In the winter of 2012 a measles epidemic took place in south Wales [Ref: BBC News], affecting nearly 1500 people, and resulting in the death of one person. Less than four months after health authorities declared that epidemic over, another one struck in the same area. 1988 heralded the introduction of the combined MMR (measles, mumps and rubella) vaccine in the UK [Ref: Merriam-Webster], and a decade later in 1998, a controversial and now discredited research paper by Dr Andrew Wakefield, published in medical journal The Lancet, suggested a connection between the MMR vaccination and the development of autism in children. Although Dr Wakefield’s research has been rejected, it is widely agreed that the scare about MMR [Ref: Independent] resulted in a decline in measles vaccinations in the UK - falling from a peak of 94% for two year olds in 1995, to 78% in 2003. In the Swansea area, most affected by the Welsh outbreaks, take-up had declined to just 67.5%. The importance of these figures is that the MMR scare affected ‘herd immunity’ levels for measles, putting children at much higher risk of catching the disease [Ref: vaccines.gov]. This has prompted some to argue that the current system for delivering childhood vaccines in the UK, which relies on parents voluntarily immunising their children, should be reviewed, and replaced with a compulsory vaccination programme because, “we need a 95 per cent vaccination rate for herd immunity to protect against contagious diseases” [Ref: Metro]. It is commonly agreed that herd immunity is important for disease control, and that the development of vaccines have greatly reduced childhood mortality and tackled disease globally. But in the light of declining vaccine take up in recent years, both in the UK and elsewhere, there is a debate today about the best way to ensure the greatest levels of immunisation amongst populations. Is a voluntary or compulsory system of childhood vaccination best, and what are the arguments for either side?

Immunisation then and now
Prior to the development of vaccines in the eighteenth century, people could only become immune to diseases by contracting, and then surviving them. The process of surviving meant the body had learnt to deal with, and ultimately destroy, the microorganisms that caused the disease. The development of modern immunisation [Ref: Wikipedia] against infectious diseases can be administered in a number of ways, but most commonly through vaccination. Artificial active immunisation delivers a very small and weakened quantity of virus into the body, giving the immune system a chance to create its own antibodies and other defence mechanisms, thus preparing it for any future attacks of the disease. Many childhood diseases, which in previous eras could have been deadly, are now readily managed and controlled, especially in the West. The introduction of the Polio vaccine in 1953 [Ref: History.com], for example, has seen an almost complete eradication of the disease worldwide, with just those countries with less comprehensive immunisation programmes still suffering outbreaks [Ref: Guardian]. But not everyone supports or approves of vaccination programmes, for a variety of sometimes complex reasons. Over the past two decades there has been increasingly vocal anti-vaccination movements in the UK and the USA which, according to some commentators, “frequently harbor a deep distrust of government. They often suggest that vaccination is motivated by profit and is an infringement of personal liberty and choice; vaccines violate the laws and nature and are temporary or ineffective; and good hygiene is sufficient to protect against disease.” [Ref: Washington Post] But it’s not the case that those who rejected the MMR jab for their children were ideologically opposed to vaccinations. Parents often found themselves in an impossible position, as parent Kirsty Grocott explained: “We were making decisions about an illness that many of us had never seen at first hand. Measles itself was an abstract compared to the perceived threat of autism. Parents made decisions believing them to be in the best interests of their children, people capable of rational and intelligent thought, decided to eschew the vaccination because they genuinely felt that the risk was too great.” [Ref: Telegraph]

The case for compulsory childhood vaccinations
According to the World Health organisation, measles is one of the leading causes of childhood death globally [Ref: WHO], leading them to declare earlier this year, that vaccinations must be stepped up across Europe and Central Asia in response to a series of outbreaks [Ref: BBC News]. “As a society, we don’t condone behaviour that puts others at risk for injury or death” argues American doctor Robert Pearl. “Refusing vaccination for reasons other than a serious medical condition is unfair and dangerous to those who can’t protect themselves.” [Ref: Forbes] The key argument about herd immunity, put forward by many calling for compulsory vaccinations, is that an individual choice, when it puts other members of society of risk, is no longer a valid one. “Risking other children’s lives, and other parents’ pain, is exactly what you’re doing when you don’t vaccinate your child: you’re not just making decisions about your children’s health, but the health and safety of the children around them.” [Ref: Guardian] More importantly, this debate raises difficult issues about the importance of parental autonomy to make decisions about their children, versus the needs of society as a whole: “The fact that individual rationality is sometimes at odds with the requirements of the common good is a quandary at the heart of moral and political philosophy. The function of the state, according to standard liberal theories, is to find a practical resolution to this central tension and solve collective action problems that otherwise won’t get solved in order to provide public goods—public order, military defence, public sanitation, environmental protection, etc—that otherwise won’t get provided.” [Ref: Economist] But others counter that the MMR scare played into a broader contemporary distrust of big-pharma, and government health advice, and that: “In an era when people are less accepting of authority and do not expect to do something because the government says so, trying to enforce immunization may actually make matters worse.”[Ref: New York Times]

The case against compulsion
The key issue at stake here is who gets to decide about the healthcare needs to children – the authorities or parents? Critics of enforced vaccinations argue that it may have the opposite effect to that desired, and end up demonising parental choice: “ We can agree that anti-vaxxers are wrong about the science, and still be disturbed at the state trying to compel people to do things to their children they would rather not. Anti-vaxxers are not, after all, guilty of a crime of neglect or cruelty: their actions are born of divergent (if scientifically unsound) beliefs about what constitutes child welfare.” [Ref: Guardian] Academic Jennifer Margulis says that: “There is tremendous evidence showing vaccinations prevent childhood diseases. Should public health officials do everything they can to encourage, inform and facilitate childhood vaccinations? Yes. Do they have the right to force parents to vaccinate their children? Absolutely not.” [Ref: New York Times] In the United States, vaccinations are compulsory, but there is a complex state-specific system of exemptions, allowing parents to reject mandatory vaccinations on medical, religious or philosophical grounds [Ref: National Vaccine Information Centre].  And although the antivaccine parents are very vocal they are in a very small minority and some suggest that: “Now would not seem the time to be more coercive” [Ref: New York Times]. One parent explained that, “governments’ vaccine programmes are…“population driven” - dedicated to doing what’s best for the world’s population as a whole. Parents, meanwhile, are child-focused.” [Ref: Independent] So how should we respond, both domestically and globally, to what seems like a potential return of measles on a larger scale than we’ve known for decades? Is there a case for governments to mandate that parents vaccinate their children for the ‘common good’ [Ref: Encyclopedia Britannica]? Or is herd immunity better secured through convincing parents of the efficacy and safety of immunisation, and relying on them to want to do so for their own children as well as others?

Scared parents, scary science
In addition to the recent UK outbreaks, high-profile outbreaks have happened in: California, where take-up rates can be as low as 50% [Ref: Los Angeles Times]; in Germany, where take-up is high at around 90%, and those who fell ill were mainly adult, with some suggesting the high level of un-vaccinated people emigrating from Eastern Europe may have affected wider herd immunity [Ref: Washington Post]; in Quebec, Canada, where there have been multiple outbreaks, with large parts of the population apparently un-vaccinated “… for religious and philosophical reasons, which explains the exponential rise in the number of cases” [Ref: BBC News]; and in Australia, which had previously been declared measles free in 2008, vaccination has dropped to as low of 50%, resulting in a recent outbreak, and renewed debate there about state compulsion to vaccinate [Ref: Daily Mail]. Some commentators argue it is important to look beyond the decisions made by individual parent’s choices for the root cause of a decline in vaccination take-up, and instead look at how parents became distrustful and scared of the MMR vaccination. Author Ben Goldacre argues that the media coverage of an obscure research paper, published by an unknown doctor, in a specialist medical journal on the complex issue of autism allowed MMR to become: “The proto-typical health scare, by which all others must be judged and understood. It has every ingredient, every canard, every sleight of hand and, every aspect of venal incompetence and hysteria, systemic and individual.” [Ref: Bad Science] London GP Dr Michael Fitzpatrick argues that the reaction “reflects the existence of a widespread mood of anxiety and suspicion, and a loss of confidence in our ability to rely on our powers of reason. Only in that wider climate could the peer reviewers and the editors, the doctors and scientists and journalists, have allowed Wakefield to make such an impact.” [Ref: spiked]