First things first: in every country where vaccines are freely available, most people are vaccinated. But, for highly-contagious diseases such as measles, the target for uptake is 95% – which is a struggle for most countries. Hence the strong interest of academics and commentators in understanding who exactly is opting out, and how might they be persuaded to reconsider.
The answer is far from simple. For example, libertarians may object to compulsory vaccination on the grounds that they oppose government mandates in general. In the US, ‘libertarians’ are usually found on the right of the political spectrum. In Europe too, there are examples of anti-vaccine populists (broadly) on the right in France, Poland and Italy.
But, anecdotally, there are plenty of anti-vaccine Facebook groups where the tone leans left or green. Some express general mistrust of authorities, expertise and industry. Others are engaged in what Professor Heidi Larson has called the ‘pursuit of purity’ – a kind of clean-living ethos sceptical of medical intervention. (Although, as we’ve argued before, there is a case to be made for vaccination because it reduces the need for later hospitalisation and medication.)
All of this is anecdote. In an effort to add some rigour and data to the discussion, political scientists at the University of Western Australia asked 1,000 people for their views on mandatory vaccination; their beliefs about the safety and effectiveness of vaccines; and about their political affiliation. Then they crunched the numbers to see whether political persuasion shapes immunisation rates.
It’s worth noting that Australia has taken a firm line against immunisation opt-outs. As part of a comprehensive policy, which includes a national register, information campaigns, incentives for healthcare providers and for parents, its ‘No Jab, No Pay’ policy links vaccination to government payments and access to childcare. (See video for more.) While controversial in some quarters, the policy has helped Australia hit the 95% threshold required to stop the spread of measles.
This 2017 video offers a general overview of how Australia’s immunisation policy has evolved.
So, what did the latest study find? As Dr Katie Attwell, University of Western Australia, describes in the first video above, it seems support for the national immunisation policy is generally high in Australia. The survey showed that 85% agree with the federal government’s policy of “No Jab, No Pay”, with just 9% opposing it.
‘Only 4% didn’t think vaccination was safe, effective and necessary,’ she said. ‘We found 9% disagreed with Australia’s ‘No Jab, No Pay’ policy and we found a high level of support for mandatory vaccination.’
The study, published in the prestigious international journal Politics, shows that Australians have quite different attitudes towards compulsory vaccination to Americans and the British. While vaccination is popular in all three countries, the authors of the new paper say previous research has shown that opposition to making it compulsory in the US and UK is about 30%.
Not only do Australians overwhelmingly support compulsory vaccination, that support is strong across the political spectrum. There is more than 80% agreement with ‘No Jab, No Pay’ among voters of all major parties, including the Greens and One Nation. The authors say this is important because it shows that in Australia, mandatory vaccination works – ‘it isn’t just good policy, it’s good politics’.
Moral taste buds
Separately, Professor Saad Omer, Yale University, formerly of Emory University, has been looking at how our fundamental moral outlook can flavour our health decisions. There are, he notes, six moral foundations that are universal.
However, the way these are emphasised varies from one society to the next, and depending on the stimulus. Omer’s team looked at how parents’ attitudes to purity, authority, liberty and other core values shape vaccine uptake.
‘Initially, we did some work with parents in the US and found vaccine hesitancy was associated with the purity foundation and with the liberty foundation,’ he explained. ‘On the other hand, they were less likely to be hesitant if they had an emphasis on the authority foundation.’
But US data may not hold for all populations. The results were a little different when the researchers asked the same questions of pregnant women in Kenya. ‘Purity wasn’t associated with maternal vaccination,’ Omer said. ‘And the relationship between authority and liberty were flipped: if you emphasised liberty you were more likely to accept maternal influenza vaccine.’
The lesson, he said, is that moral values vary between countries and can depend on how individuals interact with society, the government and health systems.
So…what are we to conclude from all of that? The good news is that, as most people vaccinate, political views are not an absolute barrier to vaccination: conservatives vaccinate, greens vaccinate, socialists vaccinate and so on.
The tricky part is in reaching those whose reasons for not vaccinating are hard-wired into their sense of who they are. If changing attitudes to vaccination are so wrapped up in our political and moral identity, it makes it much harder to change people’s minds on the narrow question of whether to vaccinate.
This explains why evidence alone does not change people’s minds. Some people accept climate science but are hesitant about vaccine science; others are happy to listen to medical experts but not environmental experts. It seems likely that we all cherry-pick the evidence and stories that fit with our fundamental outlook.
So, what can we do?
First, we should do no harm by not linking vaccination to identity. For example, while it may be satisfying for critics of the US President Donald Trump to mock some his unscientific statements on vaccination, it is a terrible idea from a public health perspective.
People who vaccinate but voted for Trump may feel like they should opt out of vaccination if they want to be a fully-fledged Trump fan. Trump voters who are hesitant may feel they are making a political choice – even a concession – if they move from hesitant to immunised.
The same goes for political attacks on the Italian government for its ambivalent stance on vaccination. Science should not become a partisan issue.
Instead, it would be wiser to design campaigns that allow people to vaccinate without compromising their identities. This line of thinking leads us back to Australia – and to one of the authors of the study mentioned above, albeit to a campaign that concluded several years ago.
Dr Katie Attwell’s ‘I Immunise’ initiative was tailored to her own community which variously describes itself as ‘alternative’, ‘hippy’ and ‘crusty’. In a series of posters, it featured local people explaining that they (for example) eat organic food or aim to breastfeed – but that they also vaccinate. The unspoken message is that you’re not out of the club if you choose to immunise your children.
‘I hope that these voices might begin to change the narrative whereby just because you aspire to natural birth, or eat organic food, or use cloth, or baby-wear, it doesn’t mean that you have to reject vaccines,’ Katie explained in this 2014 video.
The beauty of the campaign was that it pulled immunisation out of people’s identity, showing that you can preserve your sense of self and your place in the community while protecting yourself and others against infectious diseases.