In Los Angeles, the wealthiest school districts have the lowest vaccination rates, and have experienced recent outbreaks of whooping cough. While the poor may potentially be under-vaccinated due to poverty and lack of access to medical care, it’s generally the better-off and privileged who choose to opt out of vaccinations for their children.

Of course, vaccinations have always been political. The very idea of vaccination is group-oriented: individuals take the shot for the benefit of “herd immunity,” in which the immune majority protects the minority who are not immune. These vulnerable members of the community often include both its youngest and oldest members.

The book The Politics of Vaccination: A Global History takes a deep dive into the global history of the politics of vaccination. Book editors Christine Homberg, Stuart Blume, and Paul Greenough summarize: “Government-organised vaccination campaigns are political projects that presume to shape the immunity of whole populations. Like other pervasive expressions of state power—taxing, policing, conscripting—mass vaccination arouses anxiety in some people but sentiments of civic duty and shared solidarity in others.” Vaccinations have eliminated many diseases, increased life span, and improved public health, but they are still very much about the sometimes coercive power of the state.

“As a rule,” the editors note, “controversy clings to immunisation programmes.” History, culture, and political power come into play in the case studies by contributors to the volume, who examine vaccination in over ten countries throughout the world. The authors discuss campaigns against smallpox, polio, and yellow fever, devastating diseases that have all taken great tolls over the years, as well as measles/mumps/rubella (MMR), hepatitis B, and others that are still threats.

Health policy scholar Jennifer A. Reich takes a more microscopic approach. She surveyed the reasons twenty-five mothers in Colorado—the U.S. state with the highest opt-out-of-vaccinations rate—chose to or choose not to vaccinate their children. Her survey was of mothers only “because it quickly became clear that healthcare decisions are maternal terrain” in what she calls the “gendered discourse of vaccine refusal.” Twenty-four of the mothers were white (representative of the prevalence of white females in vaccine refusal). Twenty-four were heterosexual; most were married; a few were divorced. All but two had greater than high school education. All worked full or part time (nine were stay-at-home moms), with some running their own businesses. None cited religion as a reason for choosing to opt out of vaccinations.

These mothers who did refuse vaccines for their children saw themselves as experts on their own children and decided that the risks of vaccines were greater than the risks of infection. They thought their own mothering strategies were superior means of supporting their children’s immunity (via nutrition and healthy living). They also believed that they could control the risk of infection by controlling their children’s social exposure to “foreign” bodies outside their networks.

As Reich describes it, these mothers have drawn “imagined gated communities” around their children by rejecting assertions that their choices undermine community health and refusing to accept that their children benefit from herd immunity.

Reich explicitly draws a connection between these “women’s insistence on individual maternal choice” and the politics of libertarianism and neoliberalism. The “evidence of commitment to their children draws on and replicates structural inequality in ways that remain invisible, but affect others.”