Preventable diseases aren't supposed to be killing people in 2015. Yet the Washington State Department of Health recently had the unenviable task of announcing the first measles death in the United States in more than a decade. On July 2, the DOH revealed that a case of pneumonia brought on by measles had killed a woman from the Olympic Peninsula in the spring.
"We should be ashamed of ourselves," Representative June Robinson (D-Everett) told The Stranger the week after the DOH announced the cause of death. "We thought these diseases were eradicated, and now they're back in our midst."
The latest measles death wasn't related to the strain unleashed in Disneyland last winter. But, like the Disneyland outbreak, the new case highlighted the damage individual choices not to vaccinate can have on more vulnerable members of a community. The deceased woman—who the DOH is not identifying for privacy reasons—already had a weakened immune system when she contracted measles; according to the DOH, she was taking immune-suppressing drugs for another medical condition that prevented her body from fighting the disease. High group vaccination rates—meant to foster what's called "herd immunity"—are supposed to protect people like the woman who died. But below a certain percentage of people immunized, preventable diseases start to reappear. "So to me, that's a huge tragedy," a Clallam County health official told the Peninsula Daily News. "It was preventable by the community levels of immunization."
Unfortunately, fighting against diseases like measles no longer has anything to do with the science of community health. Instead, it has everything to do with individual beliefs—and, as research coming out of Western Washington is beginning to suggest, the science of marketing.
Like 17 other states, Washington allows schoolchildren to go unvaccinated if parents' philosophical beliefs intervene. In 2011, Washington kindergartners had the highest rate of skipped vaccinations in the country, and this is now placing the state's major public-school districts at risk. If communities fail to immunize between 92 and 95 percent of children for measles, mumps, and rubella (MMR), measles threatens a comeback—and, according to this year's enrollment data, students in Seattle Public Schools are only 83.5 percent immunized for MMR. Overall, only 71.8 percent of Seattle's public-school students have completed all their vaccinations, ranking below Tacoma's 79.6 percent and slightly above Spokane's 68.8 percent. But even though new outbreaks of preventable diseases are drawing scrutiny to exemption laws, only three states prevent personal and religious beliefs from interfering with vaccines. California is one of them. There, in late June, Governor Jerry Brown signed a tough new piece of legislation that got rid of both personal and religious exemptions in that state.
Representative Robinson, who received a master's of public health from the University of Michigan, sponsored a similar bill to get rid of personal belief exemptions in Washington State, but her bill languished in Olympia after passing out of the state house's Health Care and Wellness Committee and didn't even come to a vote on the house floor this session. Sponsors shrank away, Robinson said, fearing the anti-vaccine backlash.
Robinson admits that passing vaccine legislation in Washington may work only in times of politically convenient crisis, like in California following the Disneyland outbreak. Still, not all researchers agree that policy is the only way to go.
"If policy was as easy as, you know, reflecting current knowledge or good science, then the answer should be that we eliminate personal-belief exemptions," said Dr. Douglas Opel, an assistant professor of bioethics and pediatrics at the University of Washington School of Medicine. "But policy is not simply that. It is an intersection between current knowledge as well as societal values. Gun control, restricting access to firearms, is a good example. If we relied on simply science for restricting access to firearms, that would be a slam dunk."
Presenting science alone can even backfire. In 2014, a study published in Pediatrics showed that debunking the false autism-vaccine connection for parents can have the opposite of the intended effect on the parents with the biggest doubts about vaccines. In the Pediatrics study, debunking made those parents even less willing to get their kids vaccinated for measles, mumps, and rubella. Researchers still don't understand why, but they did suggest that correcting one falsehood could put parents on the defensive—and make anti-vaxxers want to justify their position on other fronts.
Now researchers like Opel are studying how to stage other types of interventions.
Four years ago, five public and private institutions in Washington State—including the DOH—joined forces to create VAX Northwest, a coalition that aimed to better inform parents about vaccines. This past May, a group of researchers, including Opel, published the first-ever study testing to see whether a local intervention created by VAX Northwest would work. Researchers tracked doctors at 56 clinics across Western Washington, some of whom had been trained on how to communicate with vaccine-hesitant parents, then surveyed 347 new mothers in their care. Physicians were taught to ask parents how they felt about vaccines, acknowledge their concerns, and advise them.
The intervention failed. Vaccine hesitancy decreased slightly in both the experimental intervention clinics and the control ones, but Nora Henrikson, the study's lead author, attributes that partly to a whooping cough outbreak going on at the time. Or maybe the intervention just wasn't strong enough. Doctors were trained on how to communicate with parents over 45-minute lunch sessions, so perhaps they could have used full-day sessions and more thorough follow-up.
"There are a lot of things we don't understand about vaccine hesitancy," Henrikson said. "We've heard lots of ideas from other folks that we should work with physicians taking care of moms earlier in the birth process, maybe even during pregnancy."
Joe Turcotte, a Washington-based health-care communications consultant, suggested that part of the problem has to do with branding. Physicians, unlike huge corporations, don't have sophisticated tools telling them how to connect with their target demographic. In this case, that target demographic happens to be vaccine-hesitant parents. (They tend to be white, well educated, and affluent. Politically, they vary.)
"If you think about [General Motors], and how well they understand their consumer base and what's going to influence a consumer to buy what type of car, they have very sophisticated market-research tools that help them connect directly with their consumer," Turcotte said. "On this issue, that level of understanding isn't there yet."
Some of Opel's research suggests that immunization rates actually improve when physicians start conversations by just telling parents they're going to vaccinate that day. Starting with the presumption of vaccination—and then following up with concerns—may work better than leaving the door open for hours of trying to bat down every bit of misinformation floating around the internet.
Doctors are also fighting against the fact that the anti-vaccine movement of 2015 isn't a new phenomenon. Anti-vaxxers have resisted public-health measures since the 18th-century introduction of the smallpox vaccine. In Henrikson's mind, that tension probably won't disappear from US soil anytime soon. "It's just something that almost gets at everything America stands for," she said. "This tension between individual rights and individual freedom and the community." With cowardly lawmakers in Olympia ducking the issue, now it's up to doctors to wade into that difficult tension and win over the individual parents who are putting their kids—and everyone else—at risk.