SEARCH

SEARCH BY CITATION

Keywords:

  • risk;
  • time;
  • security;
  • preparedness;
  • vaccination

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

During preparations for the Second Gulf War, Israel considered universal smallpox vaccination. In doing so, it faced a problem: how to legitimise carrying out a security action against an uncertain future danger (smallpox pandemic), when this action carried specific, known risks (vaccine complications). To solve this problem, the Israeli preparedness system created a new domain through which the security action could reach its goal with minimum risk: first responders (a group of medical personnel and security forces). First-responder vaccination represents a shift in the form of ‘securing health’ and in the governmental technology applied to this goal, in which past, present, and future occurrences are governed to enable the execution of a security action. Through this practice, risks are not located in the present or in the future but in a ‘shared’ temporal space and thus can be seen as existing simultaneously. Preparedness for emerging future biological events, then, involves more than questioning how the future is contingent on the present and how the present is contingent on the future’s perception; it also recognises the need for a new time positioning that allows operating on both present and future risks simultaneously. Governing these risks, then, means governing through time.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

During the winter of 2002–2003, the Israeli government authorised vaccination of medical teams and security personnel against the virus that causes smallpox. The vaccination programme grew out of reports that Iraq might attack Israel, possibly using biological agents, during the build-up to the Second Gulf War, as well as from assessments that the virus might be deployed as part of a biological terrorist attack on Israel (Shai 2002, Orr et al. 2004). The programme was part of a larger project whose objectives were to prepare a team of first responders to deal with casualties following a major biological attack, to prepare a sufficient quantity of smallpox vaccine for the entire population and to create a large stock of vaccinia immune globulin (VIG), which can be used to treat side effects in those receiving the vaccine for the first time. The project proved controversial and raised public concern not only about the danger of a future smallpox outbreak, but also about the vaccine, which can cause serious side effects or even death.

In this article, I analyse this event and the debate among government officials and the Israeli public regarding the need for the vaccination project. I argue that the problem of preparing for emerging or re-emerging biothreats is one not only of controlling the future, but also of handling risks caused by the very act of preparation. Thus, for governments and other authoritative agencies, a new problem emerges: how to legitimise a present action whose utility lies in a future possibility. The current case study shows how the very linear occurrences and locations of past, present and future must be governed to solve this problem. I argue that the practice of first-responder vaccination represents a shift in the form of ‘securing health’ and in the governmental technology applied to this goal.

In making this argument, I contend that the vaccination project expresses a different governmental technology than that described by Foucault (2007[2004]) under the rubric of the ‘security apparatus’. I assert that a transition is underway from governing populations in the context of existing events to managing them through the prism of time. ‘Governing through time’ does not mean the conquest of the future as a new governmental domain (Arnoldi 2004), but rather, the creation of a temporal space in which future danger and present risk can be seen to coexist simultaneously. In this construction, the risk of smallpox and the risk of vaccination are juxtaposed in the same ‘time’ so that vaccination as a preparedness measure becomes possible.

Securing the population

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

Foucault (2007[2004]) presents three technologies of governance: the legal mechanism; the disciplinary mechanism; and the security apparatus. Each emerged historically in response to a different governmental problem and was enacted with a certain aim through certain practices. However, these systems were not mutually exclusive, and the appearance of one does not imply the disappearance of another.

In the security form, the intervention of power depends on calculations of cost and expected damage. In place of the dichotomy between permitting and forbidding (as in the disciplinary mechanism), an optimal average is calculated toward which the general normal population is directed. The central mechanism in this instance is the regulation of the population in the milieu of actual events and bringing it to normalisation.

Foucault (2007[2004]) shows how the appearance of a smallpox vaccine in the 18th century was related to the emergence of security apparatuses, and he describes the transition from governing via the mechanism of discipline to governing via technologies of security. The security form incorporates statistical calculations regarding the health of the population: risks of infection, mortality rates, rates of side effects caused by the vaccine, and so on. This security technology emerged as a solution to a new problem of governance: the need ‘to know how many people have been infected’ and ‘what data we have about them’; that is, the need to regulate the population and to secure it in relation to an existing event. Foucault would later call this calculation-based form ‘governmentality’ and define the security apparatus as its central technology.1

I argue that the specific case considered here signals a movement from security practice (as defined by Foucault), to a new governmental form of preparedness: governing through time. The aim of this practice, the object on which it acts and the technology it produces are all distinctive. This preparedness practice does not deal with the problem of securing the population during an event (like its predecessor, the security apparatus), but rather, with the problem of securing the population through time. The need is to create a system that executes concrete practices in the present to address events that will only happen in the future. In addition, the very action of preparedness, as demonstrated by the case I discuss, might put the population that is supposed to be secured at risk. Similar risks existed when the security technology operated, yet they are magnified in the context of preparedness action because the danger − here, smallpox − is perceived only as a future possibility, whereas the risk from the security action − here, vaccination − is perceived to be certain and immediate.

Risk, society and the future

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

Here I do not offer a thorough review of the literature on the relationship between risk, society and the future (for overviews, see e.g. Lupton 1999, Zinn 2006, Alaszewski 2009). Instead, I highlight relevant sources in discussing two prominent approaches to risk − the risk society and the governmentality approaches − and the contribution of the current article in relation to them.2

The future as risk: risk society approach

In his famous ‘risk society’ thesis, Beck (1992) describes the emergence of new risks as society attempts to control the future through science and technology. This process results in a more uncertain and insecure future. Beck observes:

Industrial society, the civil social order and particularly the welfare state and insurance state … are subject to the demand to make the human living situation controllable by instrumental rationality … In risk society the unforeseeable side and after-effects of this demand for control, in turn, lead to the realm of the uncertain (Beck 1994: 10).

In using the term ‘risk’, Beck (2009: 5) refers to hazards ‘which nowadays often cannot be overcome by more knowledge but are instead a result of more knowledge’. That is, future risks are the result of society’s present developments and advances and cannot be addressed by means of risk technologies of assessment and calculation (e.g. Castel 1991, Ewald 1991, Hacking 1991). Giddens (2000: 40) emphasises the distinction between danger and risk (for other views on the distinction, see, e.g. Douglas and Wildavsky 1982, Castel 1991, Beck 1992, Luhmann 1993), and argues that ‘traditional cultures didn’t have a concept of risk because they didn’t need one’. Whereas, in these societies, hazards were associated with the past and with the loss of faith, in today’s world risk is linked to modernisation and to the desire to control the future. ‘Risk is the mobilizing dynamic of a society bent on change, that wants to determine its own future rather than leaving it to religion, tradition, or the vagaries of nature’ (Giddens 2000: 42). That is, societies today acknowledge new risks and, at the same time, expect to be able to control them.

The risk society approach points to a transition from viewing the future as a space of knowledge-dependent possibilities, or risks, that are manageable by means of technology and knowledge to a perception of the future as uncertain − since future threats are no longer connected to events that can be calculated (Arnoldi 2004, O’Malley 2004, Zinn 2006, Alaszewski and Burgess 2007) − which, paradoxically, derives from additional knowledge and technological developments.

In his later work on the ‘world risk society’, Beck (2009: 9) amplifies his view of risk. Drawing a distinction between possible future risk and catastrophe, he argues, ‘risk means the anticipation of the catastrophe. Risks concern the possibility of future occurrences and developments; they make present a state of the world that does not (yet) exist’. In other words, in attempting to cope with an uncertain future, society realises risks that do not yet exist, ‘for only by imagining and staging world risk does the future catastrophe become present’ (Beck 2009: 10). Here, Beck introduces a more complex connection between risk and society. Whereas his early writing mainly deals with the inevitability of risks emerging in the future as a result of society’s present development, in his later work, he asserts that only when people think about future risks do these risks eventually become real. Hence, through the very process of people preparing for it, risk becomes ‘a self-refuting prophecy’ (Beck 2009: 10).

In Beck’s view, then, one can trace a shift in focus from the risks of the ‘real’ future to ‘future’ risks that are constructed in the present. However, the question of how society has become ‘increasingly preoccupied with the future’ remains a vital one. In other words, it is not sufficient to ask how society’s present actions affect the future. One must also ask how the observation of the future as a problem affects the present and what governmental technologies emerge in response.

How to govern the future: risk technologies

The governmentality approach uses the term ‘risk’ not to represent a dangerous object or future but within the context of a technology of governing and controlling the future, and thus focuses on how technologies emerge and change in relation to that future. Risk technology works by converting future uncertainty into concrete, known risks that are manageable possibilities. Ian Hacking (1991), for instance, examines the production of statistical knowledge that is involved in creating probabilities, and he argues that these probabilities are then managed and controlled. In other words, ‘The erosion of determinism and the taming of chance by statistics does not introduce a new liberty … The less determinism, the more the possibilities for constraint’ (Hacking 1991: 194).

Other studies of risk as a governmental technology draw a similar correlation between risk and control. Ewald (1991), for example, does so in considering insurance technology. In what he terms ‘the art of combination’, he shows how insurance creates more combinations, more possibilities, over which it ultimately exerts control. Moreover, ‘Insurance, through the category of risk, objectifies every event as an accident … By objectivizing certain events as risk, insurance can invert their meanings: it can make what was previously an obstacle into a possibility’ (Ewald 1991: 199–200). In that sense, insurance is a technology of risk (but not because of the real danger it deals with), wherein risk is a way to deal with future events by defining them as controlled accidents (Dean 1999, Lupton 1999). This form of risk technology, which turns something into risk to make it governable, has also been identified in other fields of research, among them, old age (Kaufman 1994), psychiatry (Castel 1991, Rose 1996), pregnancy (Rapp 1995, Lupton 1999), AIDS (Lupton 1994), crime prevention and drug use (O’Malley 2004).3

All of these diverse fields thus share a vision of risk as a way ‘of ordering reality, of rendering it into a calculable form. It is a way of representing events so that they might be made governable in particular ways, with particular techniques, and for particular goals’ (Dean 1999: 131). In contradistinction to the risk society approach, governmentality does not confine itself to risks as objects produced by society (and how society is controlled by them); what is important is examining the way in which risk becomes thinkable and knowable through various technologies and how it is managed accordingly.

From risk technologies to preparedness technologies

The emergence of risks that are not measurable and cannot be assessed has given rise to a governmental technology that does not deal with the creation of knowledge but with doubt and yet is still focused on governing the future. Ewald, for instance, has discussed the move from insurance rationality, which transforms calculated dangers into amenable risks, to precaution rationality: ‘The precautionary hypothesis puts us in the presence of a risk that is neither measurable nor assessable that is essentially a nonrisk’ (2002: 286).

Similarly, Cooper points out the connection between the change in risks themselves and the need for an adequate technology to manage them: ‘no mass information will help us pin-point the precise when, where, and how of the coming havoc’ (2006: 119). As a result, she adds, a new approach is replacing the risk-management approach, one of speculation and pre-emption. In particular, she describes how, to prepare for this unpredictable future, concrete risks must be created so as to develop the means to cope with them: ‘one of DARPA’s (US Defense Department’s Defense Advanced Research Projects Agency) current projects includes the creation of biological sensors − living cells on chips or three-dimensional cell matrices − that respond to both known and previously uncharacterised agents to give a warning sign of attack’ (Cooper 2006: 126). This project puts DARPA in ‘a paradoxical situation of having first to create novel infectious agents or more virulent forms of existing pathogens in order to then engineer a cure’ (Cooper 2006: 126).

Lakoff (2008) expresses a similar idea. He describes practices that attempt to prepare for a future that is not assessable or measurable by the imaginary enactment (via scenario or simulation) of that future. The goal of this action is twofold: ‘to generate an affect of urgency among officials in the absence of the event itself (and) to generate knowledge about vulnerabilities in response to capability that could then guide anticipatory intervention’ (Lakoff 2008: 401).

In preparedness technology, future risk is realised to practise the system’s reaction, not to predict the ‘real’ future. Moreover, according to this approach, though future risk is incalculable, and uncertain, the occurrence of the dangerous event is certain (see also Schoch-Spana 2004, Cooper 2006, Diprose et al. 2008, Lakoff 2008). The aim of preparedness action is to improve the system’s reaction and minimise the damage of the ‘real event’ when it occurs, that is, to prevent it from becoming a catastrophe (Lakoff 2008).

In this regard, Diprose and colleagues (2008: 269) identify the emergence of a new theoretical paradigm, the ‘paradigm of prudence’: ‘what the paradigm urges is that societies be in a constant state of readiness about possible high-consequence threats to the physical security of a population’. It is apparent that preparedness technology approaches largely share the assumption that society must be in a constant mode of preparedness, and that various technologies emerge in response.

I do not, however, take the position that societal preparedness is new. Rather, I suggest distinguishing between preparing for health threats, an issue that has always concerned society, and preparedness as a mode of thought that differs in rationality and in its technological implications from the risk approach (see also Cooper 2006, Diprose et al. 2008, Lakoff 2008, Stephenson and Jamieson 2009). Other scholars have commented on the recent emergence of the preparedness approach. For instance, Lakoff (2008: 400) observes, ‘Over the course of three decades (from the mid-1970s to the mid-2000s), a new way of thinking about and acting on disease threat had arisen: It was no longer a question only of prevention, but also − and perhaps even more − one of preparedness’. Stephenson and Jamieson (2009: 533) see this rationality as the shift from dealing with ‘risk as something predictable and calculable’ to dealing ‘with unpredictable, future events, imagined vulnerabilities’. As various scholars agree, then, preparedness is not a new problem but a new mode of thought, a new rationality that (like rationales such as ‘risk thinking’) reflects a particular perception of the future, in this case, as uncertain and incalculable.

In this article, I examine the actual implementation of the kind of technology this rationality enables as I examine the case of preparedness for a possible outbreak of smallpox. The question I address is: what technology is applied when society is in a constant state of readiness and is concerned with the governing of risks? When risks are incurred as a result of the preparedness action (in this case, smallpox vaccination), the system must deal not only with the presumed need to take action to control the future but also with problems arising from implementing the preparedness action. Hence, the question becomes: what form of action is appropriate in preparing for a possible future event, given that the proposed preparedness practice is itself dangerous? How should this contradiction be approached and how can the problem of securing health in terms of future danger and present risk be resolved?

Methodology

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

From 2004 to 2006, I conducted multi-sited research on the State of Israel’s preparedness for biological threats. I held 75 in-depth interviews with 63 state officials responsible for coping with these threats. They included officials from the Prime Minister’s Office and the Ministries of Defence (MOD), Health (MOH), the Environment and Agriculture. I used snowball sampling to recruit interviewees, accessing my initial set through personal networks and formal letters. As the research progressed, new informants became available through these initial connections. The interviews were semi-structured, thus allowing unanticipated findings and lines of inquiry to arise. I initially posed general questions about the overall role of the state in the Israeli preparedness system and about an interviewee’s position within the matrix. Other questions considered specific events such as the preparations for avian flu or the smallpox vaccination project.

I also examined articles published in Maariv and Haaretz, two extremely influential Israeli dailies, between February 2004 and December 2005. I read each paper every day for almost two years, searching for articles on nonconventional threats, avian flu, smallpox, SARS and preparedness (committees or drills). In addition, I searched the Maariv and Haaretz archives for articles about the smallpox vaccination project that were published before I began my research, dating back to the end of 2002.

Reliance on newspaper articles in the case of the smallpox vaccination project was essential, because even today no official documents on the matter have been made public. Interestingly, this is not the case with official preparedness reports related to avian flu. One possible explanation for the difference is the distinction made by the practitioners in the field between ‘natural’ and ‘intentional’ events. Only since the Second Gulf War has concern with biological threats in Israel entered the civilian realm. This has happened for several national and international reasons, and it has been expressed discursively in terms of ‘exceptional biological events’ and in practice in the emergence of interdisciplinary preparedness systems that deal both with natural and unnatural events (see also Samimian-Darash 2009).

Below I present the analysis of the Israeli smallpox vaccination project. I first review the event and its historical and political context. I then present the problem posed by the attempt to vaccinate the population against a future possible smallpox pandemic. I subsequently detail the solution to this problem and examine its implications for risk management and the unique connection it suggests between risk, time and governing.

The smallpox vaccination event

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

Smallpox outbreaks occurred in various parts of the world until the 1970s. In 1967, the World Health Organization (WHO) launched a global vaccination operation to eradicate the disease. The strategy that ultimately succeeded was ‘ring vaccination’. Vaccination continued until 1978. The last recorded instance of smallpox was in Somalia in 1977. In 1978, the WHO declared the disease to have been eradicated and brought its global vaccination programme to a halt (Fenner et al. 1988, Koplow 2003, Kretzschmar et al. 2004).

Even after the eradication of the smallpox disease, the virus that causes it was still kept in laboratories around the world. In the 1980s, the WHO encouraged all countries to destroy the virus they had preserved or to transfer it to two authorised laboratories in the United States and the Soviet Union. In June 1990, the virus stock in both of these laboratories was to be destroyed. However, the date was postponed a number of times for various reasons. After the events of September 2001 in the United States,4 the destruction was postponed once again because of fear that the virus might be used as a biological weapon, and, at the end of 2002, just before the Second Gulf War, this fear increased.

Until 1978, all Israeli citizens were given three smallpox vaccinations − at one year of age, in second grade (7-8 years old) and on enlistment in the Israel Defence Forces (IDF). Even after the WHO had declared the eradication of smallpox in 1978, making it unnecessary to vaccinate the entire population, IDF soldiers continued to be vaccinated (Shai 2002, Levy 2004, Orr et al. 2004).

In 1996, the vaccination of soldiers was also terminated on the order of then Minister of Defence Shimon Peres. At that point, any new recruits would have been born after 1978 and so would not have been vaccinated as children, which increased the likelihood that they could suffer harmful side effects from the vaccine.

In 2002, while preparations for the Gulf War were underway, the possibility of vaccinating the entire population was raised again. Dr. Yadin, director of IDF Medical Services and a senior member of the Epidemic Treatment Team, was one of the health officials promoting the idea:

We were five medical officers. At the time we received reports regarding the amounts of smallpox Iraq might have been equipped with, and there were some reports that warranted our attention. We came to the Minister of Defence in order to convince him that there was a need for renewing vaccination. The decision to manufacture and purchase the vaccines was reached based on our appeal. On the eve of the Gulf War we recommended that the entire population be vaccinated. The plan was rejected. There were claims against the safety of the vaccine (Dr. Yadin).

By 2002, nearly 3 million Israelis (Shai 2002) had never been vaccinated. This population, therefore, had a higher risk of suffering harmful side effects than people who had been vaccinated at least once. In addition, a large population could not be vaccinated at all (e.g. babies up to one year of age and pregnant women), because the risk of complications was even greater for them. Also, VIG, the protein used to treat vaccine-related complications, is only produced in the bodies of people who have been vaccinated and so was in short supply.

The smallpox vaccine can cause serious side effects. As Professor Dankner, one of the leaders of the Israeli vaccination project, explained:

Each year the number of oncology patients increased, the number of people receiving implants − both of bone marrow and of organs − also increased, and afterwards they continue to receive life-long treatment; in addition, AIDS had spread throughout the world and created an entirely new population of immunocompromised patients − all of these people constitute a population at risk of the vaccine. On top of that, we have 150,000 births each year, about 150,000 babies under 12 months old, between 150,000 and 180,000 pregnant women, and a population of elderly people above the age of 65. All in all, this totals 1.5 to 2 million people who are at risk of developing vaccine-related complications. The vaccination in Israel was terminated in 1979. This means that anyone born in Israel after 1980, approximately 2.5 million people, is not immune to smallpox. And most important, the protein used for treating vaccine-related complications … did not exist in the world (Professor Dankner).

It was against this background that controversies arose in Israel: should people be vaccinated, and if so, who? Some thought that the entire population should be vaccinated, whereas others believed that only a limited group of medical and security personnel − first responders − should receive the vaccine. The decision was eventually made (by the security cabinet on 21 August 2002), to vaccinate only first responders. This group included about 20,000 people: medical personnel and security forces (Shadmi 2002a).

Israeli Public Health Ordinance (1940), Article 39, empowers the director-general of the MOH to require public vaccination. The ordinance can be enacted prior to an endemic event, before a disease like smallpox has been detected in the region. Nonetheless, government officials decided to carry out the operation to vaccinate first responders on a voluntary basis.

Of the 20,000 people who qualified as first responders, only half agreed to be vaccinated, and public debate arose about the dangers associated with the vaccine and the reasons for people’s unwillingness to be vaccinated. Nonetheless, the operation ended with those responsible for it claiming success: sufficient numbers of first responders had been vaccinated to provide a large enough supply of VIG to treat individuals who might suffer from side effects in the event of a mass vaccination.

The problem: future danger and present risk

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

A surprising aspect of discussions about smallpox among Israeli state officials involved in the project and among those who were asked to be vaccinated was that hardly anyone spoke of the dangers of an epidemic − its likelihood, the pace at which the disease might spread, mortality rates, and so on. Instead, discussion centred on how willing people were to be vaccinated given the vaccine’s side effects. As Dr. Weiss, a member of the Epidemic Treatment Team, explained, ‘It is clear to us that mortality of one in a million (from the vaccine) is a more than reasonable price to pay in order to achieve immunity against a disease like smallpox. It is a low price to achieve immunity against smallpox; one in a million is a very low price’.

I asked Dr. Weiss if he was drawing a comparison to other vaccinations. He responded:

To other vaccinations and to the danger of smallpox; but it is extremely unreasonable when there is no smallpox. In other words, one in a million is a high price when there is no smallpox. (But) when there is smallpox it is a low price. As one who has been deeply involved with the vaccination against smallpox, I assert that I could not look a mother or a spouse in the eyes and tell them that someone died because we were preparing for smallpox, a threat that has not yet appeared. You cannot put a price on that. It is very dear, even though it is one in a million. Therefore there is no justification to die from the smallpox vaccine when there is no manifest threat. That’s why I declare that it is a terribly high price, while, in my first sentence, I said it was a terribly low price. It all depends on how you put it (Dr. Weiss).

From this exchange, it was clear to me that a gap separated state officials’ understanding of the need to prepare and public acceptance of the specific preparedness actions being advocated. In theory, people accepted the need to prepare for an uncertain future, but the implementation of the security action in the present case put the population at new risk and, therefore, caused misgivings. Thus, preparing for a future danger creates a situation in which ‘the risks the decision maker takes and has to take become a danger for those affected’ (Luhmann 1993: 107).

When the risk associated with vaccination was held up against the future danger of smallpox, many characterised the latter as theoretical and the former as extremely unreasonable given the current absence of smallpox. As Dr. Lev, the head of the Israeli Emergency Unit at the time, explained to me:

The decision whether to vaccinate the entire state of Israel against smallpox today − if I’m going to vaccinate 7 million people, it means passing a certain death sentence on seven people and another 3,000 cases of complications, meningitis, damage to the nervous system. When there’s no specific threat, the question is whether that’s a price I’m willing to pay. Is the threat real or not? That is not a decision for the health system. In my opinion, the decision that was made was the correct one. The public would not have accepted it that we killed seven people and caused disabilities − we would have harmed a lot of people without being able to point to a threat (Dr. Lev).

Whereas the smallpox risk lay unrealised in the future, the risk from the vaccine was perceived as certain and present. Thus, harming people without being able to point to a real threat became a problem. In other words, the problem was neither about the danger of a potential smallpox outbreak (with its catastrophic implications and possible high mortality rates), nor about the efficiency of preparedness (whether the vaccine would prevent contagion), but, rather, about the risk implied by the decision to vaccinate.

When the vaccination project got underway, around half of those who were asked to receive the vaccine refused:

Hundreds of Magen David Adom (Israel’s first-aid and disaster-relief organisation) and hospital staff across the country are refusing to be vaccinated against smallpox. The emergency teams argue that this ‘preventative treatment’ exposes them and their families to dangerous side effects, including being infected with the disease or even death. ‘I was about to be vaccinated’, related a Magen David Adom paramedic and father of two, ‘and then I found that if my children should accidentally touch my shoulder, where I was meant to have the vaccination, then they could be infected with that terrible disease. So I decided not to be vaccinated’. And he is not the only one. Around sixty percent of medical personnel who were meant to be vaccinated have made a similar decision (Elroyee de-Bar 2002).

The vaccination was described here as a ‘preventative treatment’ for a possible future danger and contrasted with the immediate risk that people ‘could be infected with that terrible disease’. In other words, the external danger that the system was preoccupied with was juxtaposed to an internal, constructed risk. Moreover, that risk was seen as controllable: the individual at risk could remove that risk by refusing vaccination.

This perception recalls the distinction Luhmann (1993) makes between risk and danger. Luhmann defines risk as the way in which people perceive the future as contingent on the present. In his view, whereas danger is external to the system, risk is dependent on the decisions of the system:

To do justice to both levels of observation, we will give the concept of risk another form with the help of the distinction of risk and danger. The distinction presupposed … the uncertainty (that) exists in relation to future loss. There are then two possibilities. The potential loss is either regarded as a consequence of the decision, that is to say, it is attributed to the decision. We then speak of risk − to be more exact of the risk of decision. Or the possible loss is considered to have been caused externally, that is to say, it is attributed to the environment. In this case we speak of danger (Luhmann 1993: 21).

At the time the vaccination project was being considered, the MOH undertook a survey to assess public opinion and assess whether resistance to the project would change if the threat were presented as an actual event. One survey participant relates:

We carried out a survey, I don’t know if it received much publicity, but, to a large extent, if the danger is real, and you tell people, then they are willing to be vaccinated, if there is a case (of smallpox). When you tell people there is a case, most people want to be vaccinated. And all the stories about side effects and the risks are much less relevant (Dr. Gordon, Israel Center for Disease Control).

Thus, resistance to being vaccinated seems to diminish when the danger is perceived as existential and immediate. In other words, when the danger is ‘brought from the future’ and presented as an event in the present, the gap between the danger of epidemic and the risk of the vaccination narrows. Hence, overcoming the time gap is important in providing a solution to people’s resistance and enabling vaccination.

The solution: the conjunction of time

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

One of the ways of overcoming the general population’s reluctance to being vaccinated is to create an intermediary body in the present for which vaccination is clearly essential:

Now the question is how do you enforce the vaccination of 7 million people? In order for the vaccination to be effective, around 70–80 per cent of the population has to be vaccinated, and then the herd effect comes into force. We did a survey and saw that 70 per cent would be prepared to be vaccinated, but 30 per cent would not be − they are scared − who are you to make them do something that endangers their lives? And then the operation for the ‘first responders’ was decided upon. There was a decision to vaccinate emergency ward and intensive care staff, police officers, Magen David Adom (Dr. Lev, from the Emergency Unit).

The first responders constitute an intermediary body in at least three ways. First, they serve on the ‘front line’ in an emergency; they are the first people to treat casualties. Second, they are intermediary in terms of the process of preparedness: their being vaccinated is a preliminary for vaccinating the entire population, should that be decided on at a later juncture. Third, their bodies (after vaccination) will provide the VIG that will be used to treat the side effects of the vaccine, which is particularly important if the decision is made to vaccinate the entire population. In addition, the population of first responders represents the system and sets an example for the general population.

Lev and other senior figures in the system argue that the main damage caused by the frontliners' refusal to receive the vaccine and donate blood is the message that they are relaying to the public. ‘If the medical personnel won’t commit themselves to the cause, how are we meant to approach the public later on?’ said Yair Amikam, Deputy Director-General at the Ministry. ‘They must see this as a national task, as their duty’, added Dr. Aharonson from Kupat Holim Meuhedet (Shadmi 2002b).

The bodies of the first responders belong to a kind of new dimension that exhibits, almost simultaneously, the risks in the present (of being vaccinated) and the dangers in the future (a potential epidemic). They are at the greatest risk of being harmed during the event, if it takes place, because they are the ‘front line’. At the same time, they have a relatively low risk of being harmed by the vaccination, as they have been vaccinated in the past (three times before 1996, when vaccination of IDF personnel was stopped). As one newspaper article notes, the first responders are in a special position:

During the years that the entire population was vaccinated there were hardly any side effects and complications among children. ‘On the other hand’, (Dr. Lev, at the time, MOH director-general) says, ‘the mortality rate from smallpox for the non-vaccinated is 30–40%, and so these risks should be held up against one another. Rescue and security personnel must remember that they are among the groups at risk of being harmed by the virus, and so it is better for them to be vaccinated’ (Shadmi 2002b).

For this population there is no gap between the future danger and the present risk. Bringing the danger and the risk together in a parallel structure, almost conflating them into simultaneous existence, is central to the solution of vaccinating the population of first responders and it bridges the gap separating the perceived (future) needs of the preparedness system and the (immediate) concerns of the Israeli public.

The first responder, then, is not only a physical, vaccinated body but also an intermediary body that enables the enactment of ‘what would happen if’ (a preparedness practice; an action undertaken for a future purpose), as opposed to ‘what to do when’ (a security practice; an action undertaken for an immediate purpose). The preparedness system does not carry out actions in the present only for the sake of the present, and it does not affect the future by its plans for the future; rather, it carries out actions in the present for a range of possible futures. This conjunction between present and future requires not only new technologies but also new domains of action, such as the bodies of the first responders. Thus, the preparedness system operates in a new dimension, in which its actions are not carried out along the axis of linear time but, rather, in a dimension from which the present and the future can be seen simultaneously. In this temporal space, there is no gap between present risks and future danger. Instead, they become competing and simultaneous risks (the choice between not being vaccinated and having a 30–40% chance of dying from smallpox versus being vaccinated and having a one in a million chance of dying from the vaccine), and receiving the vaccine shifts from being a security practice during an actual event to a practice of preparedness for a possible future threat.

Discussion: governing through time

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

In operational terms, practices of preparedness do not derive from the problem of regulating the population by means of a specific technology (protecting the bodies themselves), but rather, from the question of how to implement the technology when the absence of a clear, present threat intensifies perceptions of the risk that it entails.

This problem might undermine many public health preparedness programmes. Where risks have changed and prevention becomes an almost impossible action, the aim of securing health depends on preparedness actions. These practices are taken in the present in relation to an uncertain future. That is, not only is the future event unknown, but any means of calculating and assessing its effects also become less and less relevant. Although various preparedness technologies are emerging, and although they differ in practice, they all share the assumption that the need for societies to prepare is self-evident (see also Stephenson and Jamieson 2009). As in risk society theory, it is a truism to say that society is increasingly concerned with the future, and there is also no doubt about the possibly calamitous nature of this future, but how societies’ concerns can be put into action, and how responses can be implemented, raises a series of problems.

The resistance to vaccination in this case can be compared with other historical cases (see Streefland 2001, Hobson-West 2003, Lakoff 2008). Streefland (2001), for example, reviews resistance to vaccination in various countries, looking at causes and correlates. In developing countries, he found rejection to be ‘related to shortcoming of the vaccination services’ (Streefland 2001: 169). In the case of smallpox vaccination during the world eradication project, resistance was associated with the coercive procedure employed. Current resistance to childhood immunisation, he found, originates in the belief that by avoiding the vaccination, parents ‘avert danger for their child’ (Streefland 2001: 170). This finding is especially interesting in comparison with Hobson-West’s (2003) findings regarding the aversion to MMR (measles, mumps and rubella) vaccination in the United Kingdom. Arguing against ‘risk’ as a sufficient concept to explain the UK evidence, Hobson-West (2003: 278) suggests ‘resistance to vaccination may be less about refusing a vaccine and more about choosing “positive heath” ’. Thus, instead of weighing risks and benefits, individuals rejected the MMR vaccination because they preferred ‘the idea of “health” and promoting healthy actions rather than preventing disease’ (Hobson-West 2003: 273).

I agree that risk, as Luhmann defines it, should not be analysed as the obverse of security or in terms of benefits achieved by avoiding it, as Hobson-West’s findings stress.5 However, in the current case study, it is evident that a perception of promoting ‘healthy life’ was not what led to rejection of the vaccination; rather, the distinction made between risk and danger was the impetus. In other words, it is not only a story of vaccination resistance but also of resistance to one risk in relation to another. What is most striking is that vaccination was perceived as a risk, whereas the future threat was perceived as a danger. This distinction between risk and danger prompts a focus on the importance of time in explaining this event and on the broader connection between risk, society and the future.

The current analysis can explain the difference between levels of resistance in different events in relation to time. Both past and present vaccination resistance can be seen as resulting from the basic distinction between danger and risk; as Luhmann (1993) puts it, whereas danger is perceived to be external and not under control, risk is perceived to be internal and is generated systemically. Hence, one can argue that avoiding the vaccine is connected to one’s perception of it as a controllable risk. However, considering time as an important variable in risk analysis, one can see that when the external, uncontrolled danger is located in the future and its associated internal, controlled risk is located in the present, resistance to accepting the present risk increases. Lakoff’s (2008) discussion of vaccination against avian flu in the United States in 1976 shows that when the danger exists in the present, resistance to vaccination decreases. This correlation was very evident in that case, especially when the risks of the vaccination became real: even after people started to die, the avian flu vaccination project continued for quite a long time (from April to December of that year, 40 million people were immunised).

These cases show that recognising the connection between risk and time is fundamental (see especially Alaszewski and Burgess 2007). Risks are always perceived in relation to time. Whether as a part of ‘future reality’ or a ‘present problem’, their location in time is crucial to their definition. As Alaszewski and Burgess (2007: 349) argue, ‘From the late twentieth century, a more precautionary approach has emerged, in which the fear of future harm influenced the management of risk’. Whereas risk was once based on past information that enabled people ‘to make predictions about such events in the future’ (Alaszewski and Burgess 2007: 349), in the precautionary mode, ‘the past is no longer a good or acceptable guide to the future’ (2007: 356). Drawing on this argument, I claim that each of the sociological approaches to risk I have discussed reveals a different connection between risk, as an object, and time.

In the risk technology approach, for example, risks are connected to the past, to past possibilities. Risks are converted to concrete, known accidents on the basis of past events. Hence, through knowledge of these past possibilities, future and present risks are governed and managed. In preparedness technology, risks are connected to the unknown future. Located in the ‘real’ future, these risks are uncertain, and thus no past or present information can be sufficient to manage them. For risk society theorists, risks are concurrently part of the ‘real’ future and the present perception of the future. Thus, any present action can affect them, and at the same time, they cannot be controlled (in the present), because they only materialise in the real future.

The current case study shows that if risks are perceived to exist simultaneously in the present and the future, current approaches to risk are not sufficient to explain how they are governed. The future, in this case, cannot be prepared for, as risk simultaneously emerges in the present. Through a new domain of time, risks are located neither in the present nor in the future, but in a nonlinear temporal realm. Thus, present risk and future danger are not considered distinct and sequential events (with the present perceived as more immediate), but as simultaneous events − brought into coexistence − here, through the body of the first responder. Preparedness for biological events, then, involves more than questioning how the future is contingent on our present and how the present is contingent on the future’s perception; it also recognises the need for a new time positioning to operate on both present and future risks simultaneously. In that sense, governing these risks means governing through time.

Following a Foucauldian approach and the study of ‘actual technologies’, I stress that this case study represents only one possible emerging form of governmental technology to address risks, one that is dependent on a specific political, historical and cultural context. In this regard, Heyman and colleagues (2010) draw attention to the cultural specificity of contingencies and differences in risk consciousness and management. Moreover, they argue that ‘contingencies (and therefore risks) which have not been conceptualized (within certain culture) cannot be managed’ (Heyman et al. 2010: 24). This idea should be taken into account when analysing any specific case of risk perception and management.6

Regardless of cultural contingencies, however, the mutual connection between risk, time and governing can be tracked and studied in other public health cases and can contribute to further analysis of the risk concept. Once one accepts the premise that, in any culture, risks are constructed, accepted, perceived and managed distinctively, the question that arises is how these risks are handled in practice and what form of action or what kind of technology is entailed in preparing for them. ‘Governing through time’ is one possible way to address this problem. Examination of empirical cases can enrich understanding of the multiplicity of possible governmental technologies of risk and uncertainty, each with its own temporality and contingency.

Footnotes
  • 1

     At a different level, when Foucault (2007[2004]) talks about governmentality, he refers to his entire analysis of the genealogy of the conduct of conduct. In other words, he does not discuss a single, universal technology but, rather, governmental technologies that have emerged in different historical contexts in response to a range of problems that have produced variable practices.

  • 2

     The classical studies of Douglas (1966, 1994; see also Douglas and Wildavsky 1982), on the cultural definition of risk are important but less relevant to my argument than the two approaches I discuss here. Rather than showing how risks are identified and prioritised in Israeli society in comparison with other societies, I ask how governmental technology operates in response to risk.

  • 3

     There are different kinds of risk technologies (Dean 1999). O’Malley (2004: 7; my emphasis) claims that the concern of governmentality studies is ‘primarily to understand risk as a complex category made up of many ways of governing problems, rather than as a unitary or monolithic technology’.

  • 4

     Here I refer to al-Qaeda’s 11 September suicide attacks on the World Trade Center and the Pentagon and the anthrax attack of 18 September in which letters containing anthrax spores were mailed (probably by a U.S. scientist) to several news media offices and two senators.

  • 5

    Luhmann (1993) does not see risk as inversely related to security: that is, the more security one has, the less risk there is. Luhmann referred this approach to a first-order observation and argued that in a second-order observation one should treat risk not as an object but as a concept that can be understood through its distinction from other closed concepts such as danger.

  • 6

     For the specific way in which risks are conceptualised and thus managed within the Israeli preparedness system (see Samimian-Darash 2009). In conceptualising the preparedness system in terms of ‘a pre-event configuration’, I refer to the idea that ‘only an event perceived in this alignment from the outset as an event (as a risk), will then be defined as an event when it takes place (and hence managed)’ (Samimian-Darash 2009: 487).

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References

The research on which this article is based was funded by the Israel Foundations Trustees and the Hebrew University of Jerusalem. I initially developed the ideas expressed in the article while I was a visiting scholar at the University of California, Berkeley, in ongoing conversations with Paul Rabinow and in collaboration with ‘labinar’ course participants, especially Meg Stalcup, Mary Murrell, Adrian McIntyre and Mattias Victorian. I am deeply thankful to Eyal Ben-Ari, Don Handelman, Victor Azarya and Avi Shoshana for their constructive feedback on earlier drafts. I formulated the article during my time as a postdoctoral fellow at the International Forum for US Studies, University of Illinois at Urbana–Champaign. I am grateful to Virginia Dominguez, Jane Desmond, and the IFUSS for support and encouragement. I am also grateful to James Ferguson for hosting me at Stanford University and for providing the environment to complete this work, and to the Morris Ginsberg Foundation and the Hebrew University of Jerusalem for generous funding. I thank the editors of Sociology of Health & Illness and anonymous journal reviewers for their thoughtful comments and Linda Forman for helping me bring the manuscript into its current form.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Securing the population
  5. Risk, society and the future
  6. Methodology
  7. The smallpox vaccination event
  8. The problem: future danger and present risk
  9. The solution: the conjunction of time
  10. Discussion: governing through time
  11. Acknowledgements
  12. References
  • Alaszewski, A. (2009) The future of risk in social science theory and research, Health, Risk & Society, 11, 6, 48792.
  • Alaszewski, A. and Burgess, A. (2007) Risk, time and reason, Health, Risk & Society, 9, 4, 34958.
  • Arnoldi, J. (2004) Derivatives: virtual values and real risks, Theory, Culture & Society, 21, 6, 2342.
  • Beck, U. (1992) Risk Society: Toward a New Modernity. London: Sage.
  • Beck, U. (1994) The reinvention of politics. In Beck, U., Giddens, A. and Lash, S. (eds) Reflexive Modernization: Politics, Tradition and Aesthetics in the Modern Social Order. Stanford, CA: Stanford University Press.
  • Beck, U. (2009) World at Risk. Cambridge: Polity Press.
  • Castel, R. (1991) From dangerousness to risk. In Burchell, G., Gordon, C. and Miller, P. (eds) The Foucault Effect: Studies in Governmentality. Chicago, IL: University of Chicago Press.
  • Cooper, M. (2006) Pre-empting emergence: the biological turn in the war on terror, Theory, Culture & Society, 23, 4, 11335.
  • Dean, M. (1999) Risk, calculable and incalculable. In Lupton, D. (ed) Risk and Sociocultural Theory. Cambridge: Cambridge University Press.
  • Diprose, R., Stephenson, N., Mills, C., Race, K. and Hawkins, G. (2008) Governing the future: the paradigm of prudence in political technologies of risk management, Security Dialogue, 39, 2–3, 26788.
  • Douglas, M. (1966) Purity and Danger: An Analysis of Concepts of Pollution and Taboo. New York: Routledge.
  • Douglas, M. (1994) Risk and Blame: Essays in Cultural Theory. London: Routledge.
  • Douglas, M. and Wildavsky, A. (1982) Risk and Culture: An Essay on the Selection of Technical and Environmental Dangers. Berkeley, CA: University of California Press.
  • Elroyee De-Bar, H. (2002) Fears in Magen David Adom: the smallpox vaccine endangers us and our children, Maariv, 2 October, p. 6.
  • Ewald, F. (1991) Insurance and risks. In Burchell, G., Gordon, C. and Miller, P. (eds) The Foucault Effect: Studies in Governmentality. Chicago, IL: University of Chicago Press.
  • Ewald, F. (2002) The return of Descartes’s malicious demon: an outline of philosophy of precaution. In Baker, T. and Simon, J. (eds) Embracing Risks: The Changing Culture of Insurance and Responsibility. Chicago, IL: University of Chicago Press.
  • Fenner, F., Henderson, D., Arita, I., Jezek, Z. and Ladnyi, I. (1988) Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization.
  • Foucault, M. (2007[2004]) Security, Territory, Population: Lectures at the Collège de France, 1977–78. Translated from French by G. Burchell. London: Palgrave.
  • Giddens, A. (2000) Runaway World: How Globalization Is Reshaping Our Lives. New York: Routledge.
  • Hacking, I. (1991) How should we do the history of statistics? In Burchell, G., Gordon, C. and Miller, P. (eds) The Foucault Effect: Studies in Governmentality. Chicago, IL: University of Chicago Press.
  • Heyman, B., Shaw, M., Alaszewski, A. and Titterton, M. (2010) Risk, Safety, and Clinical Practice: Health Care through the Lens of Risk. Oxford: Oxford University Press.
  • Hobson-West, P. (2003) Understanding vaccination resistance: moving beyond risk, Health, Risk & Society, 5, 3, 27383.
  • Israel. Public Health Ordinance (1940) Part D.: Infectious diseases, medical institutions and vaccinating against smallpox (Amendment: 1992). http://waml.haifa.ac.il/risk/index/main/4/pba.htm (Accessed 10 September 2010).
  • Kaufman, S. (1994) Old age, disease, and the discourse on risk: geriatric assessment in U.S. health care, Medical Anthropology Quarterly, 8, 4, 7693.
  • Koplow, D. (2003) Smallpox: The Fight to Eradicate a Global Scourge. Berkeley, CA: University of California Press.
  • Kretzschmar, M., van den Hof, S., Wallinga, J. and van Wijngaarden, J. (2004) Ring vaccination and smallpox control, Emerging Infectious Disease, 10, 5, 83241.
  • Lakoff, A. (2008) The generic biothreat, or, how we became unprepared, Cultural Anthropology, 23, 3, 399423.
  • Levy, D. (2004) Size does matter: aspects of a mass smallpox vaccination operation. Available at: http://www.health.gov.il/emergency/mamarim/32.doc (Accessed 23 September 2009).
  • Luhmann, N. (1993) Risk: A Sociological Theory. New York: Aldine de Gruyter.
  • Lupton, D. (1994) Moral Threats and Dangerous Desires: AIDS in the News Media. London: Taylor & Francis.
  • Lupton, D. (ed) (1999) Risk and Sociocultural Theory. Cambridge: Cambridge University Press.
  • O’Malley, P. (2004) Risk, Uncertainty and Government. London: Glasshouse Press.
  • Orr, N., Forman, M., Marcus, H., Lustig, S., et al. (2004) The readiness, security and efficiency of the Israeli smallpox vaccine in relation to the operation to vaccinate IDF first responders. Available at: http://www.health.gov.il/emergency/mamarim/811.pdf (Accessed 23 September 2009).
  • Rapp, R. (1995) Risky business: genetic counseling in a shifting world. In Schneider, J. and Rapp, R. (eds) Articulating Hidden Histories. Berkeley, CA: University of California Press.
  • Rose, N. (1996) Psychiatry as a political science: advanced liberalism and the administration of risk, History of the Human Sciences, 9, 2, 123.
  • Samimian-Darash, L. (2009) A pre-event configuration for biological threats: preparedness and the constitution of bio-security events, American Ethnologist, 36, 3, 47891.
  • Schoch-Spana, M. (2004) Bioterrorism: US public health and a secular apocalypse, Anthropology Today, 20, 6, 813.
  • Shadmi, H. (2002a) The head of the epidemic treatment team resigned because of the refusal to vaccinate against smallpox, Haaretz, 14 August, Archive no. 919810.
  • Shadmi, H. (2002b) About half of the ‘frontliners’ are refusing to be vaccinated, Haaretz, 25 October, Archive no. 939120.
  • Shai, Y. (2002) Vaccinations against smallpox and anthrax. Submitted to the Public Petitions Committee, 20 October. Jerusalem: Knesset Research and Information Center.
  • Stephenson, N. and Jamieson, M. (2009) Securitising health: Australian newspaper coverage of pandemic influenza, Sociology of Health & Illness, 31, 4, 52539.
  • Streefland, P. (2001) Public doubts about vaccination safety and resistance against vaccination, Health Policy, 55, 15972.
  • Zinn, J. (2006) Recent developments in sociological risk theory, Forum Qualitative Soziaforschung/Forum: Qualitative Social Research, 7, 1, Art. 30. Available at: http://nbn-resolving.de/urn:nbn:de:0114-fqs0601301. (Accessed 21 March 2010)