Časopis pro politiku a mezinárodní vztahy

Global Politics

Časopis pro politiku a mezinárodní vztahy

Infant Inoculation in the Light of a Foucauldian Analysis of Power Knowledge Relations

This article belongs to a special series focused on post-development issues which was created in co-operation with the University of Vienna.

The reason why I have chosen this particular topic is a personal one: as a young mother, I have decided not to have my baby immunized because I have not been sufficiently convinced of a vaccination importance for diseases which have been, at least in Europe, eliminated for decades. In addition, the pediatrics’ reactions to my choice left me more than stumbled. Not only were they shocked, but more so they began to treat me and my son in an unfriendly manner.


1. Introduction

The opposition against mandatory health care measures by governments is not new in the history of modern medicine. The reaction was especially strong at the beginning of the 20th century, as Jenner’s vaccine against smallpox was introduced in order to fight the “deadly human scourge”. (Blume 2006: 628, Kunze 2010: 8) Although governments refrained from further compulsory immunisation programs, the pressure in order to become immunised or to have one’s kids immunised as soon as possible is hight – the media and public opinion makers, such as doctors and politicians, and not least pharmacological companies spread the word of the positive effects of vaccines. (e.g. the campaign for the last „swine flu“ supposed pandemic, or, in Austria the yearly spring campaign for FSME vaccination)

The reason why I have chosen this particular topic is a personal one: as a young mother, I have decided not to have my baby immunised because I have not been sufficiently convinced of a vaccination importance for diseases which have been, at least in Europe, eliminated for decades. In addition, the paediatrics’ reactions to my choice left me more than stumbled. Not only were they shocked, but more so began to treat me and my son in an unfriendly manner. I could not get rid of the impression that there was an effort to make me feel guilty, and although I have tried, there was no way to obtain some kind of understanding or competent and unbiased consultation. (I have visited two paediatric practitioners). The obvious easiness and certainty with which I have been left uninformed about possible risks or an actual importance of the inoculation left me puzzled. Blume’s article on the Anti-vaccination movement in the UK depicts quite the same feelings and experiences of other mothers confronted with the power of the health personnel. (2006:637) Also Hobson-West’s (1999) research on the vaccination critical groups shows that other opponents of vaccination have made the same experiences and arrived at their conclusions in a similar way.

People who voice their concerns against the growing vaccinitis are called irrational, quixotic, mediaeval or simply uneducated, esoteric or religious fanatics. (cf. Walles 2009, Kunze 2010:6) They claim that many of the immunisations are unnecessary, have long-term negative effects and contain too many dangerous poisons, but foremost are a profitable income for the pharmacology industry. However, I do not aim at proving, if their claims are right or not. What I think is much more interesting in the context of the Seminar Post-Development Theory and Practice is the analysis of the power knowledge relations in medical science and discourse. Critique on the increasing industrialisation of modern medicine was first voiced by Michel Foucault who historically analysed the “Birth of the clinic” and the development of the medical gaze. Soon after, the medicalisation concept crystallised, partly based on Foucault's fin­dings, which has to be understood as criticism of the growing engagement of medical competence with social and cultural phenomena, including birth, death and pain (Illich 1972, Conrad 1979).

My particular research question for the following paper thus is, whether Foucault’s the­oretical concepts of the power relations and Illich’s medi­calisation concept can be applied here in order to analyse the debate on infant vaccination as embedded in a wider health discourse. Methodologically I will focus on literature research, and review the statements made in the publications regarding infant vaccination.

The work is structured as follows: After a short insight in the history of vaccines, which is also embedded in the wider context of the genesis of modern medicine and patterns of vaccination acceptance, I will introduce the theoretical concepts of Foucault and Illich. Thereby I will first examine how the critique of medicalisation, i.e. turning human problems fit for medical competence goes together with the growing critique on the vaccination programs, mainly through Illich’s book “The nemesis of medicine” (2007). Further I will look at the mechanisms of power working in the discourses around vaccination. According to Foucault power is a productive force which works through discourse. I will show on the exemplary notions of citizenship, knowledge and trust how discourse on infant vaccination is constructed in order to support existing power relations in medicine.

2. Vaccination History

The term vaccination is derived from the Latin name of the particular animal virus varolae vaccine, otherwise cowpox, which became the first scientifically acknowledged serum for immunisation against smallpox at the beginning of the 19th century.

For a long time, Edward Jenner’s path breaking publication An Inquiry on the Effects and Causes of the Variolae Vaccine from 1798 was seen as the hallmark of the modern form of health prevention. What was new and revolutionary about Jenner’s “invention”, however, was first and foremost the scientific approach in relation to infection prophylaxis. Jenner was the first to work with methods of verification and falsification on a broad and documented scale and subsequently made his findings available for the wider public. (Plotkin 1994:2) In fact, immunisation against smallpox after infectious contact with the cowpox germ was a well known folk wisdom in Wales for some time before Jenner. (Minna Stern/Markel 2005:612) Apart from dairymaids, who were often immunised in this way by virtue of their work, there is one known case of deliberate infection with cowpox for purpose of smallpox prophylaxis by a welsh cattle breeder, Benjamin Jesty some decades before Jenner’s publi­cation. (Baily 1899:221, Plotkin 1994:2)

Different techniques of immunisation have been known and practised across cultures and geographical areas for centuries. (Bhattacharya/Brim­nes 2009:3,4, Minna Stern/Markel 2005:612) Besides the already mentioned method used by the Welsh dairymaids, the practice of variolisation was introduced in Britain in around 1730, several decades before Jenners breakthrough. It was brought back by Lady Mary Wortly Montague after her stay in the Ottoman Empire, where she and her family have been successfully inoculated as well. (Baily 1899:219. Plotkin 1994:2) Variolisation, also called inoculation, is a method of inserting the human smallpox virus into scraped skin. The virus is collected from powdered smallpox crusts, preferably from an already inoculated person. (Apffel Marglin 1990:104, Minsky 2009:170) Records of the employment of variolisation techniques in Asia and Africa go back to the 7th century (e.g. using the snake-poison as anti-toxin immunisation), to the 10th century when varoliation was used in China (Plotkin/Plotkin 1994:1) and to the 16th century, when inoculation has become a common praxis among peasants in India, Punjab (Apffel Marglin 1990:104, Bhattacharya/Brim­nes 2009:3, 4, Minsky 2009:169). Together with the fact that the practices of smallpox and other infectious disease prophylaxis varied largely across time and space, and features such as the hand to hand method, the use of human and animal, or dried and fresh lymph have been known long before vaccination was deployed with governmental power, supports the thesis that varioliation was a direct forerunner model to vaccination. (Minsky ibid.) Nevertheless, the view of a linear and one-way communication of knowledge has long been represented by medical historians when dealing with smallpox eradication (Bhattacharya/Brim­nes 2009:14, for e.g. vis Mark/Rigau-Pérez 2009:84, Baily 1899)

However, Jenner’s work laid ground for what is known today as the science of vaccinology and immunology (Hilleman 1999, Wolfe/Sharp 2002:430). Soon afterwards, in 1875, Louis Pasteur made the second step when he sought to replace the “person-to-person” vaccination with a safer method and simultaneously adopted what is today known as bacteriology. The vaccines against cholera, plague and anthrax are attributed to him in the same way as is the technique of growing organisms in pure culture solely for the production of vaccines. (Plotkin 1994:2,3) Other giants of the ending 19th century were Robert Koch and Emil von Behring who discovered the antitoxins to tetanus, tuberculosis and diphtheria bacilli, and Paul Ehrlich whose technique for the development of synthetic drugs is substantial until today (ibid 1438). The subsequent years were full of optimism and belief in progress. However, before the WWI those were dashed by the great influenza pandemic. (Galamos 1999:8) and a stagnation in medical progress followed, until the decade of WWII, when wartime research and military medicine again led to important findings in virology. From the 1950s on the rate of new findings become closely bound to financial investment and institutional concern in this field, which in that time were most pronounced in the USA, leading to what became known as the “golden age of vaccine development” (Plotkin1994:6, Galamos, ibid) A fact which clearly reflects the socio-political power of the health discourse. Polio, measles, rubella, varicella and encephalitis all became opposable diseases before 1970, and soon HAV (hepatitis A), influenza, meningococcal, pneumococcal as well as HBV followed. The last however has experienced some difficulties in the licensure because it was made from derivatives of human blood at the time when the HIV epidemic arrived. A fact which actually animated the genetic production of DNA vaccine by the end of the 1980s. (Plotkin 1994:6, 7)

3. Medicalisation

From the 1970s on, medicalisation increasingly became the object of scrutiny in critical social sciences. Ivan Illich and other adherents of the medicalisation concept aimed primarily at challenging the discursive practice of subsequently turning social and cultural aspects of human life into medical problems. (Illich 1975, Conrad 1992:210, 211) One objective of medicalisation critique is to question medicine as an instrument of social control. (Conrad/Schneider 1995:212) Another point, as set up by Illich, is based on the critique of modern science and society as built upon the belief of infinite progress and development. In the realm of medicine this aims at the abolishment of pain and continual improvement of human health condition, mainly through drugs and technical inventions. (Illich 1975:30, Rose 2007:701, Foucault 1988:52) In spite of the quantity of approvals and compliments to the achievement of medical science (cf Conrad 1992, Rose 2007), Illich suggests that most of medical therapies are in fact ineffective and that the public unfoundedly takes up an optimistic position towards its technical and scientific accomplishments. (Illich 1975:32, 58) Illich designates three modes in which medicine is iatrogenetic, i.e. generates illness. The social iatrogenesis fosters the patient character and the dependence on medical interventions at the side of a growing part of the population, not only in times of illness but also in times of health. This happens mainly through the power of medical institutions to define health and the display of their ability of early detection of health risks. Thus increasingly more people seek medical support even if they feel healthy. In addition, the authority of medicine to prescribe withdrawal from work, and thus officially ascertain the status of health or discomfort, compel its integration in society, especially in cases in which a patient would be able to recover without seeing the doctor. As structural iatrogenesis medicine promotes the establishment of the ideal of a perfect health, an ideal which naturally does not exists as such. The modern medicine denies the necessity of the human being to deal with pain, disease and death and promises their extinction instead. In reaction the human ability to deal with physical discomfort and its self-healing forces weaken over time, and the created desire for the better health leads to increasing financial expenditure and pressure for medical progress. As the delivery of an eternal health life fails, the efforts lead to longevity with sub-lateral diseases, which in turn makes high financial input necessary in order to keep those sub-laterally ill patients alive. The clinical iatrogenesis refers to bodily harm caused through a medical treatment. (Illich 1975: 25, 26, 95)

Nevertheless, such misperformance is hardly ever mentioned, in fact is often dispersed as arbitrary. Furthermore, the authoritarian manner of physicians often leads to obedience and fear of scrutiny on the side of patients. Such an attitude, common in our expert led service economy, actually bears the danger of disabling and incapacitation of the knowledge and skills of large parts of the population. In order to enable a real non-hierarchical and emancipated popular authority, Illich suggests a necessity to maintain a doubtful and dismissive position towards expert knowledge. (Illich 1978:30) Such is the view of the vaccination critiques, which were already successful in forcing the medical institutions to review their pronouncements. So, the efficacy of physicians is, according to Illich, an illusion. Concerning epidemics and their extinction, he continues, it was not for the vaccines but simply for changed living circumstances and foremost for better nutrition which improved the resistance of the human organism, that epidemics disappeared or were substantially weakened. Illich shows that most of the epidemics were diminished before vaccination could be active. Illich further proves with the example of aggregated mortality rates of children that the casualty on grounds of infection with tuberculosis, cholera or typhus sank by 90% before the introduction of relevant vaccines or antibiotics. (Illich 1975:12, 13) The form of power in Illich however, differs from that of Foucault. The power as Illich defined it is repressive and consists of legal control and guarantee, especially in respect to production and satisfaction of needs. (Illich 1978:38)

“Because of this monopoly position, which empowers the tyrannical expert guilds to forbid you to shop elsewhere, or to distil your own schnaps, they seem, at the first glance, to equal the lexical definition of a mafia. But the gangsters make profit out of the human needs by controlling the supply of adequate goods. Today, teachers, physicians and social workers can do, what earlier only priests and judges were able to – namely to create, out of their own legal integrity, needs which only they are enabled to satisfy.” (Illich 1978: 38)

Opposed to this is Foucault’s per­ception of the interaction between power and supply of needs. The fundamental need, created in the 18th century by the medical science was health, and it is through the successful addressing of this need that power relations could densify into strategies of power, which finally led to a constitution of the dominant discourse, for that matter, the health discourse. (Foucault 1980:142)

Foucault argues that it was the peculiar way of dealing with and looking at diseases, in Foucault’s words the medical gaze (Foucault 1988), which finally led to medicalisation and social control through medicine. Particularly, Foucault’s work provides a useful analytic tool when looking at the status of infant vaccination today. The Birth of the Clinic (1988) as well as The Politics of Health in the 18th Century (1980) both offer a study of how certain power – knowledge relations support a specific regime of health politics.

4. Power / Knowledge and disposition of health

Indeed, the critique of medicalisation is virtually built upon the assumptions of social control, which Foucault began to analyse with his first monograph Histoire a la folie a l’age classique in 1961. (cf. Illich 1975:115) Concerning health and medicine, Foucault noted, the exertion of control is not as easy to detect as in psychiatry, however, there also is a discourse equally dominated by epistemological truths, which are an outcome of power knowledge relations. (1980:109)

Medicalisation and the obsession with health are as much an outcome of 18th century events as is medical science and the institution of hospital. In his historical analysis Foucault shows, how modern medicine was based on the control over epidemics which made necessary a whole new structure of medico-administrative institutions. This included the practice of medical staff, organs for record and control of the social body’s biological set up as well as medical education and acculturation of the population. (1988: 40–42) According to Foucault for this purpose a reorganisation of medicine in several ways was necessary. First and foremost, through scientification expertise of medical knowledge, previously available to and exercised by a number of professions, such as healers, herbalists or midwifes or by other lay or religious institutions was in a way monopolised. The medical gaze, a concept central to Foucault’s ana­lysis, describes how the visibility, as well as the skill of disclosure, of parts of human body played a dominant role in the constitution of this knowledge. The scientific methods of measuring, ranking and classification as well as the upcoming mode of truths production1 in positivism (Foucault 1988:10, 27) allowed doctors to assume power over definition of the illnesses and the right methods of cure. As Conrad notes medicine profited also from the overall social context of the 18th century, such as a growing “faith in science” and the belief in “individual and technological solutions” (Conrad 1992:213) The new hospitals replaced the old form of asylum for the sick and the poor, and existed from then on only as places of medical treatment. There too, diseases were classified and sorted according to their assumed origin or effect. Albeit the vision of those engaged in the construction of the modern medicine was that once the inequality and injustice of corrupt governments were redressed (it was a revolutionary project) diseases would disappear and hospitals would finally become obsolete. (1988:51) This however, proved rather illusionary.

In addition to the scientification of medicine, health became central in bio-politics2 in such a way that it’s maintenance became a moral duty for the society and was inscribed in the notion of citizenship (which was often employed by pro- and opponents of vaccination, see further below), and in further consequence an essential objective for political power. (1980:169,170). Foucault identifies therein one of the major functions of power – “the disposition of society as a milieu of health, physical well-being and optimal longevity” (1980: ibid)

According to Foucault, for power to move top down, there also has to be at least some movement from bottom to the top, i.e. power has to be productive. In a very simplified example of the modern medicine, power from above would mean to make the visit to the doctor in cases of illness compulsory. But then, people would also start to see the doctor voluntarily because there has been buzz about modern medicine’s wonders in press and word-of-mouth and they would like to be modern. Some would also go because the doctor’s attest is the only way to have money back from the insurance. Others would go because they want to be sure everything is al right even if they suffer no discomfort. Finally, a discourse would be established which restricts thinking and acting beyond its boundaries, thus leaving no other option than to accept that being healthy is the most desirable thing and that it is only through the expertise of the physicians that he or she can achieve it. Thus these power relations are most effective if they succeed to deploy a discourse in which prime principle of health and the best possible physical well-being is as broad and inclusive as possible. That means, that not only increasingly more human beings but also more areas of human life become medicalised, and that only designated experts are able to provide this medical attention3.

In order to allow the power to work from below and in a productive manner, as envisaged by Foucault, it was thus necessary to make health a condition of personal endeavour. The demographic boom and its problems in political and economic terms, as well as the zeitgeist of capitalism and its need for productive labour, led to what could be called privatisation of health. The aim was to set “the able-bodied poor to work and transform them into a useful labour force, but it [was] also to assure the self-financing by the poor themselves of the cost of their sickness and […] incapacitation […]” (Foucault 1980:169) The establishment of the clinic for purposes of healing only led to the elimination of the category “the sick poor” which, as a group, had socially defined claims to welfare, such as the asylum. Consequently, from then on, those who withdrew from arbitrarily, and were not under medical treatment at the same time, were labelled and made financially self-dependent. (ibid 168)

For reasons of further optimisation of bio-politics the burgeoning notion of health implicated also a new purpose for the family, away from an organisational model towards a unit of population regulations. Foucault suggests that all following imaginations of family as a place of care, protection and cleanliness go back to this new set of rules imposed on the family. (1980:173) Consequently this newly defined milieu is used as object of moralising and normalising interventions, which ceased to serve the upbringing and development of the happy and healthy human being but primarily aim at guaranteeing a certain population regime. Thus, family as we know it today helps to provide disciplined and healthy (i.e. physically functioning) individuals which constitute a safe, ordered and economically productive society. (Simons 2004: 169)

5. Vaccine Critical and Vaccine Friendly groups

Since the triumphant acceptance of vaccination as a new means of health prevention, it became a common practice to implement state-led and supervised immunisation programs which, depending on the degree of democratisation, could be more or less stringent. (Streefland et al 1999:1707) However, simultaneously with these programs emerged resistance to them. In Britain, the first Vaccination Act in 1840 only outlawed varioliation, whereas the following Acts of 1853 and 1867 made vaccination compulsory for infants and for children and made omitting parents liable to court sentences. (Wolfe/Sharp 2000:430) After complaints and pressure of anti-vaccination groups, however, the Vaccination Act of 1898 introduced the clause of “conscientious objector” to the English law, which allowed concerned parents to withdraw from the mandatory vaccination program. (Guillon et. al. 2008:402) Not only in England opposition against the extension of government authority over their bodies increased among civilians. In Stockholm anti-vaccination ideas become very popular around 1872, and in the USA the Anti-Vaccination Society was founded a little later. (Wolfe/Sharp 2000:431, Blume 2006:629) Remarkably, in Britain a coalition across class boundaries could be established in order to fight vaccination. Durbach describes how populist rhetoric of a common enemy, the ruling class, was determining for such an alliance. (Durbach 2005:69) Nevertheless, bourgeois resistance was inspired through libertarian concerns of the relationship between the state and the individual, and was thus more related to party politic. The working class instead perceived much more the physical effects of the Vaccination Acts as any middle-class member, and thus put their body at the centre of their fight against vaccination. (Hobson-West 2007:201, Durbach 2005:85,92) The concept of citizenship, for instance, was crucial in the controversy and all involved parties employed it to support their arguments. Whereas its proponents proclaimed vaccination as a civic duty in order to protect the whole of the society, its opponents postulated good citizenship as protecting the bodies against assault, which a compulsory vaccination would be. (Durbach 2005:85, Blume 2006:629)

There seems to be some discontinuity in the writing about vaccination resistance in the first half of the 20th century, a period relatively under-represented in the literature. (Hobson-West 2007:201, Wolfe/Sharpe 431, Blume 2006:629) Steefland et. al. mention resistance against the WHO smallpox eradication campaign in the 1970s, albeit on individual level only. (Streefland et. al. 1999:1710) As Hobson-West notes, there is a notable revival of writing about organised and collective resistance from the 1990s on, where vaccination opponents are largely portrayed as dubious and as a serious risk to the society. (Hobson-West 2007:201) Mostly, such resistance refers to the MMR vaccination and associated discomfort about the vaccine additive thimerosal, which was suspected of causing autism and autoimmune diseases. (e.g. Amanna/Slifka 2005:308) However, not every opponent to vaccination actually is a member of an organised anti-vaccination group. In a cross-country study about immunisation acceptance Streefland et. al. (1999:1709) classify present patterns of attitude towards vaccination as ranging from acceptance, over social demand to non-acceptance. The latter demonstrates itself on the individual level as refusal and on the collective level as resistance. Whereas the reasons for refusal can be on the demand side (e.g. personal beliefs) as well as on the supply side (bad experiences with staff), the reasons for resistance are mainly on the demand side, and those adherents are often well organised and connected through communication campaigns. (Streefland et. al. 1999:1710)

There is naturally a clear divide between the opponents and proponents of vaccination, and their arguments are quite constant and uniform over time, however, both camps claim to have the real knowledge and are more trustworthy and both employ the notion of citizenship for their interest. Furthermore, better state of health is a common aim for both groups which is why it can be stated, that both engage in the same strategy of power.

6. Infant Vaccination in the health discourse

Finally, in this section, I would like to examine the concepts constituting the health discourse. Against the background of Foucault’s analysis of power, the strategy of bio-politics uses the health discourse to consolidate dominion over the social body, one of the components, or tactics, in the discourse are the vaccination programs. As mentioned earlier, the family is constructed as a point of intersection between the general objective of bio-power to govern the social body and the social body itself. This happens mainly through the imposition of its new major task, the care and protection of its offspring which implies a sort of moral obligation to participate in medical care. (Foucault 1980:174)

I would like to recall Foucault's sug­gestion for the understanding of the mechanisms of power. According to these, power relations encompass the whole social body, so that all relations are interwoven with power relations and it is at the joining of these relations where dominion emerges. Also, inseparable from these power relations is their resistance. Foucault’s concept conveys that resistance does not come about from the outside, but is inherent in the power relations it is opposed to. (Foucault 1980:142) In order to understand Foucault’s power analysis it is essential to separate power from some interest, a group of people or a class. The procedures of power, which react to an arising need, a kind of necessity, and the beneficiary of its outcomes, have a somehow reciprocal relation. (ibid 203, 205)

In this light I would like to examine the strategies employed by advocates and opponents of vaccination, which astonishingly (or not) are more or less the same. Exemplary I have chosen the notion of citizenship, trust (and related truth) and knowledge. As noted earlier, the notion of citizenship is pivotal to the modern health discourse since its beginnings. (cf. Durbach 2005). The participation in preventive health measures and especially immunisation programs often becomes interpreted as a duty, rather than right of citizenship by vaccination supporters. As one US study has shown, the interest of maintaining a healthy society is one of major motivations behind having one’s child inoculated (Wu et.al. 2008:766) However, in general sanctions for withdrawal, be it imprisonment in earlier times, or e.g. non-admission to schools and colleges today, also implicitly invoke the notion that vaccination is a good citizen’s duty. (Dew 1999:393) Opposed to this is the invocation of the rights of citizenship to decide whether or not being, or have one’s infant, immunised by objectors of inoculation. In a profound analysis of what he calls Vaccination Critical groups, Hobson-West finds that many of them argue the duty of a good citizen is to make an informed decision about vaccination. (Hobson-West 2007:208) The notion of citizenship and its implication of rights and duties are not questioned by those opposed to vaccinations. To the contrary, their understanding of real citizenship implies emancipation and empowerment strategies (ibid.) Thus, the concept of citizenship can be understood as a strategy of power in Foucault's sense, as it is not only employed in order to invoice dominion, but it is also used from below, in order to obtain authority over its redefinition.4

Another constantly recurring theme in the social science literature on vaccination is the conception of trust. (cf. Hobson-West 2007, Guillon et al 2008, Wu et.al. 2008) In this context, trust could be interpreted as faith, which, according to Misztal (1996, in Hobson-West 1999:207), expresses confidence in another person on grounds of their specific knowledge or skills, but also within social networks or family relations. The latter is referred to as a “leap of faith” and largely influences the decision making on side of the vaccination opponents, who often perceived trust towards medical personnel negatively as a risk by itself (Brownlie and Howson 2005, in Hobson West ibid.). While on the side of the opponents trust is thematised in context of individual risk management, obtained knowledge and anxiety about the right judgement (pro or contra the vaccination), the expert understanding of risk is rather concerned with the population level and “herd immunity” (ibid 199) Thus trust is an important mechanism in the strategies of bio-governance. In order to overcome distrust, government and health institutions often decided to embark on information campaigns and strategies to provide knowledge about vaccines. For example, one study of vaccination attitudes in the USA revealed that there is lack of knowledge about vaccines among post-partum mothers which supported issues of distrust and scepticism towards vaccination. The US Preventive Health Service Expert Panel thus recommended to offer “education to support and promote healthy behaviours, provide general knowledge about pregnancy and parenting” at prenatal visits, whereby “knowledge about parenting” included information about vaccination. (Wu et.al. 2008:771) Distrust towards the government and health workers and institutions might however be supported through the coercive nature of immunisation programs.

Closely interrelated with trust is the notion of knowledge which also plays a central role in the debate over vaccines. Many lay person opponents to vaccination have received their information through their own research and from a variety of sources which might not necessarily be acknowledged by the scientific community. Such popular, or lay epidemiology is often pictured as unreliable and inaccurate, among others because it includes “personal experience and personal (i. e. non-scientific) information gathering” (Guillon et.al. 2008:403). Knowledge, in terms of education and study, is also crucial in Hobson-West’s study of the Vaccine Critical groups as this is the way they construct themselves other to the vaccination friendly population. Their stress on being “free thinkers” enables them to empowerment from the expert dominated discourse. The author however problematises the way in which knowledge and information becomes central to the notion of morality in childrearing which may put those who are not able to obtain the necessary expertise under pressure (Hobson-West 1999:211,212). Such strategies could be described with Foucault as the “capillarity from below to above” (Foucault 1980:201) insofar as the opponents of vaccination try to challenge the dominant strategy in this discourse which is to employ expert knowledge, but yet do so at their own game and thus support the power knowledge relations at work here. Knowledge is also central to those who accentuate the vaccination friendly positions. In their case study of an anti-vaccination spokespeople, Leask and McIntyre analyse the arguments employed in the vaccination discussion. It is clear that for both, the researcher as well as the researched, scientific methods play a central role in generation of knowledge. While the vaccination opponent uses her degree in natural science to reinforce credibility and presents material from medical literature to support her arguments, the authors claim that her findings lack support and can easily be refuted. Here however, it is the dominant power relations which claim ownership of knowledge and the right epistemology.

7. Conclusion

In the present paper I tried to reconstruct the workings of power and knowledge in the health discourse, using the example of infant vaccination. I have shown that albeit apparently outside agents, the vaccination opponents actually participate on the construction of the health discourse. In order to conceive the impact vaccination had on the health discourse in its whole bearing, I have started my work with a review of the history of vaccination, and in which ways it becomes what it is today – the most favourite means of health prevention within the medical industry. Albeit vaccination critiques and medicalisation theorists have long been pointing out that this might not be entirely correct little has changed on this perception, and I have provided a short insight on the concept of medicalisation as well.

I have further employed Foucault’s power relation analysis which conveys that in order for grant power strategies to work, they are mutually dependent on other relations, not only power relations. In addition, apparent relations of resistance, such as the vaccination critical actors, operate within the dominant health discourse. According to Foucault, there is no power relation outside the overarching, discourse creating power relations. (Foucault 1980:142) This becomes clear in the fact, that the main objective of vaccination opponents for their children is perfect health as well. This is supported by the more or less explicitly indicated affection for alternative lifestyles. (Hobson-West 1999: 211, Guillon et al. 2008) and again supports Foucault’s thesis after which family was purposely constructed as a place of health and care provision, in order to reduce public cost. (Foucault 1980:178) Nevertheless those parents who refuse to immunise their offspring perceive themselves as outside the prevalent discourse. Here, further research could help to shed more light onto the ways in which such resistance supports or alters the health discourse, or if it has any effect at all. In order to show how the pros and the cons of vaccination work along the same lines, I have chosen the themes prevalent in the literature, namely the concept of citizenship, trust and knowledge. All three concepts have shown that the concerns of both camps are surprisingly similar. So do both camps claim to be a better citizenship, either because being immunised and thus guarantee the herd immunity or not being inoculated and thus determine their own rights. With regard to trust, the result is that there is crisis in confidence towards the expert; on the other hand, the proponents of vaccination do not really trust either, as they rely on statistical results. (cf. Hobson-West 1999: 200) Also central to the arguments around vaccination is the question of knowledge, which again is instrumentalised from both sides. One side claims that only medical experts or the like can really know about vaccination, other praises knowledge and self-education as the only, or at least the most important, way of really knowing.


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Figure 1

The author is a political science student at the University of Vienna.

Poznámky pod čarou

  1. Foucault understands truth as the outcome of a systematic procedure of selecting statements, as e.g. in scientific discourse. (DuBois 1991: 7)
  2. Bio-politics refers to the technology of population with its instrument of life expectancy and levels of mortality estimates, demographic records, measures of marriage, etc. (Foucault 1980: 171, DuBois 1991:9)
  3. One example of such different discourse would be the Indian medical system of ayurveda, which places the focus on the balance of elements in body tissues. To maintain this balance treatment and advice of an ayurveda practitioner certainly is advantageous, but the main work of obtaining and maintaining health remains with the patient. (Frawley / Ranade 2001) Another example of discoursively determined perception of health-related issues is the perception of pain. Dick-Read shows in his work Childbirth without pain how the discourse about painful labour leads to fear by the delivering woman and how this fear actually causes the pain, which, under normal circumstances, has no other physical basis. (Dick-Read 1949: 66)
  4. It is through such central, and at the same time ambiguous, concepts that the dominant power relations not only remains in power but eventually become stronger because of the internalisation of such apparently counter-discoursive positions. Thus citizenship, as well as knowledge, which both were empowering concepts used by certain social classes in order to obtain power in the wake of modernity (i.e. the bourgeoisie to the detriment of the nobility and the religious elites), are such powerful notions because they still succeed to offer this sense of empowerment. However, this is merely apparent, as their main objective is to serve the dominant power relations. Thus, in order to really challenge these relations a wholly new set of concepts, which would allow for the establishment of a different discourse, has to be developed and brought into use.
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Alexandra Heis
9. 7. 2011