As long as there have been vaccinations, there has been an antivaccine movement, and as long as there has been an antivaccine movement, there have been parents who refuse to vaccinate. In a past that encompasses the childhood of my parents, polio was paralyzing and killing children in large numbers in yearly epidemics, the fear of which led to the closure of public pools every summer. In such an environment, the new polio vaccine introduced by Jonas Salk in the mid-1950s wasn’t a hard sell. In fact, satisfying the initial demand for it was the problem, not parents refusing to vaccinate their children. Since then, more and more vaccines have been developed to protect more and more children from more and more diseases, to the point where the incidences of most vaccine-preventable diseases is so low that, unlike 60 years ago, most parents today have never seen a case or even known other parents whose child suffered from a case. Even as recently as the 1980s, Haemophilus influenza type B was a dread disease that could cause meningitis, pneumonia, sepsis, and death. Since the introduction of the the Hib vaccine a mere quarter century ago, Hib has been virtually eliminated. Most pediatricians in residency now have never seen a case.

As much of a cliche as it is to say so, unfortunately vaccination has been a victim of its own success, at least in developed countries. Parents no longer fear the diseases childhood vaccines protect against, which makes it easy for antivaccine activists to provide what I like to call “misinformed consent,” by spreading misinformation that vastly exaggerates the risk of vaccines compared to the benefit of vaccinating. Basically, parents who believe the misinformation conclude, based on a warped view of the risk-benefit ratio of vaccines, that not vaccinating is safer. Add to the mix fear mongering against the MMR based on Andrew Wakefield and his dubious 1998 case series that popularized the then-recent idea that vaccines cause autism, and it’s no wonder that parents decide that not vaccinating is safer than vaccinating. If you believe the misinformation, it’s not an entirely unreasonable conclusion. Then add to that the easy availability of “personal belief exemptions” to school vaccine mandates in many states, which include anything from religious exemptions to parents just signing a form that says they are “personally opposed” to vaccination, and it isn’t a huge surprise that vaccine uptake has fallen in some areas to the point where outbreaks can occur. It was happening in California and my own state of Michigan.

The question then becomes: What to do about it? This question always brings up hard questions about how far the state should go to encourage vaccination, and that’s what this post is about, prodded by a recent article on Slate.com advocating mandatory vaccination for all children written by two pediatrics residents, Dr. Phoebe Danziger and Dr. Rebekah Diamond. This lead me to ask the question: Should vaccines be mandatory? Basically, mandatory vaccination of the sort described by Danziger and Diamond would represent a major change in policy. In the US, the general strategy to encourage adherence to the CDC-recommended vaccination schedule does not rely on making vaccines mandatory for all children, but rather requiring certain vaccines as a precondition for enrollment in day care centers and public schools. Basically, the idea is that parents don’t have to vaccinate, but if they choose not to there will be consequences and measures taken to lessen the risk of outbreaks due to their refusal to vaccinate. You might think this is a distinction without a difference in that most children go to public schools, but in reality it is a clever compromise between individual liberty and responsibility to one’s community. Included in this compromise are nonmedical exemptions, specifically religious exemptions and so-called “personal belief exemptions,” which basically boil down to parents saying that vaccinating their children conflicts with a “strongly held personal belief.” As long as nonmedical exemptions were uncommon and the number of unvaccinated children small, there wasn’t a major problem. However, over the last couple of decades, the number of unvaccinated children has increased, and those children’s parents tend to cluster, facilitating outbreaks of vaccine-preventable diseases, particular the highly contagious ones like measles and whooping cough.

One strategy to counter this tendency, initially tried, for example, in California and Michigan , has involved keeping nonmedical personal belief exemptions but making them more difficult to obtain. In California, a law (AB 2109) was passed that required parents seeking personal belief exemptions to have a physician sign the exemption certifying that he had counseled the parents on the benefits and risks of vaccines and the dangers of not vaccinating. In Michigan, parents were required to go to a local health department office to sign their waver, which would not be permitted until they had undergone a brief state-mandated education session with a local health official educating them on, yes, the benefits and risks of vaccines and the dangers of not vaccinating. At this point, there were only two states that didn’t allow nonmedical exemptions, West Virginia and Mississippi.

Then came the Disneyland Measles outbreak a year and a half ago. In response, California passed SB 277, a law that, as of July 1, 2016, eliminated all nonmedical exemptions. The battle over SB 277 has been vociferous and reignited the argument of how far the state should go to ensure the vaccination of children. Not surprisingly, antivaccine activists painted SB 277 as incipient fascism, a horrific violation of parental rights, and “forced vaccination.” Also not suprisingly, a cottage industry of quacks and antivaccine-sympathetic physicians like Dr. Bob Sears, has sprung up to generate cookie-cutter medical exemptions not based in legitimate science. (More on that later this week.) Still, the basic compact remains in place, even in California: Parents can’t be forced to vaccinate, but if they refuse their children can’t access public schools and certain services, like day care. It’s just that exemptions to that social compact are now much harder to come by in California. Whether other states will follow California’s lead seems doubtful right now; so the current status quo appears likely to remain for the foreseeable future.

Enter Drs. Danziger and Diamond and their Slate.com article The Vaccination Double Standard, which is subtitled: “Despite years of research, there’s no good way to convince anti-vaxxers of the truth. It’s time to make vaccination mandatory for all kids.” It’s a viewpoint to which I’m sympathetic but in the end just can’t bring myself to sign on for. I’ll explain why momentarily, but first there is much in the article that does hit the proverbial nail on the head. For example, Danziger and Diamond start out with the story of a 28 week preemie who was doing well in the NICU with a caring, appropriate, but disadvantaged mother. They describe how “when we were able to reach his mother by telephone in between her work shifts, she was always loving, caring, appropriate, and eager for the day when her son, a perfect illustration of how modern medicine can impact even the tiniest baby’s chance for a long and healthy life, would be ready to come home.” Then, after they rotated off of the NICU, they later heard from their successors as NICU residents that there was a Child Protective Services (CPS) investigation underway because “CPS and the medical team were concerned his mother—young, single, and working two full-time jobs in a town hours away from the hospital while supporting two other toddlers at home—simply could not pull together the resources to be present enough at the hospital to demonstrate her competence and commitment to caring for her baby.” Danziger and Diamond compare this mother as “another example of poor, disadvantaged parents being held to impossible standards” standing in stark contrast to what they view as a case of more serious parental neglect, refusing vaccines.

They note:

We see the mother, who works double shifts at minimum wage to avoid eviction, traumatized by a CPS investigation instigated because she cannot possibly be present at a hospital bedside. We see the family whose incompletely immunized child is refused entry to a school, not because they oppose vaccines but because they lack reliable transportation and predictable time off to receive all the shots. And then we watch parents who willingly expose their children, and society at large, to the real and specific risk of deadly diseases that should have been eradicated long ago—and we kowtow to them. These parents almost always come from privilege, and they are almost never punished for their actions. It seems to us that this reaction is at least partially—and perhaps subconsciously—informed by the fact that they are by and large white, educated, and affluent.

This is, of course, nothing that I haven’t been saying for a long time now. Parents who refuse vaccines are largely privileged, affluent, and white, although, I noted, despicable antivaccine activists like Del Bigtree, Polly Tommey, and Andrew Wakefield sure are trying to persuade disadvantaged African-Americans not to vaccinate too, apparently not caring that not vaccinating will likely impact minorities people much more seriously than their privileged white followers.

Be that as it may, our good pediatrics residents do couch their arguments in a lot of social justice, and, to a large extent, they make good points. Right now, the bulk of the most vocal antivaccine activists are in general white, educated, and affluent. Because they’re educated they’re very good at motivated reasoning, and because they’re affluent they have the resources to cluster in expensive neighborhoods and pay cash-only, antivaccine-sympathetic pediatricians like Dr. Bob Sears.

Drs Danziger and Diamond also correctly note that science is unlikely to persuade antivaccinationists that vaccines are safe, but there’s a problem. Their statements lack nuance and appear (to me at least) to incorrectly lump all antivaccinationists into one group, with all of them being equally unpersuadable. I’ve said it many times before: My message is not aimed at die hard antivaccine parents. Those are the parents Danzinger and Diamond no doubt mean when the write about science not persuading them, but there are, as I like to put it, shades of antivax. They range from the hard-core leaders of the antivaccine movement and Andrew Wakefield’s admirers to parents who are concerned because so many needles are being stuck into the most precious thing in the world to them and they saw some stuff about vaccines on the Internet—and everywhere in between. The former are, with rare exceptions, not persuadable. The latter are very much potentially persuadable.

I also agree that there is a double standard with respect to vaccines:

...we have also decided there is a limit to what parents can choose. Parents must use correct car seats and seat belts for their children; they must care for them in safe homes and provide sufficient food; they must also follow basic medical standards for their children’s health. Thus, there is ample precedent for removing the decision-making capacity from parents who are determined not to act in their child’s best interest. Take, for instance, the 2009 case of this child with leukemia who was successfully treated with chemotherapy on court order against her parents’ wishes, because they believed in “natural” treatment for cancer. And yet, unlike any other aspect of pediatric medicine and child safety, if a parent explains that they have a personal objection to vaccination, they are allowed to deny their children proper care. It is true that some promising laws have been passed, such as California’s SB 277, which eliminates personal belief exemptions. But even these lauded policies have significant loopholes and pitfalls.

As Drs. Danziger and Diamond note with frustration:

We have spent hours explaining to CPS case-workers that it is impossible for the homeless parents of a critically ill infant to simultaneously attend medical rounds, to participate in medical decision-making for their child, and apply for public housing and employment. Then we turn around and treat a purposefully un-immunized child for a serious brain infection caused by vaccine-preventable bacterium—requiring weeks of hospitalization with intravenous antibiotics—and watch his mother continue to refuse vaccines for him or his siblings, and we can’t do anything about it.

I can see the appeal of this argument. I really can. I can see how such an argument could lead to this conclusion:

There is simply no reason vaccinations should be treated differently than any other form of medical care, and they must be protected within the same framework that has been created for child protection and against medical neglect. There are many ethically gray areas of medicine, but this is not one. Our laws must unambiguously and without loopholes reflect this, and there cannot be conflicting standards of child protection based on race, wealth, and education. By continuing to allow exceptions, we are fueling the misconception that vaccinations are an option, a choice, a subjective topic about which people can have different opinions that ought to be respected, when in fact all of the data proves they are not. Enacting a policy that is consistent with the science would provide clarity for the parents—the majority of whom are loving caretakers trying to do the right thing. We are failing our society by creating unequal standards of parenting, and worse, we are failing our children by not protecting their right to be vaccinated against deadly, preventable diseases. Competent parenting must include fully immunizing all children according to the medical standard of care.

While I sympathize with this point of view, I also have a hard time adopting this sort of a plan for the simple reason that I don’t think that Dr. Diamond and Dr. Danziger have thought their position through to its conclusion or clearly thought about what it could lead to. Let’s assume, as appears reasonable based on what they have argued, that what they mean by “make vaccines mandator” is that vaccines administered according to the recommended CDC schedule should be mandatory, barring any medical contraindication of course. If someone made them emperor of the US, have Drs. Danziger and Diamond thought about how they would go about enforcing this policy? It’s easy enough to say that “vaccines should be mandatory” and to castigate antivaccine parents for being privileged, selfish, entitled white people, but laws and policies have to be clearly written, and there has to be an enforcement mechanism, complete with some form of punishment for non-compliance.

The big question is: How far are Drs. Danziger and Diamond willing to go to enforce the “mandatory vaccination” that they liken to medical neglect? Don’t get me wrong, regular readers know that I am as pro-vaccine as anyone; I’ve spent a dozen years combatting antivaccine misinformation I’ve suffered online attacks and attempts to get me fired from my job for my trouble. So I won’t let anyone claim that I’m not sufficiently pro-vaccine. Let’s say, as would arguably be reasonable in a policy of mandatory vaccination, that parents who refuse to comply face an escalating series of consequences or punishments the longer they remain out of compliance. One could imagine, for instance, a series of escalating fines or even potentially jail time. Now, let’s imagine parents who still absolutely refuse to vaccinate. Again, how far are Drs. Danziger and Diamond willing to go? Have they really thought about this?

Again, I don’t think they have, and to illustrate that point I’ll just ask a couple of questions about what they would do in the case of parents who, despite escalating fines and the threat of jail time, still refuse to vaccinate their child. This is not such a far out scenario, either. Just look at all the parents in California talking about moving out of state, home schooling, and in general resisting SB 277. Are Drs. Danziger and Diamond, for instance, willing to allow courts to order forced vaccination and have the police enforce this order? I can’t help but note that in such a case, a lot of physicians would have ethical qualms about being the ones to oversee the administration of vaccines. Or, more relevant to their analogy, are they willing to give CPS the power to remove children from their homes solely because their parents won’t vaccinate them? This is something CPS is exceedingly reluctant to do even in the case of families refusing to treat their cancer-stricken child with standard-of-care chemotherapy and radiation, and in this case the children are perfectly happy. I won’t make the question easy for them, either. Imagine that this is the only problem that CPS finds and that otherwise CPS finds that the parents are loving, supportive, provide all other medical care, do not abuse their children, and are well off? Would they remove a child from a home like that to place him in foster care and be vaccinated? I assume they know just how overburdened the foster care system is and how hard it is to find good placements. Would it really be better to have the child in a the crappy foster care systems in some parts of this country and vaccinated rather than unvaccinated and with their family?

Perhaps Dr. Danziger and Diamond will think I exaggerate, but make no mistake. When they equate failure to vaccinate to medical neglect on par with or even worse than failing to let a child with cancer be treated with chemotherapy, almost any measure is justifiable. I would also remind them that whenever parents refuse to treat their children with cancer with chemotherapy, they make martyrs. Popular opinion rarely favors CPS. I’ve documented this time and time and time again. Consider the case of Sarah Hershberger and Cassandra Callender. Consider Makayla Sault. Consider Abraham Cherrix, whose battle to refuse chemotherapy led the Virginia State legislature to pass “Abraham’s Law,” basically permission for teens over a certain age to refuse medical treatment in favor of quackery.

Now imagine the public reaction if CPS tries to take what appear to be perfectly healthy children away from their parents because their parents don’t vaccinate. While it is true that most people support mandatory vaccination in the abstract, for a significant minority “parental rights” and “health freedom” arguments resonate among the electorate to the point that Republican politicians were pandering to them last year during the primaries, and my home state of Michigan considered a bill to re-loosen nonmedical exemption requirements. How well do you think that would go over? I think you know the answer.

No, Drs. Danziger and Diamond, for all their justified righteous anger, have not thought this through. In fact, taken from a point of view of social justice, whom do you think would be most affected by such a policy of compulsory vaccination? Hint: It won't be the affluent white antivaxers whom they rail against. They have the resources, the social media, and the ability to project a sympathetic picture of themselves that could easily turn them into "health freedom martyrs." We see it every time parents refuse to treat their child with cancer in favor of choosing "natural therapies." Although much less numerous, there are vaccine-hesitant minorities. The African-American community, in particular, has reason to be suspicious of modern medicine. I rather suspect that, as is the case for most issues, enforcement of a compulsory vaccination law would fall disproportionately on minorities and the poor, who are not as able to afford fines and legal representation.

There’s a reason why we don’t have compulsory vaccination in the US. The CDC vaccine schedule is not mandatory. However, we do have school vaccine mandates, which require that children be up-to-date on the their vaccinations before they can attend school or be placed in day care, and all but three states allow nonmedical exemptions, either religious, personal belief exemptions, o The current system of requiring vaccination before children can attend school and day care is actually a reasonable compromise between social responsibility and individual liberty, as long as nonmedical exemptions are not too freely available. In an ideal world, there would be no nonmedical exemptions, and all states would have a law like SB 277—or at least policies like Michigan that make it more difficult to obtain a nonmedical exemption and require parental education. The system we have now, for all its flaws, actually works well, producing high overall vaccination rates, even if there are pockets of vaccine uptake sufficiently low to abrogate herd immunity. Of course, could be improved if additional states would either eliminate nonmedical exemptions or make them harder to obtain. In any case, making vaccination compulsory is a bad idea if it is enforced to its logical conclusion in cases of parents who will not budge and an even worse idea if it isn’t enforced.