Last week, President Trump met with his Australian counterpart, Prime Minister Malcolm Turnbull, on the USS Intrepid in New York. Beyond smoothing over a tense phone call and a hostile tweet from January, reports say that they discussed topics like ISIS, North Korea, global security, and tightening immigration policy. Relations were mended, and Trump even said to an audience that Australia has "better healthcare than we do," just hours after the American Healthcare Act passed the House.
But perhaps if Turnbull and Trump were speaking in private, the Australian prime minister would have pushed the envelope, and pressed Trump to change his mind on vaccines—a tool of global security in an increasingly connected world. After all, the US is facing a dangerous resurgence of diseases once thought to be long behind us (witness Minnesota's current outbreak of the potentially deadly measles virus, the worst in three decades).
Since taking office two years ago, Turnbull has aggressively pushed back against the powerful anti-vaccine movement that created a foothold in Australia in the early 1990s, driving immunization rates down to near 70 percent in many parts of the country. Outbreaks of measles, still classified as an eliminated disease in Australia, have since become an annual event, triggered by gatherings of large crowds like dance festivals. The worst of these episodes happened in 2012, infecting 168 people in a string of suburbs outside of Sydney.
Directly responding to these outbreaks, Turnbull's government passed a controversial amendment to Australia's key social services legislation which went into effect in January last year, called No Jab, No Pay—withholding child care benefits of up to $11,500 to families who refused to vaccinate their children by March 2016, unless given a medical exemption. (A jab is common vernacular in British or Australian English for immunizations, similar in use to shot in American English.) The premise of the policy was simple; fiscal blackmail would convince enough vaccine skeptics to reconsider the merits of vaccines, pushing immunization rates up to at least above 95 percent—the threshold commonly accepted by experts to confer herd immunity to a community against highly-contagious viruses like measles.
Last week, a familiar outbreak of measles started to unfold once again in Sydney. But vaccines are a long game in public health, and just over a year after No Jab, No Pay passed, its results so far have been impressive in achieving its goals for coverage. In the run up to the March-imposed deadline, the number of "conscientious objectors" dropped by 9,500. Compared to figures from 2015, every state in Australia finds itself considerably closer or even surpassing the 95 percent immunization rate target set by Canberra for one- and two-year-old cohort populations.
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In more than a few ways, the public health landscape for vaccines in the US today resembles that of Australia in the early 1990s. The anti-vaccine movement is rapidly gaining both cultural and political credibility, reinforced by a cadre of celebrities publicly sharing their reticence to immunize their children, and an administration that has flirted with the idea of elevating influencers in the movement to lead government commissions on vaccine safety. For the past few years, the percentage of children granted exemptions from complying with immunization schedules has grown. And the CDC reports that nationally, only 71.6 percent of 19- to 35-month-olds have received the recommended seven-vaccine series. In a few states, that percentage has even dipped below two-thirds of the population, leaving millions possibly susceptible to vaccine-preventable diseases.
Today, changes to those abstract numbers carry real consequences. Just last month, a mumps outbreak infected four students attending the University of Rhode Island, and that above-mentioned measles outbreak in Minnesota shook Somali immigrant communities heavily targeted by members of the anti-vaccine movement. Immunization rates in these communities have dropped by 50 percent in ten years.
Under-vaccination in the United States is an especially difficult conundrum for med students and others entering the field. They're taught to respect the concerns of our patients and grant them autonomy in the decisions they ultimately choose to make, after providing relevant information and answering their questions. Yet decades of research have expounded the virtue of vaccines, demonstrating repeatedly that they're cheap, safe, effective, and save literally millions of lives. One could even argue that not administering them would do harm to the personal health of our patients and the herd immunity of our communities. In other words, we'd be doing them and the rest of our patients a grave disservice by not pushing a vaccine-skeptic patient on the issue.
A variation of Australia's No Jab, No Pay policy in the United States might provide a viable solution to the vaccine conundrum, by communicating the public good of vaccines, while preserving a patient's autonomy. Given our taxation structure, a policy similar to No Jab, No Pay—directly affecting child tax credits—would exclude families making over $110,000 in income per year. A vaccine tax, first informally proposed by health economist Mark Pauly, however, could impact all families. And maybe we should try it.
Although it might initially sound strange, a vaccine tax would make sense economically when considering externalities, or the unexpected benefits and losses for society that spill over from a person's single decision. Herd immunity is a classic example of a positive externality: A community, at no additional cost, becomes more protected against a disease when an individual chooses to get vaccinated. Predictably, an individual refusing to get vaccinated would create a negative externality, and cause everyone else in a school, neighborhood, airport, or theme park to lose their herd immunity.
Negative externalities persist across public health, like secondhand smoke in a bar from cigarette smoking, or air pollution in a community from a carbon-emitting coal plant, and governments regularly correct for them through taxation, forcing a consumer to pay for the full "social" cost of an action. In our own country, we've become publicly comfortable with sin taxes imposed on tobacco, alcohol, and, more recently, marijuana. Using this same logic, governments around the world have considered and implemented carbon taxes to curb pollution.
For years in global health, governments and NGOs together have also created successful conditional cash transfer programs (known as CCTs) to eliminate poverty, often mandating immunizations for their beneficiaries. A vaccine tax would act as a continuation of this trend and other sin taxes, using evidence to inform policy. Politically, it could build upon strong (and rare) bipartisan support on vaccines. A recent Pew Research poll found that 73 percent of self-identifying conservatives and 90 percent of liberals support requirements for children to get vaccinated before starting school. It also found that 88 percent of Americans believe that the benefits of an MMR vaccine outweigh its risks.
Of course, a policy like this, however savvy it is for public health, still carries the stench of technocratic politics fraught with ethical controversy. Indeed, it would likely dredge up similar public debates surrounding Michael Bloomberg's proposed soda tax in New York nearly a decade ago. At the time, his campaign against the Big Gulp was decried as freedom-limiting, coercing individuals to make an uncomfortable decision at the behest of big government. For No Jab, No Pay, critics have moved even further to argue that the policy discriminates against specific religious groups opposed to vaccination. Within the complicated health insurance landscape in America, a similar policy could also penalize working-class families, lacking quality access to healthcare and the ability to comply with vaccination requirements. As Pauly has suggested, pricing the vaccine tax itself, and deciding what to do with the collected revenue, could also present challenges.
Many of these concerns about our thought experiment, however, can be rebutted. Public health interventions built upon evidence as strong as vaccines, like water treatment and seat belts, are rarely characterized by the mainstream as freedom-limiting and coercive. A recent review published in Vaccine found that only two religions, the Christian Scientists and Dutch Reform Church, take definitive positions against vaccinations, both of whose constituents could be offered an exemption to the policy. Vaccines in America are more accessible than ever, as insurance companies for now are mandated by the Affordable Care Act to offer vaccines as an essential health benefit (although unfortunately, this could change in some states under the American Healthcare Act). For the under- and uninsured, community health centers and local county health agencies use federal-dollar programs like Vaccines for Children to offer immunizations at little to no cost to patients. Even revenues from the implemented tax could be used to fund a program that subsidizes vaccines for any remaining children who fall through the cracks.
A policy like a vaccine tax may sound like an extreme overreaction to correct just one public health issue. But beyond the devastation of transient outbreaks, it is easy to forget about the long-term complications of many vaccine-preventable diseases common in the past. Both measles and chickenpox can stay latent in the human body for years, only to re-emerge as debilitating neurological diseases like encephalitis and shingles decades later. Rubella during the first trimester in an unvaccinated pregnant mother-to-be can contribute a host of congenital disorders, like deafness and blindness. A vaccine tax just may help in the fight to finally leave those stories behind.
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