DR. UBAKA OGBOGU SAYS YES.
In March 2016 over 100 people were exposed to measles—a serious, vaccine-preventable disease—at Stollery Children’s Hospital in Edmonton. The source of the infection was an unvaccinated child admitted to the ER. One of the affected was an immunocompromised toddler battling brain cancer. The risk to this child was immense—his weakened immune system couldn’t handle an infection or a vaccine. For him, measles would effectively have been a death sentence.
This story underscores why vaccination should be mandatory (with exemptions for people who, because of age or health-related factors, can’t be vaccinated). Such a policy protects people who are vulnerable to infectious diseases but can’t be vaccinated. Most would agree that our society ought to look out for persons who, through no fault of their own, are susceptible to harm from others. Some might counter that a person shouldn’t be forced to submit to a health intervention for the sake of benefiting others. However, public health laws in Canada already allow governments to forcibly treat persons infected with communicable diseases. Also, vaccination doesn’t just confer a gratuitous benefit on others. Rather, it is an act of citizenship that community membership and life require.
Requiring vaccination also guarantees the best interests of children whose parents or guardians fail or refuse to vaccinate. In this way, mandatory vaccination can be viewed as a logical extension of existing child protection laws. Perversely, the state requires parents to provide nutrition, medical care and other necessities of life to their children, but not readily available, free, safe and effective protection from deadly diseases. As stated in a Croatian court decision which upheld a successful mandatory vaccination law, “[t]he child’s right to health is more than the right of parents to the (wrong) choice.”
It is also reckless not to use the most effective tool for tackling the national and global infectious-disease burden. Vaccination doesn’t just prevent the introduction and spread of such diseases, it eradicates them. The list of vaccine-eradicated and vaccine-eradicable diseases is a veritable what’s-what of human misery: smallpox, polio, measles, diphtheria, tetanus, yellow fever, whooping cough. According to a US Centers for Disease Control and Prevention estimate, among children born 1994–2013, vaccination will prevent 322 million illnesses, 21 million hospitalizations and 732,000 deaths. In Canada many childhood infectious diseases were eliminated through vaccination; new outbreaks arise mainly from imported cases.
No other health intervention can boast these statistics. And no strategy for achieving vaccine uptake works better than mandatory policies: coverage is generally better in jurisdictions with mandates. Vaccination reduces costs and other burdens on healthcare, assuring a healthier and more productive citizenry. It seems irresponsible not to adopt a strategy that best ensures these many benefits.
DR. JOAN ROBINSON SAYS NO.
Alberta has relatively low vaccination rates, and such immunizations are not mandatory. For decades, children in Ontario, New Brunswick and all 50 US states have required immunizations to attend school. A systematic review of the literature showed that such mandates have generally increased immunization rates in places where rates were abysmal. However, rates in jurisdictions with mandated vaccinations remain similar to Alberta’s mediocre rates, because parents are allowed to claim religious or philosophical objections to immunization. To solve this, some states allow exemptions only if a physician confirms that the child has a medical contraindication. Why am I, as a pediatric infectious-diseases physician, not keen on Alberta adopting such a policy?
Vaccines likely prevent more mortality in the first year of life than in all subsequent years. Parents annoyed at the state “telling them how to raise their kids” could delay immunizations until just prior to school entry, as may be occurring in the US, according to a 2015 study in the American Journal of Preventive Medicine. Crucial years of protection would be lost.
Homeschooling may be the best option for some children, but most benefit from attending school. Parents who are truly anti-immunization might opt for home-schooling solely to avoid having to immunize their children. Convincing them to immunize is as difficult as convincing pediatricians not to immunize their own children.
What about having a law that all children must be immunized according to a routine schedule? After all, immunization is the right of every child. In Canada, however, parents have the right to make decisions about their child’s medical care unless the child is in immediate danger. I fear some parents would see legislated immunization as an infringement on this right, leading to fury and increasing mistrust of the medical profession. As has happened in the US, it might be possible to find a physician in Alberta who would claim that a child has a contraindication to immunization even though this is not proven.
In lieu of mandatory immunization, our goal should be that parents immunize their children because they understand the benefits. Parents can be swayed by stories about children who were allegedly harmed by a vaccine; they can also be swayed by stories about children who were unequivocally harmed by a preventable disease. We need to educate children in school about the evidence that immunizations work and about how to interpret scientific evidence such that they understand the difference between a case report and a randomized trial.
The main reason given for not immunizing in Alberta is because parents “didn’t get around to it.” Public health clinic hours must better accommodate working parents and walk-ins. Alberta Health does its best, but more resources would allow it to text parents when a child is overdue for an immunization and to obtain more consents for immunizations in schools.
DR. UBAKA OGBOGU RESPONDS TO DR. JOAN ROBINSON.
Dr. Robinson and I both agree that vaccination is an essential medical and public good. We also agree that mandatory policies are generally more effective at increasing vaccination uptake. Where we seem to diverge is in the details, specifically with respect to three matters: that existing mandatory policies have certain practical drawbacks, rendering them largely ineffective; that compulsory vaccination will create anger and promote mistrust of the medical system, particularly among those who see compulsion as an affront to parental decision-making rights; and that an alternative strategy based on education and improving vaccination access and resources offers a more viable solution to low vaccination rates. I’ll address each point in turn.
Parental objections on behalf of children should never defeat a child’s right to receive necessary health interventions.
Dr. Robinson notes, rightly, that current approaches to implementing mandatory vaccination have opt-outs for religious and philosophical objections that render these policies largely ineffective (or at least no more effective than not mandating vaccination). I agree. However, I don’t think approaches that allow for such opt-outs can fairly be called mandatory. Truly mandatory vaccination policies only allow for medical exemptions. Parental objections on behalf of children (who are too young to form philosophical or religious opinions) should never defeat a child’s right to receive necessary health interventions.
My preferred mandatory vaccination policy would take effect from the earliest date that children can be immunized (typically between six months and one year from birth), not at school entry. Delaying vaccination until school entry exposes children to risk of infection in the most vulnerable stages of their young lives.
Furthermore, the fear that an objecting parent or guardian may find an unscrupulous physician who is willing to provide an unwarranted medical exemption is, in my opinion, speculative. It is also likely untenable considering that this would be a gross violation of ethical and legal duties and a risk that most, if not all, physicians might be unwilling to take. In any event, the risk of unsupported medical exemptions could be mitigated by asking parents to obtain two opinions in support of an exemption. The latter approach would pose hardship for parents and would only be implemented if evidence suggested physicians were indeed issuing unjustified or false medical exemptions.
The concern that mandatory vaccinations would promote mistrust of the medical system among parents who object to “the nanny state” is also speculative and somewhat misplaced. For one thing, many parents who are willing to home-school their children or who insist that their parental rights trump public health already mistrust the medical and public health system. As far as these parents are concerned, no trust will be gained or lost with or without a mandatory policy. And the fact that some parents might lose trust in the medical system is not a reason to forgo a policy intervention that will improve childhood vaccination rates. Certainly, some parents insist the state should get out of their way when it comes to parenting matters—but we don’t let them deny their children food, shelter or basic healthcare. Rather, the law insists they provide these things, while at the same time it maintains and supports their right to object.
It is also worth noting that vaccination rates tend to go up during or after infectious disease outbreaks. Alberta’s childhood immunization rates rose by 3 per cent to a five-year record following a major measles outbreak that lasted from fall 2013 to spring 2014 (all of the cases involved unvaccinated children from a largely unvaccinated population). The improvement suggests that even those who do not trust vaccines (and by extension the medical system) as well as the so-called “vaccine-hesitant” are capable of understanding and appreciating the need for the protection that vaccines offer. It appears, therefore, that their attitudes toward vaccination are less about trust and more about complacency that comes with the absence of disease. In a sense, vaccination has been a victim of its own success.
Public education on the merits of vaccination is undeniably important and necessary. And no one can disagree that we need to improve access and allocate more resources to this important public-health goal. I am in full agreement with Dr. Robinson on these matters. However, I don’t think education or other resources are substitutes for a mandatory policy. Rather, they are strategies to be pursued in addition to mandatory vaccination.
The main reason is that education, as a standalone approach, does not improve vaccination rates. Education may in fact be counterproductive. Studies have shown that among people with negative opinions of vaccination, education tends to entrench the negativity. Such parents are also unlikely to seek out educational resources. By contrast, a mandatory policy may prompt protest, but it could also prompt questions about vaccinations, which could be addressed by a public education strategy.
Indeed, if the only benefit of a mandatory policy were to get both sides of the debate talking to one another, we would have taken one step beyond the present situation, which is a hopeless polarization that leaves the most vulnerable among us unprotected.
Parental objections on behalf of children should never defeat a child’s right to receive necessary health interventions.
DR. JOAN ROBINSON RESPONDS TO DR. UBAKA OGBOGU.
Of course it’s unfair that children must suffer needlessly and parents worry about their infant or immunocompromised child acquiring a vaccine-preventable disease simply because other parents have refused to accept the overwhelming scientific evidence that vaccines prevent infections. The risk of potential serious harms from vaccines are minuscule compared to the risk of proven serious harms from the infectious diseases they prevent. For every person alive today, immunization ranks second only to clean water for the number of deaths averted during their lifetime by a public-health intervention.
And indeed, Albertan children who have received all recommended immunizations do unfortunately occasionally develop vaccine-preventable diseases transmitted from children who, by parental choice, were not immunized. This is probably most common with pertussis (whooping cough) and varicella (chicken pox), resulting in illness and sometimes hospitalization—but almost never death. Infants who are too young to be immunized or children with immune problems may require immune globulin following exposure to an unimmunized child with a vaccine-preventable disease. This entails an injection and exposure to a blood product.
However, immunizing children whose parents object is no mean feat. It’s difficult to imagine how one would operationalize mandatory immunization in Canada today. Would we take parents to court and apprehend their children for immunizations? Since approximately 50,000 infants are born in Alberta each year and roughly 0.5 per cent of parents are firmly anti-immunization, one would potentially have to apprehend 250 infants annually, and each would then have to be apprehended five more times prior to school entry. Even if most parents abandoned their anti-immunization stance to prevent their child being repeatedly apprehended, the time and resources required to immunize the children of parents who did not back down are probably far better spent on other public-health interventions (such as paying for the new and improved shingles vaccine for seniors).
It’s also debatable whether the courts would ultimately allow children to be apprehended for immunizations. Apprehension following a court order is currently available for the tiny number of children whose parents refuse life-saving therapies. However, even that practice has become controversial; in 2015 the Ontario government did not succeed in apprehending Makayla Sault when her parents refused chemotherapy for leukemia despite a predicted 75 per cent survival rate with treatment and no chance of survival without. Anti-immunization parents might successfully argue in court that they should not be forced to inject their child with a product that isn’t for treatment but is solely for prevention of infectious diseases that their child may never be exposed to. Public-health laws do rightfully allow for mandatory treatment of recalcitrant patients who are infectious to others, but unimmunized children might never develop a vaccine-preventable disease and be a threat to anyone.
Perhaps a better approach would be to penalize delinquent parents. A little-known law in Ontario allows parents to be fined $1,000 if their children are not immunized. I suspect that if this law were ever enforced, however, parents might successfully argue in court that human rights legislation and their parental rights trump this law.
Along the same lines, parents in Australia have since 2016 forgone child support tax rebates if their children aren’t fully immunized. That country’s immunization rates in 1-year-olds increased from 91 per cent in 2015 to 93 per cent in 2017. Far fewer than 7 per cent of Australian parents are thought to be truly anti-immunization, so it appears this policy hasn’t yielded the desired effect of at least ensuring that parents who are vaccine-hesitant but not firmly anti-immunization immunize their children on time. In 2018 the policy was changed so that the payment reduction occurs biweekly rather than as an annual lump sum—a constant reminder to parents of the cost of not immunizing.
Immunizing children whose parents object is no mean feat. How would one operationalize mandatory immunization in Canada today?
A similar policy could be considered in Canada. However, because the Fathers of Confederation declared in 1864 that healthcare should be a provincial responsibility, the federal government doesn’t have access to immunization records. (And while Alberta has accurate records of childhood immunizations because they’re provided by public-health clinics rather than medical offices, that’s not the case in most provinces.) If the Australia experiment proves effective in the long run, we could attempt to overcome the administrative barriers that prevent the federal government from identifying the immunization status of each child, and trial such a system in Canada. Nonetheless, children might suffer if their parents truly need the support payments but still choose to not immunize. Also, withholding public money from parents is akin to making them pay a fine, which practice could eventually be successfully challenged in court (though this has yet to happen in Australia).
As one eventually learns when raising children, enabling and obtaining buy-in for good behaviour is far more effective in the long run than enforcing rules that punish bad behaviour. The simplest way to increase immunization rates would be to increase the opportunities for children to be immunized in public-health clinics, hospitals and schools.
Dr. Ubaka Ogbogu is the assistant professor of law, pharmacy and pharmaceutical sciences at U of A. Dr. Joan Robinson is the professor and divisional director of the U of A’s department of pediatrics.