Measles 2015: A Pox On Our Public Healthcare Policy

There is a phenomenon that people don’t pay much attention to and certainly don’t base public policy on. This is unfortunate in that the public would be better off if they did pay slightly more attention to it, and public policy would advance rather than atrophy from inattention. The phenomenon: Knowledge does not persist from one generation to the next; knowledge must be communicated and learned or it is lost. We all know it’s true that knowledge must be learned, but we are perfectly willing to ignore what has been learned or not.

The 2015 US measles outbreak is a symptom of neglecting such knowledge. And we can add negligence to the mix by a weakening of public’s healthcare policy by widening the exemption/waiver policy as if there were no consequences to permitting non-inoculations. As the measles cases increase and spread to multiple states, we can anticipate the public reaction. There will be those who cry for the government to do something, this will be particularly prevalent among politicians. Another response will be to demand an investigation on how this (and irrationally for by whom this) was ‘allowed’ to happen. There will be the segment of the public that advocates a personal rights / individual freedom position that no one should be forced to inoculate their children (and they will have their politicians who support them).

But where is leadership on this issue? What besides the obvious has any leaders or pretender to the throne stated, declared or proposed? Where is the analysis, the debate or the proposed policy to address the demonstrated problem that the measles event has projected onto the national scene?

Don’t expect any satisfaction on this front. Leadership has apparently spent its load on what they can bring to the issue. If you missed it, it basically: “I think people should get vaccinated to protect the public.” Some add: “But I also believe individuals should have a role in this decision for their family.”  These two items cover all bases as long as you don’t think about the statements, attempt to develop a sound and reasoned policy from the statements, or consider whether the statements represent the problem space that this issue needs to cover.

What is the issue? Is it really as simple as whether everyone should be vaccinated or whether there are legitimate exemptions to be allowed under the law? I contend that that is only a part of the issue. The whole issue encompasses the scientific and medical understanding, the public health policy, individual’s right to medical decisions, the social cost/benefits for a pro- or con- position, and the responsibility of individual members of a society to other members.

The scientific and medical side of the issue should come down to what the ‘best’ scientific and medical expertise indicates we should do. In the current world, the answer is that vaccinations are the correct actions to take. This view acknowledges that there are medical conditions which will require an exemption but those conditions are not because of being afraid that vaccinations will cause autism. The view of medical and scientific communities is the public should vaccinate. This position is appropriately apolitical, it does not and should not be weighing in on the philosophy of government dimension.

The public health policy side of this issue presents the government’s (local, state and federal) involvement and responsibility in establishing the requirements for citizens, businesses, organizations and government agencies to follow in protecting the public and the nation from threats originating from diseases or situations that impact citizens’ health. The policy unfortunately varies at and across the various levels of government which makes for an unreliable situation in terms of the cause and effect consequences of one variation relative to another.  While there is a general consensus on the measles vaccination position within the nation, there are widely different exemption criteria and rules which make it much easier for an individual or parent to opt-out of being vaccinated. This opt-out allowance is a particularly relevant aspect of the current measles outbreak.  So the public health policy supports vaccinations but the instances where exemption rules are looser it is weakened and thus less effective in confronting the risks to the public from diseases.

The individual right to make personal choices in medical treatment that has come into prominent display with the measles outbreak is a dimension of the issue that most readily comes into conflict with the public policy, scientific, medical and other dimension of the issue. The reason for this is that the individual rights principle is almost understood to be at odds with a public / societal rights concept. I don’t believe that this conflict is as real, necessary or sufficient as it is treated but that doesn’t prevent it from creating a conflict that must be addressed. The fact that this conflict has been addressed in the past and will have to be dealt with again and again in the future is just part of the transmission of knowledge from the past into the future.

The most salient element of the individual rights position that must be considered with respect to a medical decision is whether the decision is truly a decision about the individual (or their family) or whether the decision involves the health of other individuals in the society. I don’t believe there is any dispute as to who should be able to make a medical decision about a wide range of medical conditions. Who else but you should decide if you go to a dentist for a filling; should you get glasses or contacts for correcting vision problems; should you get cholesterol pills, blood-pressure pills, erectile dysfunction pills, or other treatments for various health conditions that are non-contagious.

On the other hand, does our social contract for a free democratic society allow individuals to choose to make individual decisions about highly contagious and deadly diseases? If you have a highly contagious disease, our laws allow for the public-good to override your right to act indiscriminately and risk the health of others. You can be quarantined, you can be forced to take medication and you can be held to be accountable for negligence. Now these overrides of your right are narrowly defined in terms of the science, medicine, public health policy and level of risks presented; but they clearly demonstrate that like all things in our social contract there are limits, conditions and obligations that go hand in hand with the right. So where does this leave the individual right view on vaccinations? At best it seems to depend on the risk to whom question, and it has to acknowledge that it does not consistently trump the other factors irrespective of other interests.

Now I realize that people don’t like to consider or worry about the trade-offs that have to be accounted for on such topics as healthcare, but that doesn’t make the financial considerations unimportant or even critical to the decision. From a Cost/Benefits view, the vaccination issue presents a whole range of factors that are relevant to how the vaccination policy position for a particular disease should be calibrated. There are some diseases that while highly contagious are not highly injurious to anyone who catches it from another, and of course at the other extreme there are those diseases that have very high mortality rates and thus are significant risks to anyone. In cases where there are vaccines for the low risk outcome diseases the importance of a non-compulsive public policy position is rational, this would be especially true if the dollar cost to vaccinate were high. For diseases on the high mortality side, a policy to not require high-level vaccination compliance is equally warranted. In fact if the dollar cost was high and it isn’t feasible to protect every citizen the other-side of an individual’s right to choose would surface.  The element of the cost/benefit assessment on a disease, like measles, is how to determine some of the cost areas that come into play. How much does it cost to treat individuals who are not vaccinated and who come down with the disease? To what degree are long-term costs for someone that suffers a chronic consequence from being infected? Are there costs to individuals who are vaccinated beyond the vaccination, and if so what? On this dimension the answer is disease specific the costs/benefits trade-off decision will need to be made with an eye to what is the best policy for the public as a whole. This view presents the individual choice right under the notion of being able to choose for yourself without forcing a risky consequence onto someone else’s right to life.

Lastly there is an area of the vaccination issue which is rarely, perhaps never, included in a discussion of the vaccination policy. It’s the Responsibility factor. When we engage one of our ‘rights’ into a conflict, we diligently support the principles of rights that we acknowledge in our society. And when one right comes into conflict with another of our rights, we hope that there are precedents in the law to help guide which has the primacy and which is subordinate. What we don’t often do is think about, discuss or confront the question of is: Given a particular right, what are we then responsible for in the exercise of that right? If your individual right to not get vaccinated results in my suffering a loss is there no responsibility for you to account for that consequence? If your decision produces or contributes to a significant cost to the nation should you be responsible for that cost? The responsibility question is the one at the heart of balancing the individual right with the society’s obligation to protect all citizens. The fact that it’s not easy or comfortable to resolve is just what it means to live in a free society.