Why some vaccines must be mandatory
anti-vaccine sentiment is growing and threatens decades of public health progress. A reader argues that “You’ve been writing that people should gauge individual risk when it comes to COVID. Why isn’t it the same with measles? Your article says that the vaccine is 97 percent protective. Vaccinated kids don’t need to worry, so why isn’t it up to parents to decide whether to give their kids the shot?”
He raises an interesting point that goes to the fundamental tension in public health of weighing individual freedom vs. what’s best for society. Individual freedom should generally take precedence, but there are some circumstances where policymakers have to decide in favor of protecting the public.
Freedom vs. safety
I was thinking about this question when I took my kids to an indoor play gym over the weekend. The ones in my area become very crowded, with hundreds of kids and parents packed into relatively small spaces.
As soon as I signed my 6year-old son in, he ran off with some friends and disappeared in the throng of excited kids. I wasn’t so worried about keeping an eye on him, but I did worry about my 3- year- old daughter. I knew that if I let her out of my sight, it could take a while to find her.
My husband told me not to worry; in his view, this kind of play is exactly what these indoor gyms are designed for. Another mom who overheard our conversation agreed with him.
Her young child was playing wherever she wanted, without her mom hovering over her as I was doing with my daughter. On the other end of the spectrum are parents who wouldn’t even think to come to these indoor gyms for safety reasons.
All of these are reasonable individual decisions. They should be made by parents about their own kids.
Now let’s take a totally different scenario. Let’s say that there were a couple of kids who were hitting other kids and pushing toddlers off climbing structures. Even if their parents had no issues with this behavior, they pose a threat to others, and few would argue against intervention.
The question of where measles and COVID-19 lie on this continuum of individual choice comes down to three factors: how dangerous is the disease, what is the risk posed to others, and how effective are the mitigation measures?
Measles and COVID
While my reader is right that the measles vaccine is highly protective, it is not 100% effective, which means that some vaccinated individuals might still get infected. Also, there are babies and young children who are too young to be vaccinated.
The unvaccinated, if exposed to measles, have a nearly 90% chance of becoming infected. Infection poses many harmful consequences including a one in five chance of hospitalization, permanent neurological defects and death.
Crucially, targeted mitigation measures of boosting vaccinations and quarantining exposed people work to contain measles, as they have in recent outbreaks in New York, Ohio and Pennsylvania. In addition, it’s possible to stop measles from propagating by achieving herd immunity, which is what the United States has been successful in doing.
This is not the case with COVID. The nature of the coronavirus is such that no level of population immunity will stop the disease from circulating. In addition, the coronavirus vaccines, while protective against severe disease, have limited effect on reducing infection.
Large-scale population measures such as required masking, vaccines and isolation periods have not contained the virus, and indeed have spawned such substantial backlash that other public health interventions — including the measles, mumps and rubella (MMR) vaccination — are now harder to implement.
To go back to the indoor play gym analogy, the interventions required to stop measles in Florida are akin to stopping a couple of kids from playing until they are no longer harming others. Yes, it restricts their freedom, but it’s a temporary measure imposed on a small number of people because the risk to others outweighs the individuals’ right to self-determination.
On the other hand, using societal interventions to try to control COVID at this point would be more analogous to shutting down all playgrounds in perpetuity, knowing that the aggressive behavior would continue outside their premises. The interventions are wrong not only because most would perceive them as government overreach, but because they simply won’t work.
Different calculation
This is why it makes sense to me to view risks around covid as individual decisions, and why the risk-benefit calculation is different for preventing the resurgence of previously eliminated deadly diseases such as measles and polio.
As a reader reminded me, “I remember all too well the days when every child got measles and chicken pox and our parents kept us out of public pools because they feared we would be next to be paralyzed from polio. We all lined up and got our shots because our parents saw what these diseases can do. We simply cannot afford to go back in time.” I couldn’t agree more.