Measles and Vaccine Hesitancy

Last month, Mayor Bill de Blasio declared a public health emergency in New York City in response to a measles outbreak that has sickened hundreds in ultra-Orthodox Jewish communities since last fall. His requirement that unvaccinated individuals in Williamsburg and Borough Park, Brooklyn submit to mandatory vaccinations or face possible fines brought to light the tension between civil liberties and community welfare that underlies the basic principles of public health.

As I wrote here several years ago, vaccines have easily been one of the major public health successes of the twentieth century, especially for the childhood diseases that were once leading causes of mortality. Instead of dying from diphtheria or rubella, we’re now vaccinated against them. Other illnesses such as polio and chicken pox that are not necessarily fatal but could cause lifelong complications are now avoidable with a series of immunizations.

Yet despite these victories, rates of vaccine-preventable diseases, notably measles, continue to rise. According to the Centers for Disease Control, there were 75 new cases of measles across the country last week, for a total of 839 cases so far this year, already double the entire number for 2018.

When a measles outbreak hit California in late 2014 and early 2015, the state responded by tightening its restrictions. At the time, it allowed parents to opt out of vaccines for personal reasons; now, it allows exemptions only for medical reasons. States that allow fewer exemptions generally experience fewer outbreaks. In Oregon, for example, which has been affected this season by an ongoing measles outbreak next door in Clark County, Washington, parents are still permitted to decline vaccinations for philosophical reasons; they can self-certify their status as objectors by watching a video module online and printing out and signing a form.

Although numerous studies have debunked any link between vaccines and autism, including one in Denmark published this spring, vaccine hesitancy remains so alarming that the World Health Organization declared it one of the top ten threats to global health in 2019, along with climate change, antimicrobial resistance, and weak primary health care. Parents in the United States who resist vaccinations are not necessarily uneducated or ill-informed; more often, they’re getting their information from a set of sources that confirm what they’re already likely to believe. In ultra-Orthodox neighborhoods in New York City and surrounding counties, anti-vaccination handbooks and pamphlets have been circulating and spreading misinformation within the insular community. In Oregon and Washington, middle-class parents who distrust big pharma and chafe against governmental interference are likely to encounter in their communities like-minded peers who reinforce their views.

One of the obstacles in overcoming to vaccine hesitancy is the inherent difficulty of proving a negative. Scientists will state a lack of correlation between vaccines and adverse health consequences, but for methodological reasons won’t claim that the former never causes the latter. To parents who resist vaccinations because of (discredited) fears of autism, the danger lies in the risk of triggering the disorder. This risk, in its uncertainty and unknowability, is more frightening than the disease against which the vaccine is designed to protect.

Several months ago, I was chatting with a recently married young woman, who told me that she and her husband weren’t sure they would vaccinate their children when the time came. They both, she said, personally knew of kids who were never the same after receiving childhood immunizations, whose personalities changed from outgoing and sociable to withdrawn and introverted. I trotted out the standard scientific and public health arguments in favor of vaccination, but she remained unmoved. It reminded me of the challenge of arguing against the evidence of personal experience, of trying to convince someone that what he or she has witnessed firsthand might be unreliable. It’s hard to argue a contrary position when the cause-and-effect seems so convincing. And how certain can one really be that the former didn’t result in the latter? Such are the complexities of countering vaccine hesitancy.

The battle against vaccine hesitancy will necessarily be multifaceted, and must include broad educational campaigns as well as one-on-one outreach. But governmental mandates play an important role, as well. We enjoy many rights in this society, allowing us to live, speak and assemble with a great deal of freedom. The right to endanger others with a dangerous and easily preventable disease should not be among them.

An End to HIV by 2030?

In his recent State of the Union speech, President Trump made an ambitious pledge in the area of public health: to eliminate the HIV epidemic in the United States within ten years. The actual plan, released that week by the Department of Health and Human Services, aims to end new HIV infections by 2030. HHS proposes to do this by targeting “geographic hotspots”: forty-eight counties, plus Washington, DC and San Juan, Puerto Rico that account for more than 50 percent of new HIV diagnoses, as well as seven states with high rates of infection in rural areas. The plan calls for diagnosing the disease quickly, starting treatment as soon after as possible afterward, and increasing the use of PrEP (pre-exposure prophylaxis), a medication for people at high risk for HIV.

Researchers and HIV/AIDS advocates call the initiative aggressive but achievable, as all of its medical components—diagnostics, anti-retroviral therapies, PrEP—have been available for some time. However, many remain skeptical of the Trump administration’s actual level of commitment to ending HIV, given its ongoing assault on LGBTQ communities, immigrants, and people of color, populations with high rates of new infections. Furthermore, the administration has continually attacked and undermined the Affordable Care Act and Medicaid, making health insurance both more difficult to obtain and more expensive to use. Premiums continue to rise, and seven states have implemented work requirements that have had the effect of kicking people off Medicaid, with applications pending in eight more.

As both a social and a medical endeavor, public health must engage communities, where local norms and cultural attitudes can affect disease transmission. Take for example the recent measles outbreak in Clark County, Washington, a state that allows exemptions to mandatory vaccinations for medical, religious, and philosophical reasons. As NPR has reported, some schools have vaccination rates under 40 percent, rather than the 90 percent or so required for a community to be protected. Parents who are responding to inaccuracies and rumors on social media and from other parents forego vaccinations for their children, placing entire communities at risk. Combating such fears requires not only a tightening of applicable laws, but also a campaign to address vaccine misinformation in locations where it can itself spread like a virus.

If the Trump administration is truly committed to eradicating HIV, then it must combine social with medical approaches. It’s not enough simply to diagnose more people and subsidize new PrEP prescriptions. Resources must also go toward affordable housing, nutrition assistance, and counseling to ensure that patients are emotionally supported and are adhering to regimes of treatment. Stigma and discrimination remain obstacles to meaningful care in affected populations; any far-reaching plan must tackle social attitudes among those affected, including families and healthcare providers. We may have in hand the medical tools to end new transmissions, but success will not rest on these components alone. The Trump administration must understand this if it genuinely wants to succeed in its goal.

The Coerciveness of Public Health

This morning I awoke to the news that Chris Christie, the governor of New Jersey, thinks parents should have a choice about whether to vaccinate their children. He has since backtracked on his statement and affirmed his support for vaccination. But as a measles outbreak spreads across California, Arizona, and twelve other states, it’s exposing the tension between personal autonomy and community well-being that’s an ever-present part of the doctrine of public health.

The current measles outbreak most likely started when a single infected individual visited Disneyland over the holidays, exposing thousands of vacationers to a highly communicable disease that the CDC declared eliminated from the U.S. in 2000. At another time—say, ten years ago—the outbreak might have been contained to a handful of cases. But as numerous media outlets have reported, immunization rates have been dropping in recent years, particularly in wealthy enclaves where parents still believe the debunked link between vaccines and autism, aim for a toxin-free lifestyle, or distrust Big Pharma and the vaccine industrial complex.

I am young enough to have benefited from the scientific advances that led to widespread immunization in the 1970s, and old enough to have parents who both had measles as children and can recall the dread surrounding polio when they were growing up. Vaccines are a clear example of how public health is supposed to work. One of the unambiguous public health successes of the twentieth century, vaccines have transformed ailments such as pertussis, diphtheria, and chickenpox from fearsome childhood afflictions that could cause lifelong complications, and even death, to avertible diseases.

The basic premise of public health is the prevention of disease, and public health guidelines have led to increased life expectancy and decreased incidence of communicable illnesses, as well as some chronic ones. Yet public health regulations have always had to balance individual civil liberties with public safety. People are free to make their own choices, as long as they don’t infringe on the public good. For the most part you’re still allowed to smoke in your own home (although your neighbors could sue you for it), but you can’t subject me to your secondhand smoke in restaurants, bars, or office buildings.

I believe in handwashing, USDA inspections, the use of seatbelts, and the pasteurization of milk. I believe in quarantines when they are based on the best available information and are applied evenly. (A quarantine that isolates all travelers from West Africa who have symptoms of Ebola would be reasonable; one that singles out black Africans from anywhere on the continent regardless of health status would not.) In short, I am in favor of a coercive public health apparatus. The problem with the current measles outbreak is that enforcement has become too lax, with too many states allowing parents to opt out of immunizing their children because of ill-conceived beliefs that are incompatible with the public good.

Every parent spends a lifetime making choices about how to raise their child, from environment and lifestyle to moral and ethical guidance. But some choices have a greater capacity to impact the lives of others. If you want to let your child run around with scissors, watch R-rated movies, and eat nothing but pork rinds all day, you can. If you want to home-school your child because you want greater control over the curriculum he or she is being taught, you’re free to do that, too. And if you want to keep your child from getting vaccinated against communicable diseases, then the state won’t step in to force you. Opting out of vaccinations might not make you a bad parent any more than raising a fried-snack fiend might. But unless you’re planning to spend your days in physical isolation from every other human on the planet, it does make you a bad member of the public.