"I also understand that parents need to have some measure of choice as well. So that’s a balance the government has to decide.”

-- NJ Governor Chris Christie, February 2, 2015

"The state doesn't own the children. Parents own the children, and it is an issue of freedom."

-- Senator Rand Paul (R-KY), February 2, 2015

Longtime readers know that I lived in central New Jersey for eight and a half years before taking an opportunity to return to my hometown just under seven years ago. Having spent the better part of a decade there, I think I understand New Jersey, at last the northern and central parts of the state. It's a strange state with a lot of corruption and mismanagement. (For instance, I was there when Jim McGreevey was governor, and I even met him before he became governor, back when he was still mayor of the Woodbridge Township and then later when he was governor.) Indeed, while I lived there I had a hard time deciding if Chicago politics was more corrupt than New Jersey politics or vice-versa. I ended up deciding that it was pretty much a wash.

Be that as it may, I can sort of understand why New Jersey elected Governor Chris Christie. He's big—literally. He's boisterous. He's blunt and plain-talking (for a politician), and he gives the impression of not taking any guff from anyone while being relatively moderate politically. All of these are very much part of how Jersey natives appeared to view themselves. (Personally, I don't like him much because I view him as a loudmouthed bully, but I don't live in New Jersey anymore.) As of yesterday Gov. Christie's also a poster child for the political peril of pandering to the antivaccine movement. In fact, I view him as Exhibit A supporting a growing belief that I've been developing that the Republican Party has become the antivaccine party. Wait, maybe that's a little too strong, but certainly it has become the party supporting antivaccine viewpoints more strongly than the Democrats.

Behold how this controversy began. There Christie was, in England on a trade visit, doing the things politicians do to try to bolster their foreign policy credentials in preparation for running for President, and he had to go and put his foot in it with respect to vaccines during a visit to a medical research facility. First, as background, you should know that the night before, Sunday night, President Obama had issued an unequivocal call to parents to have their children vaccinated:

"I understand that there are families that in some cases are concerned about the effect of vaccinations. The science is, you know, pretty indisputable. We've looked at this again and again. There is every reason to get vaccinated, but there aren't reasons to not," the president explained.

And:

"You should get your kids vaccinated. It's good for them, but we should be able to get back to the point where measles effectively is not existing in this country."

So far, so good. You can't expect a much more unequivocal statement of support for vaccination than that from a politician.

So Monday morning it just so happened that Governor Christie was touring MedImmune's research facility in Cambridge. MedImmune just so happens to manufacture a nasal influenza vaccine, FluMist. It's not clear what moved the subject to vaccines, but during the visit, Christie basically took the opportunity that presented itself to pander to antivaccinationists. It was so bad that even the far-right (oh, heck, let's just call it what it is, namely wingnut) website Breitbart.com described it thusly:

New Jersey Governor Chris Christie’s outreach to the anti-vaccination crowd is one of the strangest things anyone has done during the 2016 shadow primary season. In the midst of a significant outbreak of preventable, communicable diseases among children, Christie decided to throw anti-vaxxers a bone, making President Obama look enormously sensible by comparison.

So what did Christie say that annoyed even Breitbart.com's correspondent? This:

“All I can say is that we vaccinate ours. I think it’s much more important as a parent than as a public official, and that’s what we do,” he told reporters during his trip through London on Monday. He went on to say that’s “part of making sure we protect their health and public health.” “I also understand that parents need to have some measure of choice as well. So that’s a balance the government has to decide,” Christie added. Asked whether he was advocating leaving parents the option to not vaccinate their kids, Christie said “I didn’t say I’m leaving people the option,” but that “it depends what the vaccine is, what the disease type is and all the rest.”

Oh, dear. Whether Christie realized it or not when he said these words, which must have seemed to him at the time to be an eminently reasonable attempt to describe balancing personal freedom versus public health, he was, as Breitbart.com put it, "throwing antivaxxers a bone." Of course, he was also doing this at the worst possible time. Think about it. Here we are in the middle of a measles outbreak that's cracked 100 cases, an outbreak in which the majority of cases were not vaccinated, indeed an outbreak that almost certainly wouldn't have happened if there weren't pockets of unvaccinated children in southern California near Disneyland, and Gov. Christie's blathering about vaccine "choice." His sense of timing is impeccable in its wrongness.

He also revealed himself to have an uncanny ability to demonstrate in a couple of sentences that he doesn't understand issues of public health with respect to vaccines. After all, parents already do have "vaccine choice." There is no such thing as "forced vaccination" in this country, no matter how much the antivaccine movement likes to try to characterize it this way. Rather, what we have in this country are school vaccine mandates. It's very simple, so simple that even Gov. Christie should be able to understand it. No parent is forced to vaccinate her child for anything, but if the parent makes that choice the child will not be allowed to enroll in school or day care. It's an eminently reasonable compact: You don't have to vaccinate, but you don't have the right to let your child endanger others. It's a system that has served us well for many years. It's less coercive than actual forced vaccination, which inevitably produces a really nasty backlash, but it still functions well to maintain high levels of vaccination in most cases.

That is, until the rise of various non-medical exemptions.

If you've studied vaccination policies, you know that every state allows medical exemptions. That is how it should be. However, there are non-medical exemptions as well. For instance, every state other than West Virginia and Mississippi allows religious exemptions to school vaccine mandates. Yes, I know it's odd that West Virginia and Mississippi would be leading the nation in rational vaccine policy, but there you have it. Of course, few religions have a problem with vaccination; certainly with only rare exceptions is vaccination against a religion. So religious exemptions tend to be uncommon (although antivaccinationists are not above teaching parents how to lie about their religion in order to obtain religious exemptions).

That's why antivaccinationists are becoming increasingly fond of personal belief exemptions or, as they are also sometimes called, philosophical exemptions. Currently 20 states permit these exemptions. Basically, these exemptions are granted based on parents' personal beliefs against vaccines, be they personal, moral or other beliefs. In essence, all a parent has to do is to say she doesn't believe in vaccinating, and the exemption is granted. True, different states have different requirements, but in all too many states such exemptions are far too easy to obtain. Indeed, that's why California recently passed a bill to make it harder to obtain personal belief exemptions by requiring parents requesting them to have a health care professional sign the form certifying that he's counseled them about the risks of skipping vaccination, although Governor Jerry Brown basically neutered the law through a signing statement. In any case, in at least 20 states, parents can obtain exemptions to vaccine mandates, with varying degrees of difficulty in doing so, simply by saying that they "don't believe" in vaccinating or have some sort of moral or personal objection to vaccination. It is these personal belief objections that have led to pockets of low vaccine uptake and subsequent outbreaks, such as the ones in California and, alas, my own home state.

So right in one interview, Gov. Christie showed that he doesn't have a clue about vaccine mandates, but worse, that he's willing to pander to those holding antivaccine beliefs.

Of course, if you've been following the story, you know that Gov. Christie started feeling the heat over his ill-advised remarks almost instantly. Twitter erupted in righteous fury mocking Christie's remarks. In particular, his willingness to quarantine a nurse who might have been exposed to Ebola without medical justification was contrasted unfavorably with his love of "choice" and "freedom" with respect to vaccines. So great was the backlash that Christie's office scrambled to "clarify":

New Jersey Gov. Chris Christie walked back comments he made here Monday morning calling for "balance" on the measles vaccine debate to allow for parental choice, asserting that "there is no question kids should be vaccinated." "The Governor believes vaccines are an important public health protection and with a disease like measles there is no question kids should be vaccinated," Christie's office said in a statement. "At the same time different states require different degrees of vaccination, which is why he was calling for balance in which ones government should mandate."

And:

Christie, however, said, “There has to be a balance and it depends on what the vaccine is, what the disease type is, and all the rest.” He added, “Not every vaccine is created equal and not every disease type is as great a public health threat as others.”

This is, of course, a clarification that doesn't clarify, empty words that say almost nothing, other than that kids should be vaccinated against measles. "Balance"? What does that mean? Does Christie think himself more capable of balancing risks and benefits in determining what vaccines should be recommended than the CDC and American Academy of Pediatrics? Does he think himself more qualified to determine which diseases are a sufficient public health threat to warrant a mass vaccination campaign than medical authorities? How would he judge which diseases are sufficiently threatening? What criteria would he use? Based on what science?

Unfortunately, Gov. Christie wasn't the only one laying down the antivaccine pandering. In fact, compared to Rand Paul, Christie is virtually the voice of reason. See what I mean:

Paul, in comments on conservative talk-radio show host Laura Ingraham's show Monday, said he's "not anti-vaccine at all." "But particularly, most of them ought to be voluntary," he added. Paul cited incidents where you have "somebody not wanting to take the smallpox vaccine, and it ruins it for everybody else." "I think there are times in which there can be some rules, but for the most part it ought to be voluntary," Paul went on. "While I think it's a good idea to take the vaccine, I think that's a personal decision for individuals to take." He also said he was "annoyed" that his kids were supposed to receive the Hepatitis B vaccine as newborns, and that he had doctors space out the 10 vaccines they wanted to give his infant children over time. And in a later interview with CNBC, Paul suggested he had seen the negative effects of vaccines that those in the anti-vax movement cite in their opposition. None, however, are widely supported by the scientific community, and Paul's office did not respond to a request for comment for details. "I've heard of many tragic cases of walking, talking, normal children who wound up with profound mental disorders after vaccines," Paul said. "I'm not arguing vaccines are a bad idea. I think they're a good thing. But I think the parents should have some input."

Rand Paul is another sad excuse for a physician. Remember how I described antivaccine "dog whistle" terminology that "Dr. Bob" Sears was so adept at using? Rand Paul is doing exactly the same thing here. He's using the same appeal to "freedom" as Dr. Bob, and that "annoyance" he expressed at the neonatal dose of hepatitis B vaccine reveals an ignorance that he could easily have remedied with a little reading; you know, that thing we doctors do when we encounter a medical issue with which we are not familiar. Dr. Paul is, after all, an ophthalmologist, and ophthalmologists do not routinely administer vaccinations, much less childhood vaccinations. Indeed, he has even less reason to be familiar with childhood vaccines than the ever-vile Dr. Jack Wolfson who, being a cardiologist, would be expected to offer at least the pneumococcal vaccine to his heart failure patients. As I mentioned before, administering the hepatitis B vaccine at birth is a very reasonable strategy for preventing hepatitis B, and that moralistic trope about its being a sexually transmitted disease is not a reason not to vaccinate newborns.

And Rand Paul also seems unaware that we do not have forced vaccination and that parents do have in put. If they didn't have the choice, with easy personal belief exemptions allowing parents in 20 states not even to have to choose between public school and vaccines, it's unlikely that outbreaks would be a problem.

I once described how antivaccinationism is very much at home with libertarianism, to the point where many libertarians express a view recently espoused by Dr. Jack Wolfson that it is not their responsibility to vaccinate, that they have no obligation to society, so much so that they reacted rather violently when one of their own, Ron Bailey of Reason.com, advocated coercive vaccine mandates. Rand Paul is simply dog whistling from that very playbook. Indeed, check out this interview given later in the day:

You don't have to watch all nine minutes; that is, unless you want to. Just watch the first 2:20 minutes of the video, which is all about vaccines. Notice how he starts out clearly sarcastic, replying early on, ""I guess being for freedom would be really unusual." No, Dr. Paul, being "for freedom" is not unusual, but spouting antivaccine nonsense about vaccines causing permanent neurological injury is unconscionable. Personally, I think Paul's most telling remark comes near the end of the vaccine segment, when, clearly irritated by the reporter's insistence on pursuing questions about vaccine choice, Rand Paul replies with petulant annoyance, "The state doesn't own the children. Parents own the children, and it is an issue of freedom." Yes, it's the antivaccine dog whistle about "freedom," but it's more than that. See what Rand Paul let slip? It's an attitude that is all too common, namely that the parents own the children and that parental "rights" trump any rights children might have as autonomous beings. The right of the child and any public health considerations are subsumed to parental "freedom to choose" and "parental rights," with children viewed, in essence, as their parents' property, to do with as they will.

As for the rest of the interview, it's the same old antivaccine dog whistles on steroids. There's the antivaccine trope against the birth dose of hepatitis B vaccine as being not indicated because it's a sexually transmitted disease, even though hepatitis B is transmitted by more than just sex. The trope is an obvious ploy to outrage parents by telling them that they're being "forced" to have a vaccine for a sexually transmitted disease as though they were immoral. We also learn that Paul delayed vaccines for his children, thus leaving them vulnerable to childhood diseases longer than they needed to be, just like many vaccine averse. Indeed, I'd be very interested in knowing what vaccine the Pauls gave their children and at what ages. He even repeats his claim that vaccines cause neurologic injury, even though, as a physician, he should know damned well that this question has been studied time and time and time again, with the overwhelming scientific consensus being that vaccines do not cause autism, neurodevelopmental disorders, or "profound mental disorders." And through it all, to Paul vaccine "choice" is all about "freedom."

Oh, and his selective reading of the history of smallpox vaccination as being "voluntary" throughout most of our history is telling as well. He neglects to note that, as History of Vaccines notes, the Supreme Court has consistently ruled that the state has the power to make vaccines mandatory.

Is it any surprise that Rand Paul is a prominent member of the American Association of Physicians and Surgeons (AAPS), the organization of "brave maverick physicians" that has a history of promoting the lie that shaken baby syndrome is a misdiagnosis for "vaccine injury" and extreme libertarian views, such as the view that Medicare is unconstitutional?

In any case, as a result of Christie's and Paul's statements, this story has even hit the national news. For example:

Antivaccinationism is often presented and criticized as a belief that arises primarily among crunchy, affluent liberals. Even The Daily Show makes that mistake. In fact, existing evidence suggests that the prevalence of antivaccine views are very similar on the left and the right, or, as I like to say, antivaccine views transcend politics.

However, the roughly equal prevalence of antivaccine views on the left and right do not mean that both parties are equally good (or bad) when it comes to vaccines. Over the last several years, I've noticed that antivaccine views, supported under the rubric of "freedom," have grown in prominence more in Tea Party and conservative circles. Antivaccine views are very much intertwined with the "health freedom" movement, which tends to be primarily (but certainly not exclusively) a product of right wing circles, given its emphasis on freedom from government regulation and mandates with respect to health. Indeed, it is no coincidence that my one experience watching Steve Novella debate antivaccine physician Julian Whitaker occurred at FreedomFest in 2012, a yearly conservative/libertarian confab that happened to be going on in Las Vegas as TAM that year. Also that same year, the Texas Republican Party had strong "health freedom" and "vaccine choice" planks in its party platform, planks that were still there in 2014.

I don't think that Gov. Christie is antivaccine (although I'm not so sure about Rand Paul). What I do know is that the conflation of "choice" with vaccination has led to a powerful incentive for politicians, particularly Republican politicians, to pander to antivaccine views. Nor is pandering to the antivaccine movement a new thing for Christie. In 2009 he met with Louise Kuo Habakus (whom we've met before) and the NJ Coalition for Vaccine Choice, a very much antivaccine coalition whose member organization list reads like a who's who of the national antivaccine movement and includes Life Health Choices, an antivaccine organization founded by Habakus. Indeed, Habakus herself is coauthor with antivaccine lawyer Mary Holland of a book entitled Vaccine Epidemic: How Corporate Greed, Biased Science, and Coercive Government Threaten Our Human Rights, Our Health, and Our Children. Indeed, so prominent an antivaccine loon is Habakus (at least in New Jersey, if not nationally), that she has her very own entry in the Encyclopedia of American Loons. To these people, Christie followed up his visit with a letter, quoted thusly:

“I have met with families affected by autism from across the state and have been struck by their incredible grace and courage,” Christie wrote in the letter. “Many of these families have expressed their concern over New Jersey’s highest-in-the nation vaccine mandates. I stand with them now, and will stand with them as their governor in their fight for greater parental involvement in vaccination decisions that affect their children.”

Indeed, Republicans and Independents are more prone to oppose vaccine mandates:

Republicans and independents are more likely than Democrats to advocate against required vaccinations. Thirty-four percent of Republicans and 33 percent of independents told pollsters that parents should be able to decide about vaccinations, versus just 22 percent of Democrats who said the same. And, within the past five years or so, Republicans have become LESS likely to say vaccinations should be required, while Democrats are now MORE likely to advocate for the mandatory shots. In 2009, 71 percent of both Democrats and Republicans said vaccinations should be required. By last August, that number decreased to 65 percent for Republicans, but it's increased to 76 percent for Democrats.

Not only do antivaccine views fit in nicely with libertarian and Tea Party political beliefs, but such views have become so conflated with "freedom of choice" that it's become worth it to Republican politicians to espouse these views, or at least to give a nod to them in order to curry favor. It's not universal, of course. Another Republican physician running for office who is known for saying stupid things about other issues actually has come out strongly supporting vaccine mandates. Yes, believe it or not, Ben Carson did just that. Still, he seems to voicing a less common view within the base of the Republican Party.

I noted back in 2008 that both Barack Obama, Hillary Clinton, and John McCain had, to one degree or another, pandered to the antivaccine movement. Now, in 2015, what we see here appears to be a rising tide of support for "vaccine choice" among Republicans, with a concomitant decrease in support for vaccine mandates, while among Democrats, it would seem that the opposite is happening. Yes, the Democrats have Robert F. Kennedy, Jr, and he is indeed an antivaccine loon, but you don't see major Democratic candidates pandering to antivaccine views the way Rand Paul did and Chris Christie recently did, nor do you see major liberal confabs staging debates with antivaxers, as happened at FreedomFest.

Maybe the Republican Party really is becoming the party of the antivaccine movement. If that's true, it is very bad news indeed.

ADDENDUM: This morning the New York Times published a story entitled Measles Proves Delicate Issue to G.O.P. Field. While noting that it isn't a clean left-right break and that there are pro-vaccine Republicans (such as Scott Walker), the NYT also notes: