The fear of the spread of measles is now swamping the fear of vaccines. Sadly, but predictably, the fear of disease is provoking an overreaction to risk, precisely what the anti-vaccine community is accused of. There are calls in California to completely eliminate personal-belief and religious exemptions for mandatory childhood vaccination. That call, though understandable, is a step too far.
Yes, opting out of childhood vaccination has allowed nearly eradicated diseases to pop back up. And, yes, this threatens more than just those who decline or delay some or all childhood vaccinations because of environmental values, or libertarian values, religious values, conservative mistrust of government or Big Pharma, or just hyper-protectiveness. But the solution need not be to entirely eliminate choice. We just have to reduce the number of people opting out so that enough kids are vaccinated to achieve herd immunity, the level at which enough people are resistant to a disease that it can't spread.
California made opting out harder in 2012 — just not hard enough. Raising the bar isn't difficult to envision. For personal-belief exemptions, we might require parents to provide an essay or letter describing their beliefs, and evidence that they apply those beliefs to how they live. For religious beliefs, people should be required to submit a letter from their priest, rabbi, imam or spiritual leader specifying how their faith precludes vaccination (few do) and evidence that they are living consistent with those religious beliefs. (This is the sort of evidence required in court cases when such conflicts get that far.)
For medical exemptions, a simple note from the doctor isn't enough. There are too many doctors who would either sign a note without any attention (to quickly placate their patient) or who promote non-vaccination or partial vaccination (which, given recommended practice by professional boards, should be challenged as malpractice). Instead, require proof that the doctor has spent 15 to 20 minutes in personal consultation with the parents. One way would be to require evidence of the date and time of the meeting, which can be spot-checked by the local board of health against the doctor's professional schedule.
Economic influence should also be applied. People who drive poorly or who smoke, for example, pay more on their insurance to cover the costs of those higher-risk behaviors. States can encourage insurance companies to do the same thing for the higher risk posed by unvaccinated kids. It is entirely justifiable for government to require insurers to do this. Communities pay enormous costs to control outbreaks.
And here's a big one: Personal-belief exemptions based on rejection of solid scientific evidence about vaccine safety should be rejected outright. School systems have to set policy based on what medical experts recommend. People may disagree with what the evidence says about the minimal risks of vaccines, but school systems are simply not the venue for that fight.
Evidence suggests that making it harder to opt out discourages all but the most adamant from doing so. In Florida, Texas and Minnesota, where the administrative burden of opting out is high, fewer parents do so than in Connecticut, Wisconsin and Missouri, where it's easier. And in some states that have recently made it harder, the opt-out rate has dropped. In Washington state, it went down 25% after parents were required to provide a note from doctors saying they'd been educated on the issue.
The evidence shows that it is not necessary to entirely eliminate exemptions to move vaccination rates toward herd immunity levels. Yet that is the extreme action some legislators are calling for. It's what we tend do when we're afraid. We react with emotion first and careful thought second, sometimes at great societal cost to civil liberties.
Americans willingly accepted the Patriot Act and unprecedented levels of government surveillance in the fearful days after the 9/11 terrorist attacks. The U.S. sent Japanese Americans to internment camps during World War II. When smallpox broke out in the U.S. in the early 1900s, police in several cities raided homes and clubs and forcibly held people down to be vaccinated. Some were quarantined, others handcuffed and vaccinated at gunpoint. The poor and minorities were especially targeted.
These are fearful times, when attention to a relatively small disease outbreak is getting unprecedented attention, fueling wider public awareness of a serious health threat that has been with us for more than a decade — the undue fear of and resistance to vaccines. But the emotional backlash now threatens to carry us too far the other way. We need to do what's best for public health and safety, but in a way that avoids doing serious harm to society in the process.
David Ropeik is the author of "How Risky Is It, Really? Why Our Fears Don't Always Match the Facts" and a consultant on risk perception and risk communication.