A Way Out of the Vaccine Wars
Parenting in America has long caused passionate debates, but rarely do they turn as vicious as they have since the outbreak of measles at California’s Disneyland. “Here’s hoping the anti-vaxxer movement will naturally deselect hipsters from the human race,” wrote one Twitter user. And another: “If I find out you’re an anti vaxxer I will kidnap your children and give them the shot myself.” One parent vowed that if her baby contracts measles, “I’m ripping an anti-vaxxer limb from limb.” And this, which boils the fear and hatred down to its essence: “Anti-vaxxer parents are the disease that must be wiped out.”
In January alone 102 people in 14 states were diagnosed with measles, a disease declared eliminated from the U.S. in 2000. It can lead to life-threatening pneumonia as well as deafness and swelling of the brain. Most vulnerable are infants, pregnant women, and people with compromised immune systems who can’t get the vaccine. The Centers for Disease Control estimates that 92 percent of the January cases can be traced to the outbreak in Southern California, which happens to be where some of the most fervent vaccine refuseniks reside.
These parents—who don’t vaccinate at all, or stretch out the schedule, or skip some vaccines—continue to say they’re just doing what’s right for their children. They rely on the small minority of physicians and others who tell them that the inoculations are more dangerous than the diseases they prevent. Their representative, the National Vaccine Information Center, decries “a massive Pharma-led lobby attempt to demonize and punish all Americans who defend the human right to exercise informed consent.”
The measles war is ugly and intense, with fear motivating both sides. It also presents vexing questions for policymakers. How should individual freedom be balanced against public health? What should a democratic society do when a determined minority does something that seems to endanger not only itself but also the majority? History is filled with minority groups who have been perceived as physical, moral, or political threats to society—sometimes rightly, sometimes wrongly.
Opposition to vaccination goes back to 1796, when the English physician Edward Jenner began using pus from cowpox infections to generate immunity against the more serious disease of smallpox. Cartoonists drew cows’ heads growing on the bodies of people who had gotten Jenner’s inoculation. After Parliament made vaccination against smallpox compulsory in 1853, with fines for noncompliance, anti-vaccination leagues and journals sprang up. “Campaigners saw compulsory vaccination as an extreme example of class legislation” since vaccine drives were targeted primarily at the working class, historian Nadja Durbach wrote in a 2000 article in the journal Social History of Medicine. Opposition spread to the U.S., with anti-vaxxers suing for the repeal of vaccination laws in California, Illinois, and Wisconsin, among other states.
Such voices, however, remained in the minority. A 1905 Supreme Court decision ruled that states could enact compulsory laws to protect the public in the event of a communicable disease. Other high court decisions followed in the same vein. During the 20th century, the near-universal inoculation of children in developed countries all but eliminated the threat of such diseases as measles, mumps, and polio. Yet in the U.S., at least, federal law is silent on compulsory vaccination, leaving the matter to the states. The upshot is a muddled legal system in which all 50 states compel parents to vaccinate their children—but 48 of them (all but West Virginia and Mississippi) allow exemptions for religious objectors. Twenty more recognize personal or philosophical objections to vaccination.
There are strong social, medical, and moral arguments for limiting exemptions. If enough members of a population are vaccinated, there’s herd immunity: Even those who don’t get vaccinated are safe because the disease can’t reach them. Anti-vaxxers are free riders who get the benefit of vaccination programs without sharing the real or perceived burden. One study found that whooping cough is rarer in states that make it harder for people to obtain exemptions—for example, requiring parents to meet with a doctor who goes over the benefits and public policy purpose of vaccinations. Last year, California began requiring parents to produce a health-care practitioner’s note to claim a personal-belief exemption.
On the other hand, getting rid of exemptions entirely, even in the name of public safety, would be unwise. Over more than two centuries, authorities have found that some people really, really don’t want the jab and will fight if pressed. Adam Finn, a professor and vaccine expert in Bristol, England, told the BBC that eliminating exemptions “would be handing a gift to the anti-vaccine lobby, because they would say, ‘Look, they can’t persuade you it is right, so they are going to have to force you.’ ” Lawmakers’ calculus might change if epidemics broke out, but that hasn’t happened yet. The 644 measles cases in the U.S. last year, while too many, was about one-tenth of 1 percent of the annual number in the early 1950s.
If vaxxers can’t force people to get their shots, they can try shaming them into it. But vilification, however satisfying, doesn’t do much good. People who are told that their dearly held beliefs are stupid and selfish tend to withdraw from the conversation while continuing to do whatever they did before. “If you insult people or you disrespect people, you can harden their perspective,” says Saad Omer, a professor of global health and epidemiology at Emory University’s Rollins School of Public Health.
Another thing that doesn’t work—and this is unfortunate—is distribution of reliable information. Brendan Nyhan, a Dartmouth College political scientist, compared the beliefs of parents before and after exposing them to various messages. A dramatic narrative about an infant who almost died of measles increased fears about the side effects of vaccines. Images of children with measles, mumps, or rubella increased belief in a link between vaccines and autism. And among parents who had the least favorable attitudes toward vaccines, refuting claims of a link between vaccines and autism actually decreased intent to vaccinate. “People are pretty good at coming up with reasons to continue to hold the beliefs they already hold,” says Nyhan.
What does work is to communicate through respected leaders. During the Ebola crisis in West Africa, village leaders played a crucial role. In the U.S. and Europe, teachers, pastors, and doctors can take the lead. Physicians can increase compliance by making clear that full and prompt vaccination is an expectation, not just an option, says Dr. Douglas Opel of the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Hospital. It’s important, though, to show respect for the parents’ opinions. “We, the public health community, should recognize that they’re starting from the right place,” agrees Emory’s Omer. “All parents want to see their kids healthy and are looking out for their welfare.”
One of the toughest calls for a provaccine physician is what to do when a family rejects her or his counsel. Some parents and lawmakers have called on pediatricians to ban unvaccinated kids from their offices. But Omer says ditching an uncompliant family is a mistake. “You’re decreasing the possibility of changing their mind and pushing it toward zero,” he says. “A lot of these parents don’t refuse all vaccines. They still get some vaccines.” He says there should be an insurance billing code for vaccine counseling, which would give doctors a financial incentive to bring around a resistant family. (Vaccines are highly cost-effective, so insurers have all the incentive in the world to compensate counseling.)
As the number of measles cases in the U.S. rises, it might be tempting to stop with the exemptions and the counseling and just vaccinate everyone. But imagine the ugly scenes of children being torn from the arms of their howling parents; sieges; even shootouts. Mandatory vaccination might be justified in a made-for-Hollywood emergency, but we aren’t anywhere near that. The key is proportionality. As those Twitter tweets show, it’s not just the anti-vaxxers who come from a place of fear and anger. It’s the vaxxers, too. A democratic society must search for common ground. Let’s make this a time for healing. And not just from measles.