This article is a preview from the Spring 2020 edition of New Humanist

Should governments make the vaccination of children compulsory, even if their parents are opposed to it? Calls for such measures have mounted since the UK lost its “measles elimination” status in 2019. Measles is a highly infectious disease whose side effects are often temporary but can include seizures, pneumonia and brain inflammation, sometimes resulting in permanent disability. In the past few years, measles cases have surged in many European countries. In 2019, Public Health England reported a sharp increase in cases of both measles and mumps, which is what led the World Health Organisation (WHO) to revove the UK’s “measles free” status in August. Three other countries – Greece, Albania and the Czech Republic – were similarly downgraded. The immediate cause seems indisputable: falling vaccination rates.

After rising steadily in the previous decade, the Measles, Mumps and Rubella (MMR) vaccination rates for two-year-olds have now fallen for four years in a row. The proportion of five-year-olds in England receiving both doses of the MMR vaccine has fallen to 87 per cent. This is below the 95 per cent the WHO says is necessary to provide “herd immunity”: the resistance to the spread of a contagious disease within a population which results if a sufficiently high proportion of individuals are immune, either from vaccination or previous infection.

Some doctors and public health experts attribute the fall in vaccinations to parents succumbing to propaganda from anti-vaccine campaigners. A US study published in the journal BMC Public Health last October noted that those seeking to promote vaccination “face multiple challenges on social media, including misinformation, anti-science sentiment, a complex vaccination narrative and anti-vaccine activists”.

Who exactly are these anti-vaxxers? They seem to be small in number, but have managed to capture significant volumes of search traffic, sometimes by using names which sound authoritative and reasonable – such as the “National Vaccine Information Center” (a US group) or “Revolution for Choice”. An investigation by the Atlantic noted that just seven anti-vax web pages generated nearly 20 per cent of the top 10,000 Facebook posts about vaccination. In the last few years, anti-vaccine views have become a staple of right-wing populist movements: politicians who have appeared to question the efficacy and safety of vaccines include Donald Trump, Marine Le Pen and Beppe Grillo, the founder of Italy’s Five Star movement. “When I was growing up,” Trump told one American newspaper, “autism wasn’t really a factor. And now all of a sudden, it’s an epidemic . . . My theory is the shots. We’re giving these massive injections at one time, and I really think it does something to the children.” Vaccine hesitancy is not limited to the political right, however; others may simply have absorbed fears that have been periodically aired in the media over the last two decades. While it is difficult to say precisely how much impact each of these concerns has had, the fall in immunisation rates has been significant, and as a result, some have argued in favour of mandatory vaccination.

In September 2019, a group of leading GPs wrote a letter to Health Secretary Matt Hancock demanding that the MMR jab be made compulsory, and that parents be required to certify that their child has had both doses of the MMR vaccine before they can attend school. The four senior GPs – including a former acting chair of the British Medical Association – argued that school entry procedures should be tightened so that the only exceptions to the new rule would be for children whose parents have registered a conscientious objection to the MMR vaccine, or those whose health means they cannot have it. The GPs urged the government to implement the change urgently: doing so would save lives and tackle dangerous “complacency” among parents who do not ensure that their child is fully immunised. “Schools need to check that all their pupils have been vaccinated. In other countries, certificates of vaccination are required prior to school entry,” they argued. They went on to cite precedent, noting that child vaccination against smallpox was made compulsory in the UK in 1853 and that today, doctors need to show evidence of vaccination or immunity from various illnesses so they do not put patients at risk. Hancock responded that the government would “consider all options. I don’t want to reach the point of compulsory vaccination, but I will rule nothing out”.

There is no absolute consensus in the medical profession, however, and some doctors have argued that making MMR vaccines compulsory would be a premature response to the falling immunisation rates, and carry its own fresh risks. Their concern is that compulsory
vaccination could lessen trust between patients and doctors, and lead hostile parents to home school their children. Professor Helen Stokes-Lampard, the chair of the Royal College of GPs, told the Guardian: “As GPs, we have an important relationship with our patients, built on trust and understanding, and in order to keep that we need to help people make their own decisions. Positive, informed and educated choice is always going to be more desirable long-term, and we are concerned that rushing down the route of enforcing methods of healthcare could have unintended consequences.” She argued that it would be wrong on principle to deny patients a choice over what medical interventions they had or to “impose” compulsory vaccination on them. A spokeswoman for the Royal College of Paediatrics was quoted in the same report as saying: “Mandation should be the end of the road, after we’ve tried everything else. There’s no body of evidence that it works. It’s a kneejerk reaction”.

To make sense of this debate, we must unpick several issues. What is the true cause – or causes – of the decline in vaccination rates? Will these be successfully addressed by mandatory vaccination? Is mandation legally sustainable? And if vaccination is made compulsory, should there be exemptions on the basis of conscience or religion for some parents? Would these undercut any mandatory requirement?

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Most of the discussion about decline in vaccination rates has focused on the impact of social media and the campaigning activities of anti-vaxxers, recently described by Matt Hancock as having “blood on their hands”. Much of the current hostility to MMR can be traced back to 1998, when gastroenterologist Andrew Wakefield published an article in the Lancet claiming a link between the MMR vaccine and autism. The article received huge media attention. However, by the early 2000s, questions were raised about its validity, and in 2010 Wakefield was struck off the UK medical register after it was found that he had deliberately falsified his research.

Although Wakefield has been a discredited figure for over a decade, he continues to promote his claims from his new base in the US. The impact is painfully apparent. In the UK, the MMR scare caused vaccination rates to drop sharply, from 92 per cent in 1996 to 81 per cent in 2004, falling as low as 61 per cent in some parts of the country. This in turn led to a sharp rise in measles cases. Measles was declared “endemic” in the UK in 2008. The rate of vaccination uptake started to recover after 2004, but the lingering after-effects of the Wakefield controversy and the more recent anti-vaxxer campaigns associated with political populism seem, on the face of it, to be a factor in the vaccination rate remaining below the 95 per cent herd immunity threshold.

However, anti-vax agitation may not be the primary cause for lowered rates of vaccination. Because politicians are now so conscious of the impact of social media, there may be a danger of over-estimating the extent to which it influences parental behaviour on immunisation. Researchers examining this issue have often started with an assumption that anti-vax propaganda on social media has caused a reduction in vaccination rates, but have discovered that the evidence tells a different story. In its own research published in 2019, Public Health England identified a striking paradox: between 2016 and 2018, the period when vaccine uptake for children fell across most immunisations, the proportion of Britons who agreed that vaccines are safe increased, and the proportion who strongly disagree – a negligible figure in any event – nearly halved. Health professionals were identified as the most trusted source of information on vaccines, with the internet and social media being least trusted. Between 2002 and 2019 the number of parents who had seen or heard something to make them doubt the efficacy of immunisation fell from 33 per cent to nine per cent, a record low. These
figures suggest that anti-vax campaigns, whilst prominent on social media, may have limited purchase in the British population at large, and that on this issue it may be wrong to conclude that any significant proportion of parents have “had enough of experts”.

Analysing the reasons for non-vaccination in a recent issue of Prospect magazine, Barbara Speed highlighted how opting out may be occurring in three different groups: “ardent anti-vaxxers”, “fence sitters” and “accidental non-vaxxers”. Basing any public policy response around assumptions of homogeneous views amongst these groups would be unwise, but the analysis is useful. The hardcore group – ardent anti-vaxxers who fervently believe vaccines are dangerous and whose views are completely intractable – may be impossible to shift but small in number. “Fence sittters” have concerns, but may be persuadable with better or different presentation of information. Another significant group, Speed notes, may be passive non-immunisers – parents who have no objection to immunisation in principle, but face practical barriers, often as simple as not understanding where and how to get their child vaccinated, and when a follow-up jab is required. Speed noted that the recent decline in MMR uptake began in 2015, the year that structural reforms to the NHS conceived by David Cameron’s coalition government were implemented. These reforms remade the NHS in potentially confusing ways, redrawing the boundaries between health service and local authority responsibility for public health, with the result that some forms of expertise were dislodged. One impact was that immunisation teams became responsible for much larger geographic areas than under the previous system, and immunisation expertise and capacity for follow-up with parents were reduced. Health visitor numbers were also cut.

Some argue that whilst the anti-vax propaganda on social media is a convenient scapegoat, these changes in NHS structure and roles have been far more significant in reducing vaccination rates. In a piece in the Guardian in August 2019, the chief executive of the British Society for Immunology, Doug Brown, argued that the “best remedy” against anti-vaxxers would be to reverse budget cuts to public health: “Strategies such as sending parents reminders, having appointments available at appropriate times and widening services to go out into communities are all initiatives we know work to increase vaccine uptake, but which also require appropriate resources.”

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So would mandatory vaccination work, and would it be legally feasible? It has been tried in the UK before, with positive outcomes: the 1853 Vaccination Act made it compulsory for all children to be vaccinated against smallpox during the first three months of life. Parents who failed to comply were fined. By the 1860s, two-thirds of babies were vaccinated, and the number of deaths due to smallpox dropped. In the US, mandatory vaccination has been very common, and as of 2018 almost all US states mandate vaccinations against certain diseases (often including measles). They largely do this by making vaccination a condition of (state) school entry. That means that parents can opt out of vaccination by home schooling, a sacrifice that in practice not many parents are prepared to make. These laws have withstood many challenges in the courts. The US Supreme Court upheld compulsory vaccination laws in 1927, reasoning that “there are manifold restraints to which each person is necessarily subject for the common good”. Subsequent legal challenges, for example based on religious freedom, have almost always failed. Religious objections to vaccines tend to be based on the ethical dilemmas associated with using human tissue cells to create vaccines, and beliefs that the body is sacred and should be healed by God or natural means.

A notable feature of the US experience seems to be that compulsory vaccination works most effectively when religious or personal belief exemptions are removed – otherwise, those who are most vehemently opposed can simply claim a belief-related exemption. This point may be particularly relevant to addressing localised outbreaks of disease associated with the cultures and religions of particular communities.

In August 2019, the Jewish Chronicle highlighted how the strictly Orthodox Haredi community in Stamford Hill in north-east London had been hit by a major outbreak of measles following falling vaccination rates. A local GP attributed the fall to a “mistrust of secular authorities”. Similar localised outbreaks have occurred in ultra-Orthodox Jewish communities in New York, causing the state to experience the worst measles figures in the US. These outbreaks clearly followed falls in vaccination rates, some of which had dropped below 50 per cent in the affected communities. Many of those living in these communities have little or no contact with social media. This suggests that cultural and religious factors specific to these communities were more relevant – and therefore that removing belief exemptions would be necessary to tackle falling vaccination rates.

Mandatory vaccination is certainly legally feasible. But there is still a question mark over whether it would be the most effective public policy response. Whilst extreme anti-vax campaigns have garnered much media attention, closer investigation suggests that over the past few years, other factors may have had more impact on falling vaccination rates in the UK. In the long run, improving immunisation capacity and public information might be the better policy. The difficulty is that these changes will take time to implement, and the measles crisis is happening right now. Radical measures are needed, and if, in reality, ardent anti-vaxxers constitute only a minority of the thousands of parents who are failing to vaccinate their children, then it follows that mandation would capture the large majority. This suggests that mandation should be part of the response, but that in the longer term,
policymakers should reflect more carefully on the origins of the present crisis.