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Rhode Island and the Right to be Sick

As the leaves change color and the temperature drops, winter and the flu season are fast approaching. With the chill also comes the choice of whether or not to get the flu vaccine. Many factors go into this decision: religious beliefs, philosophical beliefs and medical history being the primary concerns. However, the ability to consider multiple factors when deciding to take the flu vaccine — and even choose not to get it out of laziness or lack of concern — is the exception to the rule across the country, where many immunizations are mandatory. Compulsory vaccinations, far from being just a quick pinch and a fun Band-Aid, highlight some of the most dynamic conflicts between our society and the individual today.

Diphtheria vs. Happy Baby. Easy choice.
Diphtheria vs. Happy Baby. Easy choice.

The first thing to note is that the process of mandatory immunizations is not some Big Brother-esque enterprise. Rather, the United States’s program follows a highly decentralized approach. There are no federal laws requiring vaccinations; instead, states individually determine which vaccines are necessary and implement the policies through requirements for school attendance. While each state has different specific laws, the general approach is that children cannot attend schools unless they have been vaccinated against various illnesses. Such programs began with Massachusetts in 1809 and states’ rights to require immunizations was validated in 1905 by the Supreme Court, with a later case approving the use of school attendance to enforce immunizations in 1922.

Compulsory vaccinations are considered by the American Medical Association to be “the most cost-effective and successful public health intervention” for several reasons. First, they allow for preventative measures to be taken before outbreaks and epidemics occur. Second, children are especially susceptible to diseases especially when in close contact with other children, so school age vaccinations prevent illnesses from spreading in a highly susceptible breeding ground. Thirdly, they create a stable system that encourages a lifetime focus on public health and preventative measures.

Rhode Island requires immunizations at the pre-kindergarten, kindergarten, seventh grade, and college levels.  At each level additional dosses of the following vaccines are compulsory: Hepatitis B, DTaP (diphtheria, tetanus, pertussis), polio, MMR (measles, mumps, rubella), Pneumococcal Conjugate, Hib, Varicella, Tdap (tetanus, diphtheria, pertussis), and Meningococcal conjugate. Children without medical records of those vaccines or without a formal exemption cannot attend school at any level in the state of Rhode Island. Meaning a Brown University student must have those vaccinations or a religious exemption in order to attend the university.

However, while the vast majority of children and adults are vaccinated, Rhode Island allows individuals to object to the program of mandatory vaccinations. Most states have options for medical, religious, and philosophical exemptions, and Rhode Island  allows for all but the philosophical one. Medically, if a patient is allergic to the vaccine or if the vaccine could bring about a life threatening condition, the individual is exempt. But religious and philosophical exemptions create a murky grey area of choice and individual liberty, especially when considering the effects of un-immunized individuals on the community.

An important outcome of mandatory vaccines is “herd immunity” — a public health theory the American Medical Association details as establishing “indirect protection for a community … when a high enough proportion of the population is immunized to interrupt transmission.” Scientists estimate that for true efficacy, ninety percent of the population has to be vaccinated. Herd Immunity is the idea behind the elimination of diseases and a highly cited argument for proponents of mandatory vaccinations, but it often induces parents and individuals who would otherwise have gotten the vaccination to choose exemption — since the unvaccinated are protected by their vaccinated peers. The choice to be an exemptor, while limited in most states, leads to negative public health impacts.

Exemptors are not only more likely to become ill from diseases but they are highly likely to become carriers and transmit diseases to vaccinated persons. For example, the 2010 Whopping Cough outbreak in California caused 9120 outbreaks – a number not reached since 1947. Researches have directly linked those who contracted the disease with trends of unvaccinated children. Forbes furthers this conclusion with the example of Wisconsin, which has experienced the “highest rate of infection in the nation” and has experienced some of the most impassioned anti-vaccination advocacy.  Thus, in order to achieve the most public health benefits, immunizations must be nearly fully compulsory.

Rhode Island’s Constitution expressly establishes freedom of religion in Section 3 of Article 1. “No person shall be burdened in body or goods … nor otherwise suffer on account of such person’s religious belief; and that every person shall be free  … to profess and by argument to maintain such person’s opinion in matters of religion; and that the same shall in no wise diminish, enlarge, or affect the civil capacity of any person.”

But in Rhode Island students can be excluded from school at anytime public health officials deem their unvaccinated status as a risk to other students or to themselves. Essentially, public health priorities override students’ civil capacity. When a student’s lack of vaccination is due to religious reasons, then that student’s civil capacity is directly affected based on his or her religious status. This is a major conflict in Rhode Island public health policy. In order to maximize public health efficacy and prevent disease outbreaks and epidemics, Rhode Island needs a program of compulsory immunizations that has largely been implemented. However, in order to maximize religious freedom and civil rights, Rhode Island would need to prioritize religious freedom over public health.

It is a slippery slope to prioritize society over the individual, but it is equally as dangerous to prioritize the individual over society. Religious freedom is important but so is protecting civilians from preventable and potentially fatal diseases. The citizens of Rhode Island ought to confront this conflict in the ballot box – either directly or indirectly. If Representatives are voting on behalf of citizens, there should be additional attention drawn to candidates’ positions on compulsory immunizations. Ideally however, citizens should vote on the issue itself through a referendum. The decision between public health and religious freedom is one that extends to every citizen and must be actively decided upon, not unknowingly conceded, or —even worse — left to fester even longer as a fundamental contradiction in Rhode Island’s laws. As winter comes around, and some students sniffle in the Blue Room and others leave Faunce with a Band-Aid and seasonal immunity, we should decide whether the rights of the many to be healthy outweigh the rights of the few to be sick.

About the Author

A member of the Class of 2017, Brenna is concentrating in Public Policy and Economics.