This article was written by Dorit Rubinstein Reiss,
Professor of Law at the
University of California Hastings College of the Law in San Francisco, CA. She has written a valuable r
eview of the recently published article, “Power and Persuasion in the Vaccine Debates: An Analysis of Political Efforts and Outcomes in the United States, 1998-2012”.
Dr. Reiss writes extensively in law journals about the social and legal policies of vaccination. She is also member of the Parent Advisory Board of Voices for Vaccines, a parent-led organization that supports and advocates for on-time vaccination and the reduction of vaccine-preventable disease.
The original article was posted here.
The article reviewed here examines how the success of the anti-vaccine movement in achieving its legislative goals changed over time. The authors use the term “vaccine critiques”, and I will follow their terminology, though I think the anti-vaccine label fits many of the actors they describe. The peer reviewed article does two extremely valuable things: describes patterns, and suggests a causal explanation. While the authors are, justifiably, confident in their descriptive analysis, they appropriately warn us that their conclusions about causation are tentative. Their points are, however, very plausible.
This post proceeds in three parts: describing the patterns the authors found, describing their causal conclusions, and asking for a wish-list of further research (an easy enough and somewhat unfair things to do when you don’t have to actually do it).
Note: the authors have expressed their willingness to provide the full paper to individuals, upon request. I recommend it. The paper also states that the database will be made available on request.
Trends in Vaccine-Critiques’ Legislative Successes
The authors drew on several sources – their own database searches, others’ database searches, and a media search – to locate proposed state legislature level vaccine-related bills. They found 636 bills were introduced between 1998-2012, and coded them according to what the bills were trying to accomplish, and their achievements, from the point of view of the vaccine critiques. They supplemented this with interviews with stakeholders – though not as many as they wanted - and reading of relevant materials, such as legislative documents and other published materials.
In terms of content, the authors identified nine categories of actions (though sometime, one bill included more than one) (I am not using their terminology, though I think my terms do justice to their meaning):
- Creating exemptions or broadening them, making them easier to get.
- Removing exemptions or making them harder to get.
- Expanding the list of mandated vaccines or the power of public health authorities to monitor or add to that list.
- Removing a vaccine from the list of mandated vaccines or restricting the power of public health authorities to add or monitor vaccines.
- Creating or expanding a ban on mercury (thiomersal) in vaccines.
- Narrowing an existing mercury ban, often in ways that seriously undercut it or completely undo it.
- Requiring health providers to inform parents about mercury in vaccines.
- Requiring health providers to give parents a list of vaccines (with the underlying hope they will be deterred from vaccinating).
- Requiring health providers to inform parents about the risks of a disease for which there is a vaccine that is not mandated, in the hope it will promote vaccinating. Educational requirements of the sort adopted in Washington, Oregon and California, where the personal exemption was conditioned on getting such information from the provider, fall under category two – making exemptions harder to get.
The first six were described as “boundary struggles” – struggles around the boundaries of vaccine mandates – and the last three as “informational struggles”.
The authors then categorized the result as an offensive win – success in passing a bill detrimental to vaccinating – or defensive win, success in defeating a pro-vaccine bill. Alternatively, a bill could be characterized as an offensive loss – failure of a vaccine-critical bill – or a defensive loss, failure to stop a vaccine-promoting bill.
What did the authors actually find? Well, several interesting things. First, in terms of offensive wins – success in passing bills to advance their cause – during the entire period bills critical of vaccine policy were successful in just twenty of those out of the entire 636 bills. Some of them, explain the authors, were unimportant or redundant – removal of a smallpox mandate after the vaccine was no longer in use, a mercury ban after removal of thimerosal from childhood vaccines (9 bills total), or only useful for the most determined parent (for example bills allowing to opt out if you can prove the child was already immune). The last expansion of exemptions was in 2003 in Texas and Arizona. Most recent wins were mercury bans (2008). No ingredient bills passed.
Vaccine critiques were much more successful in defensive wins, preventing pro-vaccines bills. Between 2002-2010 no state was able to remove exemptions or constrain them – though 9 bills were introduced to contract and 19 to constrain. 127 bills to add mandates also failed, though 37 of these addressed the relatively controversial HPV vaccine, and some were later proposed again more successfully.
Since 2011, however, that changed, and the west coast states have successfully passed bills to make exemptions harder to get.
What we are observing, therefore, is first that the anti-vaccine movement had limited success in getting bills passed. It had more successes in stopping bills it opposed – in line, as the authors point out, with the realities of the policy process, at least in the United States, where getting something enacted is much harder than blocking it, even in the state level.
We also see substantial variety among states, and what seems like two points of change in pattern: a decline in success somewhere around the middle of the first decade of the new millennium, and pro-vaccine success in limiting exemptions after a long time where it did not work since 2011.
So what’s going on?
Why are we seeing this?
Again, the authors appropriately caution readers about the limits of their explanation. They had access problems with suspicious vaccine-critiques, and less interviews than they had wanted. Still, they suggest an explanation following Thomas Oliver’s framework – to achieve a policy change, there need to be three things:
First, there must be a risk assessment that captures sufficient attention to mobilize the public and their representatives; second, there must be an appropriately targeted locus of responsibility that is widely regarded as the cause of the problem; and third, there must be an appealing social construction of target populations who need help from a policy change.
In this case, they suggest that following Andrew Wakefield’s initial paper vaccine critique convinced policy makers that there was a safety risk from vaccine harms to at least some children; that those responsible for the risk were “overly aggressive public health policies, profiteering pharmaceutical companies, and a vaccine-happy federal government”; and that well informed parents and vulnerable children needed protection. Hence, they achieved successes – especially when they combined this with savvy political maneuvering, as done by
Dawn Richardson from the National Vaccine Information Center during the fight to add a personal belief exemption in Texas in 2003.
But later the situation changed, because of a number of development. As outbreaks – for example of pertussis (whooping cough) – increased, vaccine proponents managed to highlight the risk of spreading disease, as the number of unvaccinated increase. They put the responsibility on anti-vaccine misinformation – aided at least in part by the growing body of science refuting the claim that vaccines cause autism, and by the revelation of Andrew Wakefield’s ethical failings, which discredited anti-vaccine claims further. Effective mobilization of well-informed pro-vaccine coalitions made a dramatic difference. Finally, highlighting the plight of children vulnerable to diseases – those too young or those who cannot be vaccinated – also made a difference. This led to successes of the pro-vaccine forces – in spite of continued very active and very sophisticated pro-vaccine efforts.
What’s next?
Research
The article by Lillvis, Kirkland and Frick is an important one, and it adds a lot to the conversation about the politics of vaccination. I hope to see more projects come out from this collaboration. Different people can have different preferences as to what they would like to see. Among my wish list, I’d like to see the authors use their data base to address the question of state to state learning from legislative efforts in other states – content of bills, on both sides, tactics, etc.
I’d also like to see the authors delve more into the politics they started discussing. For example, I would like to see them address the role of the media more in depth, including the use both sides – vaccine critiques and pro-vaccine coalitions – made of it.
The authors also started discussing the interaction between statutes and the implementation via the executive branch, and I’d be curious to see them go more deeply into that.
Finally, I wonder if the authors considered – in the later period, when they highlight pro-vaccine successes, the effect of anti-vaccine resistance on energy and presentation. In other words, whether, even if anti-vaccine forces did not manage to prevent a bill passing, mounting vigorous opposition could deter policy makers from picking up the topic in the future. In other words, which bills never made it into committee because of such vigorous fights? It would be challenging to find that out, but the authors seem to have an extensive body of knowledge about the political struggles. I wonder if any of the policy makers – or coalition members on the pro-vaccine side – could address this.
Policy
The authors make several recommendations that I really like.
They suggest that immunization supporters highlight the victims of non-vaccination. Vaccine critiques have successfully used stories of vaccine injuries (many of which have scant medical or scientific evidence supporting the connection to vaccines, and some of which are against the evidence). The authors suggest pro-vaccine coalitions make better use of those harmed, or at risk, from non-vaccinating. This includes the immune compromised, at higher risk from preventable diseases, unvaccinated children harmed by preventable diseases, and so forth. Others have also highlighted the need to make better use of stories – that’s why we have ShotByShot.org, along with published articles that indicate kinds of conversations that can personalize the importance of vaccines.
They also suggest more innovative strategies than exemption bills, though their example – publishing school immunization rates – is not necessarily new: California, for example, does this. I would take that further and argue for using legal tools more extensively – for example, I’ve suggested tort liability (pdf) or no-fault options. But I agree that expanding the struggle beyond exemptions is appropriate.
Key citations:
