Nov. 09 2016

Vaccine Refusal (And What to Do About It)

For more than 100 years, public health has struggled with ways to boost vaccination rates, ranging from fines and quarantines to publicity stunts.

Just across the street at NewYork-Presbyterian Hospital/Columbia University Medical Center, nurses have been available around-the-clock to administer flu shots to employees for weeks. Whether at a pharmacy, doctor’s office, or clinic, it’s never been easier to protect yourself and others. But for a variety of reasons, many still choose to delay or opt out of getting vaccines.

In a recent Perspective article for the New England Journal of Medicine, James Colgrove, a public health historian and professor of Sociomedical Sciences, wrote that the history of vaccine refusal is nothing new. Many of the scientific, ethical, and political challenges around vaccinations that physicians and public health officials face today would be recognizable to their counterparts of previous eras. Public health officials continually struggle with how to get the public to get vaccinated. For some, a word of encouragement is enough; for others, more coercive methods have been used.

In the 19th century, as state and local governments struggled to protect Americans from smallpox, they passed laws to punish anyone who did not get the vaccine. Penalties ranged from quarantine for unvaccinated adults to exclusion from school for unvaccinated children. In another heavy-handed example, the state of Massachusetts imposed a $5 fee (approximately $130 today) on those who refused the vaccine. One man challenged the fine in a case that rose to the Supreme Court. In a 7-2 decision, the Court upheld the law, ruling that the safety of the general public justified the restriction of individual liberty.

The Case for Human Rights

Coercive tactics were found to be constitutional, but one could argue that such laws were ethically questionable. Unlike today, there were no explicit opt-out provisions for religious or philosophical reasons. This was also before hypodermic needles and adherence to proper antiseptic procedures, so safety was a legitimate concern. The violation of basic freedoms became a way to argue against vaccinations that is still used by anti-vaccination activists today.

The underlying reasons why people are wary about vaccinations are many, including mistrust of the scientific, medical, and pharmaceutical communities, resistance to government authority, and a preference for alternative therapies.

Polio and Persuasion

When the polio vaccine became widely available in 1957, medical and public health practitioners used advertising and public health campaigns, as well as social science research, to urge people to get vaccinated. Focus groups also identified community leaders like pastors and educators who could serve as ambassadors to help carry the pro-vaccine message. None other than Elvis Presley was photographed getting his polio shot before appearing on the Ed Sullivan Show.

Today, vaccine promotion is complicated by the Internet and social media, which make it possible for any one viewpoint, whether scientifically accurate or not, to gain traction. Colgrove notes that trying to counter misinformation can have a boomerang effect: the more strongly health officials push back against a bogus theory, the more likely it is to stick in people’s heads.

People’s attitudes and beliefs can also depend on the vaccination. For example, some parents believe their children don't need to be vaccinated against Hepatitis B because they associate the disease with sexual transmission or drug use. The flu vaccine is perceived by some as onerous because it needs to be re-administered every year.

With vaccination rates falling, some parts of the country have seen a return of more coercive tactics. California recently outlawed nonmedical-exemptions for vaccinations, and according to Colgrove, “the sky hasn’t fallen yet.” Hospitals too are increasingly strict. At NewYork-Presbyterian, those who opt against a flu vaccine must wear a mask in patient areas, and in some cases, risk being terminated. 

Both persuasion and coercion will continue to be necessary, but education and training are critical too—particularly for primary care providers, who continue to serve as the key influencer when people are making decisions about vaccinations.

There is no silver bullet to get people vaccinated. “It’s a challenge,” says Colgrove, “but also an opportunity.”