Childhood Vaccination: Science and Public Engagement
Vaccines for children are currently high on international policy, aid and funding agendas, as a major promised means to meet the Millennium Development Goals. Yet major challenges have emerged in ensuring effective coverage and dealing with public anxieties. As a point where globalised technologies meet the personal, social and cultural worlds of infant care, vaccines offer a highly illuminating lens on how people are engaging with science.
IDS, together with a range of co-researchers and collaborating partners, has recently completed two linked, comparative projects concerning the changing relationships between science, technology and society in Britain and West Africa, focusing on the issue of childhood vaccination. Details of the first project follow. For details of the second project, see the Childhood Vaccination: West Africa project page.
In both Britain and West Africa, childhood vaccination is regarded as a highly successful and cost-effective public health intervention, and vaccine technologies and applications are multiplying rapidly.
Yet scientific uncertainties are emerging that challenge established models of expert-led science, expert-determined delivery of technology, and public education for compliance, as well as distinctions between the scientific community and 'the public', and between science and politics.
A range of governance dilemmas have arisen. These have become particularly apparent in the UK over MMR vaccine, but are also apparent in Africa, especially in areas near research stations where new vaccines are developed and tested.
This study has been using the vaccination case to generate comparative insights into emerging science-society relations in European and African settings which have conventionally been theorised very differently. Focusing on the case of MMR in Brighton, UK and on the intersection of routine vaccination with vaccine research in The Gambia, the research has asked:
- How are public concerns with vaccination socially differentiated and shaped by diverse conceptual frameworks and knowledges around infection, disease and immunity, and experiences of the state and of science in other domains?
- How do different people consider trade-offs between social and individual benefits and risks, what differentiated notions of 'community' and 'communities of trust' do these imply, and how does this influence organisation around vaccination?
- How do vaccine scientists and public health professionals conceive of public perspectives around vaccination, its research and delivery, and how do 'frontline' staff mediate professional/ public views?
The research has linked approaches from social/medical anthropology with science and technology studies, and has used a combination of qualitative and quantitative methods. Through collaboration and user interaction, findings are being used to and will support reflection on new modes of public involvement by medical research and public health institutions.
Current controversies around vaccines, whether over MMR in the UK or Oral Polio Vaccine in West Africa, can be understood as emerging where the rapidly advancing, globalised health technology and technocracy involved with vaccines and their delivery encounters the deeply intimate, personal and social world of childrearing.
Perhaps inevitably, childhood vaccination has become a key issue around which debates over public trust in science and technology proliferate. Literature research and interviews with policy-makers and public health officials for this project have identified a number of stereotypical contrasts which provide sedimented terms of debate for addressing public engagement with vaccination. These include:
- North-South: 'Northern' concern with vaccine risks as a luxury amidst forgotten diseases ('risk society') vs. 'Southern' concern with accessing vaccines for still-ravaging diseases ('underdeveloped society'?)
- Class: Middle class anxst vs. compliant poorRationality: Irrationality vs. rationality (rising scientific rationality in South, rise of irrationality in North)
- Information: Knowledge deficit and misinformation vs. education and responsible media
- Emotion: Emotion (personal choice) vs. reason (evidence-based governance)
- Trust: Vaccine anxieties as part of a generalised breakdown of trust in public institutions
These contrasts and stereotypes - which often pass for 'explanation' of vaccine refusal - can be seen as rooted in scientific and public health frustrations with non-compliant publics, and research framed by these. But do they hold up? What about parents' perspectives?
In the UK, research and policy discussions focussing on parents' engagement with MMR has been dominated by analysis of the proximate influences on their choices, and in particular scientific and media information, which has led health policy to focus on information and education campaigns.
Our ethnographic work questions such reasoning in showing how wider personal and social issues shape parents' immunisation actions. The narratives by mothers show how practices around MMR are shaped by personal histories, by birth experiences and related feelings of control, by family health histories, by their readings of their child's health and particular strengths and vulnerabilities, by particular engagements with health services, by processes building or undermining confidence, and by friendships and conversations with others, which are themselves shaped by wider social differences and transformations.
Although many see vaccination as a personal decision which must respond to the particularities of a child's immune system, 'MMR talk', which affirms these conceptualisations, has become a social phenomenon in itself. These perspectives suggest ways in which people's engagements with MMR reflect wider changes in their relations with science and the state (see Poltorak et al 2005).
The survey results confirm many of these findings (see Cassell et al forthcoming), and show the strong significance of a cluster of variables linking ideas about immune system susceptibility and family health history, early thinking about MMR, and personal responsibility, associated with MMR non-compliance. These findings suggest the importance of public discourses about individual responsibility and lay perspectives on immunity for shaping parental anxiety about the MMR regime. These parental perspectives correspond with certain strands of debate in the scientific and activist debate over MMR, with implications for how the controversy is playing out (see Leach 2005, IDS Working Paper 247).
In the Gambia, the research examined attitudes towards routine vaccination in urban and rural areas, and to the MRC's Pneumococcal Vaccine Trial in rural Upper River Division. The ethnographic work revealed a range of contrasts between the perspectives of health institutions and of parents.
Health professionals see acceptance of routine vaccination as evidence that parents favour modern health care. In fact, parents view immunisation as one of many practices for promoting infant strength and health. They see the value of vaccines as improving general health, more than preventing specific diseases. The study also found that:
- While infant clinics may be attractive social occasions for some women, encouraging attendance, others feel excluded or worried by them due to their social circumstances, the health of their child or the judgement of others.
- Health professionals see vaccine defaulters as neglectful, either through ignorance or by prioritising travel or trade over health. However, mis-timings usually arise through events that could affect anyone, such as family misfortune or practical difficulties in getting to the clinic, compounded by clinic logistics or conflicts with clinic staff.
- Women negotiate clinic attendance with husbands and older female relatives.
The survey findings (see Cassell et al forthcoming) suggest that:
- There is more 'default' in urban (28 per cent) than rural (18 per cent) areas, suggesting that social integration with health delivery is more important than geographical access
- High urban 'default' is associated with a cluster of poverty-related variables (poor-looking compound, tenants, low education, lack of mobile phone); factors ethnography suggests are linked to forms of exclusion and compounding of problems at clinic
- Mother's education makes no difference to 'default' in rural areas, undermining the assumption that high vaccination uptake reflects modernising knowledge and rationality
Similar contrasts emerge for research participation:
- People treat medical studies less as a separate scientific entity and more as part of normal health practices.
- Researchers place heavy emphasis on informed consent for participation in a trial. However, the consent process is often overtaken by gender and power relations.
- Acceptance or refusal is seen by researchers as a proxy for comprehension of the purpose of the trial. But understanding the aims of a particular study may be less important than the perceptions of the MRC as an institution.
- MRC staff members see public engagement as a matter of trust or appreciating modern science, whereas for many people it involves a balance of danger and benefit, especially of blood-taking versus free treatment.
This research shows that categories of vaccination complier and defaulter and trial acceptor and refuser obscure the range of experiences, concerns and dilemmas faced by parents as they seek to raise their infants and keep them healthy. Debates around informed consent need to move beyond just the moment of decision and consider the wider social context. For further details, see IDS Working Paper 218.
Comparing the British and West African studies, the research suggests that:
- In both settings, parents think about and discuss vaccination issues as part of wider reasoning concerning child wellbeing, which interplays with intense parental observation and evaluation of a child's particular health history, strength and vulnerability
- Public engagement with (globalised) vaccine technologies is strongly mediated through this, rather than being more straightforwardly a matter of political imagination of, and trust in/distrust of, state, corporate and global institutions
- Debates and controversies about vaccine science are playing into an age of personalised immunity in Britain, and an age of blood in West Africa, and thus laying the ground for further controversy
- Similarities across Gambian and British settings undermine dichotomies which cast Southern societies as becoming biomedicalised, post-traditional, and rational/modern, and Northern societies as becoming de-medicalised, post-modern and more irrational.
- Science-policy approaches, even those seeking participation, deliberation and dialogue, need to appreciate such dynamics or they can badly misfire.