Immunity,Biopolitics and Pandemics

Immuno-politics and Pandemic Influenza

Researching Immunity Talk

The interview and focus group extracts presented in what follows were generated in international research on pandemic influenza, with a focus on the 2009 H1N1 pandemic. The project focused on the responses of members of the general public to the events of 2009 and influenza more generally, alongside interviews with researchers, clinicians and policy-makers, and analyses of public policy texts on pandemic influenza control.

To explore how members of the general public engage with pandemic influenza, we conducted interviews and focus groups in Melbourne, Sydney and Glasgow with participants recruited through community sampling. Generating data in Australia and the UK allowed us to address the international dimension of pandemic influenza, and particularly the events of 2009. The Australian public health response was watched internationally as the early stages of the global pandemic coincided with the southern hemisphere influenza season. Within Australia, the pandemic quickly affected Melbourne, which became known as the ‘flu capital of the world’. Our objective was to explore diverse responses to influenza as the basis for generating richly nuanced perspectives in dialogue with social theory. Therefore, four purposive criteria were used to select respondents in each city: women who were pregnant or women or men with young children in child care in 2009; older members of the community (71 years of age and older); people with compromised immune systems (HIV) and or respiratory illness such as asthma; and people who self-identified as being ‘healthy’. In addition, selection of participants was conducted to ensure: a balance of male and female participants, and a range of ages from 18 years upwards. These criteria allowed us to obtain the perspectives of groups identified as being particularly at risk of pandemic influenza, as well as those of the healthy majority of the population. Drawing on interviews and focus groups ensured ‘depth and breadth’: interviews explored in-depth experiential personal disclosure and focus groups examined extant social mores and norms concerning pandemic influenza.

A total of 116 people participated in the research in 57 interviews and 10 focus groups (with 59 participants). Interviews included people from each of the clinical purposive criteria (pregnant = 14; 71+ = 3; HIV/respiratory illness = 17; healthy = 23); a mix of gender (women = 34; men = 23); and an age range of 18 to 71+ years. Focus groups included people from the 71+ group (10); HIV/respiratory illness (37) and the healthy group (22); a gender mix (women = 36; men = 23); and an age range of 18 to 71+ years. This pattern of participation reflects the challenges of recruiting women who were pregnant in 2009, the very elderly and men. In addition, the categories of purposive criteria overlap. For example, people aged 71+ years are more likely to have lung disease. These figures, however, demonstrate that we were able to recruit a diverse sample and on that basis generate discussions with members of the general public variously impacted by the 2009 H1N1 pandemic.

Participants were asked to speak about their experiences with influenza and the public health response to pandemic influenza. Verbatim transcripts of interviews and focus groups were analysed for content and according to an agreed list of themes. Following this, the first author of this paper (MD) undertook a critical discourse analysis which attended to the organisation of symbols and signs in talk that bring meaningful features of social experience into existence (Parker, 2002). The focus in this instance was the immunity-related talk brought into connection with the theoretical perspectives previously outlined and, in particular, a problematisation of the S/NS model of immunity, recognition of pandemic influenza as simultaneously a biological and political problem, and the ways in which immunity talk was inflected by possessive individualism shading into what we suggest is ‘choice immunity’.

Discourse on immunity was pervasive and nuanced. It emerged in interviews and focus groups in Glasgow, Melbourne and Sydney and was given importance by those who saw themselves as healthy and those who, under the gaze of pandemic influenza control, were seen as vulnerable to infection. Immunity talk was inflected by local politics (for example the perceived perennial failings of the NHS in the UK; Australia’s supposed isolation from other parts of the world), and by the ‘immunity’ situation of our interlocutors: healthy participants adopting a more relaxed view than those with specific vulnerabilities, such as those who were pregnant in 2009, those with severe respiratory and/or immune disorders, and older people (Lohm et al., 2014; Stephenson et al., 2014), yet all were tied in to the general principle of immunity as the means of living through the pandemic. We acknowledge that it is important to avoid an overly universalising account of how members of the general public respond to pandemic influenza, since our volunteers come from affluent cities of the global North and, as we have noted, publics are convened as a matter of power and are therefore necessarily multiple. Their approaches to pandemic influenza were also informed by their life and medical situations: elsewhere we discuss the responses of women who were pregnant in 2009 (Lohm et al., 2014). We do, however, want to foreground here the pervasiveness of immunity talk across our research sites and groups of participants as a first step in developing an account of how everyday life with pandemic influenza is addressed as a matter of immuno-politics. In what follows we explore talk on immunity, consistent with our goal of building on theory on the pandemic moment in contemporary society. Our approach sustains a dialectic of elicited narrative and immuno-political theory, seeking out compelling insights which endeavour to avoid the traps of overly data- or theory-driven accounts of lived experience under immuno-political rule.

Immunity Talk

Immunity talk emerged when we asked participants to reflect on the avoidance of influenza infection. For example, Maude, living in Glasgow, pregnant in 2009 and introduced earlier, provided the following response:

Maude’s account is indicative of those of many participants. Maude focuses on her physical resilience, recalling S/NS immunity and the associated meanings of the body as fortress (Martin, 1994) and self-defence (Cohen, 2008). Maude’s account of the necessity of infection – the notion that one has to acquire infection through exposure to pathogens – points up the tension built into S/NS that comes from acknowledgement of the need to connect with what is not-self to achieve immunity. In addition, Maude’s account endorses advice for avoiding infection, but recognises that influenza is ultimately unavoidable. Immunity talk therefore emerges – not just alongside but because of the inevitability of infection; of the circulation of virus that cannot be kept out. Reflecting on bodily integrity, Vivian Sobchack (2010) has suggested that limb amputation is experienced as ‘dys-appearance’: that is, a part of the body, paradoxically, becomes present to experience when it is absent. Immunity, likewise, takes on importance when it is recognised that prevention is likely to be ineffective. It is automatically the negative object of pandemic influenza’s imaginary of the body (politic) under attack by a virus which is likely to eventually evade prevention. Important here, too, is a notion of taking on the responsibility for actively cultivating immunity: that one’s ability to respond to an influenza infection is imbued with the freedoms and responsibilities that come with choice.

Our interviewees recognise immunity as manipulable and their bodies as adaptable, echoing Emily Martin’s (1994) notion of ‘flexible bodies’. They also recognise that adaptation is acquired, in part, through contact with pathogens, suggesting network immunity. In the following, Gordon, from Melbourne and in his 60s with lung disease, outlines at length the orthodox influenza avoidance measures encouraged by health authorities:

That’s what I mean about it: it’s really difficult and you don’t think about it. I think just generally, correct hygiene. That’s basically what it is. And if you maintain a fairly hygienic lifestyle by looking after yourself, by washing your hands at the correct times and that sort of thing. And if you’re sneezing into your hands, washing them. That’s if you’ve got, you know, something serious.…I’m not a great advocate of all these antibacterial washes and things like that. I just think that they also kill the good germs as well. And our bodies are very adaptable. We get things once for a couple of weeks but then we brought up our own anti, whatever it is we build up and we don’t get it again, usually. It’s usually only one-off, a lot of these things, because our bodies adjust and so I don’t think we need to [eradicate] all the germs we’ve got because some of the germs are so good. And you’ve only gotta look at the kids. I look at my grandkids and I think they live in a sterile society. I never did, you know. Well I didn’t. I don’t know about you but I never did. I was always covered in dirt and something. I mean I’ve led a fairly healthy life. I’m still here! You see ads now for everything – it’s so sterile. Everything is sterile. You’ve gotta have germs. That’s how your body builds up against them.

Anne:

Besides, you don’t sort of build up any immunity if you never get it. I mean, it’s like these [children] who are always getting sick ’cause they don’t know about dirt ’cause they’re not allowed to play in the dirt. I mean you’ve gotta have some kind of immunity to it. I think we are a bit more careful now because of Gary’s lungs than we would have been in the past. I guess the other thing that can lead you to getting something is if you’re run down, if there’s just too many activities. So I will cut back on things that we’ve planned to do.

Anne and Gary speak of immunity and its effects as something to be built up, reserved for when it is needed. Such immunity talk is, in strict terms, at variance with scientific discourse on immunity, which is particular about the function of the different cells and biochemical process of the immune system (MacPherson and Austyn, 2012). Anne and Gary’s take on immunity is more akin to a bodily vitality that glosses over immunity’s technical nuances. Such approximation enables action but means that the address to immunity is not necessarily a scientific one. This bodily vitality also emerges as a finite resource: it must be managed carefully or risk being depleted. Indeed, ‘flattened my batteries’ connotes popular culture depictions of vitality (see, for example, the Duracell Bunny, which has its own Wikipedia entry).

Given the significance of immunity in light of pandemic influenza, its cultivation was also a feature of the interviews and focus groups. Such practices connect with wider ‘care of the body’ and, through that, the contemporary emphasis on self-mastery of one’s health and its prospects. Given the previous comments regarding the difficulties of avoiding infection articulated with the importance of exposing the immune system to make it function, do-it-yourself operations on immunity take on particular significance as the arena within which subjects can take action against the apparent inevitability of infection.

In this interview extract, Linda, a healthy woman in her 60s living in Melbourne, tells of her responses to the 2009 outbreak and refers to ‘boosting’ immunity:

Interviewer:

So did you do anything else around that time to try and avoid catching anything?

The otherwise standard practice of ‘immune-boosting’ intensified for the case of 2009 H1N1, shows that immunity is seen as open to cultivation and that it is also central in response to pandemic influenza risk. In the next extract, from a Sydney focus group, the participants also reflect on how to prevent influenza by eating foods thought to assist immunity: Interviewer:

So what do you guys do to kind of stop the flu?

This quotation is significant because the respondents, upon being asked how to ‘stop flu’, speak of bolstering immunity. They do not mention the government-sanctioned sneezing etiquette and social isolation, focusing instead on dietary habits and immunity, an approach that does have some scientific support (Cunningham-Rundles, 2002: 21; Shetty, 2010: 23). Importantly, ‘germs all around you’ connotes both S/NS and network immunity. The self/body is surrounded, like a fortress, against invaders. But there is also scope for understanding immunity as reliant on a matrix of self–other connections. In light of the limited efficacy of infection avoidance behaviour, participants seek to re-establish agency through the cultivation of immunity, giving it the meaning of practical and symbolic strategy for living with the threat of that which cannot be avoided. The cultivation of immunity, however, need not only be a matter of everyday food preparation and consumption. Biomedically sanctioned immune-boosting was also noted by Matrix, an HIV-positive man from Glasgow in his 50s:

these things [vitamin pills] are imported from the States. They’re called K-PAX. There’s a doctor called [name of doctor] in San Francisco I think who is an HIV, he’s been doing HIV specialist, he’s developed these sort of vitamins and supplements and stuff. They’re quite powerful. They’re sort of way over the recommended daily allowance. So I was assuming that taking very high strength, very potent sort of vitamins and supplements would also help my immune system deal with all these other sort of infections. That’s what I think. So that’s part of my thinking as well, but I wouldn’t say I had sort of any well thought out strategies to deal with other people’s flus or colds or sort of chest infections.

However, this rationality of bodies pitched against influenza is not without its consequences for subjects and their social relations. Immunity politics extends to the judgements of those who had apparently failed to act on their health status or who acted inappropriately, reinforcing the possessive individualism and, specifically, neoliberal and moralising modes of self-governance implied in immuno-politics. In this extract, Dylan, a man in his 20s from Melbourne with no reported vulnerability to influenza, tells a little story of a relative who is said to have contracted 2009 H1N1, in part, it seems, because they mismanaged their immunity: Interviewer:

Know anyone that got the swine flu?

As with other elements of our participants’ discourse on immunity, this account implicates exercise (Petersen and Petersen, 2002) and diet (Calder et al., 2002) in the biology of immune function. Distinctive here is the way in which cousin YYY is said to have brought weak immunity on himself. This account returns us to the original, juridical notion of immunity as it draws attention to the duty implied in munis (Cohen, 2004), the connecting point of immunity and community (Esposito, 2011). This is another way in which contemporary immuno-politics, articulated through pandemic influenza talk, shapes the individual, constructing them as morally responsible for the bodily immunity of which they have possession. As Cohen (2008) suggests, one’s immunity is also always about one’s place in community, biologically, politically and, as it seems here in Dylan’s story, morally.

Reflections on Immunity Talk and the Virus Within

In 2009, a global public health emergency materialised in the form of the H1N1 virus outbreak. While, in the end, this pandemic turned out to be less serious than expected, it touched the lives of many. For the people we spoke with, the advent of this global event, together with pandemic influenza in general, mobilises contemplation of immunity as an arena of bodily vitality set against the inevitable incursion of the influenza virus. Public health advice to adopt hygiene practices and to avoid infection was seen as sensible but also as unlikely to prevent contact with the virus. Indeed, this idea of the inevitability of infection, of the likely breach of national and bodily prevention measures, meant that one’s immunity was the only recourse until such time as effective anti-virals and vaccines became available. The pervasive, nuanced articulation of immunity in narrative on pandemic influenza supports the view that immuno-politics is axiomatic, not only for contemporary biomedicine and global public health systems, but also in the constitution of the embodied self in everyday life. Moreover, immuno-politics works across national boundaries and relative susceptibility to viral infection. Citizens effortlessly take up a dual process of self-subjectification and self-objectification, a process which individualises yet ties them to all others (Esposito, 2011). Bodies are set apart, yet necessarily connected and penetrated to ensure robust immunity and, as Cohen argues (2009), effective immuno-political rule.

We have given emphasis to what we regard as the importance of choice in this immuno-politics, as was in evidence in notions of do-it-yourself immunity-boosting and the apparent moral judgement that fell on those who failed to adequately care for their immunity. When it is acknowledged that behaviours such as hand-washing, isolation and wearing masks have limitations, action figured around immunity restores subjects to agency, providing a means of apparently moderating infection if and when it does come (e.g. vitamins, exercise, the ‘right’ amount of exposure to other pathogens, the ‘right’ amount of potentially taxing social interactions). Previous research, though not focused on immunity per se, has argued that members of the general public recognise their own resilience as an important means for coping with possible infection (Prior et al., 2011). As we have shown by drawing on immunity and bodily integrity scholarship, personal resilience is not only specific to colds and influenza: it is connected with contemporary turnings in immuno-political life which join the history of liberal thought and contemporary knowledge of the radical ways in which bodies and immune systems exceed accepted notions of S/NS (Cohen, 2004; Martin, 2010). Choice is important here as a metaphor for agency, conferring on immunity the meaning of self-managed biovalue that can be accumulated and exchanged for health in the event of infection.

Immunity talk was also inflected with what we referred to as ‘immuno-cosmopolitanism’, a concept which builds on Aryn Martin’s (2010) idea that the S/NS framing of immune function does not bear up against recent biomedical science on the topic, forcing a revision of framings of immunity as more properly a science and politics of creative, productive relations of self and other. Interviews and focus groups yielded comments regarding the necessity that an effective immune system depends on traffic with ‘foreign’ microbes and bodies, even ‘dirt’. As noted, probiotic foods trade on notions of immunity to assure interested consumers (Koteyko, 2009). We note also that contemporary marketing of probiotics uses terms like ‘friendly bacteria’, ¹ underlining notions of network immunity and implying that, to achieve good immunity, one is required to forge relationships, even with microbes. Such commodification may not be restricted to supermarket foods and vitamins: the same logic extends to anti-virals and vaccines since they too operate on immune function through the introduction of that which is not-self. Cosmopolitan ‘taking in’ and the commodification of the ‘other for consumption’ suggest both the possibility of ‘outliving oneself’ and the ontological instability of notions of a pre-existing self in relation to other.

Our article, developing this problematisation of immunity, suggests that the prospect of pandemic influenza is, in the end, an imaginary of the virus within. Our participants recognised that influenza viruses cannot, in the long run, be kept out: they become present or already are within the body (and thus the body politic), despite efforts to the contrary. The advent of influenza pandemic appears, then, to be one important bridgehead for a global health politics and related forms of embodiment and citizenship which are already directed towards the management of the not-self or foreign within. Here, biosecuritisation (Stephenson and Jamieson, 2009) and bioterrorism (Cooper, 2006) are resonant. Pandemics mobilise not simply the threat which comes to nation and body from elsewhere, but also action on the threat that is already present. Global and national public health efforts are therefore subject to duality: they act on behalf of the ‘general public’ but also regard them as part of the problem, since viruses necessarily escape prevention efforts. Kinds of ‘general public’ are called into being and asked to act for individual and collective benefit but, at the same time, come into view as the medium through which pathology circulates. In this view, prevention measures, at least in the case of pandemic influenza, have a troubling hollowness that betrays an interest in the management of populations where microbial danger is likely to be already present.

We are led to think of pandemic influenza as the ‘apotheosis’ of immuno-politics, to borrow heavily from Cohen (2009). Simple expectations of coughing and sneezing etiquette, social isolation and the other measures deemed to be necessary in times of public health emergency are also appeals to self-subjectification/objectification which draw on and intensify the immuno-political address to the volitional and responsible embodied self. The immunity talk we have discussed here suggests immuno-cosmopolitanism: an endorsement, even nostalgia, for productive encounters with ‘dirt’ and traffic with foreign microbial life, and therefore a form of immuno-political existence that can find and sustain productive encounters with otherness. But securitisation (Fischer, 2012) and a destructive autoimmune response on the threat within (Derrida, 2003; Esposito, 2011) are also possible turnings in immuno-politics and therefore the governance of pandemic influenza. Indeed, public health has within it the logic and powers of aggression on self in the name of the greater good: quarantine laws are an example and the global response to pandemic influenza in 2009 was managed using military systems of command and control (Davis et al., 2014). Members of the general public clearly take on the various models of immunity – S/NS, network and choice – combining them and applying them in their talk of pandemic influenza. This is the other likely hidden effect of efforts to manage the public response to pandemic influenza, tied as it is to immuno-political assumptions of selves, bodies and good government in the face of microbial threat. Questions of what form such politics will take in this regard are not fully exercised in the public domain and, as we have noted, members of the general public endorse how governments responded and what was asked of them. Immuno-political questions, at least as they pertain to pandemic influenza, are therefore interiorised; they are folded within the milieu intérieur of choice immunity and literally played out inside the body. This is perhaps a kind of perfection of life under immuno-political rule, which erases opportunities for collective agency even as it calls the general public into being under advancing microbial dangers. A deeper question to which this analysis points, therefore, is what will count as public life when immuno-politics is mobilised in the instance of a global public health emergency or more generally in global society? We suggest that global and national public health arenas are already flashpoints for the rise of public life emptied of biopolitical dialogue articulated with the unruly, creative immuno-cosmopolitanism of the embodied selves of everyday life.