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My thumb rhythmically flicked leftward across the cell phone screen, pulling the snapshots of my friends’ lives with it. That day in mid-August 2021, the advertisements for soft bedding that normally punctuated my friends’ Instagram vignettes had been supplanted by a cute and eye-catching campaign from the San Francisco Department of Public Health (SFDPH).
This SFDPH campaign functions as a call to action to “Get your vaccine today,” with side-by-side images displaying two choices: an inviting experience with the therapeutic-as-kitten, or a threatening one with the pathology-as-lion. Such an either/or proposition refashioned formulations of risk surrounding COVID-19 vaccination. Public health campaigns in the United States have a long history of using persuasive techniques appropriated from pharmaceutical marketing in what medical historian Jeremy A. Greene terms “form as well as content.” This SFDPH campaign encourages the self-directed pursuit of a pharmaceutical treatment (i.e. vaccine) by mimicking representational techniques seen in direct-to-consumer (DTC) advertising. The campaign’s visual formula is simple: contrasted images of what the viewer’s life could be like with and without the advocated treatment. Joseph Dumit’s critical rhetorical readings of DTC pharmaceutical advertisements highlight the interplay between subjectivity and persuasive grammars of risk, which are also at play here. Given the contested landscape of facts surrounding COVID-19, why might a public health campaign boil down risks about COVID-19 vaccination to two vastly simplified, incompatible alternatives? How might this approach be persuasive? What kind of swiping subject is interpellated by this framing of risk?
Risk as inevitability
In demanding that the swiping subject choose between vaccine side effects or getting COVID-19, the SFDPH campaign draws attention to the vaccine’s injurious capacities, but why? Certainly, many who have resisted COVID-19 vaccination doubt the safety of COVID-19 vaccines, and perhaps, other vaccines too. In Malignant, S. Lochlann Jain reflects on how the injurious capacities of pharmaceuticals are cultivated by design such that chemotherapies are delivered to cancer patients at “the upper limit of tolerable toxicity.” Over the course of clinical trials, the statistical designation of some injurious capacities as acceptable is not only a characteristic of chemotherapy but is a deliberate feature of pharmaceutical development. When a pharmaceutical company designates side effects, they declare those effects to be at once predictable, acceptable, injurious, and risky for patients. And often, side effects demand their own therapeutic remediation, just as pathology does. If pharmaceutical treatments necessarily entail risks that trouble the boundaries of pathology, then how do people judge such risks? And how does the SFDPH campaign address such challenges?
Vaccinations can usher in unsanctioned harms. Carlo Caduff demonstrates how the 1976 US flu vaccination campaign was discontinued after public outcry over severe, unanticipated side effects. The dynamic nature of communicable pathogens and the need for responsive treatments ensure that recognizable forms of evidence will not be available to answer all questions, seeding uncertainties. As the available facts and attendant uncertainties shift, so, too, do government and public health recommendations. Relevant emergent facts and recommendations about COVID-19 are so numerous and contentious that trustworthy risk assessment can seem out of reach for many members of the public. For those who prefer to decide on best practices for themselves, risk can be too elusive and tiring a calculus to continually chase. For others, who look to the recommendations of officials, it can be hard to trust guidelines as they shift with the contours of a fast-paced information economy. Risk, meted out via context-driven probabilities, is a potentially infinite variable for calculation during a pandemic in which (different) people, surfaces, airs, and structures portend different kinds and probabilities of risk.
The SFDPH campaign acknowledges that COVID-19 vaccines possess injurious capacity by offering an either/or proposition, forcing the swiping subject to choose one of two risky futures. The future characterized by vaccine side effects is a predictably injurious one, albeit mildly so. It is represented by a kitten, belly exposed and paws in the air, who invites play but will almost assuredly scrape its play partner in the process. The mild degree and scope of injury we invite when we play with this kitten is predictable, those side effects known and determined to be within the acceptable bounds of toxicity. The image of the kitten validates the existence of vaccine side effects but silences lingering uncertainties by designating them as mild.
The swiper’s dilemma is visually diagrammed as a binary choice: the illness experience of COVID-19 or the side effects of a therapeutic intended to prevent it.
As a privileged form of knowledge associated with the creation of both epidemiological facts and pharmaceutical ones, statistics are notably absent from the either/or proposition of this SFDPH campaign. Sharon Kaufman has examined how parents in 1980s United States struggled to assess vaccine risks for their children in an information economy that was simultaneously too oversaturated and too incomplete to facilitate trustworthy risk assessment. When it felt impossible to calculate the riskiness of vaccination, parents decided they “must live as though this risk were a fact.” I understand the terms set by the comparative proposition—live with COVID or live with its vaccine’s side effects—as a flattening of risk, one that obviates questions of probability and positions risk as an inevitability.
This swiping subject
The SFPHD campaign aims for a particular swiping subject uncertain about whether to get vaccinated for COVID-19. The swiper’s dilemma is visually diagrammed as a binary choice: the illness experience of COVID-19 or the side effects of a therapeutic intended to prevent it. Such a provocation interpellates a discerning subject for whom both disease and treatment are suffused with risk. Nevertheless, a choice must be made. The swiping subject is not imagined as the passive patient undertaking the bidding of experts, but what Charles L. Briggs and Daniel C. Hallin might call an active patient-consumer who decides between alternatives. This stands in contrast to Briggs and Hallin’s passive patient model of biocommunicability, whereby biomedical authorities harness the persuasive power of expert forms of knowledge in order to compel patients. For discerning subjects, the vaccine grants the less risky, more desirable future, much like how DTC advertising frames the future health of consumers as something that can only be reached with their pharmaceutical product. The many resonances the SFPHD campaign shares with DTC advertisements make it poised to target swiping subjects who more readily embrace this role of active patient-consumer.
The SFDPH campaign’s either/or proposition appears to address swiping subjects who don’t care about communal or differential risks. As a therapeutic technology of communal biological defense, vaccines can protect the well-being of those who are ill-suited to receive them through cultivating the immunity of everyone else. Personal and communal biologies, COVID-19 exposures, age, employment, social practices, and living arrangements can all differentially distribute risk across time and between people and communities. SFDPH’s campaign, however, focuses squarely on individual experience and risk. It does not address how one’s decision about whether to vaccinate potentially feeds or stifles disease transmission rates in one’s community. COVID-19’s communicability has no trace in this campaign because the swiping subject is addressed as outside of social context. Risk has been reduced to an assumed inevitability, and probabilities of getting or transmitting COVID-19 are left unaddressed.
This situated swiping subject
A persuasive strategy that obscures central features of the current pandemic such as the either/or proposition in question may, counterintuitively, be deliberately designed to combat it. Since the SFDPH campaign does not attend to communicability, statistical reasoning, probability pertaining to transmission, differential risk, or communal risk, what kind of swiping subject might this campaign aim to reach? By August 11, 2021, when the SFPHD campaign ran, health journalism and public health campaigns had long been replete with statistics about COVID-19 vaccines. San Francisco boasted exceptionally high vaccination rates and availabilities for all interested in obtaining them. People in San Francisco who were eligible and receptive to the urgings of biomedical authorities had likely already been vaccinated; the swiping subjects of the SFDPH campaign are people who had not been swayed by the same kinds and arrangements of expert knowledge.
Facts about differential risk are unlikely to persuade swiping subjects who belong to demographics considered relatively low risk of experiencing death or complications from a COVID-19 infection. At the time of the SFDPH campaign, the lowest vaccination rate in San Francisco was among people aged 24–35, whose relative youth is commonly associated with a low risk of COVID-19 complications. Their vaccination rate was a mere 73 percent, with other age groups vaccinated between 78 percent (18–24 years) and 99 percent (75+). As an overlapping demographic, people aged 25–39 accounted for an outsized portion of transmission, the source of almost 50 percent of the new cases. If the demographic that contributes the most to transmission and that most resists vaccination is less likely to see themselves represented in discourses concerning social and differential risk, then another rhetorical focus is needed to compel vaccination. The SFDPH’s either/or campaign puts the futures of vaccine hesitant swiping subjects at stake by recasting risk. It is no longer a probability within which a subject might place themselves. Rather, risk is refashioned as an inevitability, a binary choice that must be made, and as such might wield persuasive power for those who have so far fallen through the cracks of probability.