Annabelle, Fiona, and the millions of other American children born over the last twenty years have received an unprecedented number of vaccines. Between 1983 and 2005, the number of diseases against which children are routinely vaccinated doubled, and the number of mandated and recommended vaccinations tripled. New vaccines are added to states’ lists of mandated vaccines through a process that begins with the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. The committee, made up of fifteen members drawn from the scientific and medical communities, meets three times a year. It offers official recommendations for the use of vaccines to be adopted by state legislatures and by physicians. But it is up to individual state legislatures to adopt the committee’s recommendations and make a particular vaccine mandatory, and it is up to pediatricians to recommend vaccines that are not on their states’ lists of mandated vaccines to their patients’ parents.1
A century ago, children received only the smallpox vaccine. By the early 1980s, vaccines for diphtheria, pertussis, tetanus (administered together in the DPT vaccine), polio, and measles, mumps, and rubella (administered together in the MMR vaccine) were developed and adopted in most states as mandatory (table 1). Over the last twenty years, six more vaccines were added to the list along with the annual influenza vaccine. Today, by the time they are six years old, fully vaccinated American children receive about three dozen immunizations consisting of nearly fifty vaccines (table 2). At the same time, vaccine compliance rates are at record highs. In 2007, among two- and three-year-olds in the United States, vaccine coverage topped 90 percent each for polio, measles, mumps, rubella, Haemophilus influenzae type b, hepatitis B, varicella, and pneumococcus. Today, over 80 percent of American three-year-olds have received all of their state-mandated vaccines. At the opening of the twenty-first century, more children are receiving far more vaccines than ever before in American history.2
Table 1. Diseases the CDC Recommends Children Be Vaccinated against by Age Six, 1983 and 2008
Along with the rapidly growing number of vaccines have come increasing worries among parents about the number of shots, their frequency, and the possible unintended negative consequences. Lately we have seen escalating concerns among Americans about pharmaceutical companies putting profitability before safety as well as fears about the potentially harmful effects of the medical community’s one-size-fits-all approach to vaccinations. Criticism of vaccines is coming from both ends of the political spectrum and from points in between. Left-leaning parents mingle concerns about vaccines with their environmental activism, health-conscious lifestyles, and anxieties about corporate power and profit motives. They are joined by rightwing libertarians who dislike governmental interference with what they consider personal decisions and by conspiracy theorists that see in vaccines a government plot to oppress or eliminate certain segments of the population. Individuals who might be political rivals on other issues frequently borrow from one another in making their arguments. Add to that the incredible amount of information on the subject now available through a variety of media outlets including the Internet—much of it unfiltered by accredited experts and repeated by various celebrity advocates—and you have an entire generation of parents who are apprehensive about what public health authorities herald as the single most effective tool in preventing communicable diseases.
Table 2. Vaccines Recommended by the CDC from Birth to Age Six, 1983 and 2008
Parents are not merely talking about their concerns about vaccines, they are acting on them. A large and growing number of parents are choosing not to vaccinate their children with one or more of the mandated vaccines. Today, 40 percent of American parents have chosen to delay or refuse a recommended or mandated vaccine for their children. To make matters worse, public health officials have found pockets of very low vaccine compliance in various places around the country, some with high numbers of unvaccinated children. For example, in the public schools on Vashon Island, located a short ferry ride from Seattle, Washington, 18 percent of students are exempted from a mandated vaccine. Similar hotbeds of vaccine exemptions include Boulder, Colorado, and Ashland, Oregon, where on average 28.1 percent of students are exempt from one or more vaccines. In some Ashland schools, exemptions for particular vaccines are as high as 66.7 percent. These parents are not simply forgetting to have their children vaccinated, nor are they too poor to have access to health care; they are making conscious decisions not to vaccinate their children with one or more of the mandated vaccines.
The clustering of these exemptions raises concern among public health officials about their potential to generate disease outbreaks that can spread to children in other areas. In addition to the children whose parents have chosen not to vaccinate them, there are many children who are not vaccinated because they have medical exemptions and many others who, despite being vaccinated, have lost their immunity over time and are susceptible to communicable disease. In 2008, public health officials singled out Washington State for its high number of unvaccinated children and identified the source of one of the largest outbreaks in recent history of measles as an unvaccinated child who spread the disease to seven other unvaccinated children in her household. Health authorities see intentionally unvaccinated children as threats to everyone, recognizing that vaccines’ efficacy wanes over time and that in some cases even vaccinated children are still capable of contracting diseases. Some officials warn that “difficult decisions may need to be made to deny exceptions … in order to avoid a snowballing of exceptions that would threaten not only those who seek exemption, but some percentage of those who undergo vaccination.”3
The public discussion about vaccines has grown so complicated and confusing that one can easily find competing claims about nearly every vaccinerelated fact or event. For example, both the proponents and the detractors of the mandatory vaccination schedule have used the case of the introduction and withdrawal of RotaShield to support their positions. Vaccine advocates have pointed to the high levels of safety expected of vaccines—after all, an investigation into the vaccine began after only fifteen reports of intussusception among recently vaccinated children. Detractors see this case as an example of corruption and lax standards. In 2000, a majority staff report from the U.S. House Committee on Government Reform reported that the vaccine was approved and sent to market even though an increased number of intussusception cases appeared during the prelicensure trials of RotaShield. This was perhaps because, as the report asserted, the “conflict of interest rules employed by the FDA and the CDC have been weak, enforcement has been lax, and committee members with substantial ties to pharmaceutical companies have been given waivers to participate in committee proceedings.” Critics of vaccination programs draw from the report to assert that, despite the prelicensure cases of intussusception among children vaccinated with RotaShield, the vaccine was approved because “four out of eight CDC advisory committee members who voted to approve guidelines for the vaccine in June 1998 had financial ties to pharmaceutical companies that were developing different versions of the vaccine. Additionally, three out of five FDA advisory committee members who voted to approve the rotavirus vaccine in December 1997 had financial ties to pharmaceutical companies that were developing different versions of the vaccine.”
In response, public health officials have become increasingly concerned with managing the media’s response to research results, and they have made changes to vaccine policy in hopes of avoiding a loss in the public’s confidence in a particular vaccine or in vaccines generally. Some recognize that maintaining high levels of vaccine compliance requires better educating the public about the side effects from vaccines as well as enhancing appreciation for the long-term benefits of mandated vaccines.4 Nonetheless, little effort has been put forward by health officials to address Americans’ concerns about what on the surface seems like serious conflict of interest problems in the research, manufacture, and administration of vaccines in the United States.
To bolster public confidence in the value of vaccines, proponents remind the public about the serious threat of communicable diseases and the success the medical community has had in nearly eliminating many of the most deadly diseases. As part of their efforts to educate the public about efficacy of vaccines, the Vaccine Education Center at the Children’s Hospital of Philadelphia tells parents, “Vaccines have literally transformed the landscape of medicine over the course of the twentieth century.” According to their website, before vaccines were developed for certain communicable diseases, parents in the United States could expect that every year:
• Polio would paralyze ten thousand children.
• Rubella (German measles) would cause birth defects and mental retardation in as many as twenty thousand newborns.
• Measles would infect about four million children, killing three thousand.
• Diphtheria would be one of the most common causes of death in school-aged children.
• A bacterium called Haemophilus influenzae type b (Hib) would cause meningitis in fifteen thousand children, leaving many with permanent brain damage.
• Pertussis (whooping cough) would kill thousands of infants.
In 1996, the CDC studied the efficacy of vaccines in reducing the incidence of vaccine-preventable diseases. It found that since the introduction of vaccines for rubella, diphtheria, Haemophilus influenzae type b, measles, mumps, pertussis, polio, and tetanus, we have seen a drop of between 97.8 percent and 100 percent in each of the diseases.5
Even the most ardent proponents of vaccines also recognize that the administration of any vaccine carries with it some risk of undesirable side effects that range from mild discomfort to—in very rare cases—disability or death. The CDC, for example, states, “Immunizations, like any medication, can cause adverse events.” Likewise, the Vaccine Education Center explains that every vaccine has negative consequences for some of the children who receive them: “Almost all vaccines can cause pain, redness or tenderness at the site of injection. And some vaccines cause more severe side effects.” These include high fevers, seizures, comas, swelling of the brain, severe infection at the injection site, life-threatening allergic reactions, pneumonia, permanent brain damage, major organ system failure, intussusception, deafness, and even diseases like Guillain-Barré Syndrome. However, as public health officials are quick to point out, such reactions are exceptionally rare, occurring far less often than the diseases against which the vaccines protect had occurred. This allows a vaccine to be declared safe because each vaccine’s “benefits must clearly and definitively outweigh its risks.” Moreover, despite their shared use of the term “risk,” parents and health officials may have fundamentally different notions of how to weigh it in making health care decisions. While health officials work with a sample size of thousands or even millions, parents consider risks one child at a time. In discussions about vaccine safety, it is common to hear parents say, “What if your child is that one in a million?”6
Of more concern to most parents than the risk-benefit analysis inherent to each vaccine is the larger and increasingly complicated question of how many vaccines we ought to administer to ourselves and to our children. Recent polls of parents have found that, while most appreciate the capacity of vaccines to help maintain children’s health, they were nonetheless concerned about the rapidly increasing numbers of vaccines that their children were expected to receive. A poll of parents in the year 2000 found that 87 percent “deemed immunization an extremely important action that parents can take to keep their children well,” but a third “believed that children get more immunizations than are good for them.” Only four years later, another poll found that almost 90 percent of surveyed parents expressed concerns about the number of diseases against which children were vaccinated, while only 14 percent questioned any individual vaccine’s efficacy. The elimination of polio or hepatitis B is doubtlessly desirable, and the vaccines against such deadly and debilitating communicable diseases have been incredibly effective. More recently adopted vaccines, however, target far less common or much less serious ailments like the once common and rarely deadly chickenpox infection. Nonetheless, the vaccine against chickenpox is mandated alongside vaccines for deadly diseases like measles and diphtheria.7
Further complicating the situation are the justifications and sales pitches for some new vaccines. For example, parents are frequently told that the varicella vaccine, which protects against the chickenpox, should be administered because it prevents inconvenience to the parent and child. “Even with uncomplicated cases,” the CDC’s website states, “children with chickenpox miss an average of five to six days of school, and parents or other caregivers miss three to four days of work to care for sick children.” The American Academy of Pediatrics employs the same argument, but with different numbers, asserting that “parents may have to miss work while their children are home from school or child care. In the average household, a child with chickenpox misses eight or nine days of school, and adult caretakers lose up to two days of work.” Similarly, the American Academy of Family Physicians asserts, “Because of the lost time from work, chickenpox can be a significant cost to parents of children who get the illness.”8
The message to parents is clear: The inconvenience and financial costs of missing work can easily be avoided by simply agreeing to have your pediatrician administer the varicella vaccine to your child. Such an approach smacks of an easy techno-fix for a complex social and economic dilemma. In this case, the vaccine reduces the problem created by an economic and cultural system that penalizes a parent for having to stay home from work to take care of a sick child. Some vaccines initiate criticism of so-called pharmacological technofixes for what detractors consider to be personal or social shortcomings. The ardent search for a vaccine to protect against HIV/AIDS, the promotion of the vaccine for the human papillomavirus (HPV), and the mandated vaccination for hepatitis B are all targets for critics who claim that the vaccines protect against diseases that are caused primarily by unprotected sexual activity. Instead of engaging in the arduous task of altering people’s behaviors, these vaccines, with the ease of a few simple shots, would do away with what moralists consider the natural consequences of problematic behaviors.9
The vaccine for varicella (popularly known as the chickenpox) has been the subject of a great deal of controversy recently as research has indicated that the vaccine does not provide the same kind of lifelong immunity provided by contracting the disease. This suggests that children may be protected against the disease while they are young but are left vulnerable as they become adults. As age increases, chickenpox becomes an increasingly serious ailment; by the 1980s, adults accounted for only 2 percent of the cases of chickenpox but were among nearly 50 percent of the small handful of people who died from complications associated with the disease. In 2007, research published in the New England Journal of Medicine concluded that the protection offered by the varicella vaccine waned after about five years, and a second dose of the vaccine “could improve protection from both primary vaccine failure and waning vaccine-induced immunity.” According to a Reuters interview with the authors of the study, “No one knows how long the effects of the second shot would last.” To make matters worse, shortly before the study was published, Merck had released its new MMRV vaccine, ProQuad, which added the vaccine against the chickenpox to the existing MMR vaccine. The new combined MMRV vaccine effectively reduced parents’ ability to choose to vaccinate against diseases like the measles without also having to vaccinate against the chickenpox; this gave parents another reason to be apprehensive about the current vaccine regime.10
Efforts to increase the uptake of particular vaccines have, at times, jeopardized public support of vaccines. Take, for example, Merck’s Gardasil, which protects against four strains of the human papillomavirus, two of which are associated with cervical cancer and two of which cause genital warts. Gardasil was the subject of contentious debate in 2006 and 2007 when Merck’s lobbyists pressed state legislatures to include it on their lists of mandated vaccines. The issue came to a head in February 2007, when the Republican governor of Texas, Rick Perry, sidestepped the usual legislative process for adding vaccines to his state’s list of mandated vaccines; he issued an executive order requiring all Texas girls to be vaccinated with Gardasil. Three weeks later the Associated Press reported that Perry’s aides had crafted the executive order on the same day that Merck had donated $5,000 to Perry’s campaign. It was also learned that Perry’s former chief of staff was by then a lobbyist for Merck and that the governor had accepted $6,000 from the company during his previous reelection campaign. In May, amid considerable public pressure, the state legislature passed a bill that overturned Perry’s executive order.11
Controversies like the one in Texas led to a passionate response from advocacy groups and public health experts, and Merck eventually abandoned its lobbying efforts to get Gardasil included on the list of state-mandated vaccines. The New York Times reported “the company said it made the decision after realizing that its lobbying campaign had fueled objections across the country that could undermine adoption of the vaccine.” As Merck withdrew its lobbyists, it set its advertising agency to work creating direct-to-consumer advertisements that ran on television, in movie theaters, and in many massmarket magazines. Campaigns for the drug featured a sophisticated website. Merck’s extensive “I Choose” and “One Less” campaigns urge women to protect themselves and their underage daughters against cervical cancer and some strains of HPV without ever discussing sexual issues or explaining that HPV is a common virus that is almost always harmless. No longer merely instruments of public health, such recently released vaccines have taken their place alongside other enhancement pharmaceuticals that promise to improve the quality of individuals’ lives by allowing them freedom from inconveniences like missed work days or safe sex practices.12
Vaccine proponents have worried about the politicization of vaccines as increasing numbers of parents lobby state legislatures to loosen the process to obtain exemptions. Merck has taken advantage of the political controversy over its aggressive lobbying efforts to attract more consumers. Instead of relying on state legislatures to add their HPV vaccine to the list of mandated vaccines, they have marketed Gardasil to a particular ideological category of Americans. Just as Toyota solicits environmentally conscientious consumers with the Prius, Merck has worked to attract politically progressive parents to Gardasil with advertisements that urge them to take advantage of the opportunity to protect their children, boys and girls alike, from the four strains of HPV that are most commonly associated with cervical cancer and genital warts. In this context, Merck has profited from the notion that the only significant opposition to mandating Gardasil came from members of the religious right. Merck has capitalized on the political controversy over Gardasil—perhaps even to the point of perpetuating or enhancing it—which is problematic in light of recent studies concluding that pharmaceutical companies like Merck spend almost twice as much money on advertising as they do on research and development. Moreover, these pharmaceutical companies use direct-to-consumer advertising methods for drugs that are only available by prescription.13
The vaccines against varicella and HPV are the two newest to be added to the list of mandated (in the case of varicella) and recommended (in the case of HPV) vaccines, and they are the two that seem to most frequently elicit parents’ concerns. In a recent survey, among those parents who have refused to allow their pediatricians to administer a vaccine, the HPV and varicella vaccines were the two most commonly refused. When asked about their concerns, more than three-quarters of the parents who refused the HPV vaccine said they did so because not enough research had been done on it, and because it had not been on the market long enough. In the case of the varicella vaccine, most parents (78 percent) said they would prefer that their child get chicken-pox than be vaccinated against it.14
Public health officials and medical authorities see tremendous promise in vaccines and give unwavering support for universal vaccination efforts. Any criticism of vaccines is especially worrisome for them. In response to challenges to the safety or efficacy of vaccines they often—and regrettably—raise the issue of religion as a convenient explanation for parents’ concerns. In fact, very few people refrain from vaccinating their children for formal religious justifications. Nationally, only about one percent of children are exempted from vaccinations for religious reasons. Nonetheless, descriptions of anti-vaccinators from public health officials generally make allusions to religious objections to vaccination. To be sure, some parents without religious objections to vaccines avoid vaccinating their children by employing religious exemptions, either out of convenience or because it is the only avenue for a sanctioned exemption in their state. It is also likely that public health officials’ notions are overly informed by historical memory. They overemphasize the century-old religious objections to vaccines while overlooking the more recent concerns that have little to do with formal or informal religious resistance to compulsory vaccination. Aside from tiny fringe fundamentalist healing sects, no significant American religious group categorically disallows its followers from being vaccinated. A cultural tendency among members of some groups—like the Amish, Jehovah’s Witnesses, and Christian Scientists—encourages skepticism about mandated vaccines. However, these groups make up only a tiny fraction of the American population.15
Health care providers and public health officials also frequently assert that the number of vaccine skeptics has increased because as diseases occur less frequently, parents have grown apathetic about the potential threat of these vaccine-controlled diseases. As Mark Sawyer, a pediatrician and infectious disease specialist at Rady Children’s Hospital in San Diego explains, “The very success of immunizations has turned out to be an Achilles’ heel. Most of these parents have never seen measles, and don’t realize it could be a bad disease so they turn their concerns to unfounded risks. They do not perceive risk of the disease but perceive risk of the vaccine.” Elsewhere, in an analysis of parents who opposed compulsory vaccination, researchers asserted, “Because many parents lack firsthand knowledge of vaccine-preventable diseases such as measles or polio, they are not likely to perceive such illnesses to be an immediate threat to the health of their children.” This assertion was validated, researchers say, by a 1999 telephone survey that found parents were more likely to refuse a vaccine when they perceived the severity of the disease to be low.16
From a parent’s point of view, none of the explanations commonly offered by the medical community adequately addresses the anxiety I feel vaccinating my daughter. First, I have no religious or moral impulses about vaccines. I recognize that some are made with animal products, and some were developed with the use of aborted fetuses. These facts alone do not prevent me from allowing them to be administered to my daughter. Furthermore, I fully understand that diseases like measles and diphtheria are terribly dangerous, especially to young children. Recent polls demonstrate that the vast majority of American parents likewise recognize that children need vaccines for diseases that are no longer common. Not personally knowing any children who have had these diseases in no way alleviates my appreciation of their threat to Annabelle. There are countless precautions I take against real and perceived threats to her safety—from baby proof latches on cupboard doors and expensive car seats to tossing out her plastic baby bottles when I learned about the potential threat of bisphenol A and spending the extra money to buy organic foods. Just as I know of no children who have been harmed by measles or diphtheria, I know of none who has been seriously harmed by the contents of cupboards or by plastic baby bottles. Nonetheless, I am concerned about the capacity of these things to harm my daughter, and I have taken what I believe are sufficient precautions to preserve her health, as the bottles of hand sanitizer I stash in my glove box and briefcase testify. The threat of communicable diseases, in fact, looms large in my mind, and any claims that I fail to appreciate the peril they represent to Annabelle are simply wrong.17
There is, moreover, a significant difference between safeguards like baby proofing my home and vaccinating my child: unlike most of the measures I take to protect Annabelle, vaccines come with a recognized risk of side effects. There are no potential adverse side effects other than to my wallet of organic foods, safety latches, or costly car seats. Because more vaccines means more potential side effects, parents are growing increasingly concerned about the rapidly increasing number of vaccines that they are expected to allow pediatricians to administer to their children. It is not merely the nature of vaccines that disturbs parents; it is their sheer number. American children are now expected to get between twenty-six and thirty-five inoculations by the time they start kindergarten. To make matters worse, three-quarters of these vaccinations are administered in the first eighteen months of life, with as many as six at a single office visit. Every new vaccine added to the vaccine schedule adds yet another batch of potential side effects.
Parents’ concerns about vaccines extend beyond a simple recognition of benefits and risks, and public health officials need to appreciate how a parent thinks about the potential benefits and dangers offered by vaccines. Most parents are much more willing to accept the consequences of a communicable disease than they are willing to accept the consequences of having made a child sick by giving them a vaccine. Guilt by omission—failing to administer a vaccine and as a result a child contracts a communicable disease—seems preferable to guilt by commission—making a child sick as a result of an adverse reaction to a vaccine. This attitude was nicely demonstrated in the “Readers’ Comments” section of the New York Times website in response to a story on personal-belief exemptions for vaccines. Wendell Jones of Albuquerque, New Mexico, wrote, “A part of the emotional equation for parents is the difference between consequences resulting from ‘acts of God’ (like coming down with measles) and those resulting from actions on my part (like developing a condition from receiving a vaccination). As a parent, I can more easily live with the first than with the second.” Similarly, in The Vaccine Book: Making the Right Choice for Your Child, Robert Sears described his experience with a parent who said that she would rather risk having her children contracting a disease than risk causing a side effect from vaccinating them because, “If her children suffer a severe course of a disease, it won’t be because of something she did. Rather, it will be because of something she didn’t do. She said that she would rather live with that type of choice.”18
Health authorities’ efforts to maintain public vigilance against vaccine-preventable diseases have led them to describe the potential threat posed by vaccine-preventable communicable disease in near hysterical terms. Readers frequently see the term epidemic used in descriptions of minor outbreaks of diseases, and vaccine proponents describe parents who refuse to vaccinate their children against particular diseases as free-riders or parasites because they benefit from the inoculated majority. In both Great Britain and the United States, public health officials routinely describe the threat of a measles epidemic given the supposedly falling rates of vaccination that are claimed to be caused by concerns about vaccines. For example, in 2008, the CDC reported a spike in the number of confirmed measles cases. During the first six months of the year, there were several small outbreaks in Illinois, New York, and Washington State that brought the total number of confirmed cases for the first half of the year to 131, more than twice what Americans had seen in the previous year but not substantially outside the range of confirmed cases typical over the previous two decades. Given that the United States was also experiencing record high vaccination rates and that vaccine-preventable childhood disease deaths were at a record low, there was no real cause for concern. Nonetheless, the press reported, “pediatricians and health experts are sounding the alarm, noting that measles, which is virulently contagious, is the first disease to crop up when vaccination rates fall.” It may well be true that we would see an increase in measles cases if vaccination rates dropped; however, a slight increase in cases over the previous several years was not the result of a drop in vaccination rates.19
In 2008, in hopes of reenergizing public concern about communicable diseases and fighting what it called “preparedness fatigue,” the CDC introduced the Pandemic Influenza Storybook, an online collection of personal recollections from survivors, families, and friends of victims of the 1918 flu pandemic. “Complacency is enemy number one when it comes to preparing for another influenza pandemic,” explained CDC director Julie Gerberding. The stories “serve as a sobering reminder of the devastating impact that influenza can have, and reading them is a must for anyone involved in public health preparedness.”20
Claims about how the reduced incidence of communicable diseases has altered parents’ thinking about the benefits and risks of vaccines are only half right. It is not the case that parents merely do not appreciate the danger of communicable diseases. Instead, the population-wide reduction in the incidence of these diseases has helped to alter parents’ calculus in making decisions about vaccinating their children because it has altered the amount of risk parents are willing to take in the name of prevention. The 1999 telephone poll that found a relationship between parents’ perception of the likelihood of their children contracting a particular communicable disease, the perceived severity of a disease, and their attitudes about compulsory vaccination provides us with ample evidence of this change. Parents were most likely to refuse vaccines against the diseases that were actually the least immediately threatening to their children (like the chickenpox and hepatitis B), and least likely to refuse vaccines against the most immediately threatening diseases (such as Hib, polio, and measles).
So, let us be clear here: vaccines are not “victims of their own success,” because the reduced incidence in communicable disease has not lessened concern about particular communicable diseases any more than the invention of airbags or the availability of safer car seats has reduced my concern that Annabelle will be injured in an automobile accident. If anything, the reduction in the prevalence of communicable diseases has heightened my concern to protect her against them, which follows what appears to be a generally lower tolerance among Americans for risk to their children generally. In the context of reduced tolerance for risk, parents have grown increasingly concerned not only about communicable diseases, but also about the potential short- and long-term side effects of the intensive vaccination regime.21
One good explanation of the tensions that have emerged between parents and public health officials can be found in the work of scholars of rhetoric and argumentation. Rhetoricians have described how participants on either side of an argument work from a set of agreed upon values about important claims, ideas, or goals. In scientific arguments, discussion and agreement about these values are generally confined to the early formulations of the concepts and rules that will govern the argument. That is most certainly the case with discussions about vaccines among medical professionals and in their public statements in support of official vaccine recommendations. The mutually agreed upon value of widespread public health—the largest benefit for the largest number of people—motivates their ardent promotion of vaccination for every citizen who is not deemed too immunocompromised to shoulder the relatively low risk of adverse side effects. However, in fields like law, politics, and philosophy, rhetoricians tell us that consideration of values occurs at all stages of the development and execution of an argument. We see this in debates over vaccines, as worried parents and vaccine detractors launch attacks on the medical orthodoxy over everything from the contents of vaccines and their efficacy to the safety studies before new vaccines are put on the market, the timing of their administration, and their long-term effects. While parents and public health officials may hold many values in common, their value hierarchies are sometimes at odds, and the rules by which they wage arguments often differ considerably. The result is a chaotic environment in which, parents, not public health authorities, ultimately decide whether or not to vaccinate children.22
It is not simply that parents and health officials do not agree on the relevant values or on an acceptable value hierarchy, they also engage fundamentally different sorts of values when considering the issues surrounding vaccines. Rhetoricians distinguish between two types of values: abstract values, like truth, justice, or beauty that exist only as concepts and concrete values, which are attached to specific tangible things, like a particular virus. Parents necessarily grapple with a diverse collection of abstract values when they consider the benefits and risks—both to their children and to society at large—and decide for or against particular vaccines. Paramount among these abstract values is their children’s health, which is an illimitable, perpetually improvable value that cannot be judged against some normative standard of health, but only against parents’ perception of how much healthier or less healthy that child might have otherwise been. This is what is happening when someone says, “My mother smoked when she carried me, and I turned out healthy,” and another replies, “Yes, but how much healthier might you have been had she not smoked?” There is no normative standard of health when we think about our children or even about our own childhoods. Instead, we can only imagine how much better or worse our current health might be had something been done differently.23
While parents struggle to rank competing abstract values, in discussions about vaccines and vaccine compliance, public health officials have found a way to transform the abstract value of public health into a concrete value by quantifying it. By tracking the number of diagnoses of a particular disease and by virtue of their collective acceptance that the absence of any diagnoses of a disease is equivalent to health, they have transformed the abstract value of public health into a concrete value. Their adamant assertion that the benefits of vaccines far outweigh their risks is possible only because medical authorities have generated a normative standard of health, which they measure by recording the number of diagnoses of a particular disease. Unlike the parent who is forever vexed with the question of “how much healthier might my child have been had I done (or not done) X,” public health officials can reach the point of perfect health in fighting a particular disease when the number of diagnoses drops to zero, as it did in the 1970s with smallpox, for which a vaccine is no longer necessary. Their concrete value of health emerges as a product of public health statistics, which allow the medical community a level of certainty about the overall goodness of vaccines that is simply not available to parents.24
We conclude, therefore, with a curious dilemma: how is it that a fantastically successful instrument of public health, a cheap intervention that has saved millions of lives and prevented unimaginable illness and disability, has become the target of such virulent contention? How is it that something so obviously beneficial to children’s well being has become the source of so much anxiety for parents? More specifically, how—as either a parent or a public health official—does one navigate this controversy and make the best decisions for our children?
Abandoning for now my perspective as a parent and taking up the tools of an historian of science and medicine, I hope to show how the modern American controversy over vaccines emerged in the 1990s and how it has evolved over the last two decades. There is a substantial history of opposition to mandatory vaccination, beginning in England with Reverend Edmund Massey’s 1772 sermon, “The Dangerous and Sinful Practice of Inoculation.” Massey argued that the diseases that might be prevented by vaccines were in fact God’s tools for punishing sinners. Public resistance to vaccines grew rapidly after Britain began requiring the vaccination of all infants in 1853 for smallpox, and anti-vaccination sentiment was imported into the United States by the prominent British anti-vaccinationist William Tebb in 1879.25
Regardless of the claims made by vaccine proponents, eighteenth- and nineteenth-century vaccine controversies have little direct impact on my and other parents’ concerns about current vaccine policy. Modern vaccine anxieties have nothing to do with Massey’s notions of a vengeful God, nor are they shaped by particular religious objections to the way in which vaccines are researched or manufactured. It may well be that public health officials can find past challenges to vaccines that seem similar to some of today’s claims about vaccines. They might even find some short-term solutions to the problem of parents’ declining commitment to universal vaccination. However, modern vaccine anxieties are different from those expressed in the past because both the vaccines and the contexts are vastly different. It might be heretical for an historian to argue this, but the historical memory of centuries-old British and American anti-vaccination campaigns looms too large in the minds of today’s public health officials. It distorts their notions about modern parents’ apprehension about vaccines and makes them ineffective at addressing concerns that can quickly and easily erode away the high compliance rates for vaccines we now enjoy.
The modern American vaccine controversy finds its origins in the 1990s. It is firmly rooted in the educated American middle class—the New York Times-reading parents, as one of my colleagues called them—and most public health officials oversimplify the complexity of today’s parents’ concerns. To understand the modern American vaccine controversy, we need to identify precisely who worries about vaccines and why so many American parents intentionally avoid vaccinating their children despite the substantial pressure to vaccinate.26
Who are these vaccine skeptics and how do they express their concerns about vaccines? First, let us recognize that the majority of the children in the United States whom the CDC describes as “under-vaccinated” are not the children of parents who have conscientiously chosen not to vaccinate their children. Data from 2001 show more than a third of all American children under the age of three have not received all of their mandated vaccines. In 2008, estimated rates of complete vaccine compliance among two-year olds vary from as low as 58.5 percent (Idaho) to as high as 79.6 percent (New Hampshire). This means that in any given state between 20 percent and 40 percent of children are under-vaccinated. The majority of the American children who have fewer than the recommended and mandated number of vaccinations are not intentionally unvaccinated; rather, they are children who have slipped through the many gaping cracks in our health care system. They are often poor and uninsured, and their status as under-vaccinated generally mirrors the low level of health care to which they have had access. These children deserve significant attention from all of us, but they are not the subject of this book.27
The objects of my attention, instead, are the growing number of children whose parents have intentionally prevented them from being vaccinated or have chosen to delay one or more of the mandated or recommended vaccines until their children were older than the recommended age for a particular vaccine. The most recent polling data show that 11.5 percent of American parents have consciously refused vaccines that their pediatricians have recommended, and about twice as many more parents have intentionally delayed a recommended or mandated vaccination for their children. Official religious and philosophical exemptions account for only 0.1 percent (Arkansas) to 6.8 percent (Minnesota) of the total number of under-vaccinated children in the United States. This means that most of the parents who chose to avoid fully vaccinating their children have taken advantage of the gaps in the administrative oversight in the system. Public health authorities leave it to school and daycare officials to enforce vaccine mandates, and parents can often go months or years without any need to account for their children’s missed vaccines. For children who are too young to attend school or those not in a daycare, there are no institutionalized compulsions for them to be vaccinated.28
A sizable proportion of the nearly 40 percent of parents who have chosen to alter or reject the recommended schedule includes mothers who are older than thirty years of age. It appears that mothers over the age of forty are especially prone to concern about vaccines, perhaps because they are more savvy consumers of medical care or are more unlikely or unwilling to be deferential to medical authorities. In contrast to public health officials’ assumption that ignorance plays a significant role in under-vaccination, women with college educations were more likely to delay or reject some of the recommended vaccines than were their lesser-educated peers. A 2007 survey found that college-educated women were 16 percent more likely to have children who lacked all their recommended vaccinations than were women who had no college education whatsoever. White parents question the vaccine schedule more frequently than do parents of color, and parents who live in the western region of the United States are more likely than their peers elsewhere in the country to reject or delay recommended vaccines. Hispanic parents rarely reject or delay vaccines, although they are among the most concerned of all demographic groups about the potential serious adverse effects of vaccines. Most of the parents who choose not to fully vaccinate their children appear to have poor relationships with their children’s health care providers, even when they generally seem to have positive feelings about traditional medical care. When asked about their specific concerns, the parents who expressed doubts about vaccines are most worried about the safety of vaccines and about potential adverse side effects. The varicella vaccine, more than any other vaccine, prompted parents to question the entirety of the vaccine schedule.29
The claims expressed by modern American anti-vaccinators, by the parents who choose to forgo or delay certain vaccines, and by vaccine-anxious parents can be summarized as follows:
• Vaccines are not as effective at preventing diseases as health officials claim they are.
• Many side effects—some minor and some serious—are caused by vaccines, and health care professionals understate the number and severity of these side effects.
• We give too many vaccines for too many diseases to children at too young of an age, and we give them too closely together.
• Far too little research has been done to determine the long-term consequences of particular vaccines and their components, the effects of giving multiple vaccines at one time, and the potential susceptibility of some children to side effects from vaccines.
• For-profit pharmaceutical companies exert too much influence on the nation’s vaccine policy, and the physicians and public health care officials who shape vaccine policy in the United States work so closely with pharmaceutical companies in the research, manufacture, and sale of vaccines that conflicts of interest seem inevitable.
• Mainstream medical care providers (especially pediatricians) spend too little time discussing the benefits and risks of particular vaccines with parents, too often callously disregard parents’ worries or personal beliefs, and respond to concerns in ways that alienate parents.
Health officials generally blame parents’ concerns about vaccines on ignorance and a failure to appreciate the danger of communicable diseases. This notion is called into question, however, by poll results that show that concerns about vaccines rise along with rates of educational achievement. The more education a parent has, the more likely he or she will be to question the efficacy and necessity of vaccinations. A 2000 poll found respondents with a high school degree or less were more likely to regard immunization as extremely important than were their more educated peers. Comparing college-educated parents to those with a high school degree or less, college-educated parents were more than twice as likely to refuse to rate immunizations as extremely important in protecting children’s health. As a result, almost 17 percent of college graduates chose to opt out of immunizations, while respondents with a high school degree or less opted out at less than 11 percent. A 2007 study of Californian parents’ attitudes toward the HPV vaccine had similar results. Nearly 90 percent of the parents who had not finished high school said they were likely to have their daughters vaccinated against HPV, but only about two-thirds of the college graduates would. Precisely the same situation is found in Britain, where middle- and upper-class citizens are less confident about vaccine safety than are working and lower class citizens. This pattern suggests that parents who have higher levels of educational attainment are more likely to question the judgment of medical authorities and public health officials than are their less educated colleagues. Of course, educational attainment is not at all what public health officials mean when they use the term “informed.” Instead, it implies willingness by parents to accept the recommendations offered by public health officials and to defer to the authority of their health care providers.30
There exists a small group of anti-vaccine parents who avoid all vaccines for their children. Only about 0.3 percent of American children are completely unvaccinated. When asked, nearly half of the parents of unvaccinated children expressed concerns regarding the safety of vaccines. This concern was almost five times more common among parents of completely unvaccinated children than it was among parents of under-vaccinated children. Medical professionals play a smaller role in the decisions made by parents of unvaccinated children than they do in the decisions made by parents of under-vaccinated children. Nearly three-quarters of the parents of unvaccinated children say they made the decision not to vaccinate their children without speaking to their physician, while less than a quarter of the parents of under-vaccinated children reported the same. The parents of unvaccinated children are slightly more commonly white, married, and well educated as compared to the parents of under-vaccinated children, and they tend to have even higher incomes and larger numbers of children than do the parents of under-vaccinated children. In sum, the parents who categorically reject all vaccines seem to share similar demographic attributes with the average vaccine-anxious parent. This should worry public health officials, as it suggests the ease with which vaccine-anxious parents might transform into parents who reject all vaccines for their children. Making the leap from being concerned about vaccines to being an anti-vaccinator does not require a parent to cross cultural or economic boundaries, nor does it require them to adopt a fundamentally different political ideology. All that is needed is an even firmer resolution to allow their anxieties about vaccines to win in their struggle against their pediatricians’ and the CDC’s recommendations.31
American anti-vaccinators and vaccine-anxious parents share notions about the definition of a child’s best interest, a reluctance to accept medical advice as universally applicable to all children, and a willingness to go against the establishment (or at least find loopholes that allow their children to avoid being vaccinated). In 2008, the New York Times published a story about public health officials’ concerns about the increasing numbers of parents who are choosing not to vaccinate their children against certain diseases. It included a picture of three middle-class women, sitting in a nice Californian home, apparently discussing their concerns about vaccines. One of them, Sybil Carlson, has two children, neither of whom has received all of the mandated vaccines. She explained, “When I began to read about vaccines and how they work, I saw medical studies, not given to us by the mainstream media, connecting them with neurological disorders, asthma, and immunology.” Having considered her responsibilities both to her children and to the larger public, she said, “I cannot deny that my child can put someone else at risk.” Nonetheless, Carlson concluded, “I refuse to sacrifice my children for the greater good.” The New York Times website received 431 comments on this story in the first twelve hours after it was posted. The intensity of the claims made in support of parents who choose not to vaccinate was matched by the intensity of anger expressed by people who opposed those people.32
Carlson and many other parents who have chosen against some or all of the recommended and mandated vaccines for their children are part of an unorganized movement that began two decades ago. It emerged among a limited number of fringe critics of vaccination just as the list of mandatory vaccines was beginning to grow. It established itself in a pre-Internet age through word-of-mouth, and it was advanced by a handful of authors who published with obscure presses and sold their books in venues as culturally diverse as natural health food stores and gun shows. Modern American cultural and ideological notions, not the centuries-old religious opposition to vaccination, form the basis for today’s anti-vaccination movement in the United States. Recognizing this fact will allow vaccine proponents to begin from an accurate starting place for considering the source of today’s parents’ anxieties about vaccines, and to begin responding to the long list of problems that vex the modern American vaccine schedule. There are good reasons to believe that in the near future increasing numbers of vaccine-anxious parents will opt out of some vaccines and that more parents will join the currently tiny percentage of parents who opt out of all vaccines for their children. That means that unless we address the fundamental problems inherent to the modern vaccination schedule, today’s vaccine-anxious parents may well become the parents of tomorrow’s under-vaccinated and unvaccinated children.