Should the MMR vaccine be compulsory for schoolchildren?

Harley Richardson reflects on an informative Education Forum discussion.

Is measles making a comeback? The World Health Organisation (WHO) says we are in the throes of an ‘unprecedented global measles crisis’, which killed 140,000 in 2018. The UK’s ‘measles-free status’ has been removed and over the last few months there have been reports in the media of measles and mumps outbreaks in UK schools and universities. Vaccinations against measles had been rising since the MMR controversy of the early 2000s, but the trend seems to have gone into reverse since 2014, accompanied by a fall in vaccinations for other illnesses such as diphtheria, tetanus, whooping cough, polio, and Hepatitis B.

A National Audit Office report in October 2019 found that uptake of the triple measles-mumps-rubella (MMR) vaccine was down to 86.4 per cent of children, below the 95 per cent threshold recommended for ‘herd immunity’, which reduces the likelihood of people who have measles passing it on to others and protects those who cannot have the vaccine. Of the four people who died of measles in the UK over the last quarter century, two had weak immune systems and one was too young to be vaccinated.

What’s behind the new decline in the uptake of MMR? For years the so-called ‘anti-vaxx’ movement, endorsed by celebrities such as Robert De Niro, has been claiming the vaccine is unsafe, but there are concerns its cranky views are now being amplified by social media and allowed to spread. In January 2019 a Royal Society for Public Health report warned that social media is “a breeding ground for misleading information and negative messaging around vaccination”, a view since echoed by the BBC Radio 4 programme The Misinformation Virus.

Prime Minister Boris Johnson has urged social media companies to do more to combat misinformation about vaccines. Sir Simon Stevens, Chief Executive Officer of NHS England, believes that parents are part of the problem, and warns that unwarranted doubts about vaccine safety are being spread at the school gates. According to Stevens, a ‘zero-tolerance approach to misinformation’ is required. Alarmingly, the UK’s new Criminal Law Commissioner, Penney Lewis, is considering whether spreading false information online should be made a criminal offence, even when the information is sincerely believed.

If voluntary vaccination isn’t working, ‘it may be time to consider draconian measures’, suggested celebrity doctor Miriam Stoppard recently. Should we go the way of the US, France, Italy and Germany, who have made vaccination mandatory and introduced fines and other sanctions for schools or parents who don’t play ball? Last autumn, the Health Secretary, Matt Hancock, said he was considering it and had begun looking into the legality of compulsory vaccination. On the other side of the political benches, Barry Sheerman, Labour MP for Huddersfield, has proposed making proof of MMR jabs a condition of school entry. Although Boris Johnson has ruled out compulsion for the time being, a prudent school would want to work out where it stands on the issue in case that position changes.

Is there a measles crisis?

In February, the Academy of Ideas Education Forum hosted a public debate to explore the practical and moral questions raised by the prospect of compulsory vaccinations. In preparation for chairing the discussion, I asked people on social media for their view. It was striking that most the responses boiled down to either ‘Of course it should be mandatory, it’s a no-brainer’ or ‘Of course it shouldn’t be mandatory, it’s a no-brainer’. Two opposing groups of people who are utterly sure of their own point of view and don’t see any need to discuss it - sound familiar? Sure enough, our discussion revealed that, far from being a ‘no-brainer’, there is much more to this topic than there first appears.

Our guest speaker was Dr Michael Fitzpatrick, a GP and author of the books MMR and Autism: what parents need to know and Defeating Autism: a damaging delusion . At the time of the original MMR controversy in the early 2000s, Dr Fitzpatrick was one of the few public voices arguing that claims of a connection between MMR and autism had no basis.

Today, perhaps surprisingly, he takes the position that talk of a crisis is overblown and compulsion is the wrong way to go. In the case of something like the new coronavirus, where its rate of spread is not yet known, or smallpox, where there is very high mortality rate, he says compulsory measures may be justified, but with measles, we haven’t exhausted the available options yet.

He pointed out that, even at the height of MMR scare, the rate of vaccination dropped only around ten per cent overall to about 80 per cent, before gradually returning to around 90 per cent. The recent fall is of only a couple of per cent - not a reason for complacency, but also not a catastrophe.

If there is a resurgence of anti-vaxxer propaganda, it does not seem to be having that much effect. A Public Health England survey of parents found that confidence in vaccines is at its highest-ever level, and of those parents who did not vaccinate on time, most had postponed, rather than refused, vaccination. Three times as many parents cited leaflets rather than online sources as their main source of information.

So why do we credit the anti-vaxxers with more influence than they actually have? Perhaps, as Slate columnist Daniel Engber wrote, “we love to hate the anti-vaxxers because they offer us distraction”. It’s easier to assume that everything is the fault of people we don’t like than to put the effort into investigating the issues involved. Dr Fitzpatrick believes that we are now seeing the emergence of intemperate anti-anti-vaxxers, whose views on the anti-vaxx movement are bound up with their own fears about populism, Brexit, Trump, organised religion and so on, and who tend to overreact accordingly.

I’m not religious but I was surprised at the lack of consideration for religious viewpoints in some of the online comments I received when I was canvassing views on the topic. While recent outbreaks of measles have indeed been concentrated in local faith groups, such as the Orthodox Jewish community in Hackney, they have been short-lived one-offs. Dr Fitzpatrick argued that religious objections to vaccination play a smaller role than many realise. Some faith groups tend to have larger families, which can put logistical obstacles in the way of getting all their children vaccinated. In the case of Hackney, it’s possible that measles was brought back from the annual pilgrimage of Breslov Hasidic Jews to the Ukraine, where the quality of public health services is much lower.

Dr Fitzpatrick suggested that mundane, practical factors are likely to play the largest role in the fall of vaccinations, and indeed, the closer people are to the clinical coalface, the more hesitant they are about compulsion, because they see for themselves the issues involved. Public health spending cuts have led to staffing problems in local surgeries as well as a fall in the number of health visitors. In Hackney, where Dr Fitzpatrick practised for 30 years, there is a highly mobile population and a 30 per cent turnover of registrations at GP surgeries, so it is often a struggle for over-stretched staff to register everyone, get hold of their medical records, where these exist, and send out reminders at the right time.

We heard from health professionals in the Forum audience that there are also widespread problems with data accuracy, thanks partly to outdated paper recording systems, meaning that the actual levels of vaccinations are likely to be higher than reported. As Helen Bedford, Professor of Children’s Health at University College London, pointed out, if the level of vaccinations was as big a problem as people claim, we would be seeing massive outbreaks everywhere.

The problems of compulsion

So talks of a crisis may be overstated. But if the downward trend in vaccination rates continues, would compulsion be justified?

We heard that in Italy, making vaccinations mandatory has not significantly improved the rate of uptake and that, in the US, the law of unintended consequences has been in full swing, with parents who object to vaccinations turning to home schooling, gaming the system by claiming personal exemptions for dubious medical reasons, or resorting to the black market for fake vaccination certificates.

Several US states have responded to recent measles outbreaks by removing religious exemptions, which has increased tensions between state authorities and faith groups. Notably, members of a New York State Amish family, who believe that God made children ‘right and good’ and that to vaccinate them is to lose faith in God, have filed a lawsuit in an attempt to overturn the state’s decision. The Amish community originally settled in New York State in part because its constitution protects free exercise of religion. They also believe that public community schooling is an important part of raising children, so home schooling is not an option and, as farmers, it is not easy for them to relocate to a state which doesn’t mandate vaccination.

It’s possible that compulsion has helped create a receptive audience for the anti-vaxx movement in the US, where it has a higher profile than in the UK. Dr Fitzpatrick argued that attempts to suppress misinformation are always likely to be counterproductive, and wrote in the Daily Mail that the new film by anti-vaxxer Brian Burrowes, Vaxxed II: The People’s Truth, should be shown widely to get its arguments into the open where they can be taken on and exposed. Refusing to show it hands anti-vaxxers a moral high ground they don’t merit, allowing them to cry censorship and fuelling broader suspicions that the authorities have something to hide.

Calls for compulsion also risk finding a ready audience among a teaching profession which is already encouraged to see parents as incapable of making rational decisions in the interests of themselves, their families and their communities. The vaccination question could easily become an excuse to further erode the line between school and family, as we have seen over recent years in the form of edicts over the correct contents of packed lunches and attempts to teach children about proper relationships, to name just a couple of examples.

Persuasion not compulsion

As we heard, there are lots of reasons why parents don’t vaccinate their children. The WHO acknowledges there is a significant group of ‘vaccine-hesitant’ parents, who are not against vaccines but have questions and concerns about them. It’s entirely reasonable, and very human, to wonder about the wisdom of sticking needles and chemicals into our children. Reassurance should be given that it is the right thing to do. But we should remember that not so long ago most of the mainstream media, as well as sections of the medical establishment, were promoting doubts about the safety of vaccines. It is hardly surprising that some people took what they said seriously.

This is not a straightforward battle between good science and junk science. There are reasons why fears about the safety of vaccines catch people’s imaginations in the way they do, including that they appeal to those who believe that ‘nature is best’, and they chime with a conspiratorial view of the world, which sees the hand of Big Pharma behind all medical interventions.

If we want to win the argument for vaccination, we need to engage with the underlying views that make some people receptive to scare stories about vaccines, and we need to have confidence that people are open to persuasion. It may not be possible to convince hardened antivaxxers to change their minds, but they are in the minority. A sympathetic hearing of the concerns of vaccine-hesitant parents is more likely to create the opportunity to win them over than telling them in effect to shut up and listen to the science.