Public Health and American Exceptionalism: Part I – Vaccine Mandates

The hullabaloo over COVID-19 vaccine recommendations in the U.S. raises some interesting questions about other areas where public health elites have been outraged about shifts towards policies that many of us in Europe would take for granted. Two of these seem worth further commentary: childhood vaccine mandates and raw milk, which will be discussed in the next post.

All 50 U.S. states currently have some sort of vaccine mandate for children attending public schools. Generally, this mandate has a number of faith-based or medical exemptions and may or may not apply to children attending other kinds of school. Florida has recently announced an intention to drop the mandate and to rely on parental choice. If we consider the 30 countries of the European Union and the European Economic Area, 17 had no mandates in 2024 and 13 had some kind of mandate. Here in the U.K., smallpox vaccination was mandated from 1853 but the compulsion was so unpopular that it was effectively ended by legislation permitting opt-outs in 1898 and 1907, although it remained on the books until repealed by the statutes establishing the National Health Service in 1947. No childhood vaccine has been mandated since then. The U.K. health department makes recommendations, on the basis of expert advice, which are then implemented through the health services of the various nations.

One way of looking at the contrast is in terms of a very different relationship between states and families. The U.K. has been much less ready to consider children as parental property. English law has acknowledged the state’s role in superintending parental behavior towards children since at least the 16th century and institutions have been created to give effect to it. Throughout the 20th century, public health services became increasing proactive in establishing models for the surveillance of all families with young children, both supporting maternal health and child development, and scanning for signs of abuse or neglect.

These interventions frequently shock U.S. immigrants. I recall being telephoned by a U.S. academic who had taken up a position in the U.K., bringing small children with her. She had persistently refused access to a visiting nurse (health visitor) and been warned that this might lead to her being reviewed as a potential child abuser. My Ph.D. and early career research were in this area and one of her colleagues suggested she should call me. I listened to her outrage but struggled to persuade her that this was just the way things were done in the U.K. I believe she eventually returned to the U.S. rather than adapt to the expectations of a different society. Within the context of a close engagement with parents, U.K. community child health services have achieved high rates of take-up for child vaccines without compulsion.

The U.S. followed a similar policy direction in the 1920s under the Sheppard-Towner Act, which provided federal support for state maternal and child health programs, including visiting nurses. However, this legislation lapsed in 1929 in the face of opposition from the American Medical Association, which thought it was encouraging socialist medicine, and conservative women’s organizations arguing for family privacy. School entry became the first point at which the state could attempt to intervene, as children entered the public sphere. Mandates were a quick fix, especially with liberal conscientious objection provisions. I happened to experience this when enrolling three children in Illinois schools for a term. Despite bringing documentation of their U.K. vaccination history, they were all required to have U.S. shots before they could attend school. No exceptions and whoever would think another country’s vaccines were as good as American ones…?

Reviewing European experience, it seems that mandates probably make only a small difference to well-functioning public health systems for children – and may not be worth the opposition they provoke. If a public health system does not have high levels of community engagement, mandates may have some value. Where mandates are employed, however, conflict is likely, unless the opt-outs are so generous that they undermine the whole point of the compulsion.

It is, of course, an empirical question whether Florida will be able to achieve by voluntary means what others have achieved through coercion but it is not necessarily one of principle. In practice, though, it is questionable whether Florida will make the necessary investments in public health systems for children or that Florida parents would tolerate the degree of intervention accepted in the U.K. and elsewhere in Europe. This might, however, be a more productive discussion than simple howls of outrage about one state adopting an approach to childhood vaccination that would not be considered exceptional elsewhere. Mandates may be the right policy in the U.S. context of small government and family privacy but let no-one pretend that respectable alternatives do not exist.