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Mandatory Vaccination is a No-Brainer

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GELFAND’S WORLD-Nobody has the right to spread disease recklessly in the public space, but try telling that to the people who have flooded the halls of the state legislature over the past couple of weeks. The topic in question is legislation introduced by state Senator Pan under the title Senate Bill 277 (SB277). It would require that children be vaccinated against the more prevalent (and dangerous) communicable diseases in order to be enrolled in school. That includes requiring school aged children to receive the vac  cine against measles, mumps, and rubella. 

The Senate bill is driving the anti-vaccine groups nuts, because they continue to buy into the entirely discredited myth that the MMR vaccine can induce autism in some children. It isn't true, but the myth persists in the minds of some. Some of them take it even further, to attribute all manner of ills to getting your shots. So they have been dressing up in red tee shirts and filling the hallways and hearing rooms at the state capitol. 

The anti-vaccine people argue as follows: "If there is a risk, there must be a choice." I wish to contest that argument in the following discussion. But I will concede from the outset that this is a big question, which is whether society as a whole has the right to attempt to maintain the public health, even when the methods made into law (such as mandatory vaccination) are repugnant to a minority of American citizens. 

The current attempt to make SB277 into law brings these arguments to the forefront.  So far, SB277 has passed in 3 committees by substantial majorities (the closest vote was 6-2 in favor). 

Science and decades of public health experience argue against the anti-vaccine position and provide the solid evidence for bills like SB277. But the people who resist vaccination act like they are immune to reason. The only question is whether our elected officials will show the nerve to stand up to the pressure and do the right thing. 

The state of California has required that school children be vaccinated against the common communicable diseases for a good long time, but until recently, it was easy for vaccine resisters to get away with avoiding the requirement. They simply asserted a religious objection or stated that they had some personal belief against vaccination. In some schools, this system of personal belief based exemptions resulted in percentages of unvaccinated kids well into the double digits. 

This is a problem, because infectious disease spreads more easily when there is an unvaccinated group who can come in contact with those who are infected. There is also an increased risk to a certain (luckily small) percentage of vaccinated individuals who simply don't develop a high enough level of immunity even after getting their shots. 

The higher the level of vaccination within the entire community, the less likely it will be for a disease to spread. There is a simple reason for this. If somebody comes into this country carrying measles (as apparently happened in the Disneyland outbreak), a fully immunized population presents few individuals who are likely to catch the disease, and the few who catch it are less likely to spread it if everyone they come in contact with is already immune. Epidemiologists like to demonstrate this using mathematical equations, but the idea is common sense. 

A couple of years ago, the state legislature acted to tighten the school immunization requirements, passing a bill that required anti-vaccine parents to talk to a health care professional regarding the facts on immunization in order to obtain their exemption. Unfortunately, Gov. Brown watered it down a bit with a signing statement, but it was having a modest effect. 

Then we had the Disneyland measles epidemic, and public opinion began to move towards required immunization and against giving exemptions so easily. 

This seems to have been the excuse that Sen. Pan needed, and the result was SB277. It would get rid of the system of exemptions and require children to be up to date on their immunizations in order to attend the public schools. The only exception would be children who cannot be vaccinated because they have medical issues. For example, children with deficiencies of the immune system or receiving some kinds of cancer chemotherapy shouldn't get some vaccines, and the proposed law would of course preserve these rational exemptions. 

There are various objections raised by the anti-vaccine people. Let's dispose of one of them first, by agreeing with it. The resisters argue that the bill would, in essence, make it mandatory for school aged children to get their shots. We should all just agree that this is the case. There are ways of getting out of having your children immunized, including doing your own home schooling or moving out of California. For all but those already doing home schooling, the hardship would be real. 

So yes, the bill is in effect a mandate. The anti-vaccine parents say that as if it were a bad thing. It's not. It's an attempt to protect public health against some very nasty viruses and bacteria. 

The other core argument of the resisters is that this bill is an attack on peoples' freedom to determine their own medical care and the care of their children. It is brought up under phrases such as health freedom and is even compared to freedom of choice. 

This is equally unconvincing, since there has never been a legal doctrine allowing complete personal autonomy to endanger other people. Since the introduction of public health agencies, the law has given power to the authorities to deal with typhoid carriers and, more recently, those with other communicable diseases such as tuberculosis or polio. The concept of the quarantine has a long history, going back to the post-plague years in medieval Europe. 

We are in an era when it is possible to reduce the incidence of some previously common infectious diseases to nearly nothing. In fact, measles was all but gone from the North American continent for a few years, until the spread of antivaccination sentiment among some of the population helped bring it back to the current low, but non-zero levels.  

When it comes to infectious diseases that can endanger the entire population, there is no such thing as health freedom. It's true that the public health authorities have tried to take a more diplomatic approach nowadays, but that is just an attempt to engage in a more acceptable form of public relations. The authorities retain the right to control and quarantine people, as we have seen in the recent Ebola scare and in the recent measles outbreak. 

There is an analogy to the old legal remark that "your right to swing your fist ends where my jaw begins." We could just as easily rewrite that to say, "Your right to choose your own form of medical care ends when you risk infecting me with your illness." 

I think we are going through a predictable moment of history here. For most of human existence, serious and fatal diseases were a part of life. Well into the 1950s, parents feared polio, since epidemics of paralysis and fatality came and went, cycling through the population one year, subsiding for a while, and then coming back. Everybody in my generation was familiar with the sight of somebody using leg braces and crutches as the result of polio. 

The introduction of the Salk vaccine was greeted with thanks and tears. Salk became an instant hero. Within a very few years, polio was essentially gone from American life as an infectious disease. 

It was under this historical background that vaccines were introduced for other childhood maladies that sickened millions and killed thousands. One contributor to the toll was measles, which likely infected every single person at some point in the first 15 years of life, killed about one in every thousand it infected, and left others with deficits. A not unreasonable estimate is that in the booming postwar years, about four million Americans became infected with measles each year, with some avoiding visible illness and a few hundred dying. 

The end of polio, diptheria, and for the most part measles, led to a certain complacency among the American people. In a way, the current situation in which a small fraction of the population get to live more or less free of childhood diseases in spite of their unvaccinated status is the result of the effectiveness of vaccines. The rise of the antivaccine movement is due to the success of vaccine science, because we don't have to live in fear of the next polio epidemic. 

Let's finish with that deeper question that I alluded to at the outset. Does society as a whole have the right to impose requirements that are deeply repugnant to some people, on the basis that such requirements are in pursuit of the public health? 

The legal doctrine has long since been established, and is clearly yes. The 1905 Supreme Court case Jacobson v. Massachusetts upheld a law that required all adults to be vaccinated against smallpox. It is an example of judicial reasoning and if you like, you can read it to get an idea of what the law really is, rather than what some protesters would like it to be. The argument hinges on what the justices referred to as the police power of the state. In a nutshell, that means the right of the state (or the federal government) to take such actions as are necessary to protect the people from crime, disease, or other problems, just as long as the laws in question don't otherwise violate the Constitution. 

What's particularly important about Jacobson and later decrees is this most important point: It is the legislature that gets to hear the facts and testimony of the experts and then make a decision. No individual or rebellious group gets to set the rules regarding the public health in opposition to established state law. 

There is a curious corollary with the history of the 1960s. At that time, we had a military draft. There was a great deal of political opposition, but there really wasn't a credible argument that the U.S. Government lacked the power and authority to create and maintain the draft. To those at risk of being drafted, the result could be loss of life or limb, as the news programs showed us to a frightful extent. The argument was that the government, in order to preserve freedom and its place in the international order, had the right to force young men to undergo the risks of combat. 

It seems to me that the relatively minor risks of vaccination pale in comparison to the risks of armed combat, and the benefits of universal immunization are obvious. The argument in favor of universal immunization thereby takes on a moral tone. Universal vaccination protects the entire population, even as an army protects the country from armed invasion. This metaphor may be a little strained, but the idea that a portion of our people can risk spreading disease with impunity should not go unchallenged.

 

(Bob Gelfand writes on culture and politics for CityWatch.)

-cw

 

 

CityWatch

Vol 13 Issue 36

Pub: May 1, 2015

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