the vaccination. My decision wasn't rooted in a lack of trust in her expertise; it was rooted in my own experiences with a sick child, my own previous history as a patient and new mother, and mostly my distrust of the object itself and its unknown potential for good as well as harm. She couldn't have done anything about any of that. Attempting to decouple the relationship many make between vaccine refusal and a rejection of physicians’ expertise or scientific knowledge broadly is a second purpose of this book.

Finally, I share this story to demonstrate how vaccines change over time for all of us as individual patients, for parents, and for citizens in a public who rely on community-level protections to keep us from getting diseases. We might think we support—or don't support—vaccines or vaccine mandates, but then something changes, altering our relationship to our own bodies, our definitions of personal responsibilities, and our resulting views on the prospect of being vaccinated. Vaccination is constantly evolving, emblematic of our experiences in our bodies, in our families, and in our communities. An understanding of vaccination’s embodied materiality and how it shapes the democratic, deliberative decisions we make about vaccines as a society, and how scholars in rhetoric in particular can help facilitate such a shift, is thus a third purpose of this book.

PREFACE œ xiii

Vaccine Rhetorics is reflective of these purposes and the many other experiences and changes I have observed since I began this research in 2010. Vaccination controversy looks different now than it did nearly a decade ago. In 2010 the recent HıN1ı crisis had left public health practitioners worried that they wouldnt be able to conduct a mass vaccination campaign against a serious threat if they ever needed to, because widespread controversy would get in the way. Now, recent outbreaks of measles are prompting changes in laws and policies toward expanding vaccine mandates, with significant and vocal public support. Nationally, California had one of the most permissive vaccination laws at the time, which left specific schools vulnerable to contagious vaccine-preventable diseases like pertussis and measles. As of this writing in 2019, however, vaccination rates in California are rising, following the 2015 policy change that removed all exemptions except in the case of medical contraindication. Consequently, a long-standing problem in California is being resolved so rapidly that, in another decade, the entire situation could be resolved. But new problems will take its place as new politicians take up the banner of vaccination (or antivaccination) during their campaigns, new diseases emerge, and new vulnerable populations are identified. In that same decade to come, every one of us will see our own positions on vaccination change as we become parents, get sick and then hopefully well again, enter old age, or change our living situations or occupations. We may also see the shots themselves change as diseases are eradicated or new safety concerns change their formulations. They may no longer be shots at all if new technologies like patch-based, inhaled, or food-based vaccines take favor.

Amid all those changes that may come to pass, one thing is certain: vaccines—and all the concerns, questions, and controversy about them—will still exist. As a multiple, complex thing, vaccines don't just gain their power and importance through their life-saving potential or value to public health. Vaccines have status because of their power to mediate modern life, making vaccination an evolving scientific and social experience as well as a deeply embodied and material one all at the same time, meaning that some degree of public scrutiny will always be present.

Vaccine Rhetorics attempts to unravel the key components of these complexities of vaccination to expose and examine them, with a goal of finding points for rhetorical intervention to mitigate discord. The goals of this book are therefore threefold—first, for rhetoricians to gain a new paradigm through which to understand large, public controversies involving science, health, and medicine; second, for medical rhetoricians to see how material shapes medicine and science, particularly medical and scientific systems involvxiv «© PREFACE ing infectious disease and preventative health measures; and third, to offer a mechanism through which rhetoricians can address and impact public problems, in addition to analyzing them.

Although vaccination controversy might seem like a monolithic issue where science battles denialists who are simply ill informed or misguided, this text exposes the ways in which the issue is far more complex than such a characterization indicates. Even the most ardent supporter of vaccination might one day be faced with a new requirement that comes with a new risk that might demand a reconsideration of support. As my own story about rotavirus reveals, these changes occur daily, may be heightened or resolved over time, and ultimately impact and are impacted by our experiences as we traverse medical systems. Understanding and accepting the evolution of the social, cultural, and embodied experience of being vaccinated, this text maintains, is the starting point for a rhetorical approach to vaccination.

ACKNOWLEDGMENTS

THIS BOOK took a bigger village than I ever could have imagined, and Pm humbled by the time, efforts, and support that everyone listed here has graciously extended to me over the years to ensure that this work exists.

The short list of most sincere thanks go to...

Everyone who participated in the research in this book. I want to thank the physicians who participated in the research interviews that are the subject of chapter 1, the students whose interviews on flu and flu vaccine are analyzed in chapter 4, and participants in the surveys and pilot studies that informed the methods used here. Without their time commitment and candor, this work—and the knowledge they have helped to create about what people think about vaccines—would not have been possible.

Everyone who made the publication of this book possible. I want to thank my editor at The Ohio State University Press, Tara Cyphers, Kristina Wheeler, and the anonymous reviewers of this manuscript. Your feedback and belief in this work was instrumental in helping me articulate the book’s mission, find my voice, and make the claims I needed to make as I revised. I also want to thank Mae Bonem, Kellie Bryan, and Rachael Graham Lussos for their invaluable feedback and editorial assistance, of which I was in dire need.

Colleagues nationally who helped mentor, inform, and advise my work on vaccination. Most sincere thanks go to James Colgrove, Elena Conis, Robert Johnston, and Andrea Kitta for their smart work on vaccination and for taking

XV xvi «© ACKNOWLEDGMENTS the time to listen to my ideas and give me feedback and encouragement very early in this research. I also thank leaders in my professional organizations, particularly the Rhetoric Society of America (RSA) and the Association for Teachers of Technical Writing (ATT W), for creating spaces and opportunities for feedback on this work, particularly in the development of the theoretical framing and interview analyses that appear in chapter 1; in this vein, I thank Jeff Bennett, Jenell Johnson, Blake Scott, Cheryl Geisler, and Ellen Barton in particular for providing these spaces and opportunities.

All my colleagues and mentors at Virginia Tech. My eternal thanks go to all of my colleagues, and especially to Brian Gogan, Dan Lawson, Tim Lockridge, Megan O'Neill, Ashley Patriarca, Molly Scanlon, Michelle Seref, and Matt Sharp, for your friendship, laughter, helpful questions, and smarts. I thank Paul Heilker and Carolyn Rude for persuading me to go to Tech in the first place and for guiding me through; Kelly Pender for teaching me so much about rhetoric and how to write about it; Clare Dannenberg and Katy Powell for teaching me career-changing lessons like how to do research, how to think about the world, and how to be a good colleague; and Eva Brumberger, Jim Collier, Jim Dubinsky, Carlos Evia, Diana George, and Kathryn Graham for connecting me to invaluable opportunities at Tech that have shaped me as a writer, a teacher, and a researcher. I also want to thank the members of the Vaccination Research Group at Virginia Tech for their research support, especially Olivia Kasik, Rachael Knight, Karen Spears, and Tarryn Abrahams.

My colleagues at George Mason. I want to thank the entire English department, and Doug Eyman, E. Shelley Reid, and Debra Lattanzi Shutika in particular, for taking a chance on me and providing the time, feedback, and resources necessary to complete this work. I thank Mary Baldwin and Barb Gomperts for making my work happen in key and important ways. I thank Eric Anderson for his long-time counsel and mentorship. I thank my colleagues in Writing and Rhetoric for their support, comradery, and good humor. I also want to thank my colleagues across Mason—Melissa Broeckelman-Post, Susan Lawrence, Emily Ihara, Ellen Serafini, Isidore Dorpenyo, Bonnie Stabile, Ali Weinstein, and Cathy Tompkins in particular—for all the assistance (logistical, emotional, professional, and otherwise) they offered to me at critical moments in this project. A huge thanks to students at GMU for all their research assistance on this and related projects, including PhD students Elizabeth Ferguson, Lourdes Fernandez, Veronica Garrison Joyner, Rachael Graham Lussos, and Norma Smith; MA students Mae Bonem and Luana Shafer; and members of my English 502 class, who assisted with the data collection in chapter 4: Manal Assad, Emily Bourne, Brandon Cantrell,

ACKNOWLEDGMENTS œ xvii

My closest colleagues and mentors. Amy Reed, thank you for reading my worst drafts and finding the best in them, for your confidence in me when I cant find it for myself, and for being so incredibly smart that your work always makes mine better simply by proximity. Libby Anthony, thank you for letting me laugh, cry, rant, and talk to myself; thank you for navigating some of the scariest and most joyful parts of academe (and life) with me; thank you for everything you taught me about being a good colleague and academic and friend. Byron Hawk, thank you for introducing me to rhetoric, for your invaluable feedback on the introduction to this book, and for the courage you gave me to say what I wanted to say. And of course, to Bernice Hausman. Gratitude and thanks just don’t seem like enough—you have inspired and led me to be the scholar, teacher, mentor, and colleague that I am, and I’m forever shaped by everything you have taught me. Thank you so much for all your time and constant, unwavering support.

My friends and family. There is simply not enough space here (or in two or three books) to outline the particulars of your help and how invaluable it has been to me over the years. I want to thank some of my longest-standing mentors and supporters, Steve George, Lettie George, and Steve Lowery, for being such invaluable sources of support to me throughout this work and my career. To my friends Matt Revelle, Jennifer Farrell, Shelley and Mark Rakip, Kellie Bryan, Kimberly Hall, Abby Waldron, Kevin Stoy, Chris Hall, and CJ Waldron; my sisters, Aubree and Hannah Lawrence, and their partners, Austen Hypher and Rob MacCall; and my in-laws, Rodney and Elaine Garner: all I can say is thank you. Thank you for all your tireless support and for making my life as rich as it is. To my parents, Richard and Dorothy Lawrence, thank you for everything you taught me about life and hard work and determination, because I needed every ounce of it to complete this book.

The amazing women who gave their time, labor, and talents to help me write this book by taking care of my son while I worked on it. Specifically, I want to thank (Ms.) Emily Crowley, (Ms.) Diana Wassel, (Ms.) Grace Tompkins, and (Ms.) Liane Chang, in addition to many of the friends and family members listed above.

My husband, Ryan. You—and you alone—made this book and my career happen through the countless ways you have supported me and my efforts during the past twenty years. Of course, you helped with all the usual things— the run for printer paper at the last moment; walking Charlie or feeding Milton and TS, and later Alice and Minerva, when there wasn’t a moment to xviii *« ACKNOWLEDGMENTS spare; the early-morning and late-night coffee runs; and so on. But, more than that, you kept the Voldemort Project going when I didn't just want to give up on it but insisted that I must give it up, that moving forward was absolutely impossible, and that no good could come of it if I continued. I love you, and I thank you for everything.

And finally, to Nathan. My sweet, beautiful boy. I started writing this book for me and for your dad and the goals we had together, but I finished it for you. I thank you for your patience during the days that this book took my attention away from you and for your insistence during the days that you refused to let this book take my attention away from you. You have taught me balance and love, and I’m so honored to be your mom. I love you so very much, forever and ever.

Introduction

IN THE US, school boards, doctors, parents, and citizens have two options when it comes to vaccination: compulsion or persuasion.’ People are compelled to vaccinate largely through laws and policies that restrict access to essential sites and spaces—namely, schools and jobs—on the basis of vaccination status. As James Colgrove and others have observed, historically compulsion has been highly successful at achieving higher rates of vaccination in the US. Or, as Emily Oster and Geoffrey Kocks most poignantly state: “changing minds on vaccination is very difficult, but it isn’t so important when a law can change behavior.”

Some could say that in 2019, at the writing of this book, we are in the midst of a robust movement in favor of compulsion in America. The 1905 Jacobson v. Massachusetts Supreme Court case set the nationwide precedent allowing states to mandate vaccination, and vaccine mandates for school entry in particular have been imposed to ensure that children are protected from disease.

1. This observation is made by a variety of scholars, though I am particularly citing the observations of James Colgrove and Eileen Wang et al., as they have noted the distinctions between compulsory and persuasive tactics in public health responses generally (Colgrove) and compared with other countries without compulsory laws (Wang et al. e82). I also discuss the tensions surrounding this issue of compulsion versus persuasion as a starting point for reconsidering persuasion in the 2018 article “When Patients Question Vaccines: Considering Vaccine Communication through a Material Rhetorical Lens” in the journal Rhetoric of Health & Medicine.

2 e INTRODUCTION

Although all states have some law compelling vaccination, all states also have exemptions available for those vaccines, and some states are stricter than others. In 2015 California, previously one of the most permissive states for vaccine exemptions, joined Mississippi and West Virginia as the only three states to allow only medical exemptions to vaccines. In these states, only those with a documented medical contraindication (such as a life-threatening allergy or severe immune suppression that would make vaccination dangerous) can avoid mandatory vaccination. Compulsory tactics abound outside of state-level mandates as well. Increasingly, individual physician offices are adopting stringent policies that require parents and patients to vaccinate or leave their practices, and the American Academy of Pediatrics (AAP) advocated in 2016 for state-level policy changes to remove all nonmedical exemptions across the United States (AAP Committee on Practice and Ambulatory Medicine). Even parenting groups, forums, and media reports encourage parents to ask other parents whether they are vaccinating their children and, if not, prohibit them from participating in those communities (Zibners; Stewart).

What about persuasion, then? Has the issue of vaccination, and its attendant concerns about disease, injury, and personal and community risk, really pressed at the limits of what is possible to persuade people to do? Is it even ethical to leave such important stakes to the messy and imprecise tactics of persuasion? Is compulsion the only answer? Or is there a way to give this issue back some of its rhetoricity?

As a researcher in rhetorical studies, Pm drawn to and invested in the idea that persuasion is still important despite the apparent benefits that compulsion might offer. Persuasion, in its best form, is not coercive but collaborative. Aristotle’s definition of rhetoric as “seeing the available means of persuasion” makes rhetoric an analytical, knowledge-making practice that necessitates mutual forms of understanding. Since the Greeks (and before), persuasion has been the hallmark of a democratic public, a discursive act that requires an attention and response to the needs of the public. Resorting to compulsion, in rhetorical terms, is to make situations arhetorical: to use sources and structures of power to remove opportunities for persuasion, collaboration, or deliberation. Rather, compulsion forces either compliance or infraction—nondiscursive results that carry real legal, social, and professional consequences.

Beyond my disciplinary investments in rhetoric, the research I have conducted on vaccination controversy indicates the continued need for persuasive, discursive responses to vaccines despite calls for compulsion. Time and time again, vaccination and its related controversies prove to be about more than just rates of uptake for doctors, public health professionals, and parents, proand antivaccine alike. For patients (and, most often, parents of patients), one’s position on vaccination is not just one decision among many made at the doctor’s office, viewed in simple terms of compliance. To vaccinate is to accept risk on behalf of one’s community, to accept the risk of an unknown outcome, and often to accept those risks on behalf of babies and children who have no choice or agency of their own yet bear all the consequences. Although the vast majority of medical and health professionals describe themselves as provaccine, the articulation of that support is metered by concerns about fluctuations in the efficacy of flu vaccine, lingering struggles about whether higher vaccination rates are really worth losing patients who need care, or questions about the necessity of the specific schedule outlined by the CDC. In all these cases, vaccination is articulated as a social practice, a way of shaping and crafting one’s self in the world as a parent, a patient, a doctor. These individual, embodied, material experiences demonstrate how vaccination is an unstable and uncertain practice that demands deliberation, discussion, and understanding—all the enactments of discourse that persuasion, and thus rhetoric, requires.

Vaccine Rhetorics examines the role that persuasion might play in vaccination controversy in light of calls for compulsion. By applying the theories of rhetoric and the objectives of rhetorical analysis, this text identifies spaces where a rhetorically informed, persuasive approach might open opportunities for discourse and find paths to ameliorate the controversies that have plagued the practice of vaccination for hundreds of years.

ABOUT VACCINATION CONTROVERSY

Before we can craft a rhetorical approach to this controversy, we must address the question: why are vaccines controversial? Vaccination programs have had some of the most far-reaching and expansive impacts on community health and longevity among all public health programs. By the age of five or so, children who follow the CDC’s 2018 schedule will receive vaccines to protect against a wide range of diseases: common ailments like rotavirus, devastating diseases like polio, and diseases with extreme complications like Hib. Vaccination continues over the lifespan, with teens and adults routinely getting vaccines to protect against meningococcal meningitis, some strains of human papilloma virus, shingles, various strains of flu, and pneumonia. Moreover, vaccines are safe and effective at reducing cases of disease. Beyond the infamous eradication of smallpox, diseases like diphtheria, polio, and rubella are now nearly unheard of in the US; measles outbreaks are still relatively atypical; and flu vaccines save individuals and communities valuable time, money, and resources by limiting suffering from flu. Why would something so simple, so successful, so undoubtedly beneficial across the lifespan be the subject of discord?

Despite these successes, vaccinations provoke controversy from various components of the public sphere. Since the adoption of the practice in the nineteenth century, vaccinations have been a target of skepticism because they are a unique type of procedure, for three reasons.

First, vaccinations are given to healthy people for the prevention of disease. Therefore, our expectations of safety and efficacy are heightened; risks must be nominal, involving only minor discomfort or side effects, and serious risks must be exceedingly rare. Second, vaccinations are given primarily to children. We vaccinate children for a variety of reasons: their growing immune systems are inherently highly susceptible to disease; some of the most infamous childhood diseases, like polio, can have lifelong, life-changing serious effects; many children spend most of their time in close proximity to other children in school and childcare situations, making them key vectors of disease; and the state maintains extensive control over that population through the requirements for school entry. Third, and most importantly, vaccines are most effective when the maximum number of people possible in a community are vaccinated, something called herd immunity or community immunity. Community immunity creates the central tension in vaccination controversy. Allowing voluntary nonvaccination diminishes the effectiveness of the protection offered, even to those who are vaccinated, and puts those more vulnerable to disease at risk. Vaccines are not 100 percent effective, so even vaccinated people gain protection from the herd. More importantly, some people, such as people with compromised immune systems because of illness, age, or treatments like chemotherapy and other immune-suppressing drugs, entirely rely on the community protection that vaccination provides to keep them healthy.