Calling the Shots

Why Parents Reject Vaccines

Jennifer A Reich

• Publisher: NYU Press
• Year: 2016
• ISBN:
  9781479843213
• Topic: Sozialwissenschaften
• Subtopic: Globale Entwicklungsstudien

Winner, 2018 Distinguished Scholarship Award presented by the Pacific Sociology Association Honorable Mention, 2017 ESS Mirra Komarovsky Book Award presented by the Eastern Sociological Society Outstanding Book Award for the Section on Altruism, Morality, and Social Solidarity presented by the American Sociological Association A rich, multi-faceted examination into the attitudes and beliefs of parents who choose not to immunize their children

The measles outbreak at Disneyland in December 2014 spread to a half-dozen U.S. states and sickened 147 people. It is just one recent incident that the medical community blames on the nation’s falling vaccination rates. Still, many parents continue to claim that the risks that vaccines pose to their children are far greater than their benefits. Given the research and the unanimity of opinion within the medical community, many ask how such parents—who are most likely to be white, college educated, and with a family income over $75,000—could hold such beliefs.

For over a decade, Jennifer Reich has been studying the phenomenon of vaccine refusal from the perspectives of parents who distrust vaccines and the corporations that make them, as well as the health care providers and policy makers who see them as essential to ensuring community health. Reich reveals how parents who opt out of vaccinations see their decision: what they fear, what they hope to control, and what they believe is in their child’s best interest. Based on interviews with parents who fully reject vaccines as well as those who believe in “slow vax,” or altering the number of and time between vaccinations, the author provides a fascinating account of these parents’ points of view.

Placing these stories in dialogue with those of pediatricians who see the devastation that can be caused by vaccine-preventable diseases and the policy makers who aim to create healthy communities, Calling the Shots offers a unique opportunity to understand the points of disagreement on what is best for children, communities, and public health, and the ways in which we can bridge these differences.

1

The Public History of Vaccines

Most histories of vaccines in the United States begin with the story of smallpox, a disease feared for its gruesome symptoms, high fatality rate, and ability to spread quickly. As the historian James Colgrove describes,

Its symptoms began with chills, aches, and fever, then progressed ominously to nausea, vomiting, and difficulty breathing. About a week after infection, bright red pustules developed on the victim’s face and hands, and then spread to cover the entire body. Eventually the pustules dried and itched intensely, scabbed over, and fell off. About one out of four victims died; those who survived were usually scarred for life and often blinded. Children, who were generally more vulnerable to infectious disease, died from the condition more often than did adults, but it struck young and old alike, and without regard to social class.1

To save people from this deadly disease, a procedure called variolation was developed. Variolation is a term that refers to the controlled transfer of active smallpox lesions, taking the scabs or pustules from an infected person and placing them under the skin of an uninfected person with a lancet. This technique had long been practiced in Asia and Africa. Although British travelers reported seeing variolation through the seventeenth century, British doctors were unwilling to adopt it as practice. Credit for its eventual widespread use in England is usually assigned to Lady Mary Wortley Montagu, who in 1718 encountered the practice while traveling through Turkey with her husband, a British ambassador. Having survived the disease but witnessing its ravages, Montagu demanded that her son receive variolation by the embassy surgeon, and later, in 1721, she insisted he demonstrate the technique to the British physicians while variolating her daughter. As word spread, interest grew; experiments on the safety of variolation were performed on six prisoners, and later, on orphans, and those proving successful, the Princess of Wales asked to have her daughters variolated.2 Owing to new popularity and the tightly organized practice of medicine in Europe, variolation became widespread.

Historical evidence shows that variolation was often accompanied by other now-dubious rituals that health providers encouraged, including fasting, bleeding, purging, and mercury consumption.3 Variolation was risky and actually could cause the highly contagious disease it aimed to prevent, or communicate other infections, including tuberculosis, syphilis, or hepatitis. Two to three percent of people variolated died from complications. Even so, these fatalities were ten times lower than from the dreaded smallpox infection.4

Variolation reached the American colonies around 1721. Among its early champions was the Reverend Cotton Mather, who saw a smallpox epidemic erupt in the Boston area after a traveler arrived from the West Indies. Panicked, Mather tried to recruit physicians in the area to begin variolation, but was only able to convince Dr. Zabdiel Boylston to variolate anyone who wanted it. Variolation remained controversial in the colonies and as the disease spread through the largely uninoculated population, Mather and Boylston were viewed with increasing suspicion. In 1721, with smallpox infecting more than half of the twelve thousand residents of Boston, the men fought allegations that they were responsible and used statistics to defend themselves and educate the public: while 14 percent of people naturally contracted the disease, only 2 percent of variolated patients became infected.5 In the following years, variolation became more popular in Europe, owing in large part to the data Mather published after the Boston smallpox epidemic. Although slow in the colonies, variolation received a boost during the Revolutionary War. After the American troops, stricken with smallpox, were unable to seize Quebec from British troops, who had all been variolated, Commander George Washington, himself a survivor of smallpox, required variolation of American troops.

Edward Jenner, a popular English physician, had heard stories of how Gloustershire’s milkmaids were protected from smallpox because of their exposure to cowpox, which although similar to smallpox, was not harmful to humans. He theorized that cowpox could also be transmitted through variolation, but without the risks presented by using actual smallpox matter. In 1796 Jenner found a milkmaid with pox on her arms. Using these lesions, Jenner inoculated an eight-year-old boy.6 Although he developed fever, loss of appetite, and aching for more than a week, he made a full recovery. Two months later, Jenner inoculated the same boy with fresh smallpox material. The boy did not become ill, suggesting he was protected by the initial variolation. Jenner’s efforts to publish the results of this study were unsuccessful, but drawing on the Latin for cow, vacca, Jenner coined the term vaccination to describe the procedure of variolation with cowpox matter (rather than the more virulent smallpox) and published his theory and single result in a booklet he distributed. Jenner was not able to locate additional volunteers for his study, but other physicians he contacted were willing to try vaccination. They confirmed that cowpox vaccination protected against smallpox with less risk than variolation with smallpox material had presented to the inoculated.

Jenner sent vaccination material to other physicians, who often shared it with colleagues. Finding its way to New England, vaccination became popular, gradually replacing variolation, which became prohibited in 1840.7 Jenner never sold his discovery, spent his own money to create and distribute stock of vaccination and information, and was known to vaccinate the poor in his town for free. At great personal cost, Jenner gave up his lifestyle as a physician and family man to become “a missionary to vaccination.”8 He was ridiculed and harangued throughout his life, both by colleagues who suggested that his growing fame was undeserved, and by popular critics who feared that his distribution of vaccination might lead to unknown complication, including humans sprouting animal parts, as a popularly reproduced cartoon shows.

Jenner’s influence was indisputable on both sides of the Atlantic. Thomas Jefferson wrote to Jenner in 1806, “Medecine [sic] has never before produced any single improvement of such utility. . . . You have erased from the calendar of human afflictions one of its greatest. Yours is the comfortable reflection that mankind can never forget that you have lived.”9

Jenner was not the first to recognize that cowpox prevented smallpox. He was not the first to use variolation from cowpox material, either. Yet Jenner was the first to systematically study the issue and to create widespread change through a public campaign. He helped to provide a framework for understanding how germs caused disease, challenging widely held views that illnesses were the result of spirits, miasmas, evil, or even moral failings.10 As such, the early nineteenth century saw the first compulsory vaccination laws for smallpox, often in response to outbreaks.

This 1802 cartoon, “The cow-pock—or—the wonderful effects of the new inoculation,” by the British satirist James Gillray, expressed anxieties about the risks of vaccination, including that recipients might sprout cow parts. Library of Congress Prints and Photographs Division, reproduction number LC-USZC4–3147, call number PC 1—9924, http://www.loc.gov/pictures/item/94509853.

In 1813 the U.S. Congress passed and Jefferson’s successor President James Madison signed into law “An Act to Encourage Vaccination.” This law established the first National Vaccine Agency, even requiring the U.S. Post Office to carry mail weighing up to half an ounce for free if it contained smallpox vaccine material. The goal of the act was to “preserve the genuine vaccine matter, and to furnish the same to any citizen of the United States.” Cities or townships also passed their own laws to require vaccines. In so doing, they hoped to protect their neighborhoods or townships from disruptive quarantines and to limit fatalities. Localities expected that individuals would participate out of a sense of public duty, but retained the authority to levy taxes against those who refused. For example, in 1820 the residents of North Hero, Vermont, voted to institute a tax to pay for the vaccination of all the town’s residents after cases of smallpox were diagnosed in the area. Dan Hazen, though present at the town meeting where the tax was approved, did not vote for it and refused to pay it. In response, the town constable seized Hazen’s cow and sold it to raise the payment. Hazen sued, leading to a ten-year legal battle that ended when the state’s Supreme Court upheld the confiscation. This is one of the first articulations in the United States of the state’s power to require vaccines and the willingness of the state to punish those who resist. It was not, however, the last.11

Expansion of State Power

Rates of smallpox rose with compulsory school attendance, which brought children into close quarters. In 1823 Boston became the first city to require evidence of vaccination for school attendance, with Massachusetts adopting its own law in 1855. Several other states followed by passing their own laws or developing new public health agencies and infrastructure to combat infectious disease. Thus, by the late 1890s, school attendance and mandatory vaccination laws had become linked. Courts also ruled that school boards, which hold no legislative power, may enact rules for public health, particularly in times of outbreaks, and that state legislatures may also give school boards such powers, providing legal support for these laws.12

Enforcement, however, was uneven. Teachers, principals, and school personnel were then, as they are today, largely uninterested in public health enforcement. Public health agents sporadically checked, and often discovered that fewer than half the children in a school might be vaccinated. On such instances, those agents might return and vaccinate all children who lacked a smallpox scar. In New York, for example, in 1894, fifty-six vaccinators from the health department distributed twenty-seven thousand vaccines to schoolchildren. In these ways, the state remained committed to compulsory vaccination and expended resources in support of those goals.13

Vaccines effectively limited outbreaks, which, in turn, fed complacency. Many people who had never experienced a smallpox epidemic became reluctant to undergo a procedure they viewed as unpleasant, risky, and of questionable necessity. As the legal scholars James Hodge and Lawrence Gostin suggest, “Since the vaccine has worked, why should individuals continue to be subjected to the harms of vaccination unless there exists an actual threat of disease in the community?” Those “who continued to press for vaccine were characterized as abusive, untrustworthy, and paternalistic.” Resisting vaccines, they argue, was equated with fighting government oppression.14 Suspicious of this new role for the state, organizations opposed to vaccinations grew in the second half of the nineteenth century.

Opponents distributed flyers and pamphlets, lobbied legislatures for the repeal of compulsory vaccination laws, filed lawsuits, and sought to discourage the use of vaccines. Their rhetoric rested on two linked claims: that vaccination was dangerous and unnecessary, and that legal compulsion to vaccinate was a violation of the country’s foundational belief in individual liberty. In support of the first claim, they pointed to legal cases for illness or wrongful death caused by vaccines and circulated stories of medical complications. They also alleged that health departments falsified death records to mask vaccines as the cause and refused to share information about the risks. Although they were vehemently opposed to vaccination, their claims were grounded in reason.15 As those against vaccines weighed the risks of inoculation, they did so in the context of a disease that had become rare by the end of the nineteenth century.16

For the second claim—that these laws violated individual liberty—the anti-vaccination groups opposed midnight raids, forced vaccination, and the quarantines that often destroyed the livelihood of owners and workers, sometimes enacted only because of the theoretical risk of infection or refusal to be vaccinated, rather than actual infection. They also argued that the new role of the state violated fundamental American values. Both these claims formed the basis for legal challenges.

Legal Challenges to State Power

Compulsory vaccination laws were, in fact, challenged in many court cases. After years of contradictory decisions from lower courts, the U.S. Supreme Court in 1904 considered whether requirements for vaccination were constitutional. In the landmark case of Jacobson v. Massachusetts (1905), the Supreme Court heard a challenge to the Massachusetts compulsory vaccination law. The state law allowed “the board of health of a city or town, if, in its opinion, it is necessary for the public health or safety,” to “require and enforce the vaccination and revaccination of all the inhabitants.” The law also specified that anyone “being over twenty-one years of age and not under guardianship [who] refuses or neglects to comply with such requirement shall forfeit $5.”17

Henning Jacobson, a minister who had emigrated from Sweden when he was thirteen and who lived in Cambridge, Massachusetts, challenged the legal requirement to be vaccinated or revaccinated. Although there was an outbreak at the time, he refused the vaccine for himself and was subsequently fined five dollars (about a hundred dollars today). He insisted that as children, both he and his older son had become ill after being vaccinated and he thus did not want to be revaccinated. He also refused to pay the fine.

Jacobson presented fourteen arguments against vaccination, including the general lack of safety, lack of efficacy, probability of harm, and his own experience of becoming ill after vaccination. More generally, he argued that “a compulsory vaccination law is unreasonable, arbitrary and oppressive, and, therefore, hostile to the inherent right of every freeman to care for his own body and health in such way as to him seems best.”18 Claiming that the laws violated his constitutional liberty interests, which he believed supported the right to bodily integrity, Jacobson insisted that the law was unconstitutional. He also reiterated his commitment to his religion and his objection to the use of cowpox in vaccines, asking, “Can the free citizen of Massachusetts, who is not yet a pagan, nor an idolator, be compelled to undergo this rite and to participate in this new—no, revived—form of worship of the Sacred Cow?”19

The lower courts who ruled against him and later the U.S. Supreme Court found his fourteen facts to be immaterial to the legal question at hand. In 1905 the U.S. Supreme Court ruled against Jacobson. In a 7–2 decision, the Court articulated a more narrow view of individual liberty, and clarified the rights of the state to enforce public health. The decision posits,

The liberty secured by the Constitution of the United States does not import an absolute right in each person to be at all times, and in all circumstances, wholly freed from restraint, nor is it an element in such liberty that one person, or a minority of persons residing in any community and enjoying the benefits of its local government, should have power to dominate the majority when supported in their action by the authority of the State. It is within the police power o...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Introduction
• 1. The Public History of Vaccines
• 2. Parents as Experts
• 3. Vaccines as Unnatural Intervention
• 4. The Limits of Trust in Big Pharma
• 5. Who Calls the Shots?
• 6. The Slow Vax Movement
• 7. Finding Natural Solutions
• 8. Vaccine Liberty
• Conclusion: What Do We Owe Each Other?
• Appendix A: Methods
• Appendix B: Vaccine Schedule
• Notes
• References
• Index
• About the Author