Navin, PhD, HEC-C, is Professor and Chair of Philosophy at Oakland University (Rochester, MI) and Clinical Ethicist at Corewell Health. His research is primarily in clinical ethics and ethics in public health. Attwell, PhD, is an Associate Professor in Public Policy at the University of Western Australia, where she leads VaxPolLab, and she is an Honorary Fellow of Wesfarmers Centre of Vaccines and Infectious Diseases at Telethon Kids Institute. Her research focuses on vaccination social science and policy. They are authors of the book America's New Vaccine Wars: California and the Politics of Mandates
A merica’s immunization policies are facing a bleak future. Political polarization about vaccine policies is likely to cause outbreaks of previously controlled infectious diseases. If we cannot prevent these disasters, we should pivot our focus towards managing them.
Resistance to vaccination is not a new problem, but the COVID-19 pandemic exacerbated it. It should be clear by now that neither persuasion nor coercion is sufficient to change the minds or the behavior of people who are determined to refuse vaccines. Education and research cannot defeat coordinated misinformation. And government efforts—at federal, state, and local levels—are stymied by a combination of inadequate power, insufficient political will, and a lack of perceived legitimacy by vaccine refusers. One of America’s core lessons from the COVID-19 pandemic is that a heavy-handed response to vaccine refusal can make things worse.
Many U.S. states have ended their COVID-19 vaccine mandates. But America’s childhood vaccine mandates for school entry are also vulnerable. As researchers of vaccination social science, ethics, and policy, we have sometimes encountered an optimistic view that immunization in America will soon snap back to a pre-pandemic “normal.” But this hope ignores the cracks that were already present in America’s immunization social order before the pandemic, cracks that COVID-19 only widened. State-based conflicts over school enrollment vaccine mandates became increasingly political and contentious during the 2010s. Continued political polarization about vaccine mandates is likely to reduce immunization rates and precipitate the return of previously controlled diseases. That’s why it’s time to adapt to vaccine refusal and prepare to manage these outbreaks, rather than hope they can be prevented.
All American states require vaccines for school enrollment, but most permit parents to opt out of vaccinating by obtaining a nonmedical exemption. Nonmedical exemptions may be available based upon religious or personal beliefs, depending on the state. Attempts to change these exemption policies have emerged as polarizing flashpoints for Democrats and Republicans. In 2015, California took the unprecedented first step of eliminating nonmedical exemptions to its vaccine requirements to reduce rates of vaccine refusal. Since 2015, Democrats, major physician organizations like the American Medical Association, and pro-vaccine parent activists have tried to remove nonmedical exemptions in many other states.
Democratic lawmakers have now eliminated nonmedical exemptions in California, New York, Washington State (for measles vaccine), Maine, and Connecticut. New national organizations, like the Safe Families Coalition, are pushing for similar changes in many other states. Where Democrats organized to abolish vaccine opt-outs, Republicans fought to protect or expand them. The fight continues, as Republicans look for ways to further weaken childhood vaccine mandates. A case in point: on 17 April this year a Republican judge in Mississippi reinstated a religious exemption to that state’s vaccine mandates that courts had overturned in 1979.
Attempts to scrap nonmedical exemptions inject new kinds of coercion into a fracturing immunization social order. This intensifies the politicization of school vaccine mandates and erodes public support for these critical policies. Conflicts about COVID-19 pandemic control measures were not outliers, but instead signs of a crumbling immunization consensus. The bitter truth is that nonpartisan vaccine policy was dead before the world had heard of COVID-19.
Removing nonmedical vaccine exemptions will not overcome vaccine refusal or prevent outbreaks. Only in states where Democrats control all levers of state power can such bills pass, given unified Republican opposition. These policies can deliver local increases in immunization rates. However, even in Democrat-led states, enforcement is likely to be uneven at best, and to be worse in communities where immunization rates are already low. For example, the leadership of private schools is unlikely to enforce strict vaccine mandates that they believe are inconsistent with their values, or that will cause them to lose substantial tuition revenue.
Local successes in Democrat-led states are likely to be overshadowed by immunization policy failures in Republican-led states. In the current political climate, Democrats own the issue of eliminating nonmedical exemptions. In contrast, Republicans have emerged as champions of preserving and expanding them, or even of eliminating mandates altogether. Republicans will weaken existing mandates in the states that they control, and this will lead to lower immunization rates in those places, and perhaps beyond, as vaccination policy embeds more deeply in America’s culture wars.
The implications are significant. The near future likely portends escalating disputes about immunization policy, lower vaccination rates, and a resurgence of diseases once tamed by vaccines. Our response should be to adapt to widespread vaccine refusal rather than to nurture naïve hopes of overcoming it. If we can’t prevent outbreaks, we will need to learn to live with them.
Public health institutions have a crucial role in this shift towards adaptation. They must enhance their capacities, extending COVID-19 surveillance techniques like sewage sampling to encompass other diseases. This method helped New York State Department of Health detect polio virus in wastewater samples in 2022. There is also an urgent need to train medical professionals in diagnosing and treating vaccine-preventable diseases that were once thought to be controlled or eliminated. And governments should prepare to rapidly deploy mobile clinics and response teams to areas hit by outbreaks.
Community-level planning is essential for adapting to more frequent outbreaks in schools and other institutions. Strategies should include the ability to move between in-person and online schooling and the provision of daycare services for essential workers’ children, especially to safeguard the capacities of health care institutions.
Private institutions, from businesses to cultural organizations, must plan their own disease control measures. These may include private vaccine mandates, although state legislatures may outlaw such policies, as some did for COVID-19. However, businesses will be able to keep the assembly lines going and the service counters staffed only if they can reduce the impact of disease on their workforce.
Given the prospect of uneven state and institutional support for vaccination, individuals and families must also brace themselves for more frequent disease outbreaks. Some new parents already prevent unvaccinated relatives from visiting their babies. Families will need to consider extending these forms of private immunization governance when states can no longer protect them.
We are not talking about “giving up.” Governments should continue to promote vaccine acceptance and enforce vaccine mandates. The right kinds of outreach can sway some people who are on the fence about vaccinating. But these efforts alone are unlikely to be sufficient to prevent future outbreaks. Adapting to the times we live in is the only way forward.
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