For a baby born at 28 weeks—a full three months early—he was doing remarkably well, “feeding and growing” until he was big and strong enough to be cared for at home. As medical residents on the neonatal unit, we rarely saw this baby’s family. But when we were able to reach his mother by telephone in between her work shifts, she was always loving, caring, appropriate, and eager for the day when her son, a perfect illustration of how modern medicine can impact even the tiniest baby’s chance for a long and healthy life, would be ready to come home.
We rotated to other parts of the hospital, and this baby faded out of mind until we ran into the new resident caring for him and learned there was a Child Protective Services investigation underway. After a moment of confusion and bewilderment, our hearts sank as we understood what had happened: CPS and the medical team were concerned his mother—young, single, and working two full-time jobs in a town hours away from the hospital while supporting two other toddlers at home—simply could not pull together the resources to be present enough at the hospital to demonstrate her competence and commitment to caring for her baby.
After a few moments of collective frustration, anger, and most of all sadness for this family, we went back to work, shaken by yet another example of poor, disadvantaged parents being held to impossible standards. Cases like this are particularly painful for us because they stand in stark contrast to another situation of, we would argue, more serious parental neglect: Parents who deny their children the basic and essential medical care vaccinations provide.
As pediatricians-in-training, one of us mother to three young (and fully vaccinated) children, we bear witness on a daily basis to the miracles of modern medicine that occur in intensive care units and regular pediatricians’ offices alike. Neither of us imagined we would devote so much of our time to working with parents who oppose what is arguably the very greatest invention of modern medicine.
We see the mother, who works double shifts at minimum wage to avoid eviction, traumatized by a CPS investigation instigated because she cannot possibly be present at a hospital bedside. We see the family whose incompletely immunized child is refused entry to a school, not because they oppose vaccines but because they lack reliable transportation and predictable time off to receive all the shots.
And then we watch parents who willingly expose their children, and society at large, to the real and specific risk of deadly diseases that should have been eradicated long ago—and we kowtow to them. These parents almost always come from privilege, and they are almost never punished for their actions. It seems to us that this reaction is at least partially—and perhaps subconsciously—informed by the fact that they are by and large white, educated, and affluent.
The rise of the anti-vaccination movement and the subsequent return of deadly and debilitating diseases like measles, whooping cough, and meningitis, is old news. The questions that have been raised about vaccine safety, efficacy, and necessity have already been asked and answered. The science is sound, and the immense benefits, accompanied by minimal and well-described risks, have been demonstrated. As scientists, the medical community has tried valiantly to understand through research what underlies vaccine hesitancy and refusal, and to design evidence-based interventions and strategies to resolve it. This has only yielded meek guidelines with unmemorable acronyms and mnemonics on how to discuss the topic with parents. We have tried campaigns designed to incite fear. We have disseminated cold hard numbers and frightening, real statistics on infant death. We have tried fun, relatable analogies, like the fact that there are more antigens—the foreign triggers that stimulate the body to make protective antibodies—on a single doorknob than there are in today’s entire childhood vaccine series combined.
The most striking finding from a review of the past decade of pro-vaccination efforts is that nothing has been proven to be more than marginally effective. These well-meaning studies and initiatives have remained too far removed from the issues at the core of this public health crisis, and as a result, have produced little actionable insight. We simply do not know how to make people who are against vaccinations come around to trust and accept the science behind them.
And yet, our current system asks physicians to accept vaccine refusal with impunity because it is a matter of personal belief. As doctors, we are asked to abandon both our duty to our individual patients, and our collective responsibility to protect and promote the health of all children irrespective of their parents’ beliefs, skin color, or bank accounts. It is time to acknowledge that we do not know how to bridge the gap between doctors and vaccine-hesitant parents. Instead of spinning our wheels producing ineffectual research, the time has come to call vaccine refusal by another name that more accurately sums it up: medical neglect. We can continue our scholarly inquiry to find more effective ways for convincing parents that vaccines are worthwhile, but it is time to declare, unequivocally, that vaccination is a human right no child should be denied.
The roots of the anti-vaccination movement are deep and multifaceted. There is mistrust of the medical establishment and its historically unseemly ties with large industry. There is awareness of the long history of unethical conduct in both scientific research and everyday medical practice, which has led often to the exploitation of vulnerable populations. There is, above all, a profound discontent with the current medical and cultural landscape, marked by over-medicalization of normal processes; nonholistic care fixated on signs and syndromes rather than whole people shaped by their social, emotional, and physical environments; a national food system that relies on the industrial and heavily processed; and broad social and economic policies that fail to support children, families, and communities.
Out of the distrust and discontent has emerged the concept of patient-centered care, with patient autonomy now representing a fundamental tenet of the practice of medicine. This is good in theory but risky in practice: At its best, patient-centered care leads to shared and noncoercive decision-making that prioritizes patient values. But at its worst, we see movements like the anti-vaccination crusade flourish, arising from a disjointed but seductive compilation of anti-intellectualism, pseudoscience, and unabashed individualism. The anti-vaccination movement is spearheaded by the privileged, who rally behind cries of injustice, exploitation, and autonomy. When, ironically, they are the very people who have been protected from these inequities, which continue to disproportionately affect the poor, disadvantaged, and otherwise vulnerable. This has dovetailed with an increasing societal worship of the natural, helped along by the advent of big nature as practitioners and entrepreneurs exploit fears and identity politics—with profitable results.
As a society, we have decided that parents are the best default surrogate decision-makers for their children. But we have also decided there is a limit to what parents can choose. Parents must use correct car seats and seat belts for their children; they must care for them in safe homes and provide sufficient food; they must also follow basic medical standards for their children’s health. Thus, there is ample precedent for removing the decision-making capacity from parents who are determined not to act in their child’s best interest. Take, for instance, the 2009 case of this child with leukemia who was successfully treated with chemotherapy on court order against her parents’ wishes, because they believed in “natural” treatment for cancer.
And yet, unlike any other aspect of pediatric medicine and child safety, if a parent explains that they have a personal objection to vaccination, they are allowed to deny their children proper care. It is true that some promising laws have been passed, such as California’s SB 277, which eliminates personal belief exemptions. But even these lauded policies have significant loopholes and pitfalls. SB 277 targets only the vaccines required for school entry and not infant immunizations; children who are homeschooled are exempt; and there is still the possibility of abuse of medical exemptions. Nationwide, such strong and enforceable policies are the exception, rather than the rule, and are politically unviable in other regions of the country.
Those who refuse vaccines represent a privileged segment of society, making it easier for us to turn a blind eye as part of the systemic racism and classism still deeply embedded in modern medicine. We have spent hours explaining to CPS case-workers that it is impossible for the homeless parents of a critically ill infant to simultaneously attend medical rounds, to participate in medical decision-making for their child, and apply for public housing and employment. Then we turn around and treat a purposefully un-immunized child for a serious brain infection caused by vaccine-preventable bacterium—requiring weeks of hospitalization with intravenous antibiotics—and watch his mother continue to refuse vaccines for him or his siblings, and we can’t do anything about it.
There is simply no reason vaccinations should be treated differently than any other form of medical care, and they must be protected within the same framework that has been created for child protection and against medical neglect. There are many ethically gray areas of medicine, but this is not one. Our laws must unambiguously and without loopholes reflect this, and there cannot be conflicting standards of child protection based on race, wealth, and education. By continuing to allow exceptions, we are fueling the misconception that vaccinations are an option, a choice, a subjective topic about which people can have different opinions that ought to be respected, when in fact all of the data proves they are not. Enacting a policy that is consistent with the science would provide clarity for the parents—the majority of whom are loving caretakers trying to do the right thing. We are failing our society by creating unequal standards of parenting, and worse, we are failing our children by not protecting their right to be vaccinated against deadly, preventable diseases. Competent parenting must include fully immunizing all children according to the medical standard of care.