Riverbend City: Public Health Advocacy

Introduction

In Riverbend City, an estimated 2 to 2.5 percent of children are not vaccinated. This percentage has grown significantly over the past decade. Unfortunately, there have been three reported cases of measles at Lindner Hills High School, and one boy was hospitalized. In response, the mayor of Riverbend City is considering legislation that would make it mandatory for public school children to be immunized.

As a public health professional, you may be asked to be an advocate for public health issues. This can be a challenge, especially when effective approaches conflict to some degree with existing healthcare policy. As you interact with this scenario, consider strategies that a public health professional might use to advocate for this issue. Consider whether you would advocate for or against mandatory immunizations—and how and why you would go about doing this.

Washington Allston Elementary School | Nurse’s Office

Kaitlyn Kelly is a fourth grade student at Washington Allston Elementary School. She arrives at the office of the school nurse, Mary Jackson, with a fever and a headache.

Kaitlyn tells Nurse Jackson how she’s feeling.

KAITLYN:
I have a really bad headache. It started hurting in gym class and then it got worse.
MARY:
Oh, you poor thing. Your forehead feels very hot. I’ll take your temperature. Kaitlyn, do you know if you had a flu shot this year?
KAITLYN:
My mom doesn’t like us to get shots.
MARY:
Oh. Does anything else hurt?
KAITLYN:
My stomach feels weird.
MARY:
Do you feel like you have to throw up?
KAITLYN:
No, not that kind of weird. It feels kind of itchy weird.
MARY:
Can I take a look?
KAITLYN:
Okay. MARY:
It looks like you’re getting a rash. Honey, have you ever had chicken pox?
KAITLYN:
What’s that?
MARY:
It’s a sickness where you get a bad rash. Most kids don’t get it anymore because there’s a vaccine. I’ll take a look at your record and see if you’ve had the chicken pox vaccine.
KAITLYN:
Does vaccine mean… is that when the doctor gives you shots?
MARY:
It is.
KAITLYN:
I don’t get shots. My mom doesn’t like them.

Washington Allston Elementary School | Nurse’s Office

Erica Kelly, Kaitlyn’s mother, arrives to pick up her sick child.

ERICA:
Hi, sweetheart! Oh, you poor thing… how are you feeling?
KAITLYN:
Really bad, Mom. My head hurts a lot.
MARY
Mrs. Kelly, I took Kaitlyn’s temperature. She has a fever of 103.
ERICA:
Oh, you poor kid! Let’s get you home.
MARY:
Can I show you something? Kaitlyn has a rash on her stomach.
KAITLYN:
It’s itchy and it feels really weird.
ERICA:
Yuck. Do you think it might be chicken pox?
MARY:
Well, that’s possible. Kaitlyn was saying… well, we don’t see a lot of chicken pox anymore because most children get the vaccine.
ERICA:
My husband and I choose not to vaccinate our children.
MARY:
They’re not vaccinated at all?
ERICA:
No, they’re not.
MARY:
Well.. are you aware that there have been three cases of the measles recently at Lindner Hills High School?
ERICA:
I know that. But you don’t think Kaitlyn has measles, do you?
MARY:
If she hasn’t been vaccinated, that’s certainly possible.

Washington Allston Elementary School | Nurse’s Office

Nurse Jackson asks Erica why her children aren’t vaccinated.

MARY:
Mrs. Kelly, may I ask why you haven’t vaccinated your children?
ERICA:
Well, I always assumed that I would. Big Pharmaceutal tries to make it seem like we don’t have a choice. I mean, I understand that you’re a nurse and you probably won’t agree with me. But when I was pregnant with Kaitlyn, I decided to find out for myself whether vaccinations were really necessary. I found out a lot of disturbing things.
MARY:
What did you find out?
ERICA:
I know they say they’ve disproven the theory that vacinnations are linked to autism… but you never know with the medical industrial complex. Their sole mission is to make money, not to protect our children.
MARY:
So you think there’s a link between autism and vaccines?
ERICA:
I don’t know about that. But the chemicals they use in vaccines are definitely dangerous. They’ve finally removed thimerosal. But there are still trace amounts of aluminum. The government seems to think the aluminum content is within an acceptable level, but I don’t buy that. I buy natural foods and stay away from any chemical additives, so I’m not about to give my children medications that are even more dangerous than food preservatives.
MARY:
Well.. you do understand that there’s a risk involved when you don’t vaccinate your children?
ERICA (getting annoyed):
Of course I understand. But that risk doesn’t outweigh the risk that comes from the vaccinations. I know that’s not a popular befief in the age of Big Pharma, but I stand by that decision. This school district does not require vaccinations for parents who are morally opposed, and I’m morally opposed.
KAITLYN:
Mommy, can we please go home now? I feel really sick.

Washington Allston Elementary School | Principal’s Office

A week has passed. It turns out that Kaitlyn Kelly had chicken pox, not measles—but another case of measles was recently discovered at a nearby middle school. Nathan Williams, a concerned father, comes to discuss this situation with Nurse Mary Jackson and the school principal.

Nathan Williams shares his concerns with Prinicpal Linda Paulus and Nurse Mary Jackson.

LINDA:
Mr. Williams, I understand you wanted to discuss some health concerns about your son?
NATHAN:
Yes. My son Trey is five years old. He’s supposed to start kindergartern in the fall. But we have some concerns because Trey has leukemia.
MARY:
Oh dear. I’m so sorry to hear that.
LINDA:
So am I. How is he doing?
NATHAN:
Very well, thank you. He’s responded well to the treatment and his prognosis is excellent. Childhood leukemia is very treatable these days.
MARY:
I know. But I’m so sorry he has to go through treatment. How much longer will that be going on?
NATHAN:
We’re scheduled for treatments until February. Hopefully that’s all he needs.
LINDA:
Are you concerned that Trey won’t be healthy enough for school?
NATHAN:
No no, our doctors say he should be fine with school. He’s definitely ready academically. But what we’re worried about is the measles cases in Riverbend City. I know there were four cases at other schools recently, and I heard a rumor that there was a case here too?
LINDA:
There was a suspected case of measles. But it turned out to be chicken pox.
NATHAN:
But if a child had chicken pox, that means she probably wans’t immunized, correct? So my son could contract measles or chicken pox from that child.
LINDA:
I’m afraid we can’t discuss the specifics of that case. Is your child immunized?
NATHAN (a little annoyed):
No, he can’t be.
MARY:
Linda, most children with cancer can’t be immunized. Chemotherapy suppresses their immune system, so it’s not safe. Especially for a child with leukemia who has a low white blood cell count.
NATHAN:
Exactly. We won’t be able to give Trey vaccinations for at least six months after his treatment ends. So if we send Trey to school and there’s a child around with the measles, he could catch it. And that’s really dangerous for a child with leukemia.

Washington Allston Elementary School | Principal’s Office

The nurse and the principal discuss the immunization situation.

MARY:
Mr. Williams, I completely understand your concerns. Especially with the recent incidents of measles in our school district.
NATHAN:
I don’t understand. I thought we got rid of measles. Why are kids getting it again?
MARY:
Well, there’s an increase in parents who are opting out of immunizations.
NATHAN:
Opting out? You mean they choose to not vaccinate their kids?
MARY:
That’s right.
NATHAN:
Are you kidding? Why would anyone do that?
LINDA:
There are a lot of reasons. In some cases, there are religious objections.
NATHAN:
Religious objections?
LINDA:
Yes, although that’s actually uncommon. Most parents opt out for philosophical reasons.
NATHAN:
Are you kidding? Like what?
MARY:
People have different concerns. A few years back, there was a false rumor linking vaccines to autism. That’s been widely disproven, but some parents still believe it. And other parents think that vaccines contain toxic materials, or that they cause too many side effects. Or else they’ve found information somewhere or another that they find more credible than their doctor.
NATHAN:
That’s insane. Vaccines save millions of lives. And children like Trey rely on parents to immunize their kids. Otherwise, unimmunized kids could bring diseases into the school and put my son at serious risk!

Washington Allston Elementary School | Principal’s Office

Nathan is angry that children are allowed to come to school without being immunized.

NATHAN:
What I don’t understand is, why can kids go to school if they’re not immunized? Aren’t kids required to turn in immunization records?
LINDA:
Technically, yes. But Riverbend City allows parents to opt of vaccinations for religious or philosophical reasons.
NATHAN:
What? So they just have to fill out a form or something?
MARY:
Yes. They fill out a waiver form.
NATHAN:
But that’s completely irresponsible! Like I said, my son depends on other people taking the responsibility to immunize their kids.
MARY:
Believe me, I totally understand your frustration.
NATHAN:
And it’s not just kids with cancer. We have a six month old baby at home and she won’t get the measles vaccine until she’s one. So our baby could get the measles too, right?
MARY:
Yes. Sadly, that’s true.
NATHAN:
This is absolutely ridiculous! This district needs to have a policy requiring every single child to be immunized! The only exceptions should be children like Trey who have no choice.
LINDA:
Unfortunately, that’s not the district policy, Mr. Williams. I’m sorry. I hate to suggest this, but maybe we need to discuss whether Trey ought to wait a year before starting kindergarten? By then, hopefully he’ll be done with his treatments and can get immunized.
NATHAN:
My son is ready for kindergarten now. He’s suffered way too much already and I don’t want to keep him home when he’s clearly ready for school. And besides, it doesn’t matter. Unless we lock him in a closet, he’s still part of a community where there’s measles. I’m absolutely floored by people’s selfishness.

Hennsey City County Building | Briefing Room

In response to the recent measles outbreak in Rivebend City, Mayor Bauer decides to propose legislation that requires that children in the public schools be immunized.The mayor has the support of Bruce Greenberg, superintendent of Riverbend City Public Schools. To announce his proposed legislation, Mayor Bauer calls a press conference and invites Superintendent Greenberg.

The mayor and the school superintendent introduce the proposed legislation.

BRUCE:
Thank you all for coming. I’m here to announce an important piece of legislation that I’m about to propose to City Council.

As you know, Riverbend City recently had a measles outbreak. Four children at two different public schools were diagnosed. One child was hospitalized for six days. None of the children who came down with the measles had been immunized.

As a result of this, and as a result of many conversations about this topic over the past few years, I’m proposing legislation that would require all students in the Riverbend City Public School system to be immunized. Currently, the district strongly recommends that students be immunized, but parents have the option to sign a waiver if they have religious or philosophical objections to immunizations. I propose that this waiver be lifted. Students who cannot be immunized because of medical reasons will be the only children allowed to have a waiver.

I’m going to turn this over to Bruce Greenberg, Superintendent of the Riverbend City Public School System.
BRUCE:
Thank you, Keith.

First, I want to thank Mayor Bauer wholeheartedly for proposing this legislation. I strongly feel that this is in the best interests of everyone in the Riverbend City Public School System. I’d like to give you a little background information about why I feel this legislation is so important.

Currently, between 2 and 2.5 percent of students in the Riverbend City Public Schools are not immunized. This percentage has almost doubled over the past decade. This follows a nationwide trend of parents who are opting out of vaccinations.

I strongly support giving parents as much freedom as choice as possible. However, this is a case where the needs of the community as a whole outweigh the desirability of freedom of choice. An overwhelming amount of medical evidence indicates that the minor risks associated with vaccination are outweighed by the benefits. Children who are not vaccinated are exponentially more likely to contract diseases that are dangerous and potentially fatal.

Moreover, we need every child in the Riverbend City Public schools to be vaccinated because unvaccinated children are a threat to other children and to adults. There are some children and adults in our community who cannot be vaccinated for various reasons. This includes children with certain serious medical conditions and infants who are too young to be vaccinated. In addition, approximately one percent of the population are non-responders, which means for a varety of reasons, vaccines don’t work for these individuals. It’s also important to remember that no vaccine is ever 100 percent effective, so if there’s an outbreak of a disease like measles, everyone is potentially at risk.

For these reasons, we need to require every child in the Riverbend City Public School District to be immunized. I strongly support Mayor Bauer’s proposed legislation.
KEITH:
We’d be happy to address your questions.

Hennsey City County Building | Briefing Room

Reporter Victoria Moran of WNRT Television asks about freedom of choice.

VICTORIA:
I’m sure a lot of our viewers are going to be concerned with the issue of choice. Even parents who vaccinate their children aren’t going to be comfortable with the school district dictating what they have to do in a doctor’s office. Don’t you believe that parents know best?
KEITH:
This is an excellent question, Victoria. I absolutely feel that parents should have as much autonomy as possible when it comes to decisions regarding their children. But the issue of vaccination is an exception because of public health concerns. Like Bruce said, other people are at risk when children are not vaccinated.
BRUCE:
Victoria, I recently spoke with a father whose five-year-old son has leukemia. This child is at risk of getting a disease like measles because he can’t be immunized. If other parents have the choice to not immunize their children, this child is at risk of catching a disease could could potentially kill him.
VICTORIA:
I understand that. But I also know that parents have legitimate concerns about vaccinations. I’ve spoken to a lot of these parents, and many of them are very well-educated and they’ve done their homework on this topic. Isn’t it true that vaccines always have a risk of serious side effects, like potentially fatal allergic reactions?
KEITH:
Yes. But that risk is very small.
VICTORIA:
But there is a risk. Why should parents have to expose their children to that risk if they choose not to? Parents have a right to protect their families.
BRUCE:
But don’t we all have a fundamental right to protect the wellbeing of the community as a whole?
VICTORIA:
But who gets to decide that? One person’s opinion about the so-called “wellbeing of the community” is very different than someone else’s. Many of our viewers would say that we only have the right to decide the wellbeing of our own families and not the wellbeing of everybody else’s families.

Hennsey City County Building | Briefing Room

Reporter David Julian of WDDO Television is worried about the measles.

DAVID:
Mayor Bauer, could you tell us more about the measles epidemic in Riverbend City? Can you predict how many more people might get the measles?
KEITH:
Hello, David. I’m familiar with your public health reporting at WDDO—like your report on how Easter egg hunts could potentially spread salmonella. We haven’t had any more reported measles cases in the past two weeks. We’re certainly hoping that’s the end of it.
DAVID:
But are you saying that if people don’t vaccinate their children, there’s a risk of a measles epidemic? And didn’t you say that vaccines don’t work for five percent of the population?
KEITH:
One percent of the population, David. Just one.
BRUCE:
David, if you have questions specifically about measles, I suggest you contact the public health department. We’re not experts about the measles. But I can tell you that the schools can do our part in reducing the threat of a measles outbreak by requiring that all children be immunized.
DAVID:
But what about children who are homeschooled? Or children who go to private schools? What’s stopping them from spreading the
measles? And why even bother requiring public school children to get immunized when there are lots of children out there who can still spread the measles? BRUCE:
About 72 percent of children in Riverbend City attend a public school.
DAVID:
So that’s a substantial amount of children you can’t control who could spread the measles!
KEITH:
David, I think it’s very important that we not sensationalize this story. We don’t want people to panic about the measles. We just want people to be responsible and immunize their children.

Hennsey City County Building | Briefing Room

Laurie Boyett of the Riverbend City Free press asks about “slippery slopes.”

LAURIE:
Mayor, Superintendent, have you thought about the ramifications of the government mandating something as personal as immunizations? Could be a slippery slope situation?
KEITH:
What do you mean, Laurie?
LAURIE:
This proposed legislation gives the public schools a good deal of power. You’re dictating that parents have to take their children to a doctor and get shots, whether parents want it or not. Could this set a precedent of the school making other kinds of decisions for families that they might not want to make?
BRUCE:
Can you give us an example?
LAURIE:
I guess the HPV vaccine is a good place to start. I’m sure you know that the HPV vaccine is given to girls around the age of 10 and protects them against the HPV virus, which is transmitted sexually and causes cervical cancer. But as you now, some parents don’t want their girls to have this vaccine because they’re concerned it might promote promiscuity.
BRUCE:
The HPV vaccine is not on the proposed list of required vaccines. We strongly recommend that girls get this vaccine, but it’s not a requirement. HPV is not a direct or immediate public health threat the same way that measles is.
LAURIE:
Well, okay. But there are other issues of parent choice that come to mind as well. Could the schools mandate that a child take ADHD medication, even if the parents are opposed?
BRUCE:
Of course not.
LAURIE:
But what if the ADHD medication is clearly in the interest of the child? I know that’s an unlikely scenario, but I think we should consider the possible consequences of allowing the school to make decisions about children’s heath.

Conclusion

You have completed the MPH5500 Public Health Advocacy Mission. As a public health professional, consider how you might approach this situation. Would you advocate for mandatory immunizations in the public schools, or not? How would you go about doing this?