Vaccination: Where the state meets the street
By Margaret Doyle (University of Essex)
Since April last year, I’ve been supporting a woman who lives nearby, whom I’ll call Deirdre, delivering her newspapers, doing a bit of shopping, and liaising with the Council over housing matters on her behalf. I see her every day, but Deirdre and I didn’t know each other before, and we hardly know each other now. We’ve never been in each other’s homes, we’ve never been out for coffee together, we’ve never even seen each other’s faces unmasked. But we know some things, things we’ve gleaned over these 10 months – birthdays, family members, what causes us outrage. I’ve learned that Deirdre’s partner, who is nearly 80 and has health issues, intends not to have the Covid vaccine. He once had a bad reaction to the flu jab and is convinced that a Covid jab could have the same effect. Deirdre is worried and wants a doctor to persuade him to have it. The argument she thinks will be most successful is that being vaccinated will free him up to go back to the pub with friends.
On the other side of town, and the other end of the age spectrum, my good friend’s adult children are considering not having the vaccine, for fear of risks to their fertility. I haven’t seen any mention of this risk, but I know enough about vaccine anxiety to know that most of it stems from a bit of truth, a bit of science, and a bit of skewed assessment of personal risk. In the case of the Covid vaccines, it also stems from distrust – distrust arising from the unprecedented speed at which these have been developed and trialled and the gaps in our understanding of how they cope with new variants of the infection, gaps that are enhanced by misinformation on social media and confused messaging from government. It is as if the response to the Covid vaccine is a form of miasma, of the kind of bad air we used to think accounted for most disease – a miasma that makes us deeply wary of science, of government, of one another.
No vaccination programme can be effective without the state’s involvement. From approval of vaccines, to delivery and public messaging, we rely on our governments to protect safety, to be fair with distribution, and to communicate clearly. Among these messages to be communicated are that vaccination is a matter of our collective health and well-being: You are not protected until we all are protected. It is, as Eula Bliss describes in her book On Immunity, one of the ways in which we owe each other our bodies.
We’ve seen how the state’s role has been crucial in the response to the Covid pandemic across the world, and how in different countries it has produced very different results. Historian Marc Stears writes in Out of the Ordinary of the success of Australia’s localised strategy, using local public health officials with their ear to the ground, versus the grandiose ambitions of the UK government’s ‘Moonshot’ strategies and centralised apps. Public health expert Devi Sridhar has emphasised the key role of government in providing financial support to those ‘asked’ to isolate and in closing borders – tasks that can only be taken on by the state. Hilary Cottam, social welfare activist and author of Radical Help, believes that although our centralised government is incapable of solving major problems, we often need to look to central government to provide the frameworks and funding for the local and grassroots innovation that can.
Vaccination is a canvas that brings out all those brushstrokes – of how local action can be nurtured by centralised support, of trust in the state and each other, of harnessing the power and resources of the state to bring about community-level collaboration.
I hadn’t considered vaccination as a matter of administrative justice before. But it is, for it illustrates the need for what is called ‘administrative justice’ to be shaped and understood less as a fourth pillar of the justice system, niche but neglected, and more as the network of principles that form the rockbed of the relationship between people and government. That relationship is concerned not with remote and rarefied rules and rulings but with the everyday, the tactile, the banal even. Each of us is affected every day, many times a day, by decisionmaking by or on behalf of the state. And at the moment, decisionmaking at the confluence of health and politics is of the utmost everyday importance.
Vaccination asks big questions of all of us, especially questions about what our obligations are to each other. It requires the majority to protect the minority – those individuals who cannot have the vaccine, for whom the risk is too great. In On Immunity, Biss describes this as an inversion of the 99% versus 1% equation of the Occupy movement, in which the 1% are the individuals who amass the vast majority of wealth and resources. In this inversion, the majority who are vaccinated protect the minority who cannot be vaccinated. And in the case of vaccination, it isn’t a people’s revolution we need to make that happen, but trust in the state.
‘Immunity is a public space. And it can be occupied by those who choose not to carry immunity.’ This public space is what Biss explores, examining the problematic binaries of vaccination – public versus private, science versus nature, self versus other, fact versus faith, government versus people. Biss notes that these are called ‘troubling dualisms’ by philosopher Donna Haraway in her Cyborg Manifesto, in which she argues for a truce in the war between humans and technology, an acceptance that we are all ‘cyborgs’, unafraid of ‘our joint kinship with animals and machines’. Technology, Biss writes, ‘both extends and endangers us. Good or bad, it is part of us, and this is no more unnatural than it is natural.’ She describes the way we are one with viruses – inhabited by remnants of ‘old friends’, ancient viruses that live in us and can kill us and also be essential to our survival.
‘Inoculation’ is a term taken from horticulture, to describe the process of grafting from one plant to another. Before being superseded by vaccination, variolation was used as a form of inoculation to introduce the disease in order to build resistance in the recipient, and it was performed through human touch, skin to skin.
Yet it is the ‘non-naturalness’ of vaccination that shapes many vaccine anxieties, ones about side effects, damage, contamination. These fears are not unfounded – and some groups, including women and members of black and minority ethnic groups, have historical reason to distrust, given a legacy of medical injustices and experimentation. But these fears often reflect a mistaken assumption of risk, they feed on unfounded or refuted scientific findings (as in the supposed link between the MMR jab and autism), and, most worryingly, they ignore the key role that mutuality plays. The reasons to vaccinate, Biss notes, transcend medical imperatives, even public health imperatives.
Myths and fears range from fervent anti-vax views to vaccine sceptics and doubters, and they have a long history. Some are grounded in the commodification of medicine that saw the state’s collusion in a shift from home-based healers to a protected profession of physicians, in which the right to vaccinate was reserved for ‘professionals’ who were suspected of profiting from this monopolisation. Fears of vaccination are also founded in other aspects of suspected profit for the few – the scientists paid by pharmaceutical companies, the medical experiments carried out without consent, the manufacturers cutting corners.
The concept of vaccination as something owned by the people, as part of our commons, has been slower to take root. After 18th-century scientist Edward Jenner took the idea of variolation from observing young women milking cows, he developed the smallpox vaccine and tested it on his own son. Surgeon and writer Atul Gawande notes that President Thomas Jefferson and his successor James Madison, both notoriously in favour of small government, brought Jenner’s vaccine to the United States and, despite some resistance, managed to pass the Vaccine Act of 1813 under which the smallpox vaccine was distributed to members of the public – the first universal health-care in the US. Today, many Americans who are vehemently opposed to what they term ‘socialist medicine’ nevertheless see the value in mass vaccination programmes coordinated by government.
Our attitudes toward the state, notes Biss, are easily translated into our attitudes towards vaccination. She sees both a literal and a metaphorical relationship between government and vaccination – literally in the state’s role in approving and distributing new vaccines, and metaphorically in the way our bodies depend on and trust (or mistrust) the state’s body – its decision-making head and its far-reaching (even over-reaching) arms.
Yet despite the desire for individual liberty and self-determination so ingrained in liberal democracies, bodies expose our vulnerability and our interdependence. In a pandemic, our bodies become at once the host of a virus, the means of it spreading, and the source of our collective resistance. Biss writes, ‘The natural body meets the body politic in the act of vaccination, where a single needle penetrates both.’ In the context of vaccination, mutuality is integral – I am protected when you are protected (that, at least, is the aim; because of the speed at which Covid vaccines have been developed, we don’t yet know their effectiveness in preventing transmission). There is a self-interest in that, to be sure, but an element of ‘owing our bodies to each other’ is also required.
The same is true of our body politic and the debts we owe each other. Why is this such a difficult message for our government to convey? It goes against the current of prioritising individual freedoms and the abiding view that government’s ‘far-reaching arms’ need to be kept in check. It also, as Biss highlights, goes against the capitalist underpinnings of western democracies. The ‘we owe our bodies to each other’ message is difficult precisely because we are taught to compete, not collaborate. Power, privilege, even good health are ‘positional goods’, their value defined by how much we have relative to others. Gawande makes this point as well, in the context of resistance to universal health care in the US; access to health care is seen as a zero-sum game, a limited resource for which we take our place in line and fear that it will be taken by someone else, by an ‘undeserving’ (for which read ‘immigrant’, read ‘unemployed person’, read ‘malingerer’), compromising our own access. This mindset is hard to shift. As Biss writes, ‘The extent to which it is hard to imagine an ethos powerful enough to compete with capitalism, even if that ethos is based in the inherent value of human lives, is suggestive of how successfully capitalism has limited our imaginations.’
This is the reason why appealing to ethical principles, to interdependence and mutuality, will not work without what Biss calls ‘elaborate justifications’. Getting public buy-in to astronomical public spending to provide non-means tested money to businesses and the self-employed, support the self-isolating, pay hotels to house the homeless, and restrict people’s ability to work – all of these would be unthinkable in any other context, and not only to a Conservative government wedded to the notions of individual liberty and small state. It is the reason why war metaphors are so routinely rolled out in times of crisis, and specifically during this pandemic. As Susan Sontag has observed, one of the few activities in which we expect our government to pull out all the stops, to spare no expense, is war. Biss writes, ‘Declaring a metaphorical war on a disease is how we justify the inevitable impracticalities of protecting the most vulnerable among us.’ Using war metaphor is a way for a capitalist society, one based on self-interest and blood-sucking of the 99% by the 1%, to justify preventative and costly measures to protect public health.
Blood has long been used as a metaphor for both our fears and our desires. ‘Blood brother’, ‘blood ties’ – blood is the thing that connects us and shapes our identity. Blood is also danger, injury, illness, and, especially with the AIDS epidemic, contagion.
Blood, of course, is also the food of vampires. Biss sees vampires both as a symbol of blood-sucking capitalism and as a stand-in for virus itself – parasitic. undead, relentless, constantly seeking a host. To her, vampires are a reminder of our interdependence and vulnerability, a reminder that ‘we feed off each other and need each other to live’. In that way, vampires help us think about what we owe each other. My daughter has long loved the brilliant Buffy the Vampire-Slayer TV series, in which the undead who are dependent on human blood are objects of pity as much as of fear – they miss out on so much life! – but are also a metaphor for the dangers of forgetting our own interdependency.
Bees are another creature with something to tell us about vaccination and shared immunity. The health of one depends on the health of all, and the bees’ ‘body politic’, its functioning of the hive, depends on mutuality and collective endeavour. Biss argues that we might make the concept more appealing to people if we replaced the term ‘herd immunity’, with all its connotations of senseless following the crowd and ‘herd mentality’, to that of ‘hive immunity’, working together deliberately in the knowledge that no individual is safe until all are safe. There is a satisfying sense of busy-ness there, rather than business, and an image of shared enterprise not often associated with cattle or humans.
Vaccination tells us that we need the state, and the state needs us, and needs us to need each other. This pandemic has also shown us where we need the state to step back, to give communities the framework to respond to need on a local level by making local and horizontal connections. But there is a fundamental distrust by government of allowing people to design their way through a problem, particularly one with such public health and public finance implications. And small and grassroots is not without risk – risk not only in the sense of lacking safeguards but also in failing to address inequalities and systemic barriers to accessing services faced by some of the population.
An example of designing to avoid risk is the NHS Responder app, launched in spring 2020 to harness the resources of volunteers eager to provide support to individuals who had been asked to shield in the first wave of Covid-19. Three-quarters of a million people signed up, and many thousands of hours of help have been provided, delivering shopping, picking up prescriptions, driving people to appointments. Those needing help are referred to the service by GPs and others. During this second wave of high community transmissions, although the shielding request has not been repeated, the level of fear has prompted an increase in requests for help.
I applied to join the NHS Responders in April and started taking requests following the vetting and checks. The rules were clear – we had to wear masks, not advance our own money, and not help the same person more than once a fortnight, presumably to prevent people exceeding the boundaries of their role. The underlying assumption was that yes, people can be trusted to help each other, but they can’t be trusted to know how, or when, to stop.
At the same time the NHS Responder app was getting set up, a number of mutual aid groups were formed, many using WhatsApp as a channel for communication and others relying on old-fashioned local knowledge. These are neighbourhood based and locally organised, often covering a few streets or blocks. I didn’t join one of these, as they seemed more suited to neighbourhoods of single-family homes than the blocks of flats where I live. I put up a sign in my local post office offering to help anyone local who was shielding. Deirdre responded to my sign, asking me initially to bring her the newspapers because her partner was shielding. Eventually my help expanded to food shopping, prescriptions, and other forms of help that required internet access, which she doesn’t have. I even liaised with her church about keeping their toilets open so she could attend Mass.
I carried out several requests that came via the app, but I found the experience disheartening, and as Deirdre’s needs increased, I had less time to give to the app requests. I disliked the transactional nature of the app’s exchanges, the built-in resistance to developing any sort of ties. I was also annoyed that it seemed to sound its siren when no help was needed. Nevertheless, I felt guilty as I put myself ‘off-duty’ to stop the siren sound of requests coming through my phone. I wondered why I so prefer one, the local one, to the centralised one.
As I listed the characteristics of each, I realised I was describing the characteristics of the administrative justice ‘system’ as it is, on the one hand, and on the other, the administrative justice fabric as my co-author Nick O’Brien and I proposed it could be, in our book Reimagining Administrative Justice: Human rights in small places. The established thinking is that unpredictability and uncertainty are to be avoided, that the administrative justice system requires consistency, certainty, and closure to be an effective mechanism for processing citizens’ grievances and appeals.
The same is true of the Responder App, a systematic, centrally organised data generator, with rules and guidance defining the boundaries of what can only be described as ‘help transactions’, transactions that are one-way only. It is designed so that individuals do not need to make judgments but can contribute to an operation, not dissimilar to established ambitions for administrative justice to be a smooth-running appeals machine. Mutual aid groups and similar approaches, in contrast, are ad hoc and locally organised, both immediate and ongoing, forming a loose network of mutuality. Loosely designed, they don’t generate data (of the sort that feeds machine intelligence), they have no imposed safeguards against abuse, and they don’t reach everyone in need.
Is one approach ‘better’ than the other? How can we know? One operates on a massive scale with carefully delineated boundaries. The other is small and agile but potentially full of risk. One can produce spreadsheets of the millions of hours of help given. The other can produce reams of personal testimony and anecdote. They don’t have the same texture and don’t even speak the same language in a way that makes it possible to compare them. Both are attempts to generate an ethic of caring for others, and both, as I found, are patchy in delivering that aim.
Reference to Blitz spirit, to people helping each other, facing a common enemy, have been a constant during this pandemic. But to go down that road would be to harbour a misplaced nostalgia for a past that was experienced very differently by parts of the population. Nevertheless, I am convinced that, as Stears argues, ‘there is untapped strength in the everyday’. To tap into that strength requires a loose grip on the design lever and a certain level of tolerance of risk to foster mutual trust.
At the walk-in clinic earlier this week, Deirdre’s partner did get vaccinated, to Deirdre’s huge relief. This achievement was down to a combination of pressure from his sister, persuasion from the GP, and a clever manoeuvre in the walk-in clinic by Deirdre (which meant he couldn’t change his mind and escape). It was an illustration, at a very intimate scale, of the connections we need to nurture at the most local level but with a centralised framework (a vaccination programme, a national health system) to aid that connecting. We cannot get by only with ad hoc mutual aid groups, just as we cannot get by only with systematised data-gathering apps. We need both the frameworks and resources of the state and the ingenuity and bridge-building of the street. And we need each other.
Co-author, with Nick O’Brien, of Reimagining Administrative Justice: Human rights in small places (Palgrave 2019).
* This article’s subtitle is taken from the title of Bernardo Zacka’s book When the State Meets the Street: Public Service and Moral Agency (Harvard University Press 2017).
Eula Biss, On Immunity (Graywolf Press 2014; Fitzcarraldo Editions 2020)
Hilary Cottam, Radical Help (Virago 2018)
Margaret Doyle and Nick O’Brien, Reimagining Administrative Justice: Human rights in small places (Palgrave 2019)
Atul Gawande, ‘Is Health Care a Right?’, The New Yorker, Oct 2, 2017
Marc Stears, Out of the Ordinary: How Everyday Life Inspired a Nation and How It Can Again (Belknap/Harvard University Press 2021)