What should we do with vaccine deniers? A mother named Kristen, interviewed by Saul Gonzalez for Which Way LA says that she’ll leave the state if she is forced to vaccinate her child in accordance with California’s new law. She and many others like her have deeply held beliefs, equally deeply at odds with current science. To those in public health, the merit of vaccines seems like a no-brainer. But the ethics of obliging parents to vaccinate against their will is hazardous.
Vaccination rates in California are barely adequate overall (and far from the best in the nation), and there are also huge differences within the state. Several northern California counties have dismally low vaccination rates, and even in SoCal many childcare centers have vaccination rates for measles well below 92%, the generally agreed requirement for herd immunity.
After the Disneyland measles scare, it felt like a public-health necessity to eliminate the dangerously growing trend of vaccine waivers, which had more than quadrupled statewide from the 1990s, when they were roughly half a percent to 2013, when they peaked at over 3%.
There are two reasons vaccine rates are low. One is vaccine and the other is inadequate access to healthcare. But while a vaccine mandate can help identify those who are involuntarily falling through the cracks, it poses ethical problems vis-à-vis those who have studied the issue carefully and have concluded that they really don’t want vaccines for their children.
One mother interviewed for Which Way LA said that she “has researched this issue ad nauseam. Ad nauseam!” And she has “run my own statistical analysis using CDC data.”
It would be easy to discount this research as nothing more than a new kind of McCarthyism. But this would be wrong. Science isn’t always right, especially not right away, and we in public health have gotten things wrong before. And the vaccine skeptics are not alone in complaining that the pharmaceutical industry has far too much influence on the way science is conducted and evaluated.
All the same, the research in public health is quite clear that vaccines are not only safe but highly beneficial. Based on this science—the best of our field—we can’t allow this mother to put other children in peril. But we should, out of a sense of dignity, not constrain her any more than is necessary. And in fact, we don’t need 100% vaccination to ensure herd immunity.
So here’s a proposal. Identify a rate of non-vaccination that is consistent with herd immunity for each vaccine. For measles, it would be 8% or so. Vaccines should be universally mandatory in each school for which 8% of children or more are unvaccinated for medical reasons or because of inadequate healthcare access. If fewer than 8% of children are unvaccinated for these reasons, allow those who really don’t want to vaccinate their children to obtain a vaccine waiver. If enough people apply for the waivers to push the non-vaccination rate over 8%, then auction off the available waiver slots to the highest bidder.
Most such auctions have a flaw in that the wealthy are able to pay more regardless of their level of commitment to the underlying belief. To get around this ethical problem, define the bidding not in terms of dollars, but in terms of percent of annual income. The winning bidders might pay very different dollar amounts, but would all be equally fervent in their opposition to vaccines.
This proposal is basically cap and trade for vaccine waivers. And like cap-and-trade for greenhouse gas emissions, cap-and-trade for vaccine waivers would achieve a valuable public-health goal while preserving as much individual choice as is consistent with not harming others. And all that money from a cap-and-trade vaccine waiver program? Put it into vaccine access for the underserved, of course.
The current California vaccine law is unnecessarily harsh. We don’t have to banish people from the state to achieve our public health goals, even if they don’t agree with our science.