Paper written for EDF5089: Black & Latino Education: History & Policy (Summer 2020) with Professor Robert A. Schwartz
By Martin Wood & Chelsea Shore
Introduction
In the United States, vaccinations and immunizations have been part of healthcare and increasing the life spans of populations for hundreds of years. Early methods of variolation and inoculation were crude, but reasonably effective at the time in reducing the number of deaths from diseases like smallpox. During a smallpox epidemic in 1738 in Charleston, South Carolina, four percent of the 441 people variolated died, while 18 percent of those naturally infected died (McCandless, 2011). As events and statistics like these grew with expanding populations, and as methods of inoculation improved, the United States and the world began to look to science for better methods of protection against disease.
In the 1800s, large epidemics of cholera killed thousands of people in Europe and America. In a particularly severe outbreak of cholera in London 1854, physician John Snow traced the infection to a sewage-contaminated water well. In London, during that time, water in the city was accessed by the population via hand-powered water pumps. By removing the pump handle of the contaminated well, and subsequently directing unsuspecting Londoners to use a different water source, John Snow disrupted the cholera outbreak and ushered in a new era of public health and epidemiology (Johnson, 2006).
Around this same time period, French biologist, microbiologist, and chemist Louis Pasteur was working to uncover the mechanisms behind alcohol fermentation. His research showed the growth of microorganisms that were responsible for spoiling beverages such as beer, wine, and milk, subsequently introducing the scientific world to the germ theory of disease (Newton, 2013). Approximately two decades later, around 1879, Pasteur had progressed his study of bacteria. Based on Edward Jenner’s foundational work on the protective effects of cowpox against smallpox, Pasteur devised a way to use bacteria to inoculate and create immunity from disease in chickens (Baxby, 1999; Pasteur, 1881; Worboys, 1991).
Snow’s study of transmission of disease and Pasteur’s work using bacteria to experiment with repeat infections combined to give us the foundational science for how vaccines and immunizations function in groups of living creatures. Today, vaccines and immunizations are commonplace in the global modern societies, thanks in large part to their scientific success in the 19th century.
In the United States, children are given vaccines in the first six months of their lives to protect them from hepatitis B, rotavirus, diphtheria, tetanus, pertussis, haemophilus influenza, pneumococcal conjugate, polio, and varicella, with some protocols calling for additional vaccinations and follow-up doses through adulthood to protect from measles, mumps, rubella, hepatitis A, and more (CDC, 2020a). These vaccinations are important for both personal and public health reasons, and provide the basis for “herd immunity”.
The basic tenets of “herd immunity” are simple: the greater the percentage of immune individuals in a community, the smaller the probability that non-immune individuals will come in contact with an infectious individual, helping to shield non-immune individuals from infection (Fine et al., 2011). Building and maintaining successful immunization of communities is vital to eradicating and guarding against infectious diseases, applies to communities of every size and station, and may be more or less effective depending on the viral severity of the infectious disease.
Few locations are more critical for vaccinations than public schools. Children learning together in classrooms, sharing meals in cafeterias, playing and socializing on playgrounds, sharing toys and school supplies, and being in close proximity to one another are standard fare in public education. Unfortunately, these public education staples are often accompanied by funding and space constraints which lead to overcrowded classrooms, smaller social spaces, and fewer educational and recreational commodities to provide to all students at one time (Convertino, 2017). Although overcrowding by itself does not cause infectious disease, it does give contagions a fertile environment for transmission, especially when respiratory droplets are inadvertently exchanged through such activities as talking, laughing, eating, coughing, sneezing, and sleeping close together (McNicholas et al., 2000).
This research project reviews existing literature, educational policies, governmental mandates, and professional positions to assess (1) how vaccines intersect with access to education, (2) what programs or services exist to aid in equitable access to immunizations, and (3) how the intersection of immunizations and public education influences educational policy. We conclude with a look toward the future and draw attention to considerations that can influence policies related to the implementation of a COVID-19 vaccine and its intersection with educational enrollment.
Immunizations and Access to Education
Public school systems are an important component of achieving and maintaining population immunity. Most states in America require immunizations for school enrollment, though the specifics of which immunizations are required varies by state (Hodge & Gostin, 2001). Diphtheria, tetanus, pertussis, haemophilus influenza, hepatitis B, measles, mumps, rubella, polio, and varicella are the most common vaccines in all 50 states in the United States (IAC, 2020).
Additional vaccines or immunization boosters are recommended in adulthood, especially pneumococcal, hepatitis, meningococcal, varicella, and human papillomavirus vaccines (CDC, 2020b). However, many adults fail to receive vaccines beyond childhood for a variety of reasons. In studies of the barriers to adult immunization, researchers cite concerns about side effects, lack of knowledge about illness prevention, a lack of ‘well-patient’ visits, few or no effective reminders of timing or need for the vaccine or booster, fear of needles, inadequate insurance coverage, and cost as reasons why adults miss vaccination opportunities (Johnson et al., 2008). Enrollment and attendance at a college or university effectively serves as a checkpoint and gateway for many young adults to receive vaccines or immunization boosters that they might otherwise miss.
Exemptions to vaccination requirements are allowed for health reasons, religious beliefs, and philosophical differences, depending on the state of residence. The National Conference of State Legislatures identifies 45 states and the District of Columbia that allow religious exemptions for “people who have religious objections to immunizations,” and fifteen states allow for philosophical exemptions based on moral, personal, or other belief-based objections (NCSL, 2020).
Educational Policy
Three significant cases are relevant to educational policies surrounding mandated vaccines. First, Wright v. DeWitt School District (1965) held that parents had no legal right to resist vaccination on religious grounds, specifically against smallpox, and such a requirement does not violate constitutional rights. The Supreme Court of Arkansas exercised police power of the state legislature for the benefit of society and further established the right to religious opinions cease when they transgress upon the rights of others. Second, Brown v. Stone (1979) additionally argued that religious exemption from mandatory immunization against dangerous diseases violated the First Amendment of the United States Constitution protecting the free exercise of religion. As with the Arkansas court in Wright v. DeWitt School District, the Mississippi Supreme Court held a religious exemption from immunization was unconstitutional as it violates the Fourteenth Amendment and exposes the greater community of school children to unsolicited risk.
Finally, Mason v. General Brown Central School District (1988) further defined “religious exemptions” where the United States Court of Appeals for the Second Circuit held “natural existence” and “fear of side effects” do not warrant exemption from immunizations required for educational enrollment. The court rejected the Plaintiff's membership in a church which “opposed immunization because it defiled the human body” (851 F.2d 47) as insufficient evidence to establish religious tenets inconsistent with immunization. Collectively, the position in all three cases argued that “religious exemptions[1]” from immunization were inferior to public health when mandated for access to educational institutions. The rulings also recognized that the most commonly approved reasons for requesting exemptions are medical necessity (see Salmon et al., 2005).
Depending on the educational institution and the state in which it is located, adults who were exempted from vaccination as a child may have the ability to apply the exemption to enrollment in higher education. All 50 states in the U.S. grant exemptions for students unable to be vaccinated for medical reasons (Urist, 2015). The process for seeking those exemptions and applying them to gain access to education often includes a form from a primary care physician confirming the individual has a medical condition affecting the immune system, with orders to postpone or skip the administration of certain vaccines (CDC, 2020c; Skinner, 2017).
Anti-Vaccination
Starting before the days of Louis Pasteur and the broad rollout of vaccines worldwide, there has been opposition to school vaccination laws, despite their success in protecting student populations and their families. Four national organizations opposing school vaccination requirements were active in the United States from 1879-1929, and their anti-science discourse is persistent to this day (Tolley, 2019). Over the past two decades, the anti-vaccination movement has gained popularity among a growing portion of the U.S. population, especially with celebrity champions and through the proliferation and dissemination of misleading information over social media (Hoffman, 2019). Choosing whether or not to vaccinate can be a difficult choice, and in some states, individual schools may refuse to accept students who have not been vaccinated in an attempt to reduce the risk of infectious disease among their student and teacher populations (Urist, 2015).
Regardless of why someone may voluntarily choose not to vaccinate themselves or their child, the tenets of herd immunity still apply in order to protect the community and population from infectious disease. When this herd immunity fails, we can expect to see outbreaks of infection, where those who are unable to participate in vaccinations lose the benefits of others protecting them and subsequently fall victim to the contagion.
Vaccine Access and Costs
The general consensus is that vaccines are an important component of public health, and do contribute to protections from infectious diseases afforded by herd immunity, especially in schools and educational communities. However, without a guide, knowing when vaccines should be administered and how to obtain them can be a challenge.
A physician in a clinic or other healthcare setting typically administers or oversees the administration of vaccines. Of all age groups, babies are most likely to be hospitalized and die more often from diseases that can be prevented with vaccines (APA, 2018). As their immune systems develop, vaccines help children’s immune systems learn and adapt to fight off the more deadly contagions among the various germs and viruses that children are going to inevitably come in contact with through normal breathing, eating, playing, and socializing (APA, 2018). The first months and years of life are an important period when the growth and development of the child should be carefully monitored with routine visits to a healthcare professional qualified to assess their well-being, such as a pediatrician, family medicine practitioner, or other primary care provider.
Due to their importance in public health and protecting communities and populations, vaccines are increasingly being offered beyond private practice, including pharmacies, workplaces, community health clinics, travel clinics, health departments, community events, schools, and religious centers (CDC, 2017b; U.S. Dept. of HHS, 2020a). Through this ongoing surveillance, coupled with a regimented schedule of vaccines, children are able to withstand a growing list of infectious diseases that would otherwise have much greater potential to jeopardize their livelihood without immunization.
Under the Affordable Care Act, the cost to consumers for vaccinations recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) are typically covered by health insurance, including private health insurance, military insurance (TRICARE), Medicare, and Medicaid (CDC, 2016; CDC, 2017a). There are also free and low-cost options for those individuals who do not have health insurance or whose health insurance plan’s out-of-pocket costs are not affordable. The Vaccines for Children Program (VCP), with approved funding by the federal Office of Management and Budget (OMB), provides all recommended vaccinations at no cost to children under age 19 who qualify for Medicaid, do not have health insurance or cannot afford out-of-pocket insurance costs for vaccines, or are Native American or Alaskan Native (U.S. Dept. of HHS, 2018).
Multiple studies have been conducted since the early 1970s on the cost-benefit and cost-effectiveness of vaccinations. Overall, maintaining high levels of immunization against infectious diseases has been confirmed and is strongly advised in all communities and populations (Willems & Sanders, 1981). Cost-benefit and cost-effectiveness data models show that vaccines have a net positive value, especially when the cost of the vaccine is compared to the cost of healthcare to treat individuals who contact a preventable infectious disease (Perez-Tirse & Gross, 1992). Not only is there a cost and health-benefit to higher risk populations, such as children, the elderly, and those with compromised immune systems, but vaccinations may also help to minimize health risks and socioeconomic adversity in healthy working adult populations (Bridges et al., 2000).
Race and SES at the Intersection of Immunizations and Education
We have established the importance of vaccines, and we have stitched pieces of the immunization policy puzzle together to explain where individuals and families can gain access to vaccines in both childhood and adulthood. We have also addressed the cost of vaccines, again gathering knowledge from a variety of sources to provide a cohesive summary of the costs to individuals and the benefits to society of immunizations. While it is important to present knowledge that moves individuals, communities, and populations toward the prevention of infectious diseases for the good of public health, we would be omitting two major obstacles if we did not mention socioeconomic status (SES) and race as components of infectious disease prevention.
There is no shortage of research on the effects of SES on life course outcomes. SES is consistently associated with both health and education outcomes, usually as a control to compare sample populations in analyses (Adler et al., 1994). There is strong evidence to suggest that SES impacts physical, mental, and cognitive well-being later in life. Ye Luo and Linda Waite, in their seminal work on SES, found that lower childhood SES was associated with worse health outcomes later in life (Luo & Waite 2005). When looking at education and income, the impact of childhood SES explained an even larger share of this effect.
If we accept that people of lower SES have worse outcomes over the long-term for health, education, and income, then we also have to accept that there may be pathways to overcoming low SES during childhood. Achieving higher education, for example, may yield a higher income, and can help to advance a person to a higher socioeconomic status in adulthood. (Luo & Waite, 2005)
However, this assumption fails to factor in the impact of race in SES. Critical Race Theory suggests that there are social constructs in place that attempt to devalue, misinterpret, and omit the histories, experiences, cultures, languages, and values of people of color in favor of White supremacy and racial superiority (Bernal, 2002; Crenshaw et al., 1995). In the social sciences, we acknowledge that race is a “societally constructed taxonomy that is based on an ideology that views some human population groups as inherently superior to others on the basis of external physical characteristics or geographic origin” (Williams, Lavizzo-Mourey, & Warren, 1994).
In research findings that lower SES is a predictor of poorer outcomes, it may also be important to consider if being non-White and having fewer societal privileges is an obstacle to achieving a higher socioeconomic status and better predictive outcomes. For example, a 2000 study on race, SES, and mortality found that life expectancy for Black Americans is five to eight years less than for White Americans, and SES played a large role in the various causes of mortality, including accidents, heart disease, diabetes, lung cancer, stomach cancer, stroke, and homicide (Howard et al., 2000). Given the consideration of race and privilege, it is theoretically possible that some of the causes of death found in the study could have been preventable had the Black respondents had the same privileges as White respondents.
These considerations of race and SES are important to the conversation about vaccines and education. Low health literacy is associated with poorer health outcomes and poorer use of healthcare services, according to a systematic review of health literature published in the Annals of Internal Medicine (Berkman et al, 2011). People with poor educational outcomes may not possess the health literacy to understand the importance of immunizations on personal and public health outcomes. They also may not be able to navigate the incredibly complex healthcare system in the United States to find a pediatrician or primary care physician that their health insurance will cover.
Low SES, often synonymous with poverty, may result in individuals or families not having access to transportation to get to a health department, even if the vaccinations are offered at no cost. They may work multiple jobs in order to pay rent and provide food for their children, and not have the capital of time to trade for the necessary health interventions required for them or their children to enroll in school. In these instances, parents and children may have to wait for the systematic checkpoints to catch up with them, such as enrollment of their children in public elementary schools, in order to participate in vaccination programs. At that point, children may have already contracted an infection, potentially altering their life course, and their suffering could have been ameliorated had an immunization intervention taken place earlier.
These cumulative disadvantages, explained by cumulative inequality theory, stack up and accumulate as successive losses for those who are disadvantaged early in the life course (Ferraro, Shippee, & Schafer, 2009). Research has shown that ensuring equal and timely access to vaccines, including poor or disadvantaged communities, has a greater positive effect on overall population health outcomes than if vaccines are provided inequitably (Lee et al., 2011). Because poorer populations tend to live in higher density dwellings and communities, and more of the population is considered high-risk, the odds of contagion spreading unchecked throughout the community is much higher than it is for wealthier populations with greater resources and less compacted living spaces. Recalling the concept of herd immunity, the greater the percentage of immune individuals in the community, the smaller the probability of an outbreak.
COVID-19 Vaccine and Access to Education
The New Global Pandemic
The arrival of a new infectious disease in late 2019 brought worldwide attention to the consequences of a contagion from which we had little to no public health protections. Most popularly known as COVID-19 in America, but also referred to as the 2019 novel coronavirus, 2019-nCoV, and SARS-CoV-2, the infection quickly grew to a pandemic, affecting countries all over the world (HHS, 2020b). As the outbreak of COVID-19 swept across the globe, its effects spiked interest in epidemiology, herd immunity, public health prevention techniques, and the science behind the development, testing, and dissemination of vaccines, while infecting millions of people worldwide and killing hundreds of thousands (Dong, Du, & Gardner, 2020). While the United States is less than six months into the COVID-19 pandemic at the time of this writing, and the numbers of cases and deaths continue to rise nationwide and globally, there are some things we can glean from our study of immunizations and education that may help us prepare for a much hoped for COVID-19 vaccine.
Vaccine Development and Implementation
First, we can expect that it will take researchers some time to deliver a vaccine. No one involved in the research and development process expects a COVID-19 vaccine to take the nearly 80 years that it took Edward Jenner’s work to influence Louis Pasteur’s discoveries. Scientists do estimate that a working vaccine could be available within 12-18 months (Dresden, 2020). Because COVID-19 has had a global reach, scientists in every country are working to develop a solution to the contagion. This effort also translates to more financial resources from both public and private sectors of the global economy that will fuel the research and development process to create a viable vaccine. These financial investments will fund recruitment and training of researchers, lab tests and equipment, clinical trials, validation of successes to ensure that the vaccine has minimal adverse side effects, efforts to scale a vaccine to production, and then dissemination to populations of need. According to the National Institute of Health (NIH), mass clinical trials for a COVID-19 vaccine are already underway (see ClinicalTrials.gov Identifier: NCT04283461) which makes educational policy surrounding mandatory immunization of imperative importance (NIH, U.S. National Library of Medicine, 2020).
Educating the public about the vaccine will be a second, time-consuming step toward long-term herd immunity. With the global rush to produce a vaccine, consumers are understandably skeptical of the safety of a solution to COVID-19 that may seem to be too quickly produced and too minimally tested (Hormazabal & Broom, 2020). Scientists, physicians, public health and epidemiology experts, political leaders, and governments at large will need to work in unison to allay fears of a COVID-19 vaccine doing harm. Experts and leaders will also have to explain why the vaccine is important, and have a clear plan for how it will be administered to a global population.
Organizations of all sizes will need to plan for an extended period of time, likely measured in years as opposed to months, for how they will provide safe work environments and how they will accommodate those who are exposed to COVID-19 and continue to require quarantine and physical distancing. This will hold true even with a vaccine, as vaccine deployment will likely be sporadic early on as manufacturing and supply slowly meets population demand. The global situation related to COVID-19 is dynamic, and supply chains in nearly all industries have been and will continue to be disrupted to some degree (Varney & Knibloe, 2020). The same disruptions to the supply chain for commodities seen during early waves of COVID-19 will also impact the supply chain and distribution network for the vaccine itself as it is distributed worldwide.
Cost, Access and Accessibility
It is broadly expected that a COVID-19 vaccine will be cost-minimal or cost-neutral to the consumer. For a global pandemic, there will be much political and social pressure to make the vaccine available to everyone, regardless of their station in life. Funding for development of the vaccine is primarily being provided by private pharmaceutical companies and governments, so many of the capitalistic mechanisms will be negotiated through state sanctions and government contracts. In the United States, it should be expected that a COVID-19 vaccine will also be included in either those immunizations that are recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), or as a component of an annual influenza vaccination comparable to the seasonal flu shot (Nisen, 2020).
There has been much discussion and legal maneuvering toward returning our national and global economies to a pre-COVID-19 normal. Educational institutions are a large part of that sense of normality. We should expect similar safety precautions as other organizations in prevention and response to exposure of COVID-19 in education. It is unclear whether a COVID-19 vaccine will become mandatory for access to education, and those decisions will likely be determined at the state level in the United States.
Any legislation regarding COVID-19 should be based on legal precedent regarding vaccines, based on peer-reviewed and validated science, and not pose an unreasonable threat to any community or population that would benefit from immunity. It will be important for constituents to work with their representative lawmakers to make sure their concerns about COVID-19 and its preventative measures are heard. Finally, it is critical that the needs and safety of all communities and populations are met independent of any economic or political gains.
Conclusion and a Path for Future Research
In the United States and around the world, we have seen great success in the utilization of vaccines to promote public health and protect at risk populations. Solutions that minimize costs to consumers and provide equitable availability of vaccines have the greatest effect in warding off debilitation and death from the most common infectious diseases. With the introduction of COVID-19 to our way of life, we must take a close look at the mechanisms of vaccine development and deployment. We may need to also alter the social constructs of our civilization to provide the greatest protection and opportunities to our populations. It may be up to individual educational institutions to include the vaccine in student health care plans and make the vaccine easily accessible on campus for students, not to mention faculty and staff as well.
Future research needs to consider the longitudinal policy and societal responses to COVID-19 vaccine development, its impact on access to education, its cost to consumers and benefits to society, the equitable distribution of the vaccine to populations regardless of their socioeconomic status, and lessons learned that can be applied to future outbreaks of infectious disease.
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[1] The courts have strictly defined what constitutes “religious exemptions” in Wisconsin v. Yoder, 406 U.S. 205, 215-16, 92 S.Ct. 1526, 1533, 32 L.Ed.2d 15 (1972) and Maier v. Besser, 73 Misc.2d at 242-43, 341 N.Y.S.2d at 412-13 (i.e. of active and practicing Amish faith).
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