Matt Evans: Vaccination In A Free Society

Everyone is talking about vaccination this week.

As usual, we are lucky to be North Dakotans. In our fine state, we have very low population density, yet have modern water treatment and sanitation facilities.  Our hospitals are excellent.  Our winters are bitterly cold and our hot season is relatively short.

Microscopic pathogens are going to have a marginally tougher time rapidly evolving and rapidly moving through the harsh conditions and the sparse population here.  So we can be thankful for that.

The CDC measures vaccination rates in a few different ways.  They present data for people that have received a certain number of doses of a particular vaccine, and they also present data for the number of people that have received all of the doses in one of several recommended sequences.  They slice and dice this data in lots of ways, including by age group.  You can visit here if you want to play with data.

[mks_pullquote align=”right” width=”300″ size=”24″ bg_color=”#000000″ txt_color=”#ffffff”]”North Dakotans, at least, are not widely opting out of vaccinations, and when they choose to do so, their reasons for are primarily medical.”[/mks_pullquote]

When considering any specific vaccine, North Dakota’s childhood vaccination rate is slightly below the national average.  As you start to look at the longer vaccination sequences (e.g. if a 12 year old got every single vaccine on schedule), North Dakota begins to pull higher than the national average.  In general, for any specific vaccine or vaccine sequence, CDC estimates between 70 and 95% vaccination rate in North Dakota.  If you are ever playing bar trivia and get asked which US state or territory has the lowest childhood vaccination rate, the answer is “The US Virgin Islands”.

Interestingly, the ND health department attempts to track people who are exempted from vaccination, and makes this data available based on the age of the unvaccinated person and their reason for being unvaccinated.  According to the state health department, there are about 55,000 known vaccine exemptions in North Dakota.  This doesn’t necessarily account for every person who isn’t vaccinated.  However, this does represent fewer than 10% of the state’s population.

The data here says that the overwhelming majority of these exemptions are due to past disease history.  Possible other reasons for exemption include medical, religious, philosophical, or moral objections.

North Dakotans, at least, are not widely opting out of vaccinations, and when they choose to do so, their reasons for are primarily medical.

This is good, because the evidence suggests very strongly that past mass-vaccination programs have had miraculous positive impacts on public and individual health.

So it’s settled then.  Vaccination is an unambiguous public good, everyone should just do it, the science is conclusively in favor of vaccinating everyone all the time, anti-vaxxers are ruining everything and reintroducing these terrible diseases, and anyone who says otherwise should have their kids taken from them and vaccinated anyway.

Right?

Well, not so fast.

First, we’ll deal with the science.  Public vaccination programs that attempt to protect the public from specific pathogens have generally shown amazing results in improving public health.  This means that if you count up the number of people that suffer before and after these programs, the number of people suffering or dying from the targeted afflictions goes down.  Way down.

A possible objection that is occasionally raised is that there is some other explanation besides vaccination that accounts for this historical reduction in suffering.  While this objection is possible, no satisfactory evidence currently exists to suggest that this is the case.

Until a more compelling explanation than the effectiveness of vaccines is presented, I’m going to continue to conclude that past vaccination campaigns have indeed been responsible for the great reductions we’ve seen in the number of infected people.

In short, vaccines, in general, seem to be effective.  That is not to say that every vaccine is effective in every population, every individual, or every era.  People who suppose that all vaccines are ineffective are probably wrong; people who suppose that every vaccine is always effective are certainly wrong.

But, let us say for now, that vaccines are generally effective, and that while we won’t know ahead of time how effective a particular vaccine will be in fighting a particular pathogen in a particular individual, past successes give us reasons for broad, general optimism.

It is popular to suppose in modern times that vaccinations can occasionally be harmful.

This appears to be correct.

[mks_pullquote align=”left” width=”300″ size=”24″ bg_color=”#000000″ txt_color=”#ffffff”]In short, vaccines, in general, seem to be effective.  That is not to say that every vaccine is effective in every population, every individual, or every era.  People who suppose that all vaccines are ineffective are probably wrong; people who suppose that every vaccine is always effective are certainly wrong. [/mks_pullquote]

In the same sense that public vaccination programs are the best available explanation for observational evidence that shows better health outcomes in large populations, for some occasions of people getting sick or dying shortly after being vaccinated, a complication from the vaccination procedure is the best available explanation for the observational evidence.

That is not to say that every instance of every malady attributed to vaccination should be accepted as evidence.

But, if you like, you can visit the CDC’s page, which is their official public list of which people should not get which vaccines.  The CDC’s list is longer than this article.

It is almost certainly true that the CDC has not documented every situation where a vaccination resulted in significant disability or death.  The CDC’s list should be considered partial information about the possible risks of a given vaccination procedure.

We should agree that, like any medical procedure, there is a risk of negative consequences from any vaccination.  This shouldn’t be controversial, because the CDC says the same thing.

The best evidence suggests that the risks of death or permanent disability, in terms of the number of individuals impacted as a fraction of the total population receiving treatment, are quite low.  That is to say, as a public health policy, widespread vaccinations are a great policy because lots more people are prevented from harm than come to harm.

Of course, if someone in your family is one of the rare people negatively impacted by a vaccination, the public health statistical argument isn’t very comforting or helpful.

There is, then, necessarily, a risk calculation that must be made when considering vaccination.  This is problematic because it is difficult to quantify risk at an individual level.  The risk of contracting a preventable pathogen depends on the individual’s behavior and biology, and those factors are both difficult to reliably measure.  The risk of a specific individual having an adverse reaction to a specific vaccination is also difficult to quantify.

It turns out that most lay people don’t rationally evaluate risks based solely on statistical methods.  There are a variety of reasons for this, and some are valid. For instance, while it may be true that an average person is more likely to die in a car crash than in an airplane crash, and therefore, people who regularly drive shouldn’t be afraid of flying, in fact, this statistical argument supposes that all drivers and driving situations are average, that is, they are all equally risky, and furthermore, that all flying situations are equally risky.  This statistical argument – which by the way, is similar to the public health argument in favor of vaccinations – largely ignores the individual factors that may be at play.  A specific individual in a specific driving environment may indeed be safer driving than flying.  Likewise, specific individuals may indeed be better off not receiving certain vaccinations – and the CDC already has a long list of when this may be the case – a list we should assume is incomplete.

An interesting scenario might be a vaccine against an ailment that is highly correlated with a specific identifiable behavior.  Suppose that an effective HIV vaccine is developed.  This hypothetical HIV vaccine is 80% effective in protecting you against HIV, but causes 1% of recipients to immediately die.  If you are at high risk of contracting HIV because of your behavior, this risk may make sense for you.  But if you are at a behaviorally low risk of contracting HIV, this risk probably doesn’t make sense – most people wouldn’t do something that had a 1% chance of killing them – especially if the reward of this risky vaccine was non-existent for their lifestyle.

So, in terms of what the science says about if you, as a specific individual, should get a particular vaccination or not for your own safety, the answer is “probably”.  However, make sure you’re talking it over with a medical staff that you’re comfortable with, and who know your history and your risk profile.

(As an aside: if you think your doctor is involved in some kind of conspiracy to give you medicine that you don’t need – to say nothing of medicine that will harm you – find another doctor.  Seriously.  Vaccines aren’t your problem – trusting your health to someone you already don’t trust should be a much bigger concern for you)

What about blaming the resurgence of vaccine-preventable diseases on those individuals who choose not to vaccinate for religious or philosophical reasons?  Shouldn’t we be angry at them?

This question actually has two components – the scientific one and the moral one.

Let’s talk about the scientific one first.

It is assumed that diseases like measles which have had resurgent outbreaks in the US are only able to pop up because of the growing trend of Americans who choose to opt-out of vaccinations for non-medical reasons.

This may be true for some outbreaks of some diseases.  However, it is not always or necessarily broadly true.

First, what we know from data is that, at least in North Dakota, the majority of people who are unvaccinated are not unvaccinated for reasons of religious or philosophical objection.  So even if a particular disease is spread via an unvaccinated person, odds are, that particular person was unvaccinated for a legitimate medical reason.

Secondly, it is possible for vaccinated people to contract and retransmit diseases that they have been vaccinated against.  Most people with a basic understanding of the subject are aware that vaccines aren’t completely effective in every individual.  Some people can get sick or can pass on the infection even if they have been properly vaccinated.

[mks_pullquote align=”right” width=”300″ size=”24″ bg_color=”#000000″ txt_color=”#ffffff”]…what people may not be aware of is that some disease causing microorganisms develop particularly well in vaccinated hosts.  This appears to happen for reasons of differing competitive pressures in the vaccinated host.[/mks_pullquote]

However, what people may not be aware of is that some disease causing microorganisms develop particularly well in vaccinated hosts.  This appears to happen for reasons of differing competitive pressures in the vaccinated host.

For instance, in an unvaccinated host, let’s say that organism-A will generally reproduce the fastest and out-compete any other variants of that organism.  Organism-A2 may be present, but will generally not reproduce to the same extent, nor cause a meaningful infection, because organism-A has already taken over.

However, in a host human who has been vaccinated against organism-A, the picture can be different.  In this environment, organism-A does not reproduce quickly or does not otherwise cause a significant infection.  In hosts vaccinated against organism-A, organism-A2 can develop more fully, and with no serious competition from organism-A, organism-A2 can end up being the dominant infection.

This is not hypothetical.  This result has been confirmed with different strains of the whooping cough bacterium in mice.  Hosts who have been vaccinated against whooping cough have received a vaccination that combats the microbe B. pertussis.  It appears that in some of these vaccinated mice, a slightly different organism, B. parapertussis, has subsequently evolved.  B. parapertussis also causes whooping cough symptoms, although thankfully, they tend to not be as severe as pertussis infections.

Here is one paper that discusses this result.  The authors of this paper believe that the resurgence of whooping cough in human populations is actually b. parapertussis which evolved in vaccinated hosts.  The authors recommend that the next generation of whooping cough vaccines also begin targeting b. parapertussis.

The point here is not that vaccinating a person just creates different diseases, the point is that fighting infectious disease is going to be a never ending arms race.  And critically, the point is that it is scientifically unjustified to automatically and categorically blame resurgent illnesses on those who have chosen to avoid certain vaccinations.

As a side note, the development of different, and sometimes more virulent strains of pathogens in vaccinated hosts has also been observed with malaria.

Whooping cough resurging because of adaptions in vaccinated people may not be a one-off scenario.

In summary, disease outbreaks in highly vaccinated populations can be a consequence of people who choose not to vaccinate, people who cannot vaccinate, people who chose to vaccinate but where the vaccination was ineffective, or, people who were vaccinated effectively and subsequently became a vector for a modified version of the pathogen.  Assigning blame for a given outbreak of a given disease requires determining who “patient zero” is and understanding their medical condition.

Ok, but isn’t it morally appropriate to be upset with people who choose not to vaccinate?

I have a hard time coming to that conclusion – because it appears to be based around a false value.

The reason to be upset with someone else’s choice to not vaccinate is that because they may end up being the person that spreads a preventable disease to you.  This is a valid reason for being upset with someone.

However, if your reason for being upset with someone else is that they may get you sick, you should apply this same frustration to people who aren’t vaccinated for medical reasons, or, who are vaccinated but are sick anyway.

You get the same amount of sick irrespective of why the other person transmitted the disease to you.

So the frustration felt towards other people who are choosing not to vaccinate is not primarily about safety – because it is unevenly directed at only those people who are possible vectors for reasons of their own choice.

Instead, the frustration is based on something else.  I’m not sure what to call it, but I might describe it as “people not doing their fair share”.

That is a moral or emotional position – not a scientific one.

Throughout all of time, and in all societies, there seem to have been parables and stories and discussions about individuals who were thought not to have done their fair share.  In children’s stories, we usually learn that those who do not do their fair share do not share in the rewards.  In the New Testament, we learn that the idea of a fair share is somewhat problematic – he who thinks himself deserving of something based on his own merit or performance – someone who petitions for their fair share, or who criticizes the contributions of others – may not be quite right with God.  And in the adult world, we primarily talk about fair share by pitting group A against group B in a fight to determine how government hands out other people’s money.

[mks_pullquote align=”left” width=”300″ size=”24″ bg_color=”#000000″ txt_color=”#ffffff”]“Doing your fair share” is a fundamentally contentious and problematic issue of morality.[/mks_pullquote]

“Doing your fair share” is a fundamentally contentious and problematic issue of morality.

This fair share problem is also being disproportionately focused on vaccinations, as opposed to more mundane illnesses.  All of us have been in public and have seen a child that is clearly too sick to be out in public, sneezing and coughing all over the place.  As a parent of severely premature twins, I am somewhat sensitive to the problem of everyone else letting their sick kids needlessly desecrate public spaces.  As per hospital discharge orders, we essentially kept our children in our house for their first year.  It would have been nice if the entire rest of the Fargo populace had stayed hidden away when they were sick, but obviously that didn’t happen, and furthermore, I’m not willing to base the safety of my children on the responsible and considerate behavior of 100,000 other people anyhow.

So, we stayed home.

I don’t know of a good way of measuring this, but I will suggest that the total amount of suffering from colds, flus, stomach viruses, etc that are not commonly vaccinated against, and are transmitted by families who know perfectly well that they are sick but still choose to go out in public anyway – is greater than the total harm done by families who don’t vaccinate for some variety of non-medical objection.  Even if you disagree with the claim, it is clear that families who should know better still go out in public, and, unlike those who object to vaccinations, run-of-the-mill sick people get no serious criticism for their misdeeds.

Finally, then, we get to the question of obligation.

Rather than place an obligation to stay home on all of the sick people of Fargo for my benefit, we decided to keep our kids at home, for their safety.

Should any sick person be obligated to stay out of the public sphere for my benefit?  If so, where did this obligation come from?  If you think sick people should be allowed to head out in public as they wish, do you still claim that people should be obligated to vaccinate themselves?  It would seem that you couldn’t expect the latter without expecting the former; that is, if people need to modify their behavior for your benefit, or for the public health, shouldn’t that policy apply not only to vaccine abstainers, but also to people who are unvaccinated for any reason, and, furthermore, shouldn’t it also apply to any contagiously sick person as well?

If you want to be consistent, yes.  If you want your policy to be focused on improving health (as opposed to judging other people), then, yes.

Being considerate of others is a great character quality.  But there is always a cost.  While it would be considerate to stay home anytime you’re sick, the cost to you can be significant – lost wages at work, for example.  Even if you accept that you are obligated to be considerate towards others, doing so comes at a cost to you.  The people who wish to place this obligation on you typically don’t see or don’t care about your cost.

In my view, it isn’t very neighborly to lay an obligation or expectation on another individual – especially one that saddles them with a cost, or a risk.

The underlying problem with the idea that getting vaccinated is everyone’s obligation to everyone else is that it diminishes the individual in favor of the collective.  Because vaccinating yourself has a non-zero risk to you, doing it for anyone else’s benefit means that you are performing an act of sacrifice.  How you view the idea of sacrificing yourself for someone else’s benefit is up to your personal code of ethics.   Note, however, that even Christianity, which is pretty clear about its expectation of self-sacrifice for the benefit of others, doesn’t force the issue.

Critically, it is inappropriate for worldly governments to demand that individuals sacrifice themselves for the benefits of others.  (Yes, that means getting rid of all kinds of taxes and other stuff.  Yes, I’m generally for getting rid of all that).

When a society decides that the preferences of the many demand the sacrifices of an individual, we have a name for this: socialism – the organization of society centered around the repression, enslavement, and exploitation of some individuals for the benefit of others.

While it is a virtuous and neighborly thing to do to vaccinate yourself for your neighbor’s benefit, it is not an obligation any other person, or any government, has a right to lay upon you.  This is an important principle to grasp, because we have seen it violated in our history.  Not so long ago, it was the policy of one of the great evil societies of the 20th century to force some of its citizens to undergo medical procedures against their will.  We learned about this and recoiled in horror at the thought of a government violating anyone in that way.

How then, are we able to tolerate the demands from some of our fellow citizens that some should be subjected to forced medical procedures against their will?  If we succumb to their demands, what is the practical distinction between our society and the previous societies we were taught to loathe?

In a free society, no one is forced to receive a vaccination against their will.  Any other policy is unjust.

[mks_pullquote align=”right” width=”300″ size=”24″ bg_color=”#000000″ txt_color=”#ffffff”]While it is a virtuous and neighborly thing to do to vaccinate yourself for your neighbor’s benefit, it is not an obligation any other person, or any government, has a right to lay upon you.[/mks_pullquote]

The good news, is, in a free society, nobody is forced to associate with anyone else.  If you don’t want sick people, or unvaccinated people to introduce health risks into your lives, you don’t need to invite them into your home.  You don’t need to employ them at your business.  You don’t need to allow them in church on Sunday, and you don’t need to let them be your customers.

In fact, the Moms Club (an organization where mothers get their children together for group play dates and other adult/child socialization activities) has a zero-tolerance policy on un-vaccinated kids.  This zero-tolerance policy even applies to kids who cannot be vaccinated for medical reasons.  Some parents are very, very upset about this – because after all, the family with a child who is unvaccinated for medical reasons wanted to vaccinate but couldn’t.

But the Mom’s Club policy is based not on moral judgments – not based on the soft socialism of expecting everyone to do their best to do their share – but on science – and the science says that pathogens don’t care why someone isn’t vaccinated – only that they aren’t.

In a free society, every individual chooses what vaccinations they receive, and every group or organization chooses which individuals they will exclude.  This is the morally correct policy, even if it appears to have some practical difficulties (how does the grocery store know which customers trying to walk through the doors are unvaccinated?)

Another difficulty is that we do not live in an especially free society.  A tremendous point of argument in this entire conversation is the topic of vaccination policy in public schools.  Public schools belong to the public, which means whatever the public likes perhaps ought to be the governing policy of the school in question.

Public institutions are saddled with a particular problem: what the public wants, the public doesn’t always get.  The reason for this is that our government still occasionally clings to the ideology of avoiding direct democracy and thereby offering some limited amount of protection for individual rights – even when those rights frustrate the desires of the mobbish majority.  That is to say, because our government must protect the rights of individuals, even when they conflict with the will of the majority, we have said that black children have the right to go to public schools even if a majority of racist whites didn’t want them there, and, in some states, we’ve said that unvaccinated children can go to public schools even if a majority of vaccine moralists don’t want them there.

A perfectly reasonable policy would be that each public school can, via its board, voters, or other appropriate representative system, decide what its vaccination policy should be.  However, if this policy has exemptions for those medically unable to be vaccinated, then it is an unscientific policy, and, rather, it is a morally judgmental policy.  I would sooner accept a zero-tolerance vaccination policy for public schools than one that only denied philosophical objectors.  The former policy can be justifiably linked to concern for child safety; the latter policy is chiefly an expression of human ugliness towards those with different viewpoints.

Finally then, if a public school adopts a policy that excludes unvaccinated children, should those families still be required to pay the taxes and fees for a school that they aren’t permitted to use?  In a freer society, no, students denied the services of a particular school wouldn’t be required to pay for it.  However, in our society, I suspect that any unvaccinated kids who are refused school participation will still be expected to pay.  Schools love their taxes, after all.

When you give lots of freedom to people with different ideas, and put them all in the same physical area, the results can be messy.  We use our free speech rights primarily to upsets others.  We have gun rights that some people tragically misuse to harm their neighbors.  Our 4th amendment rights make it harder for police officers to catch bad guys, and, our 5th amendment rights mean that some people who are guilty end up walking out of the courtroom as free men.

We put up with these frustrating freedoms not because they never cause us difficulties, but because we know that a society without them is much worse place to live.

A frustrating aspect of letting people make their own choices is that they don’t always make them wisely, but we should be happy that our vaccination rate is as high as it is.  We can continue to make vaccines safer; we can continue to make them more available, and we can continue to persuade our neighbors that the rewards exceed the risks.  We can be happy that the majority of North Dakotans who choose not to vaccinate do so for medical reasons, because this will save us a lot of accusations of ill-will and ignorance towards our fellow citizens.

What we cannot do is use government to force our neighbors to vaccinate themselves.  We might preserve our health, but at the sure expense of our principles.