Individual autonomy vs. collective protection: non-vaccination of children among higher income/educational level segments as a challenge to public health

Jorge Alberto Bernstein Iriart

Although vaccination is globally recognized by health authorities and the medical community as an important preventive intervention with an impact on morbimortality of immunopreventable diseases (such as the eradication of smallpox and the significant reduction in the number of cases of poliomyelitis in the world), the dissemination of hesitation and resistance to vaccines among individuals with high income and educational levels has become a relevant public health issue in many countries 11. Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. Attitudes to vaccination: a critical review. Soc Sci Med 2014; 112:1-11.), (22. Berezin M, Eads A. Risk is for the rich? Childhood vaccination resistance and a culture of health. Soc Sci Med 2016; 165:233-45..

In Brazil, the National Immunization Program (PNI, in Portuguese), created in the 1970s, reached high levels of vaccine coverage, leading to the elimination of poliomyelitis in the country in 1989, and to the control of several diseases, such as measles, neonatal tetanus, diphtheria, accidental tetanus and pertussis 33. Barata RB, Pereira SM. Desigualdades sociais e cobertura vacinal na cidade de Salvador, Bahia. Rev Bras Epidemiol 2013; 16:266-77.. Recent studies of vaccination coverage for children, however, have also pointed to a reduction in the vaccination rates among higher socio-economic strata 44. Barata RB, Ribeiro MC, Moraes JC, Flannery B; Vaccine Coverage Survey 2007 Group. Socioeconomic inequalities and vaccination coverage: results of an immunisation coverage survey in 27 Brazilian capitals, 2007-2008. J Epidemiol Community Health 2012; 66:934-41..

In this context, we have witnessed the re-emergence of diseases that had been controlled, as with the measles outbreaks which hit California, U.S.A., in 2014 11. Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. Attitudes to vaccination: a critical review. Soc Sci Med 2014; 112:1-11. and which have intensified in Brazil since 2011 55. Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por canais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315.. Researchers, especially in the Social Sciences, have sought to understand the causes of non-vaccination, based on the assumption that they are intimately connected to cultural context, different perceptions of risk and their relationship with social inequality and solidarity. The decision whether or not to vaccinate one's children exposes the tension between the individual and the collective. Due to the biological effect of herd immunity, which reduces the incidence and the transmission rate of diseases within a population, vaccination also protects those who are not vaccinated. In current times, characterized by growing individualism, demand for autonomy, freedom of choice and risk aversion, health is regarded as a matter of individual responsibility. The media, especially the Internet, has increasingly become a source of information for individuals' decision-making regarding their health. On the other hand, researchers in Europe point to a mistrust of doctors, governmental sources and the pharmaceutical industry as reasons for the hesitation regarding vaccination 11. Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. Attitudes to vaccination: a critical review. Soc Sci Med 2014; 112:1-11..

The erosion of public trust in the institutions involved with vaccination does not spare science, due to the concern over the possible interference or manipulation by commercial interests, which compromises the possibility of drafting solid public policies based on debates with the population 66. Camargo Jr. K, Grant R. Public health, science, and policy debate: being right is not enough. Am J Public Health 2015; 105:232-5..

Facing these questions, different cultures' understanding of risk perceptions and parents' motivations in vaccinating or not vaccinating their children are crucial in facing the prevention challenge that public health now faces.

In this edition, the article by Barbieri et al. 55. Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por canais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315. addresses the theme of non-vaccination of children, seeking to understand how fathers and mothers who belong to middle class segments in São Paulo, perceive vaccination norms in the country, based on their experiences of vaccinating, selecting or not vaccinating their children. The authors pay special attention to the symbolic dimension, the senses and meanings surrounding vaccination norms in Brazil, and how they gain meaning in practices and motivate certain patterns of orientations to action. The data were produced in a qualitative study, through in-depth interviews with couples with high income and educational levels who live in São Paulo city and who had at least one child up to five years of age. The authors used the Anthropology of Laws and Morals as the theoretical framework for the study. Results show, in a comparative perspective, the different conceptions regarding norms among parents who vaccinate, select or do not vaccinate their children. For the first group, vaccination is part of an already-introjected and unquestioned "culture of vaccination" that takes on moral outlines and relegates the perception of following the law to the sidelines. For parents who select vaccines, this practice is perceived as a deviation from the law which also has a moral connotation. It is not, however, perceived as a possible violation of the law, but as a behavioral variation within the cultural norm of vaccination. Among parents who do not vaccinate, the perception of illegitimacy surrounding the recommended vaccination calendar and vaccines is noteworthy. The prerogative of parental autonomy and individual freedom in raising their children appears as a moral value that overrides the norms, despite the fear of legal sanctions.

In their discussion on the conflict between individual freedom and the public health perspective, the authors are, however, careful to seek a balance between the two, with flexibilization for cases in which non-vaccination does not present relevant risks to public health.

This is a complex issue that poses to the global public health the challenge of understanding contexts and factors which contribute to hesitation, non-vaccination and even delegitimization of institutions and vaccines, while, at the same time, thinking of new ways of communicating and debating with the population so as to formulate and strengthen solid public policies.

  • 1
    Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. Attitudes to vaccination: a critical review. Soc Sci Med 2014; 112:1-11.
  • 2
    Berezin M, Eads A. Risk is for the rich? Childhood vaccination resistance and a culture of health. Soc Sci Med 2016; 165:233-45.
  • 3
    Barata RB, Pereira SM. Desigualdades sociais e cobertura vacinal na cidade de Salvador, Bahia. Rev Bras Epidemiol 2013; 16:266-77.
  • 4
    Barata RB, Ribeiro MC, Moraes JC, Flannery B; Vaccine Coverage Survey 2007 Group. Socioeconomic inequalities and vaccination coverage: results of an immunisation coverage survey in 27 Brazilian capitals, 2007-2008. J Epidemiol Community Health 2012; 66:934-41.
  • 5
    Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por canais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315.
  • 6
    Camargo Jr. K, Grant R. Public health, science, and policy debate: being right is not enough. Am J Public Health 2015; 105:232-5.

Publication Dates

  • Publication in this collection
    2017
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