Staying On the Right Side of the (Public Health) Road  

When I taught my kids how to drive a car, the first thing we did in the empty shopping mall parking lot was try the brakes. Let the car roll, press the sideways pedal, and stop. Roll, press, stop. Soon they trusted that when they pressed on the pedal, the car would stop. Working the steering wheel and the accelerator followed. Once they had confidence in the mechanics, it was time for the road. Stay to the right. Stop at the red stop sign. Go when the light was green. When they discovered that other drivers were following the same rules, they could grip the steering wheel a little less tightly and surveil for other dangers.  

When teenagers get the coveted license, what keeps these and other newly minted, hormonally raging, and cerebrally immature drivers (mostly) on the right side of the road? Is it the conditioning of their instruction? The awareness that Officer Friendly is around? A rational choice based on a fully informed conclusion that a traffic free-for-all is in nobody’s interest? It does not matter — so long as they follow the rules and trust that fellow drivers will as well.  

And so new drivers are introduced to a set of norms and rules from which we all benefit. If you have had the (mis)fortune to be in a car where the rules of the road are not followed and other drivers are not to be trusted, the results are at least chaotic — loud horns, frayed tempers, and long delays — and more often flat-out dangerous.  

The same conditions apply to much of public health, which depends on cooperation, rules, and trust to reduce the toll of infectious diseases. New data indicates that when it comes to vaccinations in the United States, the rules of the road are crumbling. Failures in leadership are to blame. And the consequences are far worse than traffic jams.  

In the absence of up-to-date data from the Centers for Disease Control and Prevention, researchers from Johns Hopkins University assembled county-level childhood vaccination data trends where available. They focused on measles — the most infectious disease against which kids are vaccinated — and showed that the percentage of counties where vaccination rates are below the 95% level accepted as necessary for preventing widespread outbreaks has dipped precipitously in the last six years. (Figure 1). 

Figure 1. Only One-Quarter of US Counties Reach the 95% Immunity Threshold

Percentages are calculated using the counties with data available for each school year. The number of counties changes each year, so a confidence interval, shown as the shaded area, was included. The interval indicates the range within which the true figure is likely to fall. Counties with no 2 MMR or all series data were excluded.

Source: Bhat S, Calderon I, Heasly J. New vaccination maps reveal outbreak risks. Is your county protected? USA Today. https://data.usatoday.com/projects/county-vaccination-coverage-and-measles-outbreaks/index.html  

Working with that data, journalists at USA Today documented that measles outbreaks are occurring in communities with some of the lowest vaccination rates, and that the extent of variation in vaccination rates within states is significant (Figure 2). 

Figure 2. Most Recent County-Level Vaccination Among Children

States track vaccination coverage using different dosage schedules and age groups. When specific data for two or more Measles, Mumps, and Rubella (MMR) wasn’t available, we show the broader vaccination series that includes MMR. ‘No data’ indicates that recent data for the state wasn’t available.

Note: MMR rates may appear higher than overall series rates since some children may have received the MMR vaccine but not all other recommended shots. Rates in different states might not be comparable in some cases as collection methods vary. Source: Bhat S, Calderon I, Heasly J. New vaccination maps reveal outbreak risks. Is your county protected? USA Today. https://data.usatoday.com/projects/county-vaccination-coverage-and-measles-outbreaks/index.html  

The former finding is not surprising. Science shows MMR vaccines really do prevent the spread of measles. If children don’t get vaccinated, they are more likely to get measles, suffer, and possibly die. They will also infect others. 

Declining vaccination rates and variation in rates by county indicate that the rules of the road — we vaccinate our kids before they go to school to keep everybody safe — are collapsing in some places. Rather than keeping to the right and proceeding at the green light, some are picking the driving rules that seem safest to them. Chaos ensues. 

How did we get here? 

First, we don’t think much of the rule makers these days. Declining trust in the ability of government to do what is right most of the time is at 60-year lows, according the Pew Trust, and at one-third of its highest levels.  

Contributing to this, increasingly, we are encouraged to find (and create) our own facts and make our own rules. As the internet has destroyed the readership and business model for local journalism, social media has amplified attention-seeking behavior that relies on exaggeration and outrage and encourages like-minded echo chambers of skepticism. The proliferation of information — not all of it credible, let alone true — has allowed these skeptics to “do their own research” rather than defer to the protracted and de-individualizing process by which scientific consensus emerges. 

When it comes to making and following rules, personal health behavior is a particular sore spot. Over the last decade public sector leaders have repeatedly failed to gain and maintain the public’s trust for setting rules of the road that all can live by.  

Concerns about the safety and efficacy of new vaccines, the infringement of personal liberties, and skepticism about the exercise of government authority over personal behavior have been hallmarks of vaccination efforts for almost two centuries, going back to the first smallpox efforts. Experience shows these concerns have been best addressed with mandate decision-making and messaging that is clear, consistent, humble, community-engaged, and phased-in. However, much of federal, state, and local leadership applied these lessons unevenly when giving quarantine guidance at COVID’s outbreak in 2020 and introducing the COVID vaccine in 2021. It relied instead on expert-driven, top-down decision-making and communications regarding issues like masking, social distancing, and priority populations for vaccination that often overstated certainty and changed over time.   

The distrust engendered by the government’s COVID response has infected other vaccine discussions and accelerated the “medical freedom” movement, which prioritizes personal liberty and has focused on generating political momentum for broader vaccine exemption language in state law. Faced with vocal and organized activists who threaten to vote them out of office, state legislators have in many instances gone against broad public support for childhood vaccine mandates and widened existing exemption laws. (Figure 3).   

Figure 3. 47 States Allow Exemptions From School Vaccination Requirement for Religious and/or Personal Beliefs

Not surprisingly, states with broader exemption laws have lower vaccination rates. Since exemptions are implemented by local school departments, local leadership also matters, and accounts for some of the county-level variation noted previously. Advocates are not content with merely broadening vaccine mandate exemptions. After an initial veto, this spring Idaho Governor Brad Little signed the Idaho Medical Freedom Act which makes it illegal for state and local governments, private businesses, employers, schools, and day cares to require anyone to take a vaccine or receive any other “medical intervention.” 

Some public sector leaders have not only bowed to the advocates of vaccine skepticism and “medical liberty” but fostered them for reasons both ideological and political. As KFF notes, Secretary of Health and Human Services Robert F. Kennedy, Jr., “…who has a long record of opposing immunizations and spreading vaccine misinformation, has led recent efforts to re-examine the federal childhood vaccine schedule, replace members of Advisory Committee on Immunization Practice, and restrict COVID-19 vaccines and mRNA vaccine research.” 

And at the state level, last month Florida Governor Ron DeSantis and the state’s Surgeon General Joseph Ladapo announced plans to follow Idaho’s example and do away with all vaccine mandates in the Sunshine State. In front of a cheering audience, Ladapo said, “People have a right to make their own decisions, informed decisions….They don’t have the right to tell you what to put in your body. Take it away from them.” In a grammatically confusing but abundantly clear abdication of his moral and professional responsibility as a physician and public servant, Ladapo asked, “Who am I to tell you what your child should put in your body?” and added a rhetorical flourish comparing mandates to slavery. 

These leadership statements are green lights to medical freedom advocates but confusing signals for the majority the population supportive of mandates but bombarded with misinformation. A recent survey revealed that when confronted with four demonstrably false statements about vaccines, in each case, at least four in ten respondents expressed uncertainty about their veracity. A nascent public-interest journalism movement, built on sustainable business models, offers hope for building trusted local sources of information and holding the purveyors of misinformation accountable.  

Fundamentally, this kind of leadership — which preys upon uncertainty and anxiety to create division and political advantage and cement power — threatens the health of individuals and erodes the most precious commodity a society has: our trust in one another.  

Life is sufficiently uncertain and challenging; if we are deprived of the sense that we can rely on one another to show respect, cooperate, and stay on the right-hand side of the road, those challenges are compounded. While mutual respect and cooperation start with our own behavior, we deserve and must demand public sector leaders who promote similar traits. Vaccine mandates — when developed through trustworthy structures and processes and fairly enforced — are some of the rules of our public health road, and we are all better off when they, and the public’s trust, are in place.