That some vaccinations should be mandatory

whiteflame

Thanks to Larz for joining this debate, as I'm sure this will be a fantastic one for his presence participation! I'm looking forward to it.

I'll start with some housekeeping:

The topic is a little broad, allowing me to choose what vaccines I would define as “some.” I could defend multiple vaccines as important, but that would make my case rather complex and increase my burdens unnecessarily. As such, I will be advocating solely for the MMR vaccine.

So what is the MMR vaccine? The acronym stands for measles, mumps and rubella, three single-stranded RNA viruses, and the vaccine is meant to impart a protective immunologic response to those who take it. The vaccine is composed of live attenuated viruses, meaning that their virulence has been strongly reduced, but the virus is still viable. This ensures that the vaccine will have the strongest and longest-lasting effect, meaning that the vaccine only has to be taken in its two-shot series once over a person's lifetime.

But that only defines the two terms – some and vaccinations. What does it mean to be mandatory? I will define that contextually by providing a model.  

The U.S. Federal Government will require that all individuals before attending school receive the vaccination, which applies for home schooling by age 5. All individuals who are beyond schooling age and under the age of 65 would have to get the vaccine within 5 years. These will be subsidized on an as-needed basis, ensuring that it is broadly affordable. Failure to vaccinate oneself or one's family results in a fine that scales with income. There would be other exclusions based on allergies, pregnancies, and those individuals who are immunocompromised.

With that, I'll into some contentions.

1. Disease Spread

We must recognize that vaccination is not a choice that solely affects the individual being vaccinated. The decision to get the MMR vaccine affects everyone around you. Measles, mumps and rubella are all transmitted through droplets that are sprayed into the air, making them airborne pathogens with a high likelihood of transmission to those around the infected.[1, 2, 3] The mere fact that others are put at risk by people who refuse to take these vaccines creates a substantial societal harm in the status quo, as many are allowed to refuse to get the vaccine.

We're living this harm today, seeing a resurgence in these entirely preventable diseases in the U.S. and abroad.[4] This resurgence is most marked with measles, a disease that the U.S. had eliminated by the year 2000, but which returned in 17 outbreaks among 222 people just in 2011.[5] Mumps has had 4 reported outbreaks this year alone, and has had several small and two large outbreaks in the last 5 years, encompassing thousands of people.[6] Rubella has also returned from a long absence, appearing in three cases in the U.S. in 2012 after being eliminated back in 2004.[7] This change resulted mainly from a false public perception that vaccines have been linked to autism.[8]

In order to understand why vaccinating a large portion of the population is necessary, we have to understand the term “herd immunity.” This has been defined differently by different authors, but I will use the term in this fashion: “a particular threshold proportion of immune individuals that should lead to a decline in the incidence of infection.”[9] What that means is that if someone becomes sick with a given disease, herd immunity would ensure that that person is so much more likely to run into someone vaccinated against that disease than someone who is vulnerable that they would be extremely unlikely to infect other people. We cannot possibly vaccinate everyone and achieve absolute immunity because of the necessity of the exclusions I listed in my case, but we can seek to achieve herd immunity.  

What does that threshold look like for these diseases? For measles, this is 95%.[10] For mumps, it's at least 88%, though it “may need to be higher” than this previously established threshold.[11] For rubella, it sits at 90%.[12] Only through mandatory vaccination could we ever hope to reach those numbers.  

2. Disease Impact

My first contention established a threshold for harm in status quo, but I will now show that that threshold has a tremendous impact on society. In order to understand that, we have to know what the impact of these three diseases is.  

Measles:  

“Prior to the vaccine, 3-4 million people were infected in the U.S. each year, resulting in 48,000 hospitalizations, 400-500 deaths and approximately 1,000 who developed chronic disabilities.

Even with modern medical care, the disease can lead to serious complications, including blindness, pneumonia, otitis media and severe diarrhea. Despite the availability of a vaccine it remains a leading cause of death among young children worldwide, with deaths mainly attributable to the complications of the disease...

More than 90 percent of susceptible people, usually unvaccinated, develop the disease after being exposed. There is no treatment except to make the patient as comfortable as possible by keeping them hydrated and trying to control the fever. Unvaccinated young children and pregnant women are at the highest risk for measles and its complications, including death.”[13]

Mumps:

“Mumps is not normally a fatal disease, and up to 30% of mumps infections are asymptomatic. There can be serious complications, however, including aseptic meningitis, orchitis, oophoritis, mastitis, pancreatitis, and deafness. Meningitis occurs in up to 10% of mumps cases; it is usually subclinical and self-limiting. Symptoms of mumps-related meningitis include fever, headache, vomiting, and neck stiffness, which peak for a period of 48 hours before resolution and might appear up to 1 week before parotid swelling. More serious neurologic symptoms are rare and are due to encephalitis. Hearing loss following mumps infections is rare (1 in 2000 to 30,000 cases) and usually results in mild to moderate hearing loss.  

Orchitis [swelling of the testicles] occurs 4 to 8 days after the onset of parotitis and is a common complication, affecting 20% of men who develop mumps after puberty. Of those cases, 40% will develop testicular atrophy and 30% will have lasting changes in sperm count, sperm motility, and sperm morphology.”[14]

Rubella:  

While the disease usually only results in a light fever and small rash, this disease is mainly problematic for pregnant women. “In 1964-65, America had a major rubella epidemic, with more than 12 million cases and 20,000 babies born with congenital rubella; of these, 13,000 were deaf, 3,500 were blinded by congenital cataracts, and 1,800 more suffered severe cognitive impairment.”[7] Since pregnant mothers are among the few who cannot get the vaccine, every single person who decides not to get the vaccine is putting these mothers at risk.

Taken together, this means these three viruses present as enduring, broad threats to public health that are made dramatically worse in the absence of herd immunity.

I now leave it to Lars to present his case/rebut mine.

1. http://www.cdc.gov/measles/about/transmission.html

2. http://www.cdc.gov/mumps/about/transmission.html

3. http://www.cdc.gov/rubella/about/index.htm

4. http://www.npr.org/blogs/health/2014/01/25/265750719/how-vaccine-fears-fueled-the-resurgence-of-preventable-diseases

5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6115a1.htm

6. http://www.cdc.gov/mumps/outbreaks.html

7. http://www.thedailybeast.com/articles/2013/03/30/why-rubella-s-scary-comeback-should-convince-vaccine-deniers.html

8. http://online.wsj.com/news/articles/SB10001424127887323300004578555453881252798

9. http://cid.oxfordjournals.org/content/52/7/911.full

10. http://www.theguardian.com/society/2013/apr/25/measles-mmr-the-essential-guide

11. http://jid.oxfordjournals.org/content/202/5/655.full

12. http://www.ncbi.nlm.nih.gov/pubmed/23099870

13. http://guardianlv.com/2014/07/measles-resurgence-in-u-s-after-development-of-vaccine-in-1966/

14. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135444/

whiteflame

Alright, thanks again to Con for engaging with me in one of the most interesting debates I've had. I do apologize for the tremendous amount of text to follow – Con gave me a rather long round himself and a large amount to cover from cross-x, and I'm sure his final round will be similarly verbose. Thanks to the voters in advance for taking the time to go through these posts; it may be only two rounds, but with this amount of text, it seems more like 6.

Fundamentally, this is a debate weighing the aggregate utility of the MMR vaccine to public health and the lost liberties that result from its being mandated. The reality is that neither of these should be preferred in every case. I'm not going to sit here and argue that every measure we can take to address a given public health threat is worth the loss to liberty it may engender, nor do I think my opponent would argue that those lost liberties should always outweigh any benefit to public health that could occur. So really, what this debate is about is how we strike that balance, and where MMR comes out when that balance is struck. So there are a few questions that this debate comes down to by the end that need to be thought through as I go through Con's points:

1) Do the MMR viruses present a substantial risk to the public health of the United States?

2) Can that risk be ameliorated to a significant degree by mandating vaccination?

3) Does that risk reduction outweigh the potential loss of rights that accompanies it?

By the end of this round, I plan to show that the answers to all of these questions is an emphatic “yes!” A big part of the reason why is that Con is continuing to treat vaccination as an individual choice on the basis that their purpose is for their own protection. And this is the problem – a vaccine isn't solely meant to protect the person receiving it. Voters, this is the main point you must keep in mind as I go through this rebuttal and conclude; Con's arguments for individual rights just miss the basic point, and treat commonly dangerous viral infections as little more than nuisances without cause.

But onto the rebuttals.

Mass Medication

1. Con does a good job ginning up fear of mass medication without any real explanation of harm. Note that nowhere in this point does he ever state why mass medication is wrong. He says that mass overmedication is harmful, but the sole reason he provides is that it's like eugenics. The problem is that a) he never says why eugenics is wrong, merely insinuating that there's an inherent harm to all of eugenics (recognize that genetic counseling could be considered “eugenics,” as it's also the “practice of improving the genetic quality of the human population”)[15] and b) changing genetic structures, thus altering traits inherent to a person, is substantially different from providing basic nutrients, which only alters what they eat and drink. Con provides no analysis on why any given vitamin shouldn't be packaged more commonly in foods and drinks to improve public health.

2. Most of this has absolutely nothing to do with my case. A person neglecting or refusing to take a vaccine puts others at risk by their inaction, as the spread of a disease to them could consequently increase the chance of its spread to others. If a person neglects or refuses to take a certain nutrient, the harm is solely their own. One could argue that some of these vitamins are important for staving off disease, but the sole diseases that are definitively linked to vitamin deficiencies aren't infectious.

3. The sole piece of this contention that is applicable to my case misrepresents both the purpose of vaccines and my case. In the former case, vaccines are much better as a preventative measure. Yes, vaccines are pursued largely in instances where there are large outbreaks in order to prevent the spread. However, the main purpose is to prevent those outbreaks. The most effective usage of vaccination prevents any epidemic, it's not responsive to one. As for my case, I'd say I'm not responding to outbreaks (as these are usually sporadic in the U.S.), but rather responding to a changing mentality, which has pushed people to fear vaccines that functions mainly on the basis of pseudoscience.

Human Rights

1. This appears to be at least part of the impact story for the previous point, but it still lacks anything definitive. He essentially just asserts that there's a harm to obligating people to receive the necessary medications to be healthy, but never states what that harm is beyond this general assertion of “human rights.” He never provides any specific analysis as to why people should have the right to refuse treatments that are proven to be beneficial to them and those around them. Why is it moral to allow a person to refuse care on the grounds of personal autonomy? It sounds nice, but Con is going to need to provide more than just his assertion that it's wrong, especially when he admits that many schools can and do already require incoming students to be vaccinated, and when many jobs require a wide variety of vaccinations.[16]

2. Con uses the Universal Declaration of Human Rights to support his argument, but never points to anything within it that specifically upholds this principle. If anything, the one aspect he quotes points towards the necessity for each person to have this right to health and medical care, something that's only realistically possible in a world where herd immunity protects those individuals who are most susceptible to these diseases.  

3. I take issue with this presumption of guilt argument. I'm not presuming guilt any more than tax policy assumes people are cheapskates. I'm assuming that it's negligent to ignore one's capacity to easily spread a dangerous disease when one has the capacity and the means to prevent it.

4. Con's argument seems to apply to practically any instance in which autonomous actions are restricted for the benefit of the general public. It could just as easily be applied to taxation policies, requiring automobile insurance, and obeying road signs. Con has provided nothing specific to choice of treatment that makes it special, except to equate body autonomy to a nebulous “right to life” that apparently has to be exercised through medical decisions, but can be abrogated in other areas for the benefit of the general public. Why should I be able to “make [my] own destiny” when it comes to vaccinations, but not able to engage in these other risky behaviors?

5. Let's look at the sole example of a vaccination that resulted in eradication of a disease: smallpox. It was mandated for the first time in the U.S. in 1809.[17] It was upheld there in Jacobson v. Massachusetts. The justices compared it to the Civil War, “saying that a community has the right to protect itself both from disease and from military invasion...'there are manifold restraints to which each person is necessarily subject for the common good.'”[18] The British government followed in 1853.[19] These procedures led to complete or nearly complete elimination of the disease over the next century in these countries. People like Frank Fenner are responsible for the eradication of smallpox in Africa, which often went against the will of native populations.[20] And that's not even what I'm seeking here. The alternative of accepting the fine for those who do not wish to be vaccinated, which is also upheld by that USSC decision, makes my case far more reasonable.[18]  

If that's not enough, we could take a look at current policies. There are dozens of countries that require the yellow fever vaccine.[21] Saudi Arabia requires meningococcal disease and polio vaccines, mainly because of a large influx of pilgrims to the country.[21] These are recognitions of broad public harms that many countries have agreed need to be prevented using a consistent mechanism, and that mechanism is vaccination.

We're not the same

1. This is generally just an obvious point. Of course we're not all the same. However, each of us is vulnerable to the spread of these diseases on the basis that we are human beings without immunity to them. That doesn't change on a person-by-person basis. Unless you've built up the highly specific antibodies to the virus that you need to combat it, it's exceedingly unlikely that you could fight off any of these viruses before getting any symptoms. People will generate those antibodies and mount an immune response at different rates, changing how long the infection lasts and how strong of any effect it has, and other immune defenses come into play, but to my knowledge, there is no population of humans that is immune to any of these diseases before being exposed to them.

2. My plan would be implemented using doctors' discretion, as that keeps medical records confidential.

3. Con says that there are possible health complications that could result from something that the patient doesn't want to reveal to their doctor. That's true enough, but if the patient is aware of this source of complication, then they can either choose to reveal that to their doctor, or choose to pay the fine. They are not forced to put themselves in a medically dangerous state, and doing so would be their choice. If the patient is unaware of this problem, then mandatory vaccination isn't the concern, but rather a lack of education on the matter is. They would be put in the same danger if they chose to get vaccinated under those circumstances. If they've chosen not to discuss it with a medical professional or look up prescription drug interactions online (they're not that hard to find [22]), then the state should not be deemed responsible for those consequences. The harm is something they brought on themselves.

4. Much of this can still be solved by a basic blood or urine test before vaccination. This doesn't have to be mandatory – it can be linked with vaccination, and patients can sign off if they don't wish to have these tests. This provides them with an option that can further improve the safety of their vaccination, and afford them an opportunity to exercise their bodily autonomy if they wish. It's a way for doctors to ensure that there's no possible concerns in their system, and essentially know them as well as they know themselves in this regard. If a given drug doesn't appear in these tests, then it probably is no longer at perceptible levels, and therefore is not a concern.

5. Note that Con never provides any examples of this happening. An attenuated vaccine of the sort I am discussing is not a chemical. It's virus particles. To my knowledge, there are no dangerous chemical interactions with vaccines. Problems like vaccine overload are the result of excessive challenges to the immune system, and are prevented by ensuring that patients aren't given too many vaccines at once.

6. I'm not sure what's dehumanizing about ensuring a higher standard for public health. Con simply asserts that this is “a ritual activity for the sole purpose of making us more similar,” but that's not even part of the purpose. The purpose is disease prevention, not similarity. You and I will likely have dissimilar reactions to the vaccine and produce dissimilar antibodies to different viral proteins/nucleic acids or different parts of the same viral protein/nucleic acid. I don't even see why medical similarity (or for that matter, any similarity) is inherently dehumanizing. Con doesn't explain.

7. The comparison to tetanus is absurd. Tetanus is not an airborne disease with the ability to spread easily from person-to-person. The whole idea of “liv[ing] healthily” is similarly bogus. If I eat all my vegetables and exercise every day, I'll still be able to contract measles from my next door neighbor if I don't have the vaccine and have never been exposed to the virus before. Con's claim that we “should have the right to decide what means of avoiding sickness is right for” us is entirely empty – the only means he provides are only partially effective at best. Choosing one of them over vaccination represents an unsound decision that puts the well-being of others at risk.

8. I don't understand this argument that not being vaccinated somehow makes you more health conscious. Con barely warrants this statement and says it's, in his own words, “a weak correlation.” That's the best case scenario for him. The truth is that there's likely no correlation. In fact, I would argue that a society that is built around a public consciousness of an ongoing healthcare threat is going to be the one in which more people are health-conscious. Hearing about this in the news and having constant discussions on viral infections and staying healthy is going to inform people of the health risks involved and push them to improve on behaviors that would otherwise be treated as unimportant, like a healthy diet, exercise, and hygiene. This discussion is far less prominent in status quo.

Murphy's Law

1. This entire contention is non-unique to any case that modifies away from the status quo. Murphy's law is essentially an elegant way of saying “shit happens,” a pessimistic comment on how many view the world and anything that happens in it. Actually I take back what I said – if Murphy's law is right, then anything can and will go wrong in the status quo as well, so it doesn't just apply to alterations, but to the status quo itself. And I don't need an adage to show that it is going wrong, not with all my epidemiologic evidence. Con will need to provide some exceptional support for his statement here to match that. All he's done is express a generalized negative view with insufficient warrants.

2. The reality is that Murphy's law is incorrect, and it doesn't take much in the way of examples to show this. When the Space Shuttle Challenger exploded, NASA quickly figured out the culprit was the O-rings that had already been under suspicion in 25 previous Shuttle missions. If we run with Murphy's law and its implications, those flights should have blown up as well. They didn't, but they also didn't pass on their lessons, as engineers already knew that charring and hot-gas “blow-by” were problematic in these previous missions. That failure is what led to theChallengerexplosion, not Murphy's law.[23]

3. Moreover, the U.S. has learned from the past – we have disposable needles, we have the Food and Drug Administration and the Center for Biologics Evaluation and Research as a monitoring agencies, and we require multiple quality controls and assurances to be certain that vaccines are safe. Past sources of harm are now vanishingly small concerns. These aren't O-rings, they are problems that have been addressed.Con has basically built this entire contention on a very low probability set of outcomes that, I would argue, are negligible in this debate. We could discuss doomsday scenarios all day long (like how every human being these diseases get into is a possible source of mutation into something extremely deadly), but what we're concerned with is likely outcomes. Con needs to show that the risks he's presenting for the MMR vaccines are a reality, not just claim that they're part of some possible dystopian future. He can't just assume that the risk is present solely based on the existence of human fallibility, especially when he cannot present a single instance of botched vaccine production in the U.S., fails to present any examples in the U.S. that support the incidence of unique disease resulting from vaccination or any transmission of separate disease by vaccination here, and claims a false incidence rate of these three diseases resulting from the vaccines.[24]

4. Con discusses the possibility of adverse reactions, actually providing some of my rebuttal for me through the VICP. However, that's not all. According to the Vaccine Adverse Events Reporting System (VAERS), there have been just over 6,000 adverse events associated with MMR between 1990 and 2012.[25] That's with much of the population receiving these vaccines. One might notice that it attaches a death toll onto that as well, which I'm sure Con will attempt to belabor. However, that misses the reality that these deaths have never been linked directly to taking the MMR vaccine, especially given an extensive (1.5 million person, 11-year) post-marketing, controlled surveillance study that showed no deaths or permanent damage.[26] Con will no doubt point back to Madyson Williams, but this will do him no good, as the problem here was that she had taken two live virus vaccines – MMR and varicella zoster – at the same time, something advised against by Merck itself, partially for this reason.[25] Also note that the age of the child was just 1 year, and that the majority of the VAERS-reported issues occur among children of 3 and younger, none of whom are required to take the vaccine at that age. Doctors can and do recommend that this should come later in life.

In any case, Con will have to establish a scientifically sound link between MMR vaccination and a death toll if he wishes to prove this. Merely pointing to past failures of adherence to clear guidelines is insufficient, as is his correlative analysis of the more severe side effects of taking the vaccine. I've shown a causal relationship between getting these viruses and the outcomes I've described, he will have to show that same relationship between the vaccine and its purported outcomes. While vaccines have and will continue to become safer, these diseases will continue to be extremely dangerous to the immunocompromised, as well as the very young and old.

Still, that's 6,000 adverse events over 22 years, and while most of those may not have been caused by the vaccine itself, those events are still worrisome. Let's compare that to the harms I cited for these diseases earlier. With 3-4 million people infected by measles, 48,000 were hospitalized, 1,000 developed chronic disabilities, and 400-500 deaths occurred. That's 1 in 84, 1 in 4000, and 1 in 10,000, respectively. 10% of patients with mumps end up with meningitis, and 1 in 2000-30,000 cases develops hearing loss. Out of 12 million cases of rubella, 20,000 suffered complications. That's 1 in 600. Notice how each of these numbers is far higher than the 1 in 300,000 and 1 in 1,000,000 my opponent provides. Something goes wrong far more often with these diseases than it does with the vaccines.

5. Con points to the possibility of a botched production system, but seems to have little knowledge of how a vaccine is approved and just what procedures a company has to go through to produce, store and deliver a vaccine. They have to be manufactured consistently under current good manufacturing practices (cGMP, which you can find extensive details on here [27]), each product characterized, and lots are tested before release to the public.  

Con backs this claim up with the bold assertion that smallpox vaccines were once contaminated with syphilis. What he fails to realize is that a) this only occurred during the days of arm-to-arm transfer, b) it occurred well before scientists developed the basic molecular detection systems used today to screen vaccines, and c) is only occurred in 750 cases out of 100 million vaccinations, making it incredibly low likelihood.[28]  

Con's second attempt to back this claim is through the example of India in 2011. This is flawed as well. Con will need to show evidence that the MMR vaccine leads patients to shed communicable and virulent virus, something he has so far failed to do. The few sites that I can find arguing that this is the case are all strongly anti-vaccine, and lack any proof to support their assertions. Con is also comparing two very different countries with very different circumstances. India suffers from “poor sanitation, including open sewage in underdeveloped countries, where drinking water is too often also used for bathing and disposal of human waste,” which “can make it easy for vaccine strain polio virus to be transmitted...especially among those, who are immune compromised, malnourished or suffering from serious health problems.”[29] Not only does my model not take place in India and therefore doesn't suffer nearly so greatly from these problems, but it would allow many of those who are most seriously affected outs from getting the vaccine, not to mention ensure that they are less likely to contract these illnesses in general. Even Con admits that there are substantial differences between the two countries in terms of quality control, but he understates those differences markedly.

6. I would argue exactly the opposite – botched batches of vaccines are far less likely in a country where vaccination is required. Many of the groups who are anti-vaccine are likely to launch extensive campaigns to make sure what they are taking is not contaminated, and measures by the FDA are likely to be stepped up to ensure that companies like Merck put out the best quality stuff. A failure on the part of the FDA or any of these companies would be a dramatic harm to either one, and so they would endeavor to prevent such errors to the greatest extent possible.

7. Generally, I disagree with the way my opponent phrases his disagreement with my case here. He says that taking a vaccine is “putting their body on the line and gambling with their health,” but he hasn't proved that MMR creates any substantial threat, focusing instead on other, unrelated diseases and low-risk impacts. The idea that “people are [going to be] force-killed by the government” is simply Con trying to make it sound far more dramatic than it is. He will have to do more than quote Murphy's law to make this stick.

MMR: The Diseases

1. By Con's logic, no one ever died of HIV either. This is just a ridiculous point – most illnesses don't kill people by themselves. Death is the result of multiple illnesses, but the immunosuppressive effects of one are often necessary to allow the others to infect. Since measles can't be cured by medicine, there is a severe problem here that can't always be cured by Gran Turismo. If a person's immune system is not capable of defeating the virus, then it can easily lead to complications. Coca-Cola and “getting comfortable” aren't cures or treatments, just ways to ride out light symptoms.

2. Con has a rather large burden that he's building for himself here by claiming at these diseases are minimally important. I've shown that, yes, even rubella has terrible consequences for pregnant mothers. I don't think that it's reasonable to put any of them at risk of contracting this airborne disease. I showed that mumps causes meningitis, which can read to a number of neurologic symptoms, as well as encephalitis and even hearing loss. Con ignores orchitis as a plausible harm as well, something both of us could easily appreciate. Con similarly ignores every complication beyond death for measles, which results in a tremendous number of hospitalizations and an admittedly smaller number of chronic disabilities, as well as numerous serious complications that I listed.

3. I don't need to present a disease with a high death rate to show that vaccination is worthwhile. I've already explained how damaging each of these diseases is to large populations, and what complications can arise. The fact that they're not significant enough for my opponent to care doesn't make them insignificant. If anything, smallpox showcases just how effective a program like this can be. There may be other diseases that are more deserving of these efforts, but all of them (including tetanus) aren't easily transmissible between patients.  

Nonetheless, Con is entirely right that the most common symptoms of these diseases is akin to the common cold. Unfortunately for him, that's a big problem for Con's case. What this means is that most people will treat them like a cold – some may stay home, but many will go out and fight through their illness, treating it like a minor impediment to their day. This is why diseases like Ebola are insidious – most of the symptoms one experiences early on don't look like anything special: basic headache, fever, and muscle pain, which one might attribute to having a bad day and perhaps an early flu. It's during these early symptoms, and not the excessive bleeding stages, that one is most likely to spread the illness. At this stage, they're contagious, and it's not obvious what they have. People experiencing these symptoms would be tempted to just walk it off, and would thus continue their usual interactions. This is all the worse for MMR, where most people never experience the more damaging and obvious complications, and therefore may continue to spread the disease over the entire time they're infected.  

Maybe Con would stay home if he's infected, but many would just try to move on with their day. Unlike Ebola, these diseases have less common complications. However, also unlike Ebola, they're highly contagious to everyone sharing the same space, especially if it's enclosed like a subway train or crowded office. Avoiding direct contact isn't enough, as these diseases are airborne. The chances of them spreading broadly are far higher, putting more people at risk of developing these complications.

In America!  

1. The fact that Con can present problems with our health care system is non-unique – every system has problems (and incompetent doctors, for that matter), and he hasn't shown these to be excessive or pervasive, only providing evidence of an audit that found unspecified “inconsistencies” in the system, and those only appear to be in regards to information submitted online. He doesn't show any actual problems with Obamacare as a system, just claiming that the failures of data submission reflect huge problems with the system as a whole.

2. I don't understand the choice to lampoon Obamacare, as it has nothing to do with my policy. Implementation is done by the health care professionals doing it, not how insurance is provided.

3. Con never actually shows where the problems are that would affect implementation. He says “there's probably something wrong somewhere,” but that doesn't suffice as proof that my system will fail, in part or in totality. He points to 4 doctors who are not currently practicing in public health nor at all likely to participate in the distribution of vaccines, and then claims that they're representative of how terrible our public health care system is. If, as he claims, “they won't be able to pull this off perfectly,” then Con has to state specifically where the deficiencies are, how they are likely to affect the system, and how that will lead to failures. He can't just generalize this and say that he doesn't know where, he doesn't know when, he doesn't know how, but something bad is going to happen.  

4. Failures of public health occur now with regards to controlling outbreaks like those resulting from these viruses. There have been multiple outbreaks involving hundreds of people over the last several years. Those failures far outdistance any of the probable failures with regards to vaccination.

5. Con never warrants his predictions, particularly on the cost issue. Either a lot of people will pay fines, a lot of people will be vaccinated, in which case health costs (for diagnosis, treatment, quarantines, epidemiological tracking, etc.) will decrease, or it will be some permutation of the two. In any case, these ameliorate if not eliminate cost burdens.

Brief Rebuttals 1: Herd Immunity

1. I didn't realize I needed to link the numbers to the suffering experienced by those numbers, but I'll do the basics. The human body normally exists in a homeostatic state, meaning that the system is regulated to a stable point. Viruses like these chuck that state into uncertainty by causing disease, and cause people harm. Whether that harm is through the basic fever, chills, stuffy nose, cough, etc., or if it's through more dramatic complications like encephalitis, there's an objective harm to experiencing them, though how bad the experience is is subjective. Nonetheless, we can make rational assumptions about what is a worse experience for victims of a given disease and make conclusions as to how strongly those experiences affect them. This is a utilitarian argument – health and wellness are better for society than disease.

I'd say that this suffices as a strong link between the science and the morality – individuals may be able to select for themselves which experiences they will willingly engage in, but they should not be able to make those decisions for others, let alone strangers. When disease spread can be reduced or eliminated, utility says that that public health outcome should be preferred.  

2. I'm glad my opponent and I agree that the link between MMR and autism has not been established, and that it is therefore unimportant to this debate.

3. Part of the problem here is that Con's making assumptions based on what I've said. The reason why I don't believe herd immunity is possible is because I think it's likely a substantial portion of the remaining population will choose to pay the fine or manage to avoid the law. However, going off Con's own claim that 94.5% of the population is vaccinated (as he hinted in cross-x), then this makes it very much a possibility. Con's link shows that 95% of vaccines are effective against measles, 96% are effective against mumps, and 99% are effective against rubella, and that's just the first dose.[26] Taken together, that might lead to the figures Con claimed, but then, this ignores the second dose, which induces an immune response in 99% of recipients.[27] If the numbers are as close to 95% as Con seems to believe, then my case could certainly achieve herd immunity with those numbers.

4. Con assumes that outbreaks will never become more substantial than they have been over the last few years. The data bears out a very different trend.

Note that, in years with substantial epidemics in other countries that lead to large amounts of imported cases. The larger the amount of imported cases, the larger the outbreaks in the U.S. The size of the outbreaks in the U.S. have increased substantially as well by comparison in recent years, revealing a widening disease spread.  

In case that's not enough proof, we can see the trend playing out this year as a result of a large outbreak in the Philippines.[30] The point being that any epidemic abroad threatens to do tremendous harm in this country, and those epidemics aren't going away anytime soon. Since the level of protection in the U.S. appears to be going down, which I would argue is the result of reduced vaccination levels. While the country as a whole appears to have a vaccination rate among kindergarteners of 94.5%,[31] the vaccination rates in many states are well below that number, with 5 states (Colorado, Arkansas, Pennsylvania, Idaho, and North Dakota) below 90%.[32] In case that's not enough proof that the trend is downward, here's a CDC report to that effect, as well as a study showing that vaccination rates are down in Texas.[33, 34]

5. Con makes the argument that cost of allowing these diseases to run rampant is lower than the cost and impact of preventing it. Con's own link, however, doesn't bear this out. The link points to the Haemophilus influenzae and Pneumococcal vaccines barely reduce the incidence of these bacterial diseases, are expensive, and put those who take them at substantial risk. I agree on both fronts, but these do not apply to the MMR vaccine. The article itself only mentions measles once, and does so in the context of “the 6 basic vaccines” that they deem at least as beneficial. 

6. If Con had wanted to present a counterplan regarding feeding starving children, he could have. All he's done here is present it as a nebulous alternative to the putative costs he sees as coming from my case. The reason he didn't is probably because it's not mutually exclusive to my case. We can both mandate immunization and improve governmental programs aimed at feeding starving children. He provides no reasoning for why U.S. resources are so scarce that we can't do both, especially when he hasn't proven that there's any deficit of funds resulting from my policy.

7. Note that Con's chart solely addresses the mortality of measles in England and Wales, not its incidence. I agree that mortality has reduced due to a variety of factors that have changed since the early 1900's. There has probably been a reduction in measles outbreaks as well resulting from those factors. But I would argue that this can only take us so far, and that we're basically at that point already, yet we're still experiencing major outbreaks that correlate strongly with reduced immunization and outbreaks from other countries.

8. Con argues that non-immunized children have mild infections. His data comes from India, so it seems difficult to apply to the U.S., but if we did, this would be really problematic for his case. It shows that there are likely many sub-clinical infections in the U.S., which could easily be prevented from spreading by the vaccine. Con might see this as a sign that measles is effectively harmless in the majority of those infected, but this only lasts so long as they have sufficient immunity to ensure that the virus doesn't transition from a latent stage (where cells are persistently infected, but lie dormant) to a lytic stage (where there is active virus replication an d spread, resulting in cell death). If the immune system is sufficiently challenged by practically any other infection or sufficient injury – hell, even depressed by a strong bout of anxiety [35] – these patients can experience full-blown, infectious measles as a result. All Con has managed to prove here is that the generated resistance that results from getting the infection is often insufficient, leaving open the possibility for viral reactivation. Preventing the infection from becoming latent in the first place only becomes a near certainty with the vaccine. Note that the link also showcases only a 2% measles contraction rate following vaccination, which shows that the vaccine is 98% effective at preventing the infection.

9. Con's point that it may not last a lifetime, is really just mitigation. We're still talking highly likely, long-term resistance to infection.

Brief Rebuttals 2: The Impact

1. Con just seems to use much of his rebuttals here to distract from the issues at hand, and he starts it off with several fallacies. First, there's an appeal to the emotions of the voters, even going so far as to say that his points here should breed anger. Of course, he never gets around to discussing the impacts of any of these bans, assuming that they're harmful solely because they make us angry. Then, he engages in a slippery slope fallacy, emphasizing how the idea of protecting everyone from everything is problematic, and failing to provide any analysis of how my case leads to this extreme and peculiar outcome. I've made it quite clear what makes MMR dangerous, and why it is an important concern. My case doesn't include any of these bans, nor would they be organic offshoots of my case.

Finally, Con engages in an appeal to ridicule, essentially stating that I'm “scaremonger[ing]” and that my argument is an attempt to paint vaccines as supernatural. Maybe he's just talking about others who hold similar views to mine, but this is still meant to paint my argument in an absurd light with no reasoning. Presenting the data as I have isn't scaremongering. I'm making basic conclusions from the data I've presented and provided both the data and conclusions for my opponent and the voters to peruse. I'm not treating vaccination as “a magic cure-all,” and I don't appreciate that kind of embellishment of my case for Con's benefit. I'm not making claims I can't support about what the vaccine does. What these “vaccine lobbyists” Con discusses have done has no bearing on my argument. Con seems to simply be attempting to malign my case by making it sound like I'm peddling snake oil, despite recognizing that it's not earlier in his post. There's no magic here and no attempts to scare people into submission (an interesting take from someone who used several appeals to emotion).

2. Con points to a number of possible medical concerns that could come from everything from the common cold to smoking to eating cake. It is not my burden in this debate to show that these things are insufficient concerns to warrant further action. I will, however, address Salmonella, as he spent a good deal of time there.

He starts by talking about an imaginary vaccine that specifically addresses toxins made by Salmonella, assuming all the responses that would come from it.

First off, just the absence of Salmonella toxins wouldn't mean the absence of disease.Salmonella could still infect you, still alter your gut microbiota to the point that you suffer ill effects, still deprive you of many beneficial nutrients, and, without the toxin, would take longer to clear from your system (the toxin is there to ensure that it gets excreted). 

Second, there are multiple toxins coming from two different species, “six subspecies and innumerable serovars.”[36] Any vaccine would only address a subset of these.  

Third, there are a large number of diseases that can also come from uncooked chicken that wouldn't be addressed by this vaccine. These include, but not limited to, Campylobacter, various Clostridia, and Staphylococcus.[37] So even ifSalmonella was completely addressed, eating uncooked chicken would be dangerous. 

Fourth, there already exist best practices for reducing the incidence of these infections since they are solely ingested and can be killed by cooking. This isn't spread simply by contact between individuals who are infected and those who are uninfected.  

Fifth, it's not my burden to defend every single instance of vaccination. I'm defending a single one, and I'm limiting its applicability mainly on the basis of how it is transmitted, not how potent its symptoms are. That's because one person presents a risk to another, rather than a piece of chicken. Distinguishing the two is important, as your ability to choose what happens to you medically is different from your ability to make a medical choice that can directly affect others.  

Sixth, Con never actually presents a harm to doing this, so even if it is somehow a consequence of my policy, he never points to any specific moral concerns that arise as a result. Why would mandating this specific vaccine be problematic? He might say “loss of freedom bad,” but that's not enough of an answer. Freedom in this case is, at best, a nebulous benefit and cannot compare to the benefits of protection against a potentially deadly disease. 

3. I take strong issue with the following statement made by Con (and no, saying it in all caps doesn't make the point better):

“MMR vaccines may have reduced the incidence rate, but they have not reduced the harm. THE HARM HAS BEEN REDUCED INDEPENDENTLY.”

The only harm Con has proven has been reduced independently is death tolls. Yes, that harm has been reduced, just as the harm for any illness or disease state has been reduced by the advent of indoor plumbing, better nutrition, less poverty, and dramatically improved medical care. But the problem here is that Con can't just assume that these independent factors are sufficient for erasing the problem, as he has argued in the previous round and repeatedly in cross-x. The complications still happen in countries with the best possible circumstances, and the basic disease states are still the same. Cross-apply this to all the times Con mentions nutrition.

Points stemming from Cross-X

1. Con often argues that there are other effective preventative measures, but each of these is just a mitigating factor. The best he's managed to prove here is that these diseases have vastly reduced effects in the U.S. as compared with the third world. He's right, but my case has shown quite clearly that the effect is still substantial enough to matter. Con would have to show that these diseases are effectively of null importance in order for this point to win him the debate.

2. Con never really explains his view that increasing levels of vaccination are essentially worthless without actually reaching herd immunity, though from cross-x, that seems to be his contention. I don't know how he could defend this. He says that herd immunity is potentially beneficial because of a reduced spread of disease (the likelihood of spreading it to less than 1 person). He doesn't say why it's beneficial or negligible that that number increase above 1 to a significant degree, as is the case in the states I listed. It seems obvious to me that reduced spread of disease is generally beneficial because less disease/complications is beneficial – Con hasn't argued that it isn't. It seems obvious to me that the more people who are vulnerable to a given disease, the more likely they are to get it and come into contact with a person who is immunocompromised and therefore far more likely to suffer complications – Con hasn't argued that that isn't the case. He'll need to explain and warrant this view if he plans to win it.  

3. Con can't reasonably claim that everyone should adhere to his views of what is and is not damaging to their rights structures. Just because he thinks that one can only lose their rights in the instance where those rights are taken and abused by another person or group of people doesn't mean rights can't be lost in any other instance. I would argue that governments have a duty to ensure that their people don't suffer, and that the reason that duty exists isn't just utility. A person can take your rights by coughing on you and transmitting his/her disease, even if they garner nothing from it. A virus can take your freedoms from you by forcing you to stay home for several days or putting you in the hospital. Con's argument that there's essentially no rights lost in these instances seems strange when someone's freedom of action is very much threatened by both the person and the virus involved. Con's entire argument for why mandatory vaccination is harmful to our rights is based entirely off of a similar loss of freedom.

When Con said in cross-x that side effects from vaccination are “part of the same abrogation” of rights caused by requiring those vaccinations, he's essentially admitting to this. He says that they are “not further abrogations of rights, but part of the same abrogation.” I'm still not quite certain what he's trying to do with this, but I can only interpret this one way. He's saying that the abrogation doesn't increase as a result of the side effects, in which case he's simply erasing any rights loss disadvantage that he might have garnered here because it's a part of the same rights abrogation caused by mandatory vaccination. In the process, he's still saying that this is a part of a rights abrogation, which it cannot be without being a rights abrogation itself. He's therefore admitting that the harms of disease do contribute to rights losses, thereby admitting that there's a rights loss that results, while just trying to wave it away as unimportant by comparison. Maybe that's not his goal, but that's certainly how it appears. If he attempts to gain any sort of rights loss from side effects, though, he's effectively admitting that a similar rights loss occurs as a result of illness of any sort.

However, even if you agree with Con that there's no rights loss here, there is most certainly a loss of bodily autonomy, which is the whole basis for Con's contention regarding the rights losses from mandatory vaccination. If loss of bodily autonomy is a harm in and of itself, as Con insinuates, then a disease is the more insidious harm, lacking any alternatives and requiring a substantial and physically demanding sacrifice.

4. While we can establish the physical impact of a disease, we cannot establish that, for all people, each physical impact is just as harmful. Con often tries to brush off a day or two in bed, a fever and a cough, yet each of these requires that the person be out of work for a certain period of time, that they not interact with family members or friends, or that they miss important social events. The impact of even the lowest levels of disease is something that Con cannot assume is so small as to be insignificant.

In fact, Con seemed to spend a lot of time in cross-x trying to show that these diseases have low death rates in the U.S. The truth of the matter is that they do have low death rates, though Con makes no efforts whatsoever to show that complication rates have substantially reduced with time. The complications I presented in R1 are still very problematic, with ear infections in 1 out of 10 and pneumonia in 1 out of 20 children.[38]

If Con's concern is that these complications aren't common today, I showed evidence in cross-x that shows that any change in their incidence has been minimal. And that's not just for pneumonia – hepatitis and blood disorders like pancytopenia and thrombocytopenia are also appearing, even in the relatively small populations being infected.[39]

This isn't a small issue, though I'm sure Con will attempt to characterize these diseases as unimportant as well. Pneumonia is anything but, resulting from a wide variety of possible causes ranging from bacteria to viruses to fungi. This means that they have to be specifically diagnosed before they can be treated effectively. It is still the leading cause of death among children, the vaccine is minimally effective, and, like all bacterial diseases, the bacterial pneumonia is causing tremendous concern as a result of the antibiotic resistance it's generating (most notably with regards to Streptococcus, Mycoplasma, and Klebsiella-caused cases), making other forms of treatment far less certain.[40] In case that's not enough, the spread of bacterial pneumonia is also associated with more severe symptoms in adults as well (often with Klebsiella), meaning that each infection enhances the other.[41] These bacterial diseases play at least as large of a role in the deaths of those who are infected with measles as nutrition (along with many of the basic symptoms of immunodeficiency caused by measles, like peripheral lymphopenia and T-cell depletion).[42]

5. Con is wrong on the immunosuppressive effects of measles.

“[Measles virus] infection produces an immune system paradox. MV infection, while inducing lifelong immunity, also suppresses the immune system leading to an increase in susceptibility to other, secondary infections.” This article actually includes quite a bit of the data that supports this, as it's essentially a review of numerous primary research papers that established this immunosuppressive aspect and several models for immunosuppression that I won't describe here. Just to give a basic idea, though, of what infections can and do occur:

“Secondary bacterial, protozoal, or viral infections occur because of immunosuppression by MV infection. These infections can result in pneumonia, chronic pulmonary disease, otitis media, laryngotracheobronchitis, adult respiratory distress syndrome, hepatitis and diarrhea.”

These are admittedly more common in underdeveloped countries, but less common doesn't mean non-existent in the U.S. This data are still pertinent here.[43]

I mentioned influenza in cross-x. The reason I did that is because much the same concerns exist with regards to this disease, which has caused one of the most, if not the most, severe pneumonia pandemic in world history. Con may want to write that off as unique to influenza, but this is the kind of immunosuppressive effect measles has as well.[44]

Con is similarly wrong regarding the effects of measles on immunosuppressed individuals. He says that it's a minor enhancement. That isn't held up in the literature, where these individuals are far more likely to suffer terrible complications.[45] I can't find a free copy of this study, but it's outlined pretty clearly in the abstract. There are numerous other studies that support it as well, making it clear that complications, including death, are far more common among these individuals.[46]

If you need a list of the types of people put in danger, here's a list: those undergoing chemotherapy and/or radiotherapy, those with organ or bone marrow transplants, those with high dose steroids, those with HIV, and those with severe combined immunodeficiency.[47] All of these people present with substantial concerns, and they can't just “avoid people” with the illness, especially when Con himself presents data that a large proportion of the population infected with the virus carries it at sub-clinical levels, but may still be shedding the virus. Hell, considering how many times I'm using Con's source, I think I should really include it in my citations.[48]

5. Con is just blatantly wrong regarding his view that scant few of those who become infected with measles will experience complications, and he proves this in the last section. He shows that a great deal of measles infections are never cleared from the body.[48] That means that some 30% of patients are infected for life, and in the process, they're put at great risk every time their immune system is depressed. This is a huge problem, since this means that for this subset of the population, they're especially likely to experience the complications of the disease at some point over their lives any time they're immunosuppressed.

6. Con makes the claim that mandatory vaccination was not necessary in order to eradicate smallpox, a disease that he admits in his previous round was one of the biggest scourges of human society. This is a completely unwarranted and entirely false statement, providing no evidence for other methods by which smallpox is consistently prevented from infecting others. The symptoms of smallpox may have improved and its spread may have reduced, but we're talking about elimination here, and of a very deadly disease that spread very rapidly. And this is a disease that was primarily spread in a similar manner to MMR, through airborne transmission. It is factual that mandates occurred in many nations, including a number of African nations, and were instrumental in the elimination of the disease. Use of vaccines would have been far too minimal in many African nations to accomplish such a goal. Much as I disagree with the methods used to enforce this particular mandate, and I'm not arguing for international enforcement, the effects speak for themselves.

The eradication of a disease is of no small importance, and in this case, I'm addressing 3. Con is entirely right that “every infected person infects about one other person on average.” Even if the U.S. doesn't manage to get below 1, getting as close to it is a start to a trend of elimination worldwide, and if the effect does occur, even just in the U.S., the benefits there are stark. Disease eradication means minimal disease resulting from these viruses and little to no need to dedicate resources from control programs like the CDC or NIH (and therefore to put those resources towards other issues). This article even shows that we could save as much as $4.5 billion as a country if vaccination were able to be discontinued in the U.S. as a result of the eradication of measles alone, and other industrialized nations could save hundreds of millions “if measles were eradicated, even assuming that measles vaccination would continue.”[49]

Voting issues:

I know it's been a long round, so I'll post those questions I started out with again to ground it.

1) Do the MMR viruses present a substantial risk to the public health of the United States?

I've shown that these 3 viruses represent a systematic threat to our utility through our public health, that that threat is growing and very likely to continue doing so, and that it persists most strongly in a society that is further away from herd immunity. Whether it's the viruses themselves that cause the harms or the complicating and difficult to treat infections that commonly accompany them, these are diseases that present with exponentially higher dangers as the number and size of their epidemics continue to grow.

2) Can that risk be ameliorated to a significant degree by mandating vaccination?

I've shown that vaccination is the most broadly effective means of lowering the risk of infection and, therefore, both the short- and long-term harms of that infection. Any other means merely delays complications and places many others in danger of more severe outcomes.

3) Does that risk reduction outweigh the potential harms that accompany it?

I've shown that there are rights issues on both sides of the house in this debate, and that the rights arguments presented by Con fail to present any meaningful impacts that can be weighed against those I have provided. I've shown that vaccination presents a minimal and comparatively negligible risk to those who receive it under the stated guidelines, and that any outcomes for societal perception of health are likelier to be beneficial than harmful.

Based on these three questions and their answers, I've shown why you should vote Pro. I now yield the floor to Con to finish out the debate.

15. http://en.wikipedia.org/wiki/Eugenics

16. http://www.cdc.gov/vaccines/imz-managers/laws/state-reqs.html

17. http://www.immunizationinfo.org/vaccines/smallpox

18. http://en.wikipedia.org/wiki/Jacobson_v._Massachusetts

19. http://en.wikipedia.org/wiki/Smallpox

20. http://www.nytimes.com/2010/11/26/world/26fenner.html?_r=0

21. http://www.who.int/ith/vaccines/en/

22. http://www.drugs.com/

23. http://ieeexplore.ieee.org/xpls/abs_all.jsp?arnumber=993764&tag=1

24. http://www.kidshealth.org.nz/measles-immunisation

25. http://www.nvic.org/vaccines-and-diseases/Measles.aspx#Injuryv

26. http://www.merck.com/product/usa/pi_circulars/m/mmr_ii_pi.pdf

27. http://www.fda.gov/Drugs/DevelopmentApprovalProcess/Manufacturing/ucm169105.htm

28. http://en.wikipedia.org/wiki/Smallpox_vaccine

29. http://articles.mercola.com/sites/articles/archive/2012/08/28/polio-eradication-campaign.aspx

30. http://www.ibtimes.com/measles-outbreak-2014-592-cases-reported-us-after-disease-eliminated-2000-1681352

31. http://www.cdc.gov/nchs/fastats/immunize.htm

32. http://www.advisory.com/Daily-Briefing/2013/08/08/The-states-with-the-best-and-worst-vaccine-coverage

33. http://www.deadstate.org/new-cdc-report-thanks-to-anti-vaccine-hysteria-u-s-measles-cases-have-tripled-in-2013/

34. http://healthblog.dallasnews.com/2014/08/vaccination-rates-for-kids-are-down-rates-of-infectious-diseases-are-up.html/

35. www.publichealthreviews.eu/show/p/92

36. http://en.wikipedia.org/wiki/Salmonella

37. http://healthyeating.sfgate.com/risks-undercooked-chicken-2327.html

38. http://www.cdc.gov/measles/about/complications.html

39. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a4.htm

40. http://www.cdc.gov/pneumococcal/drug-resistance.html

41. http://www.ncbi.nlm.nih.gov/pubmed/10065681

42. http://www.academia.edu/1462060/Factors_associated_with_fatal_cases_of_measles

43. http://www.ncbi.nlm.nih.gov/books/NBK2487/

44. http://www.nih.gov/news/health/aug2008/niaid-19.htm

45. http://www.ncbi.nlm.nih.gov/pubmed/1538561

46. http://cvi.asm.org/content/13/4/437

47. http://www.adhb.govt.nz/starshipclinicalguidelines/Measles%20Infection%20Control%20and%20Guideline.htm#Appendix_3

48. medind.nic.in/ibl/t03/i1/iblt03i1p8o.pdf

49. www.cgdev.org/doc/millions/MS_case_1.pdf

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"the next time a media article blames the “anti-vaccination movement”, or uneducated parents, do a little more research. And remember: people used to think the world was flat, people were imprisoned for suggesting that the earth revolved around the sun (instead of the other way around), and doctors used to doubt the relationship between tobacco and disease."