Pestilence amid prosperity

Bordetella pertussis bacteria

Respectful Insolence reports that pertussis, also known as whooping cough, is back with a vengeance.

Inspired by Respectful Insolence's ongoing examination of vaccination laws and the ease with which parents are evading them, BioLaw is highlighting the findings of a new article, Saad B. Omer et al., Nonmedical Exemptions to School Immunization Requirements: Secular Trends and Association of State Policies With Pertussis Incidence, 296 J.A.M.A. 1757-63 (2006). This study of relaxed exemptions to state vaccination laws found that lax vaccination policies correlate a with much higher incidence of pertussis:

From 2001 through 2004, states that permitted personal belief exemptions had higher nonmedical exemption rates than states that offered only religious exemptions, and states that easily granted exemptions had higher nonmedical exemption rates in 2002 through 2003 compared with states with medium and difficult exemption processes. The mean exemption rate increased an average of 6% per year, from 0.99% in 1991 to 2.54% in 2004, among states that offered personal belief exemptions. In states that easily granted exemptions, the rate increased 5% per year, from 1.26% in 1991 to 2.51% in 2004. No statistically significant change was seen in states that offered only religious exemptions or that had medium and difficult exemption processes. In multivariate analyses adjusting for demographics, easier granting of exemptions (incidence rate ratio = 1.53; 95% confidence interval, 1.10-2.14) and availability of personal belief exemptions (incidence rate ratio = 1.48; 95% confidence interval, 1.03-2.13) were associated with increased pertussis incidence.

As Respectful Insolence concludes, "That's an incredible difference."

Like most other diseases, pertussis is ordinarily associated with poverty. Of the world's 30–50 million cases each year, 90 percent occur in developing country. Pertussis claims roughly 300,000 deaths each year, mostly children under one year of age. Wealthy countries have enjoyed the knowledge and the means with which they can control pertussis. It is an ongoing struggle, to be sure, because neither vaccination nor the disease confers lifetime immunity. Because the risk of neurological side effects increases with age, conventional pertussis vaccines are typically not administered to teenagers or adults.

But now pertussis has returned, with extreme vengeance, in wealthy enclaves such as Boulder, Colorado. Prosperity, so it seems, carries a steep price tag. It erodes the confidence of the wealthy in conventional medicine, to the point that distrustful parents would sooner expose their children to horrifying diseases than court the side effects associated with vaccines.

The less than polite term for this sort of person is an "altie." The core of the problem is "an anti-intellectual and antiscientific attitude that does not allow a little thing like evidence to sway one from one's belief in the power of alternative medicine." Aside from its prevalence at a somewhat higher level of wealth and income and its natural political habitat -- "alties" tend to lean left or far left in their politics -- this deep distrust of medical science shares much in common with creationism.

Just as the law should give no quarter to calls for teaching creationism in public schools (more in-depth analysis in this article), the law should tighten the terms by which parents seek and (increasingly) receive exemptions from vaccination laws. Bona fide religious objections to vaccination of course should be respected, and the law fares very poorly when it undertakes to gauge the sincerity or significance of religious belief. By the same token, states should not grant exemptions so freely that faddish reliance on alternative medicine can undermine the health of individual children and of entire communities.

Respectful Insolence and Kevin, M.D., characterize parents who refuse to vaccinate their children as guilty of child neglect. I'll go one step further. These parents' selfish decisions are hurting more than their own children. By defeating one of the core missions of public health -- that of conferring herd immunity from easily preventable communicable diseases -- these parents are harming entire populations. They are hurting other people's children. To put it coarsely but accurately, they are enemies of the people.