Countering the negative public health impacts of the anti-vaccination movement

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This blog post was authored by Javier Saladich, a Summer Research Intern at the O’Neill Institute. Javier is a third year law student at ESADE Business and Law School in Barcelona, Spain. Any comments or questions can be emailed to javier.saladich@esade.edu.

In light of recent measles outbreaks in Europe and the United States and a European Court of Justice decision in a vaccine-liability case, this blog post considers the importance of public health laws and messaging to strengthen societal consensus and compliance with vaccination programs. It argues that governments and public health advocates should continue to counter the growing presence of the reactionary anti-vaccine discourse, which threatens to erode community immunity and public health gains.

Vaccination and the importance of societal consensus

There are very few public health issues in relation to which societal consensus is taken as granted, but none as misleading as vaccination. Every so often, new data reminds us of the fragility of such consensus and the peremptory challenge non-vaccination and incomplete vaccination pose to public health, including recent outbreaks of measles in Europe and the United States. Even though anti-vaccine responses can be traced back to a purported atavistic fear of chemicals, as brilliantly portrayed by Eula Biss in her essay On Immunity, the devastating consequences of infectious epidemics throughout history and the steady effectiveness of vaccines finally brought parents and societies together around a sort of collective trust in each other’s child vaccinated status. This allowed for what the medical community calls the “immunization of the herd”, a social contract whereby the group stays protected only insofar as no significant share of members opts out.

Concerning measles outbreaks in Europe and the United States

The core of this status quo, though, has come under question in recent decades. Take measles, for instance. Immunization coverage to prevent measles outbreaks – 95% is needed, according to global standards – has fallen to risky levels in some communities within the United States. Even more worryingly, up to 15 European Union/European Economic Area (EU/EEA) member states are not complying with the minimum threshold. These countries’ failure to have their population immunized despite availability of safe and affordable vaccines has been closely followed by the WHO, which launched a 2017 campaign with the goal of showcasing “immunization’s role in sustainable development and global health security”.

In the United States, measles outbreaks are due to an insufficient rate of infant vaccination. While 2016 data shows vaccination coverage of roughly 91% population, coverage is distributed unevenly throughout the country. Under US law, states are free to adopt non-medical exemptions based on personal and religious beliefs, which contributes to lower coverage in many communities. Recent studies show that despite the improving levels of vaccination, unvaccinated persons appealing to state-level exemptions tend to cluster geographically in schools and communities, “so vaccine-preventable disease outbreaks can still occur”. For example, in 2014/5, a measles outbreak traced to Disney theme parks in California sickened 147 people. A 2016 outbreak originating in rural Minnesota has sickened more than 70 people to date.

In Europe, measles are still endemic. Italy and Romania the two major hotspots, with thousands of new reported cases. Why are higher-income countries, often considered as leaders in public health, still experiencing outbreaks of preventable diseases?

The anti-vaccine movement: weakening societal consensus and public health

An important contributing factor is the anti-vaccine movement, which promulgates messages that vaccines are unnecessary and harmful. In some ways, vaccines have been victims of their own success. Low incidence of measles outbreaks thanks to vaccine inoculation has been used by these groups to spread the belief that there is no longer a public health threat that justifies this intervention. The intersection of the traditional anti-vaccine movement and winning populist parties, whose discourse openly questions the safety of vaccines and in turn the whole pharmaceutical industry, could be another reason. Yet, these theories have been repeatedly dismissed by public health advocates and the international community, who recently endorsed a joint resolution to support vaccination.

The Disney outbreak in late 2014, highlighted the problem of misinformation and complacency, in the air since 2000, when measles ceased to be a native infection in the U.S. After the 2014 outbreak many hesitant parents soon understood that these seemingly eliminated threats were not over, but just waiting for vaccination rates to drop again.

However, this may not always be the case. Minnesota’s measles outbreak originated in a large Somali immigrant community that had been successfully targeted by anti-vaccine theories, including personal visits from Andrew Wakefield, who founded the modern anti-vaccination movement. This situation in Minnesota reveals how misinformation that conjures fear and emotion can take hold, with serious ramifications for the public’s health.

Strengthening public health laws and public confidence

Following major measles outbreaks in Western countries, political leaders have strengthened legal requirements for vaccinations. In California, where the Disney outbreak started, tough new legislation was passed, which removes non-medical exemptions (religious and personal beliefs) from the requirement to vaccinate children prior to their enrollment in kindergarten. In France, the Macron administration has promised to reverse low-vaccination rates and it will follow the path of California and Italy, by enforcing vaccination and making it a prerequisite to access public schools. To date, France has shown the worst performance in vaccination (around 75%). In France, there is a strong negative perception of vaccines, aggravated by bureaucratic and a confusing legislation, which labels only three vaccines as mandatory and the rest recommended.

Although legislative efforts are a step in the right direction, laws should be accompanied by public health education aiming to counter misinformation around the safety and necessity of vaccines. The need for pedagogy is evidenced by the recent controversy surrounding the European Court of Justice’s judgment on a liability claim for Hepatitis B vaccine harm. At the request of French Supreme Court, the EU’s highest court made a preliminary ruling, which has been wrongly interpreted as endorsing liability of vaccine manufacturers for vaccine-related injuries in the absence of scientific proof of causation. Instead, the ruling confirms that, in the absence of medical or scientific consensus on a specific cause of harm, causation may be established based on serious circumstantial evidence. The court noted that a mere temporal relationship between the vaccine and the harm would not be enough. Controversy emerged among public health experts, who fear this decision may be manipulated by the anti-vaccination movement. This reinforces the importance of public education and messaging to create a counter-narrative strong enough to impede manipulation of this ruling and other scientific questions.

It’s time for policy-makers to deploy not only an enforceable agenda for immunization, but also a persuasive battery of arguments to convince families that vaccines are safe, effective, and necessary for personal and public health. To this end, the credibility of institutions such as the Centers for Disease Control and Prevention and the WHO should be reinforced against bizarre conspiracy theories. Primary health care providers and pediatricians, who work at the front line of children’s health care, should be empowered to educate misinformed parents on the risks that non-vaccination entails.

Posted in Global Health; Tagged: , , .


Financial Security as a Public Health Good: Cash Transfers Can Improve Individual and Family Health

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Neil Sircar, J.D., is an LL.M Candidate in Global Health Law at Georgetown University Law Center & the O’Neill Institute for National and Global Health Law. Any questions or comments related to this post can be directed to nrs53@georgetown.edu.

Universal Basic Income (UBI), also known as Basic Income Guarantee (BIG), has been increasingly discussed in casual conversation, periodicals, and policy-making circles at city, state, and national levels. Over the past few years pilot programs have been proposed or undertaken in multiple countries and contexts, with GiveDirectly’s Kenya project perhaps kick-starting the newfound interest in the idea. Basic income projects (and similar programs) have supporters and critics across the spectrum, fueling a vivacious debate on whether and how basic income could be implemented. The traditional liberal and conservative divide is rarely bridged as interestingly as it is when discussing welfare reform that includes cash transfers.

The Basics on Basic Income

The gist of basic income is that everyone under a certain jurisdiction receives – conditionally or unconditionally – a cash transfer. Conditional cash transfers, as seen in Brazil’s very successful Bolsa Família Program, are one way in which basic income projects are considered that essentially create a quid-pro-quo interaction between guarantors and recipients. Unconditional cash transfers (such as with GiveDirectly in Kenya) come without strings attached and the recipients can use the money as they so choose. Similar programs – the US’ Earned Income Tax Credit, negative-income tax (and its 1970s’ pilots in the US) or Alaska’s Permanent Fund dividend program – might work towards the same end and achieve positive health outcomes, though they are conceptually and structurally different. Basic income is just that, an income floor under-which no beneficiary may fall. Whether your income is $20,000 or $200,000, you are guaranteed a stipend by virtue of your residency, citizenry, and/or humanity.

Think of the Children (and Former Children)

The question asked here is: what are the health impacts, and under what conditions if any are positive health outcomes realized? The social determinants of health include (and may be dominated by) economic factors and financial security by way of ensuring or supplementing income helps enable individual and family health. The effect of financial security might be especially meaningful for children, as one longitudinal study suggests after it followed a group of study participants over 35 years from childhood through adolescence and adulthood. Of course a litany of factors might influence such a study – individual behaviors, genetic profiles, etc. – though the increased likelihood for children to be physically and mentally healthier if up-brought in financially secure households is unlikely a new phenomena. There are benefits for adults as well, leastways lower stress. Every child of the lower or middle classes (if not all income strata) can likely remember short-tempered parents worrying about bills or expenses! The long-term health effects of stress are well known and contribute to adverse health outcomes on adults as well as children.

Cash Me Ousside (?)

Conditional and unconditional cash transfers carry with them a spate of challenges, risks, and rewards. While promising, there remain valid critiques of poorly designed cash transfer programs that go beyond whether basic income would disincentivize working (it does not; like, really) or people would spend money poorly (a cynical view of humanity to be sure, and also one that is unsupported). Absolute poverty though could be curtailed and with it the negative health consequences associated with destitution; middle-class individuals and families likewise could benefit in their health from supplemental income. Financial security for all persons, and especially those in the lower income brackets, is public health good with real and potential boons to individual and family health.

            Illustration by Margaret Scott

Posted in Global Health;


Hepatitis Policy Project Releases Recommendations to Improve Monitoring of the Hepatitis C Epidemic in the U.S.

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The O’Neill Institute for National and Global Health Law’s Hepatitis Policy Project recently released a report offering recommendations to strengthen data collection and monitoring of cases of Hepatitis C in the U.S. in order for public health authorities to gain a better understanding of the effects of the disease and most effective strategies to curb the continuing rise in new cases. The report was informed by an expert consultation of key stakeholders working on viral hepatitis issues, and legal and policy analysis by Hepatitis Policy Project staff. The report can be found here.

There are currently 3.5 million Americans currently living with Hepatitis C, and approximately 33,900 new cases of the disease occurred in 2015. Despite this high prevalence, there is little actual data collected on individual cases of the disease, with many cases going unreported to public health authorities. Many cases that are reported offer little other information on gender, age, race, or risk factors that may have contributed to the person getting the disease, such as injection drug abuse. This type of information is critical for public health authorities to be able to identify those at risk for infection, prevent new infections, and get treatment and other health services to those infected to lessen the impact of the disease on their health. Data collection and the availability of hard numbers of the scope of the health issue are essential tools to influence the legislature and policy makers to improve resource allocation and prioritization of Hepatitis C interventions, and to change laws and policies that encumber those with Hepatitis C from getting the health care services they need.

The recommendations given in the report for improving monitoring of Hepatitis C are as follows:

1) Expand and standardize reporting to the CDC: Policy makers should phase up active surveillance of HCV in more states and territories, and as well as work with local jurisdictions in identified hot spots. The CDC’s Division of Viral Hepatitis (DVH), working with congressional appropriators, should develop a five-year plan for building the capacity to conduct active surveillance in the great majority of US states.

2) Utilize electronic medical records to collect data on HCV cases and the cure cascade: State epidemiologists should be funded to establish and utilize an integrated electronic medical records database, which would also provide matching metrics with cases, such as race, age, gender, and progress of treatment.

3) Fund epidemiologic research using clinical data sets: Clinical care data are a largely untapped resource that holds great potential for better informing responses to HCV and relies on data that already exist. In addition to the CDC, agencies across HHS and in other Departments such as Veterans Affairs and Defense should be directed to fund epidemiological research on HCV.

4) Integrate improved monitoring of HCV with responses to the opioid crisis: The Nation is increasingly recognizing the scope of the public health crisis we are facing related to the opioid abuse. Preventing and treating HCV must be elevated as a signature component of the national response to opioid abuse.

5) Establish and monitor HCV elimination plans across major US health systems: Strategic plans are needed to eliminate HCV in the United States. One example is the Cherokee HCV elimination project currently being implemented, where the tribe plans to screen 85% of Cherokee Nation health patients between the ages of 20 to 69 by the end of 2018. The Department of Veterans Affairs also is leading the way toward eliminating HCV in the Veterans Health Programs. Other public programs and systems should be tasked with developing their own elimination plans, including the Ryan White HIV/AIDS Program, the Health Centers Program, and various correctional systems in the US.


**A limited number of hard copies of the report are available for distribution. Please contact the author of this article to request copies. **

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Reflections on O’Neill Institute health rights litigation intensive 2017

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Do the courts, and does the law more generally, have the power to advance the right to health? It would be hard to conclude at the end the O’Neill Institute’s weeklong Health Rights Litigation Intensive anything other than an emphatic yes — even while acknowledging limitations of health rights litigation, and exploring questions that make it difficult sometimes to even answer the seemingly straightforward question of what effect health rights litigation is having on the right to health. While hardly invariably so, the law, including litigation, can be a powerful tool to advance health rights – particularly when it is able to shift power.

The health rights litigation intensive lived up to its alternative name of the Global School Health Rights Litigation Course, for it truly was a global school. The course featured a host of health rights experts, from as far away as Mexico – none other than Supreme Court Justice Alfredo Gutiérrez Ortiz Mena – to the O’Neill Institute’s own staff, along with top-notch professors, campaigners, and human rights funders. The course participants – many lawyers, but also students and other health rights advocates – came from countries spanning the global, from Uganda, Kenya, and South Africa, with a strong American contingency including from Mexico, Honduras, and the United States, as well as Asia, with South Korea well represented.

Mexican Supreme Court Justice Alfredo Gutiérrez Ortiz Mena. Image courtesy of the Supreme Court of Mexico.

This diversity matters, not only because the different perspectives enriched the experience for all, but also because, as came out from the various sessions, the experience of and possibilities for health rights litigation vary by country. And as histories of the court system and health rights litigation in India, Brazil, Argentina, Colombia, South Africa, and Mexico, demonstrated, the health rights jurisprudence of each court system and  the very nature of that system are products of both judicial and political history, and the functioning of government institutions. Many of the courts most active in advancing health rights are those in highly unequal societies – Colombia, India, and South Africa, for example – with both the inequality and the courts’ sense of obligation to intervene a product, at least in part, of political dysfunction.

Whether judicial or otherwise, action to advance the right to health is most effective when it changes power dynamics on behalf of people who are poor, marginalized, discriminated against, on the short end of health inequities. Courts may have a role in changing these dynamics, as courts are a countermajoritarian institution that can exercise their authority to protect people’s rights, as Justice Gutiérrez emphasized. The court can stand for a robust implementation of the principle of nondiscrimination, as the Supreme Court did in Mexico, declaring unconstitutional a law establishing an employment certificate program for people with autism, where they could receive a medical certificate affirming that they had certain skills, meant to protect them from discrimination at jobs requiring these skills. Not only did the law reinforce stereotypes, but as Justice Gutiérrez stated, people’s right to be free from discrimination does not depend on their receiving a medical certificate. Power had shifted to people with autism. In the 760/08  judgment in Colombia, not only did the Constitutional Court demand a wholesale reform of the health insurance system, creating a unified scheme where the level of covered health benefits no longer depended on whether a person could pay into the system, but it also established a deliberative process to plan for the unification, with all stakeholders participating, and transparent justification for decisions. This representing a significant, if limited, opening of the political process to people otherwise kept outside and in the dark.
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Posted in Global Health, Human Rights, Tobacco; Tagged: , , , , , , .


The Outbreak That Wasn’t: Liberia’s “Post-Ebola” Moment

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Ever since WHO declared the end of Ebola virus transmission in West Africa in June 2016, the world has wondered when (not if) they would see Ebola again. In May 2017, the virus reemerged from its secret jungle lair, but not before a brief panic in Liberia just a few weeks prior that would briefly catch the world’s attention.

On Sunday, April 23, 2017, a funeral for a religious leader took place in Greenville, Liberia, a small coastal city approximately 150 miles southeast from the capital city of Monrovia. Later that day, an 11-year-old girl that attended the funeral was admitted to a hospital with symptoms of diarrhea, vomiting, and confusion; she died that evening. Another patient with similar symptoms arrived the next day on Monday; on Tuesday, April 25, 14 people arrived. In the days that followed, 31 cases would be reported, including 13 deaths, several of which had attended that funeral.

Traditional funeral ceremonies were one of the elements that amplified the West African Ebola outbreak of 2014-16. In some communities, these ceremonies may include activities that can potentially spread disease from the recently deceased to uninfected mourners — from grievers making contact with the deceased, to family members or traditional healers preparing and cleaning the corpse by hand. Illness and fatalities linked to a funeral attendance would almost certainly raise alarms of a potential Ebola resurgence, and prompt an aggressive investigation.

But Liberia’s health workers are now better trained, “post-Ebola”, to monitor and report suspicious events on the off-chance that an outbreak is linked to Ebola. That Tuesday, an investigative team was dispatched from Monrovia to Greenville, and simultaneously, patient samples were sent to Monrovia for testing. The samples arrived that same day, and that evening, laboratory testing ruled out Ebola.

And so it was that on Wednesday, April 26, the report was sent out around the world about the outbreak, along with the emphatic statement that Ebola had been “ruled out” (the disease in question was later determined to be meningitis). It’s not often that a disease outbreak is newsworthy due to not being Ebola, but it is understandable that all West Africa, and particularly Liberia, is on high alert in case the virus returns.

As time goes on, this event will likely be forgotten. But for the moment, let us appreciate this visible, positive outcome. The framework that has been put in place in Liberia “post-Ebola” is designed to integrate and improve the detection of and response to diseases. The amount of time needed for transporting and analyzing samples has been greatly reduced. Not only does it seem that Liberia “learned” from the 2014-16 outbreak, they have endeavored to improve the necessary elements for Ebola readiness. The Greenville meningitis outbreak may have been a “false alarm”, but it gave Liberia a moment to shine.

As we stay tuned to the waning days of the current Ebola outbreak in Likati, Democratic Republic of Congo, we will inevitably ask more questions of Ebola readiness, and whether we have “learned” from the West Africa pandemic. Liberia, it appears, has.

Posted in Global Health; Tagged: .


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