At last count, the Disney measles outbreak is at 114 cases, with one who took Amtrak in New York state while contagious. It's time for some serious proposals to deal with this and prevent future outbreaks. Here are three for your consideration.
The discussion & debate around measles and vaccination should end up with something concrete to take to our state legislatures. DK GOTV efforts have arguably affected local, state, and national election outcomes. If we can do that, we can do this.
Before vaccination, there were 500,000 measles cases per year in the USA. At today's population, that would be 1.5 million cases per year, 375,000 of whom would suffer permanent disabilities such as vision or hearing impairment or brain damage, and 1,500 per year would die. Measles was eradicated in the US in 2000, until the spread of anti-vax CT brought it back with a vengeance. Enough is enough, it's time to fight.
The brief version:
1) Ban nonmedical exemptions. West Virginia and Mississippi do it, the rest of the states can do as well. Universal vaccination has already withstood a Supreme Court challenge.
2) Fallback: Allow nonmedical exemptions under a "draft board" type of proceeding, the quantity of exemptions being limited to a number that does not threaten social immunity (herd immunity).
3) Compromise: Charge a fee for processing nonmedical exemptions, calculated as the 1/N cost of dealing with the previous year's outbreaks. A very rough calculation for California showed that to be about $389 per exempted family for the cost of a year with 100 cases originating here (we're already past that point).
Details below.
General background:
Historically, exemptions to vaccination were granted to members of religious sects that had strongly-held beliefs against vaccination. This did not create a public health threat at the time, since these exemptions were few, population density was far lower, and mobility was far less. With today's higher population densities and high mobility, dangerous contagious diseases can and do spread like wild fire. The Disney measles outbreak has already spread to more than six states, including Colorado, Utah, Minnesota, and New York.
The contagiousness of a disease is measured by a number known as "R0" (letter R, numeral Zero). This refers to the number of people who can be infected by one person who has a disease. For Ebola, R0 = 2, which means that, without strict isolation procedures, each Ebola patient is likely to infect two other people. For measles, R0 = 17: without isolation, each measles patient is likely to infect 17 other people. Ebola is only contagious after a person develops symptoms, and only through contact with bodily fluids (and arguably, deposited droplets on surfaces). Measles becomes contagious four days before any symptoms occur, and is truly airborne: you can catch it from being in a room where someone with measles came in and left two hours earlier.
Granting a privilege to particular religious denominations only, is an unconstitutional establishment of religion. It's also a clear violation of equal protection. For this reason, the exemptions were broadened to include "personal belief exemptions" generally.
These changes occurred in the context of fear generated by Andrew Wakefield's paper in The Lancet, asserting a connection between the MMR vaccine and autism. Wakefield's paper turned out to be an outrageous fraud. It was was retracted by The Lancet, and Wakefield had his medical license revoked, but the damage was done. Wakefield's fraudulent meme was picked up by various popular culture figures including Jenny McCarthy, Donald Trump, and Bill Maher, who spread it faster than measles, to the point where belief-based vaccine refusal is now in the 6% to 8% range in many areas, which threatens social immunity ("herd immunity"). This is an equal-opportunity destroyer: anti-vax sentiments are equal across the political spectrum, from Orange County conservatives to Marin County liberals.
Note: In what follows, I am not talking about medical exemptions, such as egg allergies, compromised immune systems, cancer patients. etc. These proposals only pertain to belief-based exemptions.
Edit: added: For all medical exemptions, the law should treat the required documents as sworn statements, so lying is equivalent to perjury. Credit to blugrlnrdst for this part, for bringing up the fact that some states allow parents to claim medical exemption with no evidence or doctor note required. Sworn statements from doctors would solve that.
Proposal 1: Ban all belief-based exemptions.
The states of Mississippi and West Virginia do not allow any belief-based exemptions, religious or otherwise. So far these laws have not been overturned in court. A Supreme Court case in 1905 concluded with the decision that states do have a right to require mandatory vaccination. It is highly likely that attempts have been made to overturn the current laws but have not been successful. However there is a threat in the form of new legislation in Mississippi (see the link below).
Therefore we should use the Mississippi and West Virginia statutes to craft legislation and present it to the rest of the states. We can do this. It is not difficult. We can lobby our state legislators to get the legislation passed. That part takes more effort, but we've done bigger things in the past and won.
Thanks to Decafdyke here (in a comment in another diary last week), we have the following links:
Current requirements & immunization schedule in Mississippi (PDF):
http://msdh.ms.gov/...
Current Mississippi law:
Medical exemptions, no belief-exemptions. Exemption for home-schooling where there are ten or fewer related children (as defined in family law, probably third cousins or closer).
https://law.resource.org/...
But uh oh there is a bill pending in the Mississippi legislature (House Bill 130) that would allow belief-exemptions. We need to pounce on this and prevent it getting passed:
http://billstatus.ls.state.ms.us/...
Here are the rules in West Virginia (PDF):
Medical exemptions only. Also includes kids participating in extracurricular activities on school grounds, which takes care of homeschoolers who do that as a social activity.
http://www.dhhr.wv.gov/...
Lastly, how these states got where the are:
http://www.newsweek.com/...
Note, for some odd reason (probably my security/privacy settings) I get a "you have reached the limit of five free articles a month" message, which can't be true since I haven't seen Newsweek since forever-ago. Anyone who can get to this article is encouraged to post a couple of paragraphs under Fair Use.
Proposal 2: Screen exemptions similarly to exemptions to the draft.
This is my fallback proposal, since it allows some belief-exemptions but keeps the number below the danger level. It requires establishing new public health boards in each jurisdiction, which is a more complex task than simply banning belief-based exemptions altogether.
1) Set herd immunity levels for each vaccine-preventable disease, e.g. X percent of population.
2) Set a safe level of exemptions in total, based on the assumption that some percentage of immunizations will not be effective, and some un-immunized persons will slip under the radar.
3) Approve all medical exemptions, with a requirement that the physician issue a written and signed document for each such case. Cover the costs of those signed letters via ACA.
4) Subtract the medical exemptions from the number of allowable exemptions in total. The difference becomes the number of nonmedical exemptions that are available to the public in that jurisdiction.
5) Each person or family seeking a nonmedical exemption has to make a detailed application to their local public health board, including an interview where they have to respond to questions. These are treated in the same manner and with the same level of scrutiny as applicants for exemptions to a wartime draft. Ideally, a new application is required each year; or at minimum, with a new application for each change of schools (e.g. elementary to secondary).
6) Alternately, issue nonmedical exemptions on a first-come / first-served basis, as determined by postmark if legible, or date of arrival at the public health board office. (Or if we want to play hardball, auction them off to the highest bidders!)
7) The public health board would have the power to decline applications where the applicant's beliefs are demonstrably false e.g. "MMR causes autism." The precedent for that is denial of political and convenience exemptions to conscription. (That would weed out the Wakefield/McCarthy followers on the first pass. Handle the rest like draft exemptions.)
8) Candidacy to serve on a local health board would require a high school diploma or GED, and members would be chosen by at-large election in their jurisdictions. (This is an edit from my previous version that would require an MD or relevant Ph.D degree: since these boards would already be constrained by law to limit nonmedical exemptions to a number that does not threaten social (herd) immunity, it doesn't matter if some areas elect a bunch of anti-vaxers to their board: they still couldn't approve enough nonmedical exemptions to cause a public health threat. Credit to Paxpdx for getting me to re-think this element, and credit to Village Vet for getting me to re-think it further.)
Background: conscription precedents and why they are relevant:
During a military draft, you could get an exemption for "conscientious objection" ("CO status"), based on the belief in pacifism as a universal principle that prevents you participating in war. But you could not get an exemption for personal convenience, or for having a political objection to a particular president or a particular war.
Originally, CO was only available to members of religious denominations in which pacifism was a deeply-held principle, e.g. Quakers, Mennonites, etc. In the 1960s, a famous Supreme Court ruling held that CO status must also be extended to Buddhists, atheists, and others, whose beliefs about pacifism held the same position in their lives as the more common theistically-based forms of pacifism. This was an important victory for members of various religions and for atheists and agnostics.
Unfortunately, that precedent, combined with precedents that established high barriers to limits on religious expression, produced the unforeseen present state of affairs where "mere say-so" is sufficient to establish "conscientious objection" to various requirements of the law. Thus we got Hobby Lobby, and the situation in some states where pharmacists can object to dispensing birth control prescriptions. There are presently moves afoot to extend "religious freedom" to include even the right to refuse to fill out the form that registers the objection of a corporation to provide contraceptive coverage to its employees. Presumably anti-vaxers would love to jump on that bandwagon and not have to notify anyone that they've decided to turn their kids into walking disease vectors.
This is the climate in which "say-so" belief-based exemptions to vaccination have become so common. If that type of process was available during World War Two, conscription would have failed and it's likely that the war would have gone on for longer, with higher casualties or even a different outcome altogether.
The very fact that wartime COs had to make presentations to their local draft boards, explaining their objections in detail and with supporting evidence (such as membership in a pacifistic church, or writings expressing principled pacifism), helped ensure that personal convenience and politics were weeded out of the process. Principled pacifists generally got their CO status (such as the "1-AO" classification for non-military national service), and "objectors of convenience" (the WW2-era equivalent of yuppies who felt serving in the military was "beneath them" or whatever) did not. There were abuses in both directions (e.g. Muhammed Ali's CO claim was denied, while Ted Nugent evaded the draft by soiling himself for a week), but by and large the system worked. An analogous system can work today in dealing with belief-based vaccine objectors.
Proposal 3: Vax it or tax it.
This is a compromise because it allows belief-exemptions without limit, but as a practical matter it should discourage the vast majority of them.
There is a financial cost of vaccine refusal. For measles the cost is approx. $1 million per case, including treatment, contact tracing, and all of the activities of public health departments and medical personnel responding to an outbreak. The present outbreak has cost local, state, and federal government over $100 million in taxpayers' dollars. That hundred million could feed and house a lot of poor folks, hire a lot of teachers, police officers, and firefighters, fund a lot of basic science, etc.
In effect, California's vaccine refuseniks have stuck the taxpayers with a $100 million cost or an equivalent reduction in government services. In economics that's known as an "externalized cost," or colloquially as "sticking it to the other guy."
Therefore, the cost should be "internalized," or borne by those who cause it. The way to do that is by imposing a tax or "exemption filing fee" (fees are taxes by another name) on all belief-based exemptions.
When I did a quick calculation for California, using reasonable assumptions and 100 measles cases for the year (we already topped that in January), that came out to about $389 per year, per family that claimed a belief exemption. That doesn't include whooping cough, but if someone has good numbers for that, we can recalculate. The could even be put on a progressive basis, ranging from e.g. $50 for poor families, to perhaps $1,500 or more for wealthy families. But in any case it would serve to substantially reduce the incidence of "belief-exemptions of convenience." And it would escalate rapidly in years that had higher numbers of cases originating any given state.
About the words we use.
The medical term for measles is "rubeola." To my mind the word "measles" sounds almost cute: it rhymes with "weasels," which are cute enough, at least when monkeys are chasing them all around the mulberry bush. If Ebola were named after something that sounded like an an animal in Africa it might not be so scary, e.g. "Mippopotamus" or something. For whatever reason, "Ebola" sounds more scary. So I'd suggest we start using the word "rubeola," which rhymes with "ebola." And for consistency's sake, "pertussis" instead of "whooping cough."
On the other hand, vaccine refuseniks should be called "measles weasels." And the doctors who support them, from Dr. Jay to Dr. Sears to the detestable Dr. Wolfson, should be called "anti-vax quacks."
Lastly, why private schools should not be exempt.
At present, private schools do not have to require vaccination as a condition of attendance. Many religious denominations' schools, such as the Catholic parochial schools, do require vaccination. But other private schools have appallingly low rates of vaccination: for example only 40% at a Waldorf School in the South Bay.
The problem with this is, those kids circulate in the general community. They go to Disneyland, to the movies, to malls, restaurants, and playgrounds. They become walking disease vectors who can and do spread preventable diseases to others.
Therefore, we need a legislative solution for private school kids, and for home-schooled kids. it might be as simple as extending the immunization laws to cover private schools, similar to the way fire codes apply to all school buildings, private as well as public. It could also extend to cover home-schoolers similar to other requirements they must presently meet. (Alternately, based on West Virginia law, it could cover home-schoolers who use any public or private school's athletic or other extracurricular facilities.)
OK folks, let's have at it, and come up with something our legislatures can pass.