February 11, 2015

Shouldn’t we know where they live?

California’s measles outbreak has touched off a debate about how to reduce the number of parents who choose—in defiance of all credible public health information—not to vaccinate their children. So far, the debate has focused on tightening California laws that make it easy for parents to obtain exemptions from school vaccination requirements. Newly introduced state legislation would eliminate the “Personal Belief Exemption” that thousands of anti-vaccine parents have used.

I’d be more than happy to see this proposal become law. But the politics of reducing parental choice are fraught, and there are limits to the law’s ability to compel good parenting. There’s also a hard cultural fact: few things are more fundamentally Californian than the freedom to believe whatever pseudo-religious or pseudo-scientific nonsense you choose. So, one way or another, it’s likely that parents will still find ways to avoid vaccinating their children, despite the risks to both their own kids and their communities. 

A tougher, smarter way of dealing with anti-vaccine parents would be to target not their choice—but the secrecy that surrounds that choice.

Under today’s privacy laws, public schools and health authorities must protect the identity of parents who choose not to vaccinate. That’s wrong for many reasons. First, the secrecy effectively forces public employees, whose first duty should be to the public safety, to be enablers of those who threaten that safety. Second, parents who endanger the community’s health don’t deserve official protection. And third, the confidentiality of such exemptions makes it harder for those families who vaccinate their children to protect themselves.

People deserve privacy in their private spheres. But a parent who won’t vaccinate is not making a private health decision: She is making a public health decision that profoundly affects others.

So let’s treat the exemption she obtains as the public act it is. Every single exemption request should be reviewed in a public meeting and approved by a public body (like a city council or school board). And if the exemption is approved, basic information—the parent’s name, address, and the vaccinations declined—should be available on the Internet via a publicly maintained registry.

The virtues of disclosure are clear. Having your family’s name published as a potential hazard to public health would be a strong disincentive to obtaining an exemption for all but the most committed (i.e., delusional) anti-vaxxers. And the rest of us would be able to identify our unvaccinated neighbors, and our children’s unvaccinated schoolmates. This would be especially helpful to pregnant women and the parents and caregivers of children who are either too young to be vaccinated (the first measles mumps rubella vaccine isn’t given until after a baby’s first birthday) or have serious diseases like cancer (as in the case of the Marin County six year old recovering from leukemia) that compromise immune systems and preclude vaccination.

In effect, the question of how to handle unvaccinated children and their parents would move from the realm of school administrators to the community at large. And the community level is where the question is best addressed, since we encounter the unvaccinated not only at school but also in parks, churches, and stores.

There is some risk of community and personal conflict in this shift, to be sure, and anti-harassment laws would have to be strictly enforced. But there would also be potential for the kind of conversations necessary to change minds and get more children vaccinated.

Those who have studied the question of how to convince people to vaccinate report that the voices of distant authorities—public health departments, governors, even President Obama—aren’t particularly effective, given deep public distrust of institutions. People you know—neighbors, friends, co-workers—make better emissaries to the unvaccinated. But you can only be an emissary to unvaccinated neighbors or friends if you know they are unvaccinated.

The recent legislation acknowledges this need for conversation with a proposed requirement that all parents be notified of the vaccination rates at their kids’ schools. But that doesn’t go far enough. Indeed, it might create additional anxiety by instigating guessing games and speculation, without triggering the desirable peer pressure of true disclosure.

Some committed opponents of vaccines may howl about their identities being made public or about the exposure of their children, but such objections are easily turned back against them. If you believe you have the absolute power to make whatever decision you want for your children, why would you deny me the right to do the same, including the right to decide whether my children should be going on play dates to the homes of people who have recklessly opted out of modernity?

That response may sound harsh and insufficiently sensitive to privacy. But for better and for worse, it fits the obligations of 21^st century childrearing. As a parent myself, I’m repeatedly reminded—by doctors, nurses, public officials, schools, and the dozens of legal waivers that daily life requires me to sign—that I am required to know everything I can about my kids. I’m supposed to know where they are at all times, and to monitor every minute of exercise and each spoonful of sugar. I’m supposed to find out everything I can about the kids they hang out with, and I’m supposed to monitor all their online movements. It’s no coincidence that most successful public service announcement series in America, now celebrating its 25^th anniversary, is NBC’s “The More You Know.”

There are other good ideas out there for putting pressure on parents who don’t vaccinate. You could hand out stickers or buttons to all vaccinated schoolchildren—creating a social pressure on those who don’t. Laws could permit insurers to raise the premiums of those who don’t vaccinate (right now, insurers can only set rates based on age, geography and tobacco use). A new tort could be created to permit people who incur medical and other costs because of an outbreak to sue and recover damages from the unvaccinated. I particularly like a proposal from Dorit Rubinstein Reiss, a law professor at UC Hastings, to charge a significant fee for vaccine exemptions to cover the costs of an outbreak.

This issue is personal. My own children are still little, and it will be a few more years before all three are old enough to have had all their vaccinations. Media outlets have recently compiled data on the number of vaccination exemptions in California schools, and it bothers me that, of the 95 kids who attend kindergarten with my oldest son at our local public school, three are unvaccinated because their parents have obtained Personal Belief Exemptions.

I should have the right to know who those families are. And I look forward to the day when I can engage them in a conversation about what our families owe each other.

Joe Mathews is California & innovation editor at Zócalo Public Square, for which he writes the Connecting California column.