Health is Wealth

By Connie Kwong

Source: LA Times

Source: LA Times

It’s a sobering thought to consider how the recent measles outbreak at Disneyland contradicts the beloved amusement park’s status as the “Happiest Place on Earth.” This outbreak is yet another catastrophe that can be attributed to the anti-vaccination movement, a movement that has unfortunately developed an especially cultish following in California.

Diseases are biological, but they reveal much about social dynamics. The anti-vaccination movement is a living testament to the fact that public health is deeply entwined with issues of class privilege and public policy. The consequence is that we are faced with a nightmarish set of circumstances: when people choose not to vaccinate themselves and or their children, they ignore years of medical research and success underscoring the necessity of vaccines, and put other people’s health and lives at risk.

How to not get sick

We can draw comparisons between vaccines and public sewage systems to see how public health infrastructure is crucial. Cholera, typhoid fever, and malaria epidemics claimed countless lives in European and American cities throughout the 19th century. Disease was especially destructive in poor neighborhoods, where tenants living in cramped apartments were easily exposed to infections through unclean water that they could also catch from their neighbors. But thanks to the implementation of clean water technologies in cities in the late 19th and early 20th centuries, mortality rates in the US fell more rapidly during those periods than any other period in American history. Sewage technology was responsible for three-quarters of infant mortality reduction, and nearly two-thirds of child mortality reduction in the US. The fact that cholera and malaria continue to affect poor communities in developing countries like Nigeria and India further demonstrates how the associations between poverty and lack of infrastructure are harmful to public health.

If improving health is greatly contingent on developing the necessary technologies, then it’s foolish and dangerous to challenge the overwhelming amount of evidence reflecting the medical community’s consensus on what health measures produce positive effects. We know from history – and hopefully, from personal experience – that vaccines have been instrumental in reducing disease and mortality rates. In the US, vaccines led to a 90 percent decline in cases of formerly common childhood diseases, such as diphtheria, polio, and, of course, measles.

However, according to the World Health Organization, measles remains one of the leading causes of death among young children. In 2013, there were 145,700 measles deaths globally – about 400 deaths every day or 16 deaths every hour. Most of these deaths were children under the age of five. Moreover, over 95 percent of measles deaths occur in countries with low per capita incomes, especially in parts of Africa and Asia. There is no existing antiviral treatment for measles, but the WHO reports that between 2000 and 2013, vaccination prevented an estimated 15.6 million deaths, making the measles vaccine “one of the best buys in public health.”

Therefore, we can conclude that just as sewage greatly benefitted low-income city-dwellers vulnerable to disease exposure, vaccines are another crucial piece of public health infrastructure that improve society’s wellbeing. So when we consider how medical developments within the last one hundred years have enabled doctors to treat patients with far graver conditions like cancers and stroke (with much of the cutting-edge research taking place at prestigious institutions and hospitals in California, such as UCSF and Stanford) – the consequences of the anti-vaccination movement are augmented. Even before the December Disneyland measles outbreak, 2014 was already the worst year of measles cases in California in over two decades, with 61 cases. Whooping cough rates also reached a record high since 1958, with over 9,900 cases. Consequently, we’re forced to ask: how have we have advanced so far, only to be held back by such basic and preventable hurdles?

It’s not about me, it’s not about you, it’s about us

As shown by the impacts of poverty mentioned above, diseases tell a great deal about social dynamics. The Disney measles outbreak further demonstrates that because of the seemingly paradoxical relationship between socioeconomics and the anti-vaccination movement’s strength in California. According to Dr. Paul Offit, Director of the Vaccine Education Center and an Attending Physician with the Division of Infectious Diseases at The Children’s Hospital of Philadelphia,“This happened exactly where you would expect to see this happen – in a place where people from different parts of the country congregate in one spot…It’s not surprising that it happened in a southern California theme park because southern California over the past few years has had pretty woeful rates of vaccination.”

California law mandates that all students get vaccinated, but existing policies make it easy for parents to file for personal beliefs exemptions (PBEs). Perhaps there is some truth behind the stereotype that Californians like to live according to a “natural, chemical-free” lifestyle. So given the oft-expensive price tags of living organic, it’s not entirely surprising that the anti-vaccination movement is especially strong in affluent areas. For the 2012-2013 school year, 7.8 percent of Marin County parents filed PBEs, giving it the highest opt-out rate in the Bay Area and one of the highest in the state. That same year, only 26 percent of incoming kindergarteners at the New Village School in Sausalito were vaccinated – only five out of 19 students. In Los Angeles, the percentage of kindergartens in which at least eight percent of students were not fully vaccinated due to parents filing PBEs has doubled since 2007, with private-school parents being more likely to file. This is a worrisome trend, because most vaccines’ effectiveness depend on “herd immunity” thresholds to be met, with these thresholds typically requiring between 90-95% of the population to be vaccinated. The growing prevalence of PBEs and declining vaccination rates bumps up against these herd immunity thresholds, and the effects become even more dangerous when considering how large clusters of young, unvaccinated children are now placed in close proximity to each other in classrooms.

One of the most common arguments anti-vaxxers cite is that vaccinations are no longer necessary because diseases like measles and smallpox are “a thing of the past.” Or, they’ll repeat the constantly-debunked claim that vaccines are linked to autism. The fact that these claims are not scientifically-backed is further underscored by how proponents often assert that the anti-vaccination movement is really about “personal choice” and “doing what’s best for me and my family.” So when we recognize how the movement is so closely associated with the reckless choices of affluent parents, we need to juxtapose this against the dire situation faced by millions of children and their families in impoverished neighborhoods and countries, where higher child mortality rates from vaccine-preventable diseases persist due to a lack of access to public health resources.

In other words, we have to compare and contrast the circumstances of a privileged class that has the choice versus a significantly disadvantaged group that does not have that luxury of choice. For instance, sociologist Jennifer Reich finds that many anti-vaxxers are middle- and upper-class mothers who are educated and have the time and resources to make decisions regarding vaccinations, and they believe that parenthood status alone qualifies them to make those decisions. In a paper published in the journal Gender and Society, Reich notes that while many of the parents she interviewed mentioned breastfeeding as a means of boosting immunity or delaying vaccination until adolescence, none of them referenced how their unvaccinated children presented a potential risk to others. At the same time, low-income mothers do not have the time or resources to consider “alternatives” to vaccination, and their children are usually under-vaccinated due to lack of access to medical care.

A rational response

We often think of “personal choice” as being associated with individual rational behavior. However, Reich’s research clearly demonstrates that much of the anti-vaccination movement is colored by a sense of irrational confidence that makes parents think they have the authority to challenge medical professionals. Reich’s research suggests that trying to find a middle ground with anti-vaxxers and ease them into accepting vaccinations might be effective. But techniques like more personalized vaccine schedules tailored to a detailed analysis of each child’s immune system would be costly and time-consuming.

A rational response, therefore, means removing dangerous loopholes that enable the presence of threats to public health. Just as sewage legislation revolutionized public health in the early 20th century, we need new legislation that better inoculates the population from increasingly frequent outbreaks. In Jan. 2014, Assembly Bill 2109 went into effect in California, making it more difficult for PBEs to be filed by requiring that parents submit a signed statement from a healthcare provider stating that the parent has received information about the risks of forgoing immunization. However, the bill’s effectiveness has been limited, as rates of kindergarten student vaccinations continue to decline. Many parents who are intent on not vaccinating their children have likely already negotiated this with their children’s doctors, making it easy for them to meet the exemption requirements.

The bottom line is that many anti-vaxxers fail to recognize that their privilege enables them to even (wrongfully) conceptualize vaccination as a matter of debate in the first place. So while it’s easy to throw around the phrase “health is wealth,” the ability to go against medical consensus for the sake of “personal beliefs” or “choice” is itself a grossly destructive privilege. Vaccines are not “personal.” Common sense and knowledge tell us that infectious diseases are interpersonal because they can be easily spread from person to person, and the best and only defense is to have a defense; in other words, a vaccine. Low-income families and children too young to be vaccinated are especially at risk. Therefore, new legislation needs to be more strict and explicit in defining what qualifies as a legitimate exemption, and also be tied to greater efforts to boost access to public health resources.

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