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A Community Approach to Health

Sometimes, pushing mandatory vaccination laws through governing bodies may not be the best way to reach the human bodies they’re intended to influence.

Take California’s new law, which has catalyzed a wave of opposition from thousands of state residents. Protestors have been mobilizing, and California’s secretary of state approved an initiative allowing opponents of the bill to gather petition signatures in the hopes of reversing the immunization bill through a referendum vote. State Senator Richard Pan, the pediatrician who authored the bill, has received death threats and may even face a recall election, which might push him out of office.

California’s law—which abolishes exemptions from vaccines for personal beliefs rather than medical necessity—is a good thing. Still, the intense public backlash to it makes it plain that the law is neither popular nor safe from repeal.

Dan Salmon, Deputy Director of the Institute for Vaccine Safety at Johns Hopkins Bloomberg School of Public Health, told me in an interview that he's concerned the law will backfire. He recommends that states considering similar legislation wait to see what happens in California before taking further action.

While Salmon supports efforts to make vaccine exemption laws more stringent, he recently wrote that “getting rid of non-medical exemptions altogether and making mandatory vaccination truly compulsory risks substantial public backlash and could be counterproductive to the ultimate objective of reaching and sustaining high rates of [immunization] coverage and disease control.”

In general, anti-vaxxers oppose immunization legislation that constrains what they see as their individual right to choose how they go about being parents.

And here’s the crux of the problem. When it comes down to it, vaccines are about community, not individuals. Pathogens and the diseases they spread defy our best attempts to define ourselves as singular persons existing in the world as individuals. They remind us that as much as we try to deny it, we are organisms living in a web of organisms, hopelessly, and wonderfully, interconnected. The more we continue to use the rhetoric of individual choice—whether to affirm or combat required vaccinations—the more we lose the thread of why vaccines are one of the backbones of public health.

When a large enough portion of the population is vaccinated against a disease, the phenomenon known as herd immunity prevents outbreaks and protects those who don’t have personal immunity from the illness. Many people have weakened immune systems and are medically unable to be vaccinated. At the heart of the concept of herd immunity must be a society’s commitment to protecting the most vulnerable: the lung transplant recipients, the cancer patients, the infants, and the pregnant mothers.

In her book On Immunity, writer Eula Biss emphasizes the connection between vaccine hesitancy and the misconception that the decision to vaccinate is an isolated individual choice. Biss writes, “When I asked a friend how she would feel if her child contracted an infectious disease and did not suffer from it but passed it to someone more vulnerable who would suffer, she looked at me in surprise. She had not, she told me, considered that possibility.”

Biss reveals that vaccine-hesitant mothers (which she was herself prior to writing On Immunity) –married, college-educated, relatively wealthy, white women – generally distrust the government and the pharmaceutical industry. My own research found that even when controlling for education, race, and socioeconomic status, parents who distrust the government and healthcare professionals are less likely to vaccinate their children and more likely to view information about immunizations from government agencies through a lens coated with skepticism and suspicion.

If we can stop talking about immunizations solely in the realm of individual choice and understand them as an essential part of being a part of a community, maybe we can work toward finding solutions that are guided by togetherness, empathy, and a sense of purpose, rather than through policies that opponents view as paternalistic. Perhaps we can change the dynamic to embrace more community-driven efforts to educate and mobilize on behalf of vaccines.

For instance, what if rather than relying on preachy pamphlets on “Why you should vaccinate” or harried pediatricians rushing to get to the next patient to convey the message about vaccines, we tapped other parents in the community to communicate with vaccine-hesitant parents?

Parent-to-parent communication is one of the guiding principles at Voices for Vaccines, a parent-driven organization that educates other parents about immunizations. The same way that parents advise one another on what diapers to choose and what preschools have the best teachers, Voices for Vaccines empowers parents who vaccinate to reach out to vaccine-hesitant parents to share stories about why they vaccinated their children.

It is essential that hesitant parents are reached as early as possible by peers with evidence-based experience, rather than friends who reinforce their skepticism. Karen Ernst, one of two young mothers who re-launched Voices for Vaccines in 2013, says that most parents make their vaccinating decisions long before seeing their pediatrician. “By the time their ears have been filled with their friends’ stories, a five-minute conversation with a doctor is not enough to replace bad information with good,” Ernst explained in an interview.

“Parent advocates are in a unique position to inoculate their friends and family members against that bad information so that when they head into the doctor's office, they already feel confident about a medical decision that should be a given,” said Ernst.

Mobilizing the majority of parents who do immunize their children to see vaccine hesitancy as a legitimate problem has been a challenge Voices for Vaccines has fought to overcome. Despite recent events like the Disneyland measles outbreak, even parents who believe everyone should vaccinate “are complacent because the diseases we vaccinate against are so rare. They do not understand that outbreaks like the one that began in Disneyland late last year are canaries in the coal mine.”

For his part, Salmon is interested in the prospects of parent-to-parent communication but cautions that while the method has “much potential,” as of yet there is little data or analysis that attests to its efficacy. In other words, as lawmakers and thought leaders consider changing their rhetoric, they might also want to start filling this gap in the research.

Grassroots organizations like Voices for Vaccines that generate a healthy dose of positive peer pressure could help increase vaccination rates in California and elsewhere, where immunizations have become a flashpoint of fundamental liberties. Parent-to-parent communication won't be a panacea for vaccine hesitancy, but it could be a step away from reifying immunizations as an epicenter of individual choice and toward viewing them more accurately as a commitment to common humanity.


Charlotte Lee is a research aide at Weill Cornell Medicine at Cornell University.