“Choice immunity” versus Collective Immunity

“Choice immunity” versus Collective Immunity Dr Niamh Stephenson (Public Health & Community Medicine, Medicine, UNSW) & Dr Mark Davis (Sociology, Monash) 8th Australian Influenza Symposium Australian National University 4 -5 Oct 2012 This work is being funded by the ARC (DP110101081) Thanks to Emily Waller, DavinaLohm & Casmir McGregor researchers involved in this project including recruiting, conducting interviews and coding

Overview • The project • Approach & Sample • Finding 1: The splintering of the public into “vulnerable” and “others”, where is the collective response? • Finding 2: “Choice Immunity” • Finding 3: Relative absence of notions of collective immunity • Discussion: Framing “choice Immunity”/absence of notions of collective immunity as an unintended by-product of contemporary clinical and health promotion practices • Concluding question: how to address the gap between a) the public health imperative to invoke the public as collectively responsible and people’s everyday lived experience of taking individual responsibility for (pandemic) influenza?

ARC DP, Pandemic influenza: people, policy, science http://www.sphcm.med.unsw.edu.au/SPHCMWeb.nsf/page/ProjPandemic

Methodology • The research was conducted in three cities: Sydney, Melbourne and Glasgow • Recruitment Strategies: • Primary: posting flyers, contacting organisations • Secondary: snowballing and direct approach • Four purposive criteria were used to select respondents for interviews and focus groups: • Women who were pregnant in 2009; • Older members of the community (71 years of age and older); • People with compromised immune systems (HIV) and or chronic respiratory illness (e.g. Cystic fibrosis, chronic obstructive pulmonary disease); and • People who self-identified as being ‘healthy’ • Conducted semi-structured interviews and focus group discussions • Thematic coding (NVivo) followed by discursive analysis of themes

Overview of Participants

Finding 1: The splintering of the public into “vulnerable” and “others”, where is the collective response? “Healthy others’” have a reasonable idea about who might be vulnerable to influenza Vulnerability as seen by the vulnerable Vulnerability experienced in a range of ways, e.g. from relatively relaxed (unusual) to an incommensurability of experience (common): I normally avoid them [colds] ... I normally avoid the flu. I think the last time that I had one would have been six, 10 years ago. I was working in retail. [Rob, 40s, lung condition] *** People do think you’re a little bit paranoid and strange. I remember actually asking my husband if he would take some hand sanitiser to work and keep it on his desk. And, you know, like washing hands and sanitising hands a bit more frequently to try to avoid getting sick. And this is before, before we had the [Pandemic Influenza] vaccination. [Yeah] He was like, “Whoa! Work and business and people will think I’m strange, and you can’t wash your hands after you shake hands with someone!” And he’d come home and I’d say, “How did you go?” And he’d say, “Oh, I washed my hands four times today.” I’m like, “Okay … four times? What, when you went to the bathroom?” “Yeah.” Oh gosh … so …Even someone that close to me it’s still, you know, it’s still really difficult to explain to someone. Yeah. He did care – that’s for sure – but I just don’t think that he could possibly understand. [Fiona, 30s, lung condition, emphasis added]

Finding 1: The splintering of the public into “vulnerable” and “others”, where is the collective response? Vulnerability was not something that others readily recognised (some exceptions, e.g. advanced pregnancy): You don’t look sick. Like I’m not walking around with a, with a walking frame or a limp, or, you know, people can’t understand what they can’t see. [Mitzi, 30s, lung condition] The chasm vulnerable people experienced between themselves and others, knowledge was not often understood as the issue: But I’ve gotta say, because most of my circles actually had swine flu or suspected they had swine flu, I think it actually brought down the fear because people experienced it themselves and because they, you know, it was this big, big scary thing and then they got over it in a few weeks and were really scratching their head going, “What was all the fuss over?” Yeah. And I, I think that’s the mentality of the, at least I witnessed [Pippa, 30s, lung condition].

Finding 1: The splintering of the public into “vulnerable” and “others”, where is the collective response? Vulnerability commonly experienced as isolating: I’ve done it a couple of times [wear a mask] where I’ve felt like such an idiot and people have, you know, been a bit, a bit awful. [and then explains that she stays at home] [Karen, 30s, lung condition] What appeared lacking, from the perspective of vulnerable people, was a sense of a shared problem that could be acted on collectively. This is a predictable but notable absence given: • evidence that effective prevention of infectious disease hinges on countering divisions within communities so as to enable collective responses (Kippax et al., 2012) • Calls for promoting altriusm, e.g. Natureeditorial: “people should be reminded that vaccination isn’t just about protecting themselves; it’s also about not spreading the flu to others, which, importantly, alleviates pressure on overstretched hospitals. Campaigns should give altruistic appeals far more prominence than they typically have in the past; research shows that they can be surprisingly effective” (2009, p. 698).

Finding 2: “Choice Immunity” • Most people conveyed and endorsed (even if they did not personally adopt them) prevention measures, e.g. quarantine, social distancing, hygiene and vaccines. • BUT, they thought ultimately prevention was likely to be impossible, so when asked about prevention they talked about “Choice Immunity” A) “You can’t live in a bubble” QU: Do you think it’s possible to avoid catching the flu in any way? No, I don't think it’s possible to avoid catching it. I mean to one, to avoid catching it you would have to live in a, in a bubble. ... I mean you can go into a room where a person coughs once, and you could walk out of there, and 24 hours later you’ve got it. So I don't think you’ll ever stop people from catching it. [Archie, 60s, lung condition] *** Avoid catching it?... I really don’t think so... I think you can do things like you know...the hand washing thing and just being a wee bit more aware of your like you know, I’m always trying to get [her son] to cover his mouth when he’s coughing and sneezing and using a tissue and all that sort of stuff. So you can do all these things, but I don’t think you can completely avoid getting it altogether. It’s an airborne virus is it not? So you’re going to breathe it, you know (laughs) You know short of locking yourself up in a room [Sarah, 20s, pregnant in 2009]

Finding 2: “Choice Immunity” B) The answer to exposure is to bolster one’s immunity So you really can’t avoid … you can sort of eat well, sleep well. You can do all those sorts of things to give your immune system a chance to, to throw it off. So, I mean basically the, you know, there’s really, there’s no barrier that will ever stop you getting a cold or the flu[Roslyn, 60s] *** QU: So what do you do to stop the flu? Is there any... Terry: Eat garlic and chillies, and [… I eat it and it seems to you know, like in chillies and garlic – Dana: They reckon garlic does. I use garlic sometimes. Terry: I try to squeeze a few oranges or something like that. Drink many fluids. [Yeah] Dana: I think you just eat the good nutrition, you know. Get all your vitamins and whatever, you know. General food. [Focus group, “healthy others”] *** And also I find what helps for me is taking a probiotic. They say that 80 percent of your immunity is in your gut. I don’t know how true that is but I try to keep healthy flora in my stomach at least. Especially seeing as though my lifestyle wasn’t that healthy. I’m a smoker [Lara, 30s, Asthma] Cultivating immunity also meant having exposure, to dirt, germs and to viruses Like you can’t, you can’t live in a bubble and you can’t live in a sterile environment or you won’t have an immune system at all. [Mitzi, 30s, lung condition]

Finding 2: “Choice Immunity” People describe how having immunity enables one to be social, to mix freely with others People describe a wide array of practices, informed by diverse sources: • a “bricolage” of medical advice/media reports/advertising/Granny’s ways that; • people individually choose and assemble

Finding 3: Relative absence of notions of collective immunity Nostalgic (mythical) accounts of collective immunity Qu: So you think that distance helps Australians ..? Yeah, yeah. And I think we’re pretty hardy stock too. I think, it’s a pretty harsh country and it’s made our descendents pretty hard people, and good, strong, solid stock, basically, even though a lot of us are immigrants. [Gordon, 60s, lung condition] *** Qu: Did your parents want you to catch [chicken pox] Conor: Yeah. Very much so...I think mum had even planned it well. I, I do remember: I would have been about seven or eight and it was the winter school holidays, middle of the year, and my brother and I had, my brother had it the first week, I had it in the second week. We went back to school and mum looked after it. It was very well planned. Get the chicken pox. Go back to school. So … but I do remember, I do remember mum being very much, “Someone’s got chicken pox. Go and play with him.” “Yeah, okay.” “Go and get it! Go and get it now!” [Conor, 20s, Focus group]

Finding 3: Relative absence of notions of collective immunity Nostalgic (mythical) accounts of collective immunity Qu: So do you think that actually playing around in the backyard in horse manure helps? Alana: My parents thoroughly encouraged playing in the dirt and getting into like all the … like playing with all the animals and stuff. Just getting in there, really. And I think it does, actually, if you get in there young and end up getting exposed to all those germs... Qu: So do you think that does build up immunity? [Mmm] Adam: I think getting sick every so often is a good thing [Yeah] 'cause it builds your immune system up. [Right] So, so if you do get something really nasty, hopefully that helps. [Yeah] ..... Conor: ...Yeah. I’m sure I ate a lot of dirt. “Eat this Conor” And I was never, I was never frightened in the backyard and getting dirty.... ..... Adam: I don't think shielding kids from that is necessarily a good thing. [Yeah] You know, either from the perspective of letting them get, you know, in contact with germs and stuff like ... Ruby: Yeah. I think it’s better for the immune system if you’re a bit close to germs. [excerpts from Focus Group, 20s]

Discussion People’s lack of interest in collective immunity is not a new problem: e.g. Broad discussions of vaccination uptake • Common explanations include: lack of knowledge, lack of familiarity with severe or widespread disease IN ADDITION • Public engagement with health issues via the lens of “individual choice” is normal today; “choice immunity” is a product of: neoliberal governance that foregrounds individual responsibility; medical practices that emphasise patient autonomy, responsibility and choice; health promotion approaches that focus on individual lifestyle  “choice immunity” can be seen as the unintended by-product of contemporary clinical practices and health promotion

Conclusion Can efforts to engage public in public health preparedness for/response to pandemic influenza (and influenza) appeal to notions of collective responsibility if the public: 1) experience themselves as divided along the lines of vulnerable/healthy and; 2) people think about managing influenza as an individual rather than collective responsibility? Is there a value in cultivating contemporary notions of collective immunity so that future appeals to the public have some “ground” to land on?

References • Davis, M., Stephenson, N. & Flowers, P. (2011) Compliant, complacent or panicked? Investigating the problematisation of the Australian general public in pandemic influenza control, Social Science and Medicine, 72(6): 912-918. • Editorial. (2009). How to win trust over flu. Nature, 461(8), 698. • Kippax, S. & Stephenson, N. (2012). Beyond the Distinction Between Biomedical and Social Dimensions of HIV Prevention Through the Lens of a Social Public Health. American Journal of Public Health, 102,789–799.

“Choice immunity” versus Collective Immunity