The myth of a measles crisis
The rage against populism is now fuelling a panic about anti-vaxxers and measles.
‘Something needs to be done’, declares Oxford University ethicist Alberto Giubilini in a lecture promoting his new book, The Ethics of Vaccination, in which he argues forcefully in favour of compulsory policies (in countries such as the UK) to tackle ‘the measles crisis’ he believes is currently facing Europe. According to NHS chief executive Simon Stevens, measles in the UK is a ‘growing public-health timebomb’, which he blames on ‘grossly irresponsible’ anti-vaxxers spreading scare stories online. UK health secretary Matt Hancock boosted his ill-fated campaign for the Conservative Party leadership by dramatically claiming that anti-vaxxers had ‘blood on their hands’ over measles deaths. He suggested that it is time to consider making vaccination mandatory for school entry and measures to curb anti-vaccination propaganda on social media. The World Health Organisation has declared ‘vaccine hesitancy’ in its top 10 threats to global health, and a Wellcome Global Monitor survey has revealed a ‘global crisis’ of confidence in vaccines, linked to an upsurge of measles cases around the world.
Commentators have discovered a ready political explanation for the measles crisis. Last summer, an article by Sarah Boseley, health editor at the Guardian, was headed ‘Measles is on the rise in Europe – and populism could be to blame’. Even though she concedes that ‘MMR take-up in the UK is back to over 90 per cent’, her article concludes: ‘Measles is a serious disease. Your healthy daughter may not die from it, but the fragile child down the road or the older man whose immune system is compromised will struggle to survive an infection… [V]accine-preventable diseases may well be making a major comeback.’ Clambering aboard this year, The Times columnist David Aaronovitch announced that ‘it’s time to get tough with the anti-vaxxers’, insisting that ‘freedom of choice is important but not when it comes to immunisation against potentially fatal diseases like measles’. Another feature writer at The Times has also pointed the finger at ‘populism’: ‘Public-health efforts suffered a significant reversal last year with a surge in measles cases across Europe, led by Italy and Romania. Britain was not immune. The reason is simple: anti-establishment populists inflamed an “anti-vax” movement.’
So there we have it. Mistrust of authority, especially by populist movements (and religious, Mother Nature, and anti-big Pharma types) may well be leading to a ‘measles crisis’ in the UK. Compulsory vaccination is the answer. This is a case of the bad use of science at work. The contemporary rage against populism is barging in on a complex epidemiological issue and offering up an illiberal authoritarian solution. Alarmist reports conflate figures from measles outbreaks in countries in the developing world (the Philippines, Indonesia) and in Eastern Europe (Ukraine, Romania), where quite different epidemiological and political conditions prevail, with those in stable high-income countries. There is no good evidence of an impending measles crisis in the UK, and no good evidence of populist influence on MMR uptake. Furthermore, the ‘let’s get tough’ attitude is woeful. Aaronovitch says that one reason why he sides with ‘the coercers’ is that anti-vaxxers ‘drive me nuts’. Compulsory vaccination is a sensitive and difficult topic, and deserves better than this.
Though British paediatricians are resisting calls for compulsory vaccination, public-health authorities and politicians are increasingly inclined towards coercive policies. In the US, where vaccination has long been mandatory for school admission, there are demands for more restrictive conditions for exemptions (allowed in various states on religious and ‘philosophical’ as well as medical grounds). From California to Calabria (1), vaccination policies have become another battlefield in the Culture Wars.
In examining the clamour for more coercive vaccination policies, I’ll first question some of the assumptions underlying the current measles controversy, distinguishing the particular conditions that prevail in Western countries. And I’ll then turn to consider a remarkable transformation in public opinion: whereas 10 or 15 years ago, anti-vaccination campaigners enjoyed mainstream approval, today they are targets of official condemnation and popular abuse. How is this transformation linked to the major political shift of the past decade – the rise of what are widely disparaged as ‘populist’ movements in both Europe and the US? Though the number of parents who reject vaccination for their children is small, doctors need to engage with their concerns if we are to boost herd immunity to preventable diseases. How best to respond to the challenge of ‘vaccine hesitancy’?
Crisis? What crisis?
The American science journalist Daniel Engber has argued persuasively that there is no major measles crisis, no significant decline in vaccine uptake and no evidence of a substantial increase in the influence of anti-vax campaigners. His argument is largely based on the experience of the US, but it is also broadly true of the UK and most of Europe. In most Western countries, there have been outbreaks of measles in recent years but these have generally been fairly small and localised. In Europe there have been larger outbreaks in Ukraine, where programmes have been disrupted by civil war, in countries such as Greece and Serbia, where there has been a substantial influx of refugees, and in some former Soviet bloc countries, such as Romania and Poland, where people are distrustful of government and public-health services have deteriorated. There was a spike in measles cases in England in 2018: up to 966 from 259 the previous year. But this was still lower than in 2011 (1,068), 2012 (1,912) and 2013 (1,413). It is also important to recognise that, though measles is not a trivial disease, nor is it a very serious one: in generally healthy populations it carries a mortality rate of less than 0.1 per cent and a rate of hospital admission with complications of around 10 per cent.
Uptake of the combined measles, mumps and rubella vaccine (MMR) has, in general, proven remarkably resilient over the past two decades. The MMR/autism scare caused a transient fall in coverage in the early 2000s (of about 10 per cent in the UK and 1.5 per cent in the US). Since then, uptake has recovered in both countries to reach prior levels of around 91 to 92 per cent (2). Though coverage has fallen by around 1.5 per cent since 2013, in 2016 measles was declared ‘eliminated’ in the UK – which means that the virus is no longer circulating and outbreaks only occur through transmission from abroad. The MMR/autism scare had little impact in western and northern Europe, where national vaccination levels are generally around the target of 95 per cent that is believed to guarantee ‘herd immunity’. There is a longstanding and well-recognised problem of localised pockets of low uptake (among immigrants and refugees, nomads and travellers, religious minorities and other marginalised groups) and it is among these communities that outbreaks tend to occur. Though these outbreaks may attract more publicity, it does not appear that they are becoming any more common, any larger in scale or any more of a threat to mainstream populations.
There is no good evidence of an impending measles crisis in the UK, and no good evidence of populist influence on MMR uptake
The perception that anti-vax campaigners are gaining influence arises from their high profile on social media. This has been attributed in part to ‘trolls, bots and content polluters’, some linked to malign ‘fake news’ agencies based in Russia. While there are claims that such sources of misinformation are contributing to a mood of ‘vaccine hesitancy’, there is little evidence that this has had any direct effect on vaccine uptake. In June 2008, actress and popular author Jenny McCarthy and her then partner Jim Carrey led an anti-vaccination rally in Washington, and gained much mainstream media publicity. Such campaigning activities have receded over the past decade and certainly no longer enjoy such celebrity and media endorsement.
The rise of the anti-anti-vaxxers
One indication of the changing climate of public opinion in relation to MMR is the dramatic reversal in fortunes experienced by former research gastroenterologist Andrew Wakefield, who instigated the MMR/autism panic in 1998. In the early 2000s, Wakefield was the darling of the British media, the subject of fawning colour-supplement profiles and the focus of newspaper features supportive of his theories. In 2003, a TV docudrama, Hear the Silence, featured screen stars Hugh Bonneville, as the caring, listening Dr Wakefield, and Juliet Stevenson, as the mother of a boy with autism and an adoring adherent of the anti-MMR campaign. Two decades on from the publication of his notorious (and now withdrawn) Lancet paper, Wakefield has been struck off the medical register and now continues to promote his discredited theories with the support of fringe journalists and conspiracy theorists in the US. Whereas his earlier film was shown on primetime TV, his latest – Vaxxed: From Cover-Up to Catastrophe – was withdrawn from a New York film festival in 2016 after widespread protests and, yet to find a distributor, has been seen only by private audiences. Having largely avoided challenging Wakefield when he was riding high, academic commentators now compete to find the most pejorative terms in which to condemn him and his works. He is ‘a money-grubbing fraudster’ according to immunologist Michael Kinch (3). Vaccine specialist Peter Hotez dismisses Vaxxed as ‘compelling, convincing and total bullshit’, a ‘blatantly dishonest and exploitative piece of nonsense’ (4). As a disgraced celebrity, Wakefield’s attendance at one of President Trump’s inaugural balls, and his romantic association with a former model, attracted only derision.
In the early 2000s, paediatricians and vaccine experts who spoke out in support of the childhood-immunisation programme in both the US and the UK received gratuitous abuse from anti-vax activists. Autism specialists who questioned the notion of an ‘autism epidemic’ caused by vaccines were accused of ‘epidemic denial’. When the Wall Street Journal published a critical commentary on the anti-vax campaign in February 2004, journalists were threatened and accused of being ‘baby killers’ and ‘compared to Hitler’.
In the early 2000s, Andrew Wakefield was the darling of the British media, the subject of fawning colour-supplement profiles and the focus of newspaper features supportive of his theories
Today, the shoe is on the other foot. Aaronovitch blames ‘quacks and conspiracy theorists’, ‘fraudsters and ideologues’ for the growth of ‘vaccine hesitancy’, and condemns anti-vaxxers as ‘back to nature fanatics’. As Engber observes, in the US anti-vaxxers have become ‘a tiny and reviled group’, though they have been ‘puffed as more influential than they really are’. In the Democratic party ‘anti-anti-vaxxers’ have become ‘the most agitated’ voting bloc in their demands that prospective presidential candidates toe the pro-vaccination line. When Pete Buttigieg, mayor of South Bend, Indiana and aspiring Democratic candidate, appeared to equivocate over vaccination policy, the only question for party pro-vax zealots was, ‘Are you with us or against us?’.
Why all this consternation?
Given the ‘minimal impact’ of measles on US public health (causing a number of deaths comparable to that caused by scorpions over the past decade), Engber asks, ‘what’s the point of all this consternation?’. He wonders whether it is all ‘just another way to slake an endless thirst for outrage’. It is clear that the explanation is not to be found in the epidemiology of measles but in the upheavals that have shaken the political mainstream of Western societies over the past decade – Brexit, Trump and the ‘populist’ upsurge in Europe. This revolt of the masses against the elites has provoked an angry backlash from all sections of the establishment. Given the evident incapacity of established parties to produce a coherent political response to this new era, elite rage has been displaced from the sphere of politics into the realm of culture and society. The Times feature, linking support for populist parties in Italy to the apparent increase in anti-vax sentiment, blames this on a wider outlook that ‘despises elites and experts’. The Guardian’s health editor agrees, linking the rise in measles cases in Europe to ‘populism, anti-establishment anger, suspicion of authority, the questioning of science and rejection of the whole idea of the good of the community’.
Elite commentators misinterpret the popular rejection of technocratic government as the rejection of science and expertise in general. Voters are suspicious of government ministers who claim the authority of scientists and economists for political decisions. But because people reject the political exploitation of expertise does not mean that they reject the advice of doctors and scientists in relation to matters of health. The figures suggest that, for the vast majority of parents, hesitancy does not carry over into a refusal to have their children vaccinated. Yet ‘hesitancy’ is repeatedly referred to as if it amounts to vaccination refusal.
In fact, the relationship between political outlook and vaccination decisions is complex. It is widely recognised that, in the US, the anti-vax outlook draws support from both liberal environmentalists and right-wing libertarians. One study claims ‘a highly significant positive correlation’ between voting for populist parties in the 2014 European election and ‘vaccine hesitancy’, as reflected in surveys carried out by the Vaccine Confidence Project (5). This trend was not reflected in the results of the 2019 European elections in the UK. Vaccine uptake (a more robust indicator than expressions of ‘hesitancy’) was at its peak (95 per cent) in the North East, where support for the Brexit Party was highest, at 38.7 per cent of voters, and lowest in London (87 per cent) where the Brexit Party won its lowest share of the vote, 17.9 per cent. It is true that opportunist politicians in Italy (Matteo Salvini and Beppe Grillo), France (Marine LePen) and elsewhere have endorsed anti-vax sentiments. But there is nothing new in this: in the early 2000s, Labour’s Ken Livingstone and Tory MPs Julie Kirkbride and Liam Fox endorsed the anti-MMR campaign, while in California Arnold Schwarzenegger backed the campaign against vaccines containing the mercury-based preservative thimerosal. There is little evidence that these postures had much impact on vaccine uptake – or indeed that they yielded much political benefit.
As Engber observes, ‘we love to hate anti-vaxxers’ and they have become a convenient target for opprobrium. Behind the attacks on anti-vaxxers lurks the familiar condescension towards the masses that characterises liberal condemnations of supporters of Brexit or Trump. Those who question vaccination policy are also disparaged as dupes of ‘fake news’ and social-media manipulation, by what Aaronovitch characterises as ‘a toxic blend of misplaced religious faith and a rejection of modern science and medicine’. They are dismissed, as Engber puts it, as ‘dumb, wrong, misinformed and selfish’ – just like Leave or Trump voters.
For Heidi Larson, director of the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine, the major challenge to immunisation policy is that ‘there’s much more questioning by the public and by health professionals as well’. Her main emphasis in dealing with this ‘tsunami of questions’ is on measures to curtail the circulation of anti-vax propaganda on social media. But if parents are asking questions – even ‘challenging’ professionals with ‘internet evidence’ about immunisation policy – then they are entitled to answers from those who want to persuade them to present their children for vaccination. They are not likely to be reassured by attempts to censor discussion on social-media platforms, or by measures to make vaccination compulsory.
Some scientists and public-health authorities believe that all that is required is to counter disinformation with accurate information. ‘As a scientist’, writes Michael Kinch, ‘I believe ignorance is best countered with facts’ (6). He has a faith in facts to rival Charles Dickens’ utilitarian headmaster Mr Thomas Gradgrind. Kinch is a modern scientist but an old-fashioned snob. He believes that ‘overcoming this ignorance should be a comparatively easy task, as the primary population from which the anti-vaxxers are usually drawn is not from the inner city or rural countryside, but rather comprises educated and comparatively wealthy individuals’. Well, good luck with that! British public-health academics Martin McKee and John Middleton similarly propose that ‘inoculating the public with the facts before disinformation takes hold may be effective’. One afternoon in a baby clinic would be enough to dispel such simplistic views. The likes of Kinch, McKee and Middleton fail to grasp that the interpretation of information is always influenced by moral and cultural values and takes place in the context of social relationships.
Doctors experienced in implementing child immunisation programmes emphasise the need for practical organisational measures rather than compulsion. ‘Before considering mandatory vaccination’, argue paediatricians Helen Bedford and David Elliman, ‘we should rectify some of the infrastructure problems’. Their list includes ensuring an immunisation lead in every GP practice, adequate ‘call-recall’ systems, family-friendly settings and session times, and staff training. Other problems include shortages of GPs, nurses and health visitors and difficulties in data collection.
In common with other coercive or paternalistic state policies, compulsory vaccination devalues the independence of the mature citizen with infantilising consequence
The great merit of Jennifer Reich’s sociological investigation into ‘why parents reject vaccines’ is that she has actually spoken to some parents and tried to understand the range of views that underlie vaccine hesitancy (7). She traces much of the contemporary anxiety about vaccines to the prevailing culture of individualistic parenting, which privileges parental – particularly maternal – choice. Parents’ conviction that it is necessary to protect their vulnerable infants from a wide range of potential environmental threats – including vaccines – dominates their outlook. Many such parents are mistrustful of Big Pharma and Big Government, and resistant to policies that restrict their individual rights and liberties.
Reich boldly seeks to find middle ground between pro- and anti-vaxxers, by emphasising the value of immunisation to communal wellbeing. She proposes that, rather than promoting vaccines on the grounds of their benefits to the individual, public-health authorities should emphasise the responsibility of the individual to the collective. Maintaining high levels of herd immunity to measles protects not only individuals who have been vaccinated, but also those who, because of compromised immunity, cannot receive the MMR vaccine. She counsels that health authorities should ‘own uncertainty’, acknowledge concerns about risks and accept greater transparency in vaccine policy. Her proposals for tackling the issue of profit incentives and the revolving door between pharma and regulatory agencies inevitably have a more perfunctory character. Her concluding calls ‘to eradicate the culture of mother-blaming’ and for a ‘kinder landscape’ in this area will have a wide resonance, though seem unlikely to be realised in the near future. Nevertheless, her approach, echoing that of Sussex University lecturer Ohid Yaqub and colleagues, who also recognise the need to build trust through ‘more engagement and dialogue’, suggests a more positive way forward than threatening parents with the law or bludgeoning them with the Facts.
The case against compulsion
Compulsion is unnecessary and may be counterproductive.
Measles is not a serious disease among healthy populations in Western countries, where it has low rates of mortality and morbidity. In recent years, outbreaks have been small and localised so the risks of exposure and transmission are low. In most of Europe, voluntary policies and well-organised public-health services have sustained high levels of uptake. Though anti-vax propaganda may be more accessible on social media, there is little evidence that it has had a significant impact on coverage.
The problem of localised pockets of low uptake is best tackled through well-resourced and sensitively organised local initiatives and measures to ensure that immunisation programmes are readily accessible and supported by an efficient primary-care infrastructure. Just as continuing compulsory smallpox vaccination in the face of a dramatically declining prevalence of the disease in the late 19th century provoked widespread popular resistance and non-compliance, so compulsory MMR vaccination could have similar effects.
Mandatory vaccination requirements for admission to childcare or school may deprive children of access to educational opportunities. This may have particularly adverse consequences for children of parents who cannot readily afford alternatives. Fines or loss of benefits are likely to have a disproportionate impact on lower-income families. School or preschool mandates may also have the effect of encouraging parents to delay vaccination until their children are due to attend such facilities, depriving them of protection through much of their infancy, when they are at greatest risk.
Compulsion impairs moral autonomy.
If parents are forced by law to have their children vaccinated, this deprives them of the moral autonomy to make their own decisions, both in what they consider to be in the interests of their own child and in the interests of society. Compulsion does not enhance individual responsibility but diminishes it. In common with other coercive or paternalistic state policies, compulsory vaccination devalues the independence of the mature citizen with infantilising consequences.
There may be pragmatic arguments in favour of compulsory vaccination, as there are for other coercive public-health policies, such as car seatbelts, motorcycle helmets, smoking bans. Yet the cumulative effect of such measures is to undermine people’s independent judgement and decision-making capacity, to the detriment of the individual and of society.
Compulsion corrupts public life.
Rather than opening up public discussion over immunisation policy, compulsion renders it superfluous as the state seeks only to enforce a policy decided by politicians and public-health authorities. It marks a further elevation of a technocratic state over a servile citizenry and the further intrusion of the state into the private life of the individual and the family, undermining parental authority.
Decisions over vaccination formerly taken by parents and families in consultation with nurses and doctors will be shifted into the realm of the legislature and the courts. While public debate about vaccination is curtailed by expert diktat, democratic accountability of government is diminished and relations of trust with health professionals – who will be expected to play a role in enforcing these policies – will inevitably be damaged.
(1) ‘Vaccination Policy in Italy: an Update’, by Stefano Crenna et al, Journal of Public Health Research, 2018; 7(3):1523
(2) See MMR and Autism: What Parents Need To Know, by Michael Fitzpatrick, Routledge, 2004
(3) See Between Hope and Fear: A History of Vaccines and Human Immunity, by Michael Kinch, Pegasus, 2018
(4) See Vaccines Did Not Cause Rachel’s Autism: My Journey as a Vaccine Scientist, Paediatrician and Autism Dad, by Peter Hotez, John Hopkins University Press, 2018
(5) ‘Populist politics and vaccine hesitancy in Western Europe: an analysis of national-level data’, by Jonathan Kennedy, European Journal of Public Health, 29 (3) 512-516, June 2019
(6) See Between Hope and Fear: A History of Vaccines and Human Immunity, by Michael Kinch, Pegasus, 2018
(7) Calling the Shots: Why Parents Reject Vaccines, by Jennifer A Reich, New York University Press, 2016
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