Last week, I wrote about how antivaccine activists have been targeting the Somali immigrant community in Minnesota, with disastrous results in terms of public health, with Andrew Wakefield himself having made at least a couple of visits to proselytize his religion in which vaccines are Satan. Basically, MMR uptake among the Minnesota Somali community’s children has plunged over the last decade, from 92% to 42%. Completely predictably, that very same community is in the midst of a measles outbreak, whose toll has risen to 32 since last week (and is continuing to rise), making it bigger than the last outbreak among the Somalis in 2011. Meanwhile, yesterday a coalition of antivaccine groups targeted the same community with the message that the “epidemic is autism, not measles,” featuring antivaccine activist Mark Blaxill. I can’t help but wonder how many children will be sickened before this particular outbreak is contained and whether it will spread far beyond the Twin Cities area where it is concentrated now. That doesn’t even consider my concern about the politicization of what used to be a bipartisan consensus on school vaccine mandates.
Such thoughts were on my mind as I received a letter from my State Representative Jeff Noble on Saturday. My wife received an identical letter the same day. The reason was that we had both reached out to his office to express alarm and opposition to two bills related to school vaccine requirements and policy being considered in the Michigan House right now, HB 4425 and HB 4426. Rep. Noble told us, in essence, thanks for ing his office, but bugger off. Here’s the letter:
Neither my wife nor I reacted very well to this letter, as you might imagine. After all, unlike me my wife is a pediatric nurse practitioner in primary care. She administers vaccines every day.So, what, you may ask, are HB 4425 and HB 4426? What did Rep. Noble mean by his comment about how the “intent of the legislation is to reign [sic] in the department who [sic] has overstepped the boundaries that were implemented by past legislatures”? I also can’t help but note that there’s another, darker provision in these bills that Rep. Noble conveniently left out of his letter, as you will see. Unfortunately, both my State Senator Patrick Colbeck (who has antivaccine-sympathetic proclivities) and now my State Representative Jeff Noble, have shown a—shall we say?—openness to antivaccine advocacy. Indeed, Sen. Colbeck is the main sponsor of the Senate versions of these bills, SB 299 and SB 300. I also should have checked more closely, as I subsequently learned that Rep. Noble strongly supports HB 4425 and HB 4426 to the point of co-sponsoring them. To understand what is happening in Michigan, it’s necessary to go back a couple of years, when the Michigan Department of Health and Human Services (MDHHS) instituted a new rule making the process to obtain personal belief exemptions (PBEs) to school vaccine requirements more difficult. HB 4425 and HB 4426 are explicitly designed to reverse that rule and forbid MDHHS from making new rules like it in the future.
A solution to low vaccine uptake that is working
In response to increasing nonmedical exemptions to school vaccine mandates and falling vaccination rates, as well as pertussis outbreaks, particularly a big pertussis outbreak in 2012, the MDHHS decided to do something about it. In brief, the state emulated California’s first attempt to combat the rising tide of PBEs. Basically, starting January 1, 2015, the MDHHS altered the rules regarding requirements for parents to claim personal belief exemptions to vaccine mandates, patterning its policy change on California Bill AB 2109, a bill from a few years ago that sought to tighten up requirements for PBEs in California. AB 2109 required parents seeking PBEs to meet with a physician or other enumerated health care practitioner to receive counseling on the risks of opting their children out of school vaccine requirements. The physician would then have to sign the PBE form to verify that he had counseled the parents. Of course, in the wake of the Disneyland measles outbreak a year ago, California passed a far stronger measure, SB 277, which, beginning with the 2016-2017 school year, eliminated PBEs in California. SB 277 has already shown results in decreasing the rates of PBEs and increasing vaccine uptake.The rule change took effect on January 1, 2015. Since then, parents seeking PBEs to school vaccine requirements must visit their local county health department office to:
- Be educated by a local health worker about the benefits of vaccination and the risks of disease.
- Sign the universal state form that includes a statement of acknowledgement that parents understand they may be putting their own children and others at risk by refusing the shots. Only the state form is allowed. No substitute forms are allowed any more, as they were in the past.
Why did the MDHHS make this rule change? Simple:
Michigan has one of the highest immunization waiver rates in the country, with some counties reporting waiver rates up to 12.5% (that is, more than 12% of school-age students in these places have not received all vaccinations). In addition, individual school buildings have reported even higher waiver rates. High nonmedical waiver rates can leave communities susceptible to the entry of diseases such as measles, chickenpox, and pertussis (whooping cough) by undermining community or “herd” immunity that protects vulnerable children (for example, children who cannot be vaccinated for medical reasons and children with compromised immune systems). Herd immunity can also slow the spread of disease if a high proportion of individuals are immune to the disease in a community. Immunization is one of the most effective ways to protect children from harmful diseases and even death.
The result of Michigan’s abysmal vaccine uptake rates have been outbreaks, particularly a large pertussis outbreak in 2012, out of which was born a campaign by a mother whose baby died of pertussis to increase vaccine uptake. There have also been measles outbreaks.
Short of an SB 277-like law banning nonmedical exemptions, this is the best that the MDHHS could do, and it’s working too. Early data indicate that PBE rates are declining and vaccine uptake is starting to increase in Michigan.
Not surprisingly, the antivaccine movement really, really, really doesn’t like this rule. As soon as the rule was publicly announced, it was attacked, with the most common claim being that the MDHHS broke the law because it didn’t have the power to institute such a rule. This is a fallacious argument, as the rule was approved, as such rules must be, by the Joint Committee on Administrative Rules, a bipartisan legislative committee charged with the legislative oversight of administrative rules proposed by state agencies. Basically, JCAR reviews state agency regulations and, if it takes no action, allows them to go into effect after 15 legislative days. The committee is composed of lawmakers, giving it a legislative imprimatur, but it is not the Legislature itself, thus avoiding the political rancor that can accompany debate on controversial issues. Antivaccinationists have described this as a “stealth move,” but it was entirely legal, and the rule change is having its intended effect.
Antivaccine parents were outraged and immediately started targeting the offices of a few sympathetic legislators, such as Rep. Thomas Hooker:
Concerned parents came in droves to the state capital Wednesday morning to protest a new vaccine waiver policy which opponents say bullies parents.
But supporters say the new policy, which requires parents to make an appointment with the county health department to officially obtain a waiver, is working. Although some counties had already been doing this, it’s a big change for parents who had previously been able to waive their child’s vaccinations with a quick signature in a school’s office.
Reps. Mike Callton, R-Nashville, and Thomas Hooker, R-Byron Center, held a joint hearing of their respective Health Policy and Families, Children and Seniors committees Wednesday morning to discuss the change.
“A lot of parents got upset right there because they felt it’s their right, why should they have to drive all the way to the health department? And for some of them it’s not that easy and some of the health departments aren’t real nice,” Callton said.
Parents testified Wednesday about the extra trouble of making health department appointments, which serve primarily to educate them about vaccines before opting out with a waiver.
My reaction at the time was basically: Oh, poor parents! They’re being “bullied” because they can’t just sign a piece of paper and let their children degrade herd immunity and endanger other children with infectious diseases any more. They actually have to go to the health department and listen to science-based information before signing a state-mandated waiver form that acknowledges that the risks to their child and their community of not vaccinating have been explained to them and that they understand. This complaint is of a piece with other things that antivaccine parents characterize as “bullying,” such as simply questioning their beliefs in the slightest.
Unfortunately, these parents have enough clout to have resulted in HB 4425 and HB 4426 their Senate counterparts SB 299 and SB 300, which, if passed, would strike down this rule and bar MDHHS from writing new rules like it in the future. That’s not all it will do if passed, though, nor are the current bills the first attempt to reverse the MDHHS administrative rule.
Pro-disease legislation being considered in Michigan
Fresh off the first case of measles in Michigan this year, having another go at reversing the MDHHS rule:
Michigan Republicans have decided to throw established science and concerns for public health out the window by introducing bills that are clearly catered to the anti-vaccine crowd — and will ultimately put the public’s health at risk.
According to MLive, “parents seeking an exemption to vaccinations must be educated by a local health worker about vaccines and sign a universal state form, which includes a statement of acknowledgement that parents understand they could be putting children at risk by refusing the shots.”
Under the proposed bills, the rule would be eliminated.
According to health officials, this rule helped drive down vaccine waivers, which led to more kids getting immunized. Data from 2015 showed that Michigan ranked 43rd lowest in the nation for immunizations covering kids from 19 to 35 months. So clearly, we still have some work to do.
Not surprisingly, there was a statement from my very own state senator, Sen. Patrick Colbeck:
“The rules enacted by DHHS pertaining to parents who wish to opt out of vaccinations for their children go beyond the intent of the current law, which was to inform parents of potential consequences of their choices, but now seems to have a punitive intent,” Sen. Colbeck said. “Whenever a department promulgates rules that go beyond the intent of the legislation, it is then the role of the Legislature to make sure those rules are reined back in. It was never the intention of the Legislature to see a vaccination opt-out procedure put into place that essentially mandates that parents have to take time off of work to meet with specific people, view videos, or sign inflammatory forms to exert a right they should be able to exercise more simply.
“State legislators are increasingly concerned about departments implementing rules that go beyond legislative intent. There is a strong desire to reform the administrative rule-making process across the board, thereby limiting the need for retroactive correction.”
Notice how much he sounds like Rep. Noble? Not surprisingly, Sen. Colbeck is the sponsor of SB 299 and SB 300. In any event, given that the rule passed the Joint Committee on Administrative Rules, it’s hard to argue that it went beyond the intent of existing legislation; otherwise, JCAR would likely have nixed the proposed rule when it considered it. This is the “wedge” that antivaxers in Michigan are using, though. They’re appealing to conservative legislators using the antivaccine dog whistles of “freedom” and “parental rights,” bolstered with an appeal to conservatives’ distrust of regulation. Indeed, on the website of the antivaccine group Michigan for Vaccine Choice you can find exactly those arguments, the claim that the MDHHS “overreached.”
The bills I’ve been discussing are not the first time that some Michigan legislators have tried to reverse the rule change on PBEs requiring a trip to the county health office and the use of only the state form to claim an exemption. Before HB 4425/6 and SB 299/300, there were HB 5126 and HB 5127, whose primary sponsor was Rep. Hooker and which were introduced during the 2015-2016 legislative session. Fortunately, they failed to pass; in fact, they didn’t even make it out of the Committee on Health Policy. HB 4425/6 and SB 299/300, introduced this year, are basically identical to the previous bills and are now under consideration by a different committee, the Committee on Education Reform. Vaccine advocates tell me that there will likely be at least a hearing on these bills sometime during the next several weeks, which, if it happens, will be further than they got last time.
First, let’s take a look at the relevant part of HB 4425:
(2) A child is exempt from this part if a parent, guardian, or person in loco parentis of the child presents a written statement to the administrator of the child’s school or operator of the group program to the effect that the requirements of this part cannot be met because of religious convictions or other objection to immunization.
(3) THE DEPARTMENT’S AUTHORITY TO PROMULGATE RULES UNDER SECTION 9227 DOES NOT INCLUDE THE AUTHORITY TO PROMULGATE OR ENFORCE A RULE THAT IMPOSES A DIFFERENT OR ADDITIONAL REQUIREMENT FOR A CHILD TO BE EXEMPT FROM THIS PART THAN THOSE DESCRIBED IN THIS SECTION OR THAT REQUIRES THE EXEMPTIONS DESCRIBED IN THIS SECTION TO BE ON A FORM PRESCRIBED BY THE DEPARTMENT.
(4) IF THE DEPARTMENT PROVIDES INFORMATION TO THE PUBLIC ON THE EXEMPTIONS DESCRIBED IN THIS SECTION, THEN WITH THAT INFORMATION THE DEPARTMENT SHALL INCLUDE INFORMATION ABOUT THE EFFECTIVENESS AND POTENTIAL RISKS OF IMMUNIZATION FOR DISEASES FOR WHICH THE DEPARTMENT REQUIRES IMMUNIZATION UNDER SECTION 9227.
Basically, this law, if passed, would handcuff MDHHS by explicitly forbidding it from making it any harder for parents to claim a PBE than to present a signed written statement to the school administrator saying, in essence, “I don’t wanna.” You can also spot the influence antivaxers had in drafting this bill by the rather obviously antivaccine-inspired language about the “potential risks of immunization.” Finally, you can see that Rep. Noble is a co-sponsor of HB 4425, something I should have noticed before I ed his office. He’s also the primary sponsor of HB 4426.
If handcuffing the MDHHS regarding the education and forms requirement to obtain a PBE were all that these bills do, it would be bad enough. However, HB 4425 goes beyond that and seeks to make it difficult for local health officers to contain small outbreaks and prevent them from becoming large outbreaks.
Make measles great again! Or: How to make small outbreaks bigly
By far the worst part of these bills is found in this language in HB 4425, which is basically custom-made to make it easier for single cases of vaccine-preventable disease to become outbreaks, for small outbreaks to become large outbreaks, and large outbreaks to become epidemics:
(2) THE DEPARTMENT’S AUTHORITY TO PROMULGATE RULES UNDER SECTION 5111 DOES NOT INCLUDE THE AUTHORITY TO PROMULGATE OR ENFORCE A RULE ALLOWING A LOCAL HEALTH OFFICER WHO CONFIRMS OR REASONABLY SUSPECTS THAT AN INDIVIDUAL ATTENDING A SCHOOL OR GROUP PROGRAM HAS A COMMUNICABLE DISEASE TO, AS A DISEASE CONTROL MEASURE THAT IS NOT IN THE CASE OF AN EPIDEMIC, EXCLUDE FROM ATTENDANCE AN INDIVIDUAL WHO LACKS DOCUMENTATION OF IMMUNITY OR IS OTHERWISE CONSIDERED SUSCEPTIBLE TO THE COMMUNICABLE DISEASE. AS USED IN THIS SUBSECTION, “GROUP PROGRAM” MEANS THAT TERM AS DESCRIBED IN SECTION 9211.
What this provision would do is to prevent the MDHHS from empowering local health officers to bar unvaccinated children from school if they suspect or confirm a case (or cases) of a vaccine-preventable disease in that school. Presumably, that would mean that only MDHHS could take such an action. So much for local autonomy that conservatives claim to champion!
I looked at this provision, looked at it, and then looked at it again. For the life of me I can’t figure out any reasonable rationale for such a law, other than to strip the MDHHS of a power that would make its ability to contain outbreaks easier. Basically, the only purpose this provision will serve, if passed, is to endanger children who are not vaccinated thanks to PBEs, while at the same time inserting additional susceptible children into an environment where a contagious disease resides, thus making outbreaks more likely. This provision is, at its core, a near-perfect strategy to make it much more likely that a single case of disease becomes a small outbreak and that a small outbreak grows into a large one—or even becomes an epidemic. Here’s a hint for Rep. Hooker, Sen. Colbeck, and the rest of the sponsors of these ill-advised bills: By the time you have a large outbreak or an epidemic, it’s too late. Keeping unvaccinated children out of school is a strategy that works best if it’s done early in the course of an evolving outbreak, and empowering local health officers to do just that would provide the flexibility needed to act early. This law, if passed, could easily result in a public health disaster.
The politicization of vaccine policy
There has been a long history of bipartisan consensus on vaccine policy and school vaccine mandates in this country. Unfortunately, this consensus is being undermined, and bills like HB 4425/6 and SB 299/300 are the result. My personal suspicion is that, energized by the fight against California SB 277, antivaccine activists stumbled upon a successful strategy based linking “vaccine choice” with “freedom” in general, “parental rights,” and the distrust of the government baked into conservative politics. Thus, over the last five years or so, the loudest voices in the antivaccine movement have increasingly tended to come from the right, not the left, such that vaccine policy even featured prominently in the second Republican debate, largely thanks to Donald Trump’s long history of antivaccine rhetoric and the increasing alignment with antivaccine groups with Tea Party and right wing political groups. To me, this alignment in rhetoric and viewpoint was epitomized by an interview with Sen. Rand Paul (who really is antivaccine) two years ago in which he said, “The state doesn’t own the children. Parents own the children, and it is an issue of freedom.” Antivaccine-sympathetic physicians like “Dr. Bob” Sears, in particular, traffic in these “parental rights” and “freedom” antivaccine dog whistles. Antivaxers were further energized when it was revealed that Donald Trump had met with disgraced British antivaccine gastroenterologist Andrew Wakefield in August and then again when he met with antivaccine activist Robert F. Kennedy, Jr. in January, allegedly about a vaccine safety commission.
There have always been politicians who are antivaccine. (Think, for example, Rep. Dan Burton, who held endless hearings on the “risks” of vaccines and the “autism epidemic” in the late 1990s and early 2000s.) However, they have generally been the fringe, to whom few paid much attention and whose antivaccine views fewer still supported. Unfortunately, antivaccine activists have become very good at conflating the “freedom” to refuse vaccines with “freedom.” Worse, they are fringe no longer, and vaccine policy is being politicized in a way that it has never been before. Indeed, a couple of months ago, The Washington Post published an article, “Trump energizes the anti-vaccine movement in Texas“, and it’s not just in Texas where they’re being energized. (It doesn’t seem to matter that Trump appointed an honest-to-goodness pharma shill who is very pro-vaccine as FDA Commissioner.) Indeed, the article explicitly makes my point:
One particularly strong strain of anti-vaccine rhetoric in Texas is libertarian and anti-government. Texans for Vaccine Choice receives help and expertise from “friendly” lawmakers and groups such as Empower Texans, said Jonathan Stickland, a tea party Republican representative from Tarrant County and a key supporter. Political experts consider Empower Texans the state’s most sophisticated and influential conservative organization.
“Our message resonates with people,” said Schlegel, 37, in a brief interview after a day of meetings at the Capitol. “Texans value parental rights,” she said. “We have a message of liberty. We have a message of choice.”
It is a powerful message that is difficult to counter. As I’ve said more times than I can remember, antivaccine pseudoscience is an irrationality that appeals to both the right and the left, but for different reasons. On the left, it’s often due to a belief that “natural” is somehow better, coupled with distrust of big business, especially big pharma. On the right it’s “freedom” and anti-government rhetoric. Think of it this way. Political operatives know that people tend to be more passionate when they are against something rather than for something. It’s easier to get them to donate and volunteer to oppose a policy rather than to promote a policy. That was how the Tea Party got started, and we’re seeing what might be the start of a similar passion on the left in response to Donald Trump.
Sadly, here in Michigan we really do have a large number of legislators who conflate “freedom” with the freedom to endanger public health and fetishize “parental rights” without even considering the rights of the child. It’s almost as though they’re trying to turn Michigan into Romania, with its massive ongoing measles outbreak. Evidence of the susceptibility of our legislators to antivaccine dog whistles comes from a recent trip to Michigan by Del Bigtree, producer of the antivaccine propaganda film VAXXED, to meet with legislators. For instance, here is Bigtree interviewing Rep. Hooker:
Note how Rep. Hooker is spouting off about “parental rights” and “parental choice” in the usual way that antivaccine activists do, such that the child is basically viewed as the parents’ property instead of an autonomous being with rights of his or her own, such as the right to good medical care. Good medical care, I note, includes standard of care preventative medicines such as the CDC-recommended vaccine schedule. Hooker also blathers on about “big pharma” in a typical conspiratorial manner. He even invokes one of the most brain dead antivaccine arguments there are, an argument that fundamentalist Christians make about the HPV vaccine:
Obviously, as a parent and a grandparent myself, it’s important to me that parents have their rights protected and, you know, their choice of what’s best for their kids. I think of the immunization Gardasil. If my children are raised in a godly Christian home, they don’t need Gardasil, because they’re going to make the wise choices, and again, the advertisements they’re putting out on television to the parent (“You could have protected me and let me have an immunization as a child”) takes the responsibility away from the kid, who should be making the responsibility for having sex outside of marriage.
When, near the end of the interview, Hooker brought up the “aborted fetal tissue in vaccines” distortion, I had to stop and thank my lucky stars that Rep. Hooker was term-limited. I’m thankful now that he’s no longer in the House. Unfortunately, there are many to take his place.
Bigtree also managed to meet with a number of other legislators, including Sen. Phil Pavlov, Rep. Hank Vaupel, and Rep. Mike Callton. Pavlov represents the 25th District, which encompasses much of the Thumb area of the state, while Representative Vaupel represents a district that includes several exurbs northwest of Detroit and Rep. Caldon represents a rural district west of Lansing. Sadly, there was at least one Democrat on the list, specifically Sen. Vincent Gregory, whose district covers several of the northern suburbs, including Farmington Hills, Southfield, Farmington, Ferndale, and more. This swath of northern suburbs encompasses an area where I’d guess that much of Detroit’s antivaccine contingent resides; no wonder Sen. Gregory is a co-sponsor of SB 299 and SB 300. Bigtree exults that his meeting with Gregory was one of the best meetings he’s ever had with a Democrat and how Gregory promised he’d get Bigtree’s antivaccine concerns heard by the Congressional Black Caucus in Detroit. Meanwhile, through it all, Bigtree was driven around by a representative from Michigan for Vaccine Choice, one of our state antivaccine groups, the same one that’s promoting HB 4425/6 and SB 299/300.
Bigtree wrapped up his visit to my state with a fundraiser for the Michigan Vaccine Freedom PAC, which is exactly what you think it is and lists Rep. Noble as supporting “vaccine choice” and “legislative oversight,” and opposing “vaccine discrimination”:
In his talk, Bigtree spends a lot of time arguing for “health freedom,” portraying “vaccine choice” as an integral part of health freedom, where the parents have the right to refuse vaccination for their children. Of course, as I’ve mentioned in this very post and more posts than I can remember, the problem with this argument is that it completely ignores the autonomy of children. Children are not the property of their parents. They are not extensions of their parents. They are autonomous beings who have an existence outside of their parents and who have the right to medical care, including the right be protected against vaccine-preventable diseases, regardless of the misguided beliefs of their parents who refuse to vaccinate. Not surprisingly, Del Bigtree traces his antivaccine activism (I know, I know, he doesn’t think that he’s antivaccine) to the introduction of SB 277, the California bill that is now law that has eliminated nonmedical exemptions to school vaccine mandates.
If we do not fight now, then there will be nothing left to fight for. And I think that is where everyone in this room, I pray you realize how important you are in this historic moment. We will never be stronger than we are right now. We will never be healthier than we are right now. Our children are looking like this, a generation of children, as we’ve said on The Doctors television show this is the first generation of children that will not live to be as old as their parents. Are we going to stand…are we going to sit down and take it? Or are we going to stand up and say: This is a historic moment, that my forefathers, those from Jefferson all the way to Martin Luther King, the moments where people stood up and something inside of them said I’m going to stand for freedom and I’m going to stand for it now. That is in our DNA. It is pumping through me, and I pray that you feel it pumping through you, because we must look back. Our grandchildren will look back and thank us for having stood up one more time and been the generation that said, “We the People of the United States of America stood for freedom, stand for freedom. We will die for freedom today.”
Histrionic? Yes. Overwrought? Definitely. Grandiose? Well, it is Del Bigtree. Even so, it’s not hard to see how this can be a very effective message among libertarian and government-distrusting conservatives.
What can science and public health advocates do?
Sadly, now that we’ve gone down this road, I don’t see a clear path to preventing the further politicization of school vaccine mandates and state vaccine policy. I fear that it might require much bigger outbreaks than we’ve seen thus far before we as a nation come to our senses about vaccines, at least. Vaccine advocates have science on our side, but the antivaccine movement has emotional stories and passion. If we can’t match that passion and couple it with science we will lose.
Medical societies should be leading the way in this fight, particularly those representing specialties that care for children. Fortunately, one such group is leading the way:
State physicians groups are also opposed. For example, the Michigan Academy of Family Physicians, which issued an action alert to urge state legislators to vote no on HB 4425 and HB 4426, as did the Michigan State Medical Society. Then, of course, there is the Alliance for Immunization in Michigan, an organization of health care professionals who advocate for vaccines.
Although Michigan medical groups have started to stir themselves to oppose the bill, so far I’ve seen little other than the action alerts above. What will be more important, however, is for parents in affected states to become active. For example, Michigan’s first pro-vaccine parent advocacy group is now up and running, The Cooperative for Safe Kids (Facebook). Not surprisingly, the group opposes HB 4425 and HB 4426, as well it should. Then there’s the Franny Strong Foundation and its I Vaccinate campaign, which was born out of the tragic death of its founder’s baby to pertussis during the 2012 outbreak.
The same is true in every state where antivaccine groups are influencing the legislature to weaken school vaccine requirements. Pro-vaccine advocates need to be active at the local level, working to elect pro-vaccine legislators, to defeat antivaccine-sympathetic legislators, and to defeat bad legislation like HB 4425 and HB 4426. Unfortunately, the situation around the country is like that in Texas, where the antivaccine groups outgun pro-vaccine groups in terms of funding and activism. Unless we can reverse this situation, the antivaccine movement will succeed in making measles great again, not to mention several other vaccine-preventable diseases.