Few
aspects of medicine invoke so much disagreement among people. Vaccines have fundamentally changed the way
we think about illness. Yet, they are
still rejected by a surprisingly large subset of the population. To ward off potential public health
catastrophes we engage in draconian measures, including preventing school
registration without proper vaccination.
In spite of this, lack of vaccination has caused a resurgence of
diseases thought to be eliminated. This
begs the question: are the mandates working or could they actually be counterproductive?
Public Mistrust of Vaccination
Vaccination
is the source of much public mistrust today.
No longer just an issue for fringe groups and religious objections,
vaccination bashing has become embedded in popular culture through statements
made by celebrities, most famously Jenny McCarthy. Given that data shows vaccines to be
incredibly safe and yet these groups still continue to gain followers, we
should look at some of what animates them.
It
seems easiest to connect the anti-vaccination movement’s beginnings with the
now infamous study by Dr. Andrew Wakefield published in The Lancet in 1993. A
relatively small study, Wakefield concluded that the MMR vaccination caused
damage to the intestinal system of growing children, which in turn resulted in
more toxins getting into the blood stream, making them more susceptible to
developing autism.[1],[2] Ultimately the Wakefield study would be
proven false, the connection between vaccines and autism thoroughly severed by
science, and yet this idea remains an incredible concern for many, with some
people going so far as to reanalyze CDC data to find a connection.[3]
The
theory of dangerous vaccines gained even more traction when the CDC began
looking into the possibility that thimerosal, the mercury-based preservative
used in many vaccines, was linked to autism.
This potential danger appealed to common sense as well as scientific
sense. After all as Neal Halsey, one of
the CDC proponents of removing thimerosal, reasoned: we are cautious about
mercury levels in fish, doesn’t it make even more sense to be cautious about
the levels in vaccines given to newborns and young children.[4] Eventually thimerosal would be removed from
vaccines, out of precaution, even though the scientific evidence was sparse
regarding its effects, if any, on children.
But this resulted in a ripple effect of growing distrust against vaccines. In turn, this would open the door for groups
like the National Vaccine Information Center, an organization that claims to be
neutral towards vaccines although it was founded by an anti-vaccination
advocate and Generation Rescue, Jenny McCarthy’s charity, to gain credibility
as experts on the national stage.[5]
Those
with anti-vaccination beliefs are still very much a noticeable group. Vaccination in some schools in California,
for example, has dropped below 50%, with “Personal Belief Exemptions” sometimes
outnumbering the number of vaccinated students.[6] Yet something has to underlie this mistrust
for it to continue to maintain a national presence. I would suggest that the government mandates provide
the backdrop which the anti-vaccination uses to gain traction in its fight.
Americans and their Freedom
Before
beginning our discussion on vaccines specifically, it may be helpful to first
discuss the importance of freedom for Americans. Freedom, of course, is a broad and somewhat
vague word. When we speak of the
American notion of freedom that is of interest here, we are referring to
personal liberty, specifically civil liberty.
Civil liberty entails one being free from state interference, except, at
the bare minimum, to ensure the public good. Consider as an example the recent pushback
against the so-called “individual mandate” included in ACA. Since the passage of the bill, there has been
an outpouring of opposition towards it.
Some 27 states filed lawsuits seeking to have the mandate overturned on
constitutional grounds, an argument eventually rejected by the Supreme Court,
which declared the mandate a tax. Ten states
have passed various forms of legislation that attempt to overturn the mandate
at the state level. Two of these passed
with crushing margins in public elections. One in Ohio passed with a double
digit margin.[7],[8] Similarly, an August 2011 poll of Americans
showed that over 80% believed the government should not have this power.[9] Regardless of one’s individual position on
the matter, I think it could be argued it is not well received by the
public. But what does this tell us about
perceptions of the government? It tells
us quite a lot. It is not necessarily
that these people are opposed to the idea of purchasing healthcare insurance or
even of government helping to control health cost (statistically speaking, many
of these people likely already purchase health insurance). It is the very idea of government telling
them that they must do something that
seems to be the problem.
And
so it may be with vaccines. Simply put,
it shows that Americans tend to reject what they see as an excessive reach of
government which would repress autonomy, especially in issues of
healthcare. Thus we can begin to see
that if vaccination is considered, at least by some, to be an overreach of
government, the result can be distrust against it.
The Paradox
It
should be noted that the intent is not to convince people at the far ends of
the vaccine debate -- such a goal would be impossible anyway -- but rather to try to understand how one side,
in this case the anti-vaccine groups, captures the minds of those in the
middle. Having said that, we can now see
how the mandates might actually be counterproductive to encouraging widespread
vaccination.
All
conversations about the merits of vaccination must now take place against the
backdrop of government mandates and power.
This allows members of the anti-vaccine movement to place these mandates
in contrast with the American liberty narrative during any discussion,
fostering distrust in government and convincing people of their cause. Considered alone, the mandates might not
cause much of a problem. After all, they
have existed for some time before vaccine rates started to decline, but we must
also consider that we’ve developed what might be called “societal amnesia” with
regards to many of these diseases. For my grandparents, concerns about polio
saturated their lives, and yet many people from my generation have never even
seen a polio victim beyond clips of Franklin Roosevelt. This leads people to erroneously conclude the
vaccines have no actual benefit, further reinforcing the idea of an overbearing
government. However, if the vaccine
mandates were dropped, this would take away one of the key pillars of their
argument. The movement would no longer be able to frame the debate in terms of
a battle between personal autonomy and an overzealous government.
Of
course the obvious potential fallout from such a maneuver would be that
vaccines now have to stand (or fail) on their own merits. However, not all hope is lost. In eliminating the vaccine mandates, we will
also have severed the connection between doctors and the state, at least to
some extent. As such, the trust between the patient and physician, as well as
the trust between medical science and society, can be allowed to grow without
being poisoned by an overarching political discourse.
There
is still a potential danger in rolling back vaccine mandates. We risk a short term drop in
vaccination. But it’s not clear that
this would be any worse than where we are now, with significant numbers of people
opting out for dubious reasons, and old diseases (whooping cough, measles,
etc.) making their rounds once again, even with mandates in place.
Tim Rubbelke is a PhD Candidate at the Saint Louis
University Albert Gnaegi Center for Health Care Ethics. This essay was chosen
as a finalist for the 2014-2015 Daniel Callahan Young Writer’s Prize.
[1]
[2] Interestingly, this is not the actual conclusions
of the paper, but it is how Wakefield portrayed them in his numerous interviews
following the publishing the study.
[3]
[6] California makes for an interesting case study
because it is one of the few states in which the PBE’s allow for
“philosophical” objections as well as the commonly held religion based objections.
The interpretation of PBE’s is broad allowing almost anyone to get a waiver.
[7]
[8]
[9]
