The Minnesota Legislature last week heard poignant testimony from parents who believe their children died of adverse reactions to common and quasi-mandatory vaccinations.
Their accounts illustrate one of the harsh ironies of modern medicine. Vaccines that save the lives of hundreds of thousands of children annually also cause the immediate deaths of a few. In such a situation, the economic evaluation of whether vaccination should be mandatory is difficult.
I am only in my 50s, but when I was young most children got measles, mumps and chickenpox. Many got diphtheria and whooping cough. Many children in the community, including a classmate and a cousin, suffered the after-effects of polio. While the United States enjoyed some of the best medical care in the world, childhood deaths because of infectious disease were significantly more common than they are today.
A decade ago, in the book “Patenting the Sun: Polio and the Salk Vaccine,” Jane S. Smith movingly described the fear that parents felt about polio in the 1940 and early 1950s. Polio could strike a community without warning and kill or cripple dozens of children in a matter of days. For that generation, any vaccine that offered protection to their kids was a godsend. It did not have to be 100 percent effective or completely free of side effects, even fatal ones, to be viewed as wonderful. Families who lost children to diphtheria, scarlet fever and measles felt the same way about vaccines.
Now, not only are deaths to such once-common communicable diseases virtually unknown, but the diseases themselves are. Serious childhood illnesses are much less common and society naturally focuses its attention on the other side of the equation, the illnesses and deaths that are caused by vaccination, rather than those prevented.
Looking at society as a whole, the benefits of widespread childhood vaccination overwhelmingly outweigh the costs. We have better, less painful lives because of the development of vaccines in the last five decades. But many vaccines do involve small, measurable risks.
The public policy questions then are whether vaccination should be mandatory and what should be done to compensate those who suffer serious, even fatal, effects. The economics are complicated because vaccinations against communicable diseases involve large “positive externalities.” That is how economists describe situations where all of the benefits of some action are not limited to the person taking the action.
In the case of many vaccines, once a significant proportion of a population is vaccinated, even people who aren’t will benefit from a reduced probability of getting the disease.
This is true for vaccinations for noncommunicable diseases. Tetanus is a horrible disease. When I was just out of high school, a farmer in my community died horribly from tetanus after stepping on a rusty nail in a former horse barn. But while the tetanus organism can lie dormant and lethal for years, it is not spread by unwashed hands on doorknobs, sneezing or the proverbial public toilet seat. If none of my neighbors get their tetanus shots, it does not increase my risk.
This isn’t true for easily communicable diseases such as smallpox, polio, diphtheria, measles, chickenpox, mumps and rubella. For these, any individual’s risk falls as the proportion of the total population who are vaccinated rises.
This leads to a phenomenon known as “free riding.” If I know that so long as most people get vaccinations, the probability of my family’s getting sick is extremely low because there are few individuals to transmit the diseases in question. If there is some chance of being harmed by the vaccination itself, I may well make a rational calculation for us not to get vaccinated.
The paradox is that the greater the number of people who make such a decision, the lower the general population immunity and the greater the risk that unvaccinated people will, indeed, get a disease.
Being poked with a needle or swallowing a drug is a personal thing. A legal requirement to be vaccinated is more intrusive than a legal requirement to scoop snow off your sidewalk.
State or national governments that mandate vaccination typically have allowed for this by allowing exemptions to those with religious objections. And typically, the mandates are not vigorously enforced. The proportion of U.S. children who, for one reason or another, do not get the full complement of vaccinations is higher than that of nearly all other industrialized countries. Whether this is a monument to tolerance or inefficiency is not clear.
Those who have lost family members to vaccination side effects are correct in pointing out the need for research and development into safer vaccines. But these needs will have to be balanced with the competing needs for research into reducing illness and premature death from other causes. Producing absolutely safe vaccines should not trump all other medical research needs.
Some suggest that there should be a more formal system of compensation to those inadvertently harmed by vaccinations. If vaccine manufacturers end up paying multi-million dollar liability settlements, they may have an incentive to produce a safer vaccine but may also decide to generally avoid vaccines as a product line.
If manufacturers pay large settlements but stay in the business, consumers or government will end up paying higher prices for vaccines. A system of public compensation to side-effect victims, modeled on workman’s compensation, might reduce the cost to society as a whole.
© 2003 Edward Lotterman
Chanarambie Consulting, Inc.