Donald Trump’s wrecking-ball style of politics has been causing chaos in healthcare, just as in other areas of domestic and foreign policy.
In his second term, Trump has appointed several anti-vaxx officials such as Health Secretary Robert F Kennedy Jr, drawing howls of outrage from doctors who say he is endangering child health.
But while some of RFK’s positions on vaccines are indeed calamitous, like backing untrue claims that they cause autism, the administration does appear to have one controversial policy right. That is overturning vaccine mandates, the US laws that say children must have a range of vaccines in order to attend school.
The growing debate about this move, which looks set to be the next battleground in the vaccine wars, also has implications for health policies in the UK, so it is not one we can afford to ignore.
US public schools – or state schools, as we would call them – have long required children to have all the recommended jabs to attend, unless they are exempt for medical or religious reasons.
In the UK and most of Western Europe, by contrast, vaccine mandates are less common, although they have come in recently in countries such as France and Italy.
Most UK vaccine experts frown on mandates. There is not only the argument that they breach people’s medical autonomy, but also that they could be counterproductive – generally people dislike being forced to do things, even things they would otherwise have done happily.
Under Trump’s administration some Republican states, such as Idaho and Florida, are already phasing out vaccine mandates. Louisiana and Texas may be next, according to the healthcare industry news site Advisory Board, which warned the move could “lead to the resurgence of several infectious diseases”.
But while support for vaccine mandates is the orthodoxy among US doctors, it is not, in fact, clear that mandates are necessary or even effective for achieving high vaccine coverage. There has never been and will never be a randomised trial – the gold standard of medical evidence – comparing immunisation rates in two similar regions, one with mandates and one without.
But there are some good reasons to think mandates are unhelpful in raising vaccine coverage. Despite their long US history – having got Supreme Court approval in 1909 – the country has not generally had higher uptake of childhood vaccines than in Europe.
The UK is “living proof of the fact that you can have a very good and effective vaccine programme without requiring people to do it,” says Professor Adam Finn, a paediatric vaccine expert at the University of Bristol.
What the US does have is a strong anti-vaccine movement. “The anti-vaxx movement has always been much more vocal and active in the United States. It is driven, in my opinion, by the fact that people are obliged to do it,” says Finn, who advises the UK government’s Joint Committee on Vaccination and Immunisation.
While it was a British doctor, Andrew Wakefield, who in 1998 started the false theory that the measles, mumps and rubella (MMR) vaccine causes autism, there was already a strong US anti-vaxx movement claiming autism was caused by any childhood jabs containing an ingredient called thiomersal. Wakefield was struck off the UK medical register in 2010, but he found a welcoming home in America on the alternative medicine conference circuit.
Further insights stem from what happened when countries outside of the US brought in various forms of Covid vaccine mandates during the pandemic for adults. In the UK, for instance, Covid jabs became compulsory for medical and care home staff. For a while, we needed Covid vaccine “passports” for places like sports grounds and theatres.
It may not be coincidence that these mandates – unprecedented in UK public health history – were accompanied by rising opposition to the Covid jab. There were rallies, scaremongering posters and protests outside schools, and wild internet rumours that they contained microchips. Some doctors suspect that backlash to the Covid jab has spread like a contagion to the standard childhood vaccines, such as those for MMR and meningitis, an idea called “hesitancy spillover”. It’s hard to prove but we do know that UK rates of MMR uptake are lower than ever, with 84.5 per cent of children having had both doses.
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This declining vaccine coverage is already leading to disease outbreaks which have led to measles deaths and complications. Combating vaccine hesitancy should certainly be a public health priority – but it will require targeted campaigns and community outreach from trusted health professionals rather than blunt tools such as mandates.
The US is also experiencing measles outbreaks – schools affected are responding by further clamping down on mandates, requiring all children with vaccine exemptions to stay off school for three weeks.
Trump’s regime has got some things badly wrong on vaccines, including a recent plan to replace combined jabs like MMR with individual shots.
But when the forthcoming US battles over mandates spill over into British media, it’s worth remembering that on this point, the Trump position – of leaving decisions to parents – wouldn’t be considered at all controversial by doctors in the UK and most of Europe.
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