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Across Europe, 2016 saw the lowest number of measles cases on record. Two years later, the number of cases, and deaths, were at their highest level for at least 15 years [REF: BMJ]. Declining vaccination rates are widely thought to be to blame. In response, the UK’s health secretary, Matt Hancock, said in May 2019 that those who spread anti-vaccine messages have ‘blood on their hands’ and that he was now considering making vaccinations compulsory [REF: Guardian]. Similarly, New York City’s mayor, Bill de Blasio, has declared a public health emergency and ordered mandatory vaccinations after the largest measles outbreak for over 20 years [REF: Telegraph].
Countries across the world are still dealing with the consequences of a controversial research paper by Dr Andrew Wakefield, published in medical journal The Lancet in 1998, which suggested a connection between the measles, mumps and rubella (MMR) vaccination and the development of autism in children [REF: FT]. Although Dr Wakefield’s research has been discredited, it is widely agreed that the doubts created about MMR [Ref: Independent] resulted in a decline in vaccinations in the UK – falling from a peak of 94 per cent for two year olds in 1995, to 78 per cent in 2003. Whilst vaccination rates in the UK have improved since then, the fears about MMR have reverberated around the world, creating a generation of so-called ‘anti-vaxxers’, and playing into trends towards, and concerns around, everything from populism [REF: Guardian] to fake news [Ref: The Big Issue]. The importance of this debate is that worries about vaccines mean ‘herd immunity’ levels for measles vaccination are not being reached, putting children at much higher risk of catching the disease [Ref: WebMD]. The United States, for example, has gone from being essentially measles-free in 2000 to suffering the largest outbreak for 25 years, which many have linked to growing distrust of medicine and medical professionals [REF: NPR]. This has prompted some to argue that compulsory vaccination programmes must be introduced or beefed up because “we need a 95 per cent vaccination rate for herd immunity to protect against contagious diseases” [Ref: Metro]. It is commonly agreed that herd immunity is important for disease control, and that the development of vaccines have greatly reduced childhood mortality and tackled disease globally. But in the light of declining vaccine take up in recent years, both in the UK and elsewhere, there is a debate today about the best way to ensure the greatest levels of immunisation amongst populations. Is a voluntary or compulsory system of childhood vaccination best, and what are the arguments for either side?
DEBATE IN CONTEXT
This section provides a summary of the key issues in the debate, set in the context of recent discussions and the competing positions that have been adopted.
Immunisation then and now
Prior to the development of vaccines in the eighteenth century, people could only become immune to diseases by contracting them and surviving. As the body deals with infection, it creates antibodies and other responses to the microorganisms that cause the disease, which means further exposure to infection is more easily dealt with. Modern immunisation [Ref: Wikipedia] against infectious diseases can be administered in a number of ways, but most commonly through vaccination. Artificial active immunisation delivers a very small and weakened quantity of a virus or bacterium into the body, but the body’s immune response is the same as for the actual infection itself, thus preparing it for any future attacks of the disease. Many childhood diseases, which in previous eras could have been deadly, are now readily managed and controlled, especially in the West. The introduction of the polio vaccine in 1953 [Ref: History.com], for example, has seen an almost complete eradication of the disease worldwide, with just those countries with less comprehensive immunisation programmes still suffering outbreaks [Ref: Guardian]. But not everyone supports or approves of vaccination programmes, for a variety of sometimes complex reasons. Over the past two decades, there have been increasingly vocal anti-vaccination movements in the UK and the USA which, according to some commentators, “frequently harbor a deep distrust of government. They often suggest that vaccination is motivated by profit and is an infringement of personal liberty and choice; vaccines violate the laws and nature and are temporary or ineffective; and good hygiene is sufficient to protect against disease.” [Ref: Washington Post] But it’s not the case that those who rejected the MMR jab for their children were ideologically opposed to vaccinations. Parents often found themselves in an impossible position, as parent Kirsty Grocott explained: “We were making decisions about an illness that many of us had never seen at first hand. Measles itself was an abstract compared to the perceived threat of autism. Parents made decisions believing them to be in the best interests of their children, people capable of rational and intelligent thought, decided to eschew the vaccination because they genuinely felt that the risk was too great.” [Ref: Telegraph]
The case for compulsory childhood vaccinations
According to the World Health Organisation, measles is one of the leading causes of childhood death globally [Ref: WHO]. In early 2019, the WHO said that there is a ‘clear trend’ of increasing outbreaks and argued that vaccinations must be stepped up across the world [Ref: Daily Mail]. The key argument about herd immunity, put forward by many calling for compulsory vaccinations, is that when an individual choice puts other members of society of risk, it is no longer a valid one. “The core issue here is the common good. If enough people are vaccinated, everyone benefits. But if enough people decide to opt out of vaccinations, for whatever reason, they put everyone at a higher risk of contracting disease.” [Ref: Guardian] Also important are the difficult issues about the importance of parental autonomy to make decisions about their children, versus the needs of society as a whole. Since the US Supreme Court case Jacobson v. Massachusetts in 1905, the United States has allowed mandatory vaccinations when they are “necessary for the public health or safety” and when the community is “under the pressure of great danger”. [Ref: Wikipedia]. Even then, “while governments could enforce vaccine mandates by imposing penalties like monetary fines on violators, forcibly vaccinating individuals against their will would be ‘cruel and inhumane to the last degree’.” [Ref: CityLab]. Much of the debate about compulsory vaccinations turns on what the line is between acceptable and unacceptable measures to encourage the uptake of vaccines. Such measures vary from education, advertising and campaigns, to fines, not allowing unvaccinated children into nurseries or schools, or even banning such people from public places. [Ref: Reuters]
The case against compulsion
The key issue at stake here is who gets to decide about the healthcare needs to children – the authorities or parents? Critics of enforced vaccinations argue that it may have the opposite effect to that desired, and end up demonising parental choice: “We can agree that anti-vaxxers are wrong about the science, and still be disturbed at the state trying to compel people to do things to their children they would rather not. Anti-vaxxers are not, after all, guilty of a crime of neglect or cruelty: their actions are born of divergent (if scientifically unsound) beliefs about what constitutes child welfare.” [Ref: Guardian] In any event, the impact of anti-vaxxers may be exaggerated [REF: The Conversation] Academic Jennifer Margulis says that: “There is tremendous evidence showing vaccinations prevent childhood diseases. Should public health officials do everything they can to encourage, inform and facilitate childhood vaccinations? Yes. Do they have the right to force parents to vaccinate their children? Absolutely not.” [Ref: New York Times] In the United States, vaccinations are compulsory, but there is a complex state-specific system of exemptions, allowing parents to reject mandatory vaccinations on medical, religious or philosophical grounds [Ref: National Vaccine Information Centre]. And although the anti-vaccine parents are very vocal, they are in a very small minority and some suggest that “now would not seem the time to be more coercive”. [Ref: New York Times] Indeed, adopting compulsory vaccinations can be counter-productive, causing concerned parents to withdraw their kids from school and entrenching anti-vaccination sentiment [Ref: The Conversation]. So how should we respond, both domestically and globally, to what seems like a potential return of measles on a larger scale than we’ve known for decades? Is there a case for governments to mandate that parents vaccinate their children for the ‘common good’ [Ref: Encyclopedia Britannica]? Many note that the anti-vaccination movement has played into a broader contemporary distrust of ‘Big Pharma’ and governments, and anything ‘unnatural’. Contemporary anti-vaccination movements do “not map neatly on to party affiliation. Alongside the Trump-following populists and the right-wing anti-establishment individualists are the left-leaning Mother Earth-lovers. These are people who worry about injecting their children with chemical compounds in the same way that they worry about pesticides in their food.” [Ref: Guardian] Perhaps addressing the broader context of concerns and fears is more productive than making vaccinations compulsory?
Scared parents, scary science
Vaccination fears, and the impact from low vaccination rates, are a truly worldwide phenomenon [REF: FT]. But does this mean that there is one big problem, faced the world over, or that different countries have different problems and so need different solutions? Some commentators argue it is important to look beyond individual decisions and instead look at the climate in which parents make vaccination decisions. Jennifer Reich, author of Calling the Shots: Why Parents Reject Vaccines, has drawn attention to the relentless focus on public health: “We have spent the last 20 years convincing individuals that if they work hard and make informed decisions, they can avoid disease. If they breastfeed or if they manage their children’s nutrition, if they eat organic food, if they choose good schools, that their children will be better off … we then get into the situation where parents really see themselves as the best able to evaluate risks and benefits.” [REF: NPR]. Other commentators have noted how anti-vaxxer parents are, in some sense, products of an atmosphere where parents are encouraged to obsess about their children’s health and orient their parenting around promoting it: “All the parents in our research made a conscious and (for them) logical choice not to vaccinate, questioned the science underpinning vaccinations and undertook a number of health-promoting practices for the wellbeing of their children. Parents engaged in an ongoing search for information about how best to parent their children” [REF: Guardian]. Of course, despite the scare stories, it is important to keep perspective: support for vaccination in the UK remains strong. Indeed, worries about fake news or the impact of social media can seem overblown when many studies suggest more prosaic responses are most helpful: “Make it easier for parents to book return appointments, run better organised and cheaper immunisation services and make more health workers available to answer parents’ questions and concerns effectively.” [REF: Science Media Centre]
It is crucial for debaters to have read the articles in this section, which provide essential information and arguments for and against the debate motion. Students will be expected to have additional evidence and examples derived from independent research, but they can expect to be criticised if they lack a basic familiarity with the issues raised in the essential reading.
The pros and cons of compulsory vaccinations
Tom Solomon Independent 8 April 2019
Measles is on the rise in Europe – and populism could be to blame
Sarah Boseley Guardian 22 August 2018
Getting a measles vaccination isn’t a personal choice – it’s a social responsibility
Robert Reich Guardian 5 May 2019
Your thoughts about vaccines don’t trump another child’s medical reality
Jessica Valenti Guardian 3 February 2015
Labelling anti-vaxxers as bad parents doesn’t help – it just leads to more distrust in science
Paul Ward Guardian 13 May 2019
Most of us support mandatory vaccines for schoolkids, but is it good policy?
Alison Braley-Rattai The Conversation 4 April 2019
Anti-vaxxer effect on vaccination rates is exaggerated
Samantha Vanderslott The Conversation 13 March 2018
How mandatory vaccination fueled the anti-vaxxer movement
Linda Poon CityLab 24 April 2019
What if not all parents who question vaccines are foolish and anti-science?
Alice Dreger New Statesman 4 June 2015
Cultural perspectives on vaccination
The College of Physicians of Philadelphia 15 December 2014
The real lessons of the MMR debacle
Dr Michael Fitzpatrick spiked 25 January 2011
Beware creating fake news on MMR
Fiona Fox Science Media Centre 29 April 2019
Why aren’t parents getting their children vaccinated?
NPR 29 April 2019
Measles is back and killing thousands, yet anti-vaxxers are winning
Vicky Carroll The Big Issue 5 March 2019
Useful websites and materials that provide a good starting point for research.
Resorting to freedom
Economist 4 February 2015
Why James Wilson and The Economist supported compulsory vaccinations
Economist 24 February 2015
Why did I think it appropriate to deny my children the MMR vaccine?
Kirsty Grocott Telegraph 25 April 2013
IN THE NEWS
Poll: 72 percent say parents should be required to
vaccinate their children
Elena Moore NBC News 6 May 2019
Pakistan’s anti-vaccination movement leads to string
of deadly attacks
Sophia Saifi and Syed Shah CNN 26 April 2019
Measles: Europe sees record number of cases and 37
deaths so far this year
Zosia Kmietowicz BMJ 20 August 2018
Matt Hancock ‘won’t rule out’ compulsory vaccinations
Aamna Mohdin Guardian 4 May 2019
Measles cases quadruple globally in 2019, says UN
BBC News 16 April 2019
Unvaccinated children face public space ban in New
York measles outbreak
Reuters 26 March 2019
New York orders mandatory vaccinations amid measles
Rozina Sabur Telegraph 9 April 2019