The United States is currently facing a public health disaster, as diseases that were thought to have been effectively eradicated as serious threats to children – like measles, whooping cough and rubella – make a comeback. There are currently eight states facing localised outbreaks of measles where the source has all been traced back to Disneyland in California, with at least 102 cases identified in January alone. At this rate, 2015 will easily break 2014’s record for most measles cases recorded in the US since 2000, when the Centers for Disease Control declared measles “eliminated”:
Note: The figure for 2015 is January only.
To get a grasp of just how much better things have become since the introduction of the first measles vaccine in the US in the 1960s, there used to regularly be between 400,000 and 800,000 cases of measles per year – adding those figures to the above graph would require a scale that reduces more recent years to a flat, imperceptible line above zero. What we’ve seen in the US, and in other developed nations with successful vaccinations programmes, is a shift from measles being a common childhood disease to one which occassionally manages a comeback in very small, specific communities where enough unvaccinated people (usually children) mingle together.
This might not sound like a disease that has been properly eliminated, but the definition as used by the CDC doesn’t mean the extinction of a contagion. Instead, it refers to measles’ usual ability to survive within a group of humans indefinitely by always having new hosts to move into – this is what’s meant by the term “endemic”. A town with endemic measles always has people carrying and passing on measles. But the CDC considered measles eliminated because, as of 2000, there was not one single place within the US where measles was transmitted successfully from person to person to person over a period of 12 months, continuously. Subsequent studies confirmed that measles had essentially become something that was accidentally imported from abroad – from 2004 (where there were only 37 confirmed cases, the lowest recorded so far) to 2011, at least 88 per cent of those with measles caught it while in another country and brought it back. Those outbreaks sourced from the US failed to achieve endemic status, thanks to widespread vaccination.
Understanding why this has changed isn’t difficult – it’s the expected result of several years of dedicated campaigning by anti-vaccination activists (so-called “anti-vaxxers”), who offer a potent ideological mix of libertarianism, pseudoscience and parental instinct. After all, what kind of parent intentionally gives their child something that would harm them? And how dare the government tell me that I must inject my child with something? Beyond being merely about public health, vaccination in the US has been successfully framed as a political choice, analogous to gun control, where the rights of parents and their children are framed as being violated by an intrusive government. The current scrambling to state clear support for vaccines by politicians hoping to be picked as the Republican candidate for president in 2016, and seeing the damage that anti-vaxxer rhetoric has caused, has been impossible to miss.
Here in the UK, attitudes around vaccinations are different, though it’s absolutely necessary to point out that the source of the modern anti-vaccination movement – as manifested in the beliefs of influential campaigner celebrities like Jenny McCarthy (above) – is the deplorable work of the British doctor Andrew Wakefield. His infamous 1998 study alleging the MMR (measles, mumps and rubella) vaccine could cause autism in young children has been debunked repeatedly, and he himself has been villified and expelled from the scientific community, but the fears his work has instilled in a generation of parents has had measurable, deterious effect on the health of children both here and around the world.
But of course explaining why this is can be difficult, because so often it’s about the clash between an abstract scientific concept and the relatable, real experiences and fears of individual parents who, understandably, take threats against their children seriously. Measles outbreaks offer a clear example of this – how herd immunity can seem very abstract and unreal, until it isn’t. This piece explains herd immunity in more detail than I’ll go into here, but the short version goes like this:
Imagine a town with a hundred people, where everyone in the town has ten friends each and everyone’s friendship groups overlap so that everyone in the town is at least a friend of a friend of a friend and so on of each other. If someone in a town catches a disease (let’s call it vaxxeria, because metaphors) which spreads easily to every friend they meet each day, then within a predictable amount of time everyone in the town will have caught vaxxeria from each other.
If one person gets vaccinated against vaxxeria, then that in itself does little to save anyone but them – but if everyone in a certain circle of friends gets vaccinated, the disease has to kind of “work around” the block in the network. One person could catch it, but if all ten of their friends are vaccinated it hasn’t got anywhere to go, and when (or if) they survive their illness the outbreak will be contained. This is herd immunity, where someone who isn’t vaccinated won’t catch a disease simply because everyone they’re likely to come into contact with isn’t going to be a carrier. For those people who aren’t able to handle vaccines (for example, those with certain immune disorders) this herd immunity is vital to giving them the same freedom from diseases like whooping cough, measles and miningitis as everyone else. When herd immunity works, even if an outsider rolls into town carrying all sorts of diseases, enough people will be immune that the disease never spreads.
This is the rub. Vaccinations have successfully given those of us in developed nations the expectation of lives free from many diseases which were both extremely widespread and often lethal in the past – to the extent that this feels “normal”. (And, if you or a child does catch something like whooping cough, well, there are hospitals and modern medicines that can help, right?) The individual experience for many anti-vaxxers, then, is that autism is the more common and serious threat – as offensive as this is to those who actually have autistic traits and know that, say, inflammation of the brain (a possible complication caused by measles) is magnitudes worse by comparison. A parent can see their friends opt their kid out of vaccinations and see that nothing bad happens because herd immunity is maintained, making them also feel safe doing the same, and especially if they happen to have a doctor who doesn’t push the issue.
America is experiencing the dangers that come when that “small” percentage of the population opting out of vaccinations grows too large, in a concentrated area. It’s important to make that distinction, because vaccination rates nationwide have barely shifted for two decades – according to CDC figures, since 1995 the MMR vaccine has had between 90 to 93 per cent coverage of American kids aged 19 to 35 months every year. For measles, herd immunity kicks in when coverage is between 90 and 95 per cent. This sudden, not gradual, uptick in cases is exactly what we’d expect to see once anti-vaxxer views gain too much sway among very specific demographics in very specific geographical areas, and it’s no coincidence that a major outbreak has centred on Disneyland in California.
Among the wealthy and middle class of Los Angeles, anti-vaxxer views have become as fasionable as preferences for organic food and detox diets – a Hollywood Reporter investigation last year found several private schools, daycares and other educational establishments where more young children hadn’t been vaccinated than had, at levels less comparable to those found in developing nations like South Sudan. Los Angeles now sees hundreds of cases of whooping cough among very young children every month, as well as its measles resurgence. However, don’t think that this is entirely a Hollywood fad – the states with the worst MMR vaccination rates are Ohio, West Virginia and Colorado, which each only managed 86 per cent coverage of children aged 19 to 35 months. As much of a problem as the wealthy choosing not to vaccinate children is the difficulty in making sure that poorer communities have access to those vaccinations in the first place.
But what about the UK? After the introduction of the MMR vaccine in 1988 to replace the single measles jab, the uptake rate for children younger than two quickly rose to close to near-90 per cent by the mid-1990s – but damage caused by Wakefield’s paper is obvious after that, especially if you track MMR’s rise and fall as a news story. It’s only very recently that the percentage of children receiving the MMR vaccine has recovered to its previous levels:
England and Wales have notably been worse than Scotland and Northern Ireland at ensuring comprehensive coverage, and, while Wales has managed to surpass pre-scandal levels, England has still struggled. That’s somewhat misleading, though, as more than 80 per cent of the UK lives within England’s borders, and it experiences significant regional variation in coverage – London is by far the worst part of the UK for it, for example, and was even before the scandal:
Note: due to NHS reorganisations under the Blair government, it’s not possible to go back further than 2001-02 and still compare like-for-like regions.
It took 15 years – until 2012/13 – for the UK’s MMR coverage to match and surpass where it was were before the scandal. And, like the US, there are still pockets of deprivation where the problem isn’t parents choosing not to have their children vaccinated, but simply that systems aren’t properly in place to ensure that they understand the options available to them, and the benefits of sticking to a good vaccination schedule. The World Health Organisation’s MMR target for nations is 95 per cent, in order to guarantee herd immunity – and it’s London and the surrounding areas that’s primarily responsible for the US not reaching that level.
London’s figures are quite amazing, actually, when it comes to MMR coverage. The latest annual report from NHS England (for the 2013/14 financial year) shows that wealthy local authorities – like Kensington and Chelsea (80.4 per cent) and the City of Westminster (79.5 per cent) – are just as culpable for the capital’s poor coverage as deprive boroughs like Newham (85.1 per cent) and Enfield (78.3 per cent). London’s best borough, perhaps surprisingly, is Tower Hamlets, with 93.8 per cent coverage. There is no single way to fix this that will work across every demographic here, but, as should be clear by now, when immunisation rates within an area are on the edge of triggering herd immunity, it doesn’t take a lot to tip over either way. As much as anti-vaccination groups (and yes, the UK has some) are extremely small relative to the rest of the population, their influence can be substantial.
And, of course, the long-term consequences of the MMR scandal are still with us, many years later, because someone unvaccinated stays unvaccinated – we have a bulge in the population pyramid for those unlucky enough to have been kids at just the right time for parents to either withdraw them from having the first MMR dose before their second birthday, or (as was even more common) withdrawing them from having the booster shot follow-up that the NHS recommends before the age of five. Those places where herd immunity is compromised can experience a mass change of heart, but often only with hindsight – as happened in Swansea from November 2012 to July 2013, when 1,219 cases of measles were reported, and at least one person died. The local paper, the South Wales Evening Post, had campaigned against the MMR jab after the 1998 publication of Wakefield’s paper. Locals who had been misled about the risks at the time and chosen not to have their children vaccinated ended up rushing their now-teenage kids to hospitals and GPs for belated vaccinations.
With the recent news from America, it’s tempting to go all-out angry at anti-vaxxers for creating the impression that their views are not just rational, but morally correct, but there are good reasons not to take that approach. The first is that the original MMR scare was, more than anything, the fault of the media as much as Andrew Wakefield, and there hasn’t been any kind of reckoning for turning a lone scientific paper into a major health scandal that included speculation as to whether the prime minister had had his son vaccinated or not. Journalists deserve criticism for poor reporting of the health risks of vaccines as much as dodgy scientists do for publishing bad science.
Then there’s also this to think about: if somebody’s distrust of scientific and/or political authority is so great, for whatever reason – maybe they’ve been scared by sensationalist stories in the media, or maybe they sincerely believe the government has no moral right to dictate health choices to citizens – that they’re willing to significantly increase their child’s risk of catching a (possibly fatal) illness, then calling them names and telling them scientists and politicians disagree with them is probably futile. Arguing that “the science is settled” with someone whose stance is predicated on the belief that the standards of proof used by scientists are flawed is definitely futile. And it may even be one of the main contributing factors in turning vaccinations into the politically-polarised issue we’re seeing in America.
As Brendan Nyhan at the New York Times notes, there is evidence that this is something that happens during outbreaks of diseases that could otherwise be prevented by vaccinations and herd immunity. The perception that anti-vaxxers are anything other than a tiny, tiny fringe group ironically increases their influence, and makes it more acceptable for other people to agree with them. Compassion and improved local healthcare provision – it’s not a glamorous measles prevention strategy, but it’s likely the most effective.