Context: This research examines the development of vaccination policy in Britain, the United States, and Australia to begin to understand the different forms of coercion that industrialized states utilize to achieve vaccination compliance from the majority of their citizens.
Methods: This research applies a comparative-historical analysis of the three countries listed, using a combination of primary and secondary documents.
Findings: The different degrees of compulsion in the vaccination policies of Britain, the United States, and Australia is explained through an analysis of the path-dependent ways that each nation adapted coercion in response to civil society resistance. Each nation has moved up and down a continuum of coercion searching for a policy that balances overcoming passive noncompliance without engendering active resistance. Arriving at different balancing points between these two objectives, the three nations have now institutionalized policies with different degrees of coercion.
Conclusions: This research shows that vaccination policy is not just created top-down by the state, but through an ongoing interactive process with citizens and civil society. Furthermore, as vaccination is a “wicked problem” that faces ongoing civil society resistance, states will need to perpetually adapt the coerciveness of their policies into the foreseeable future.
Much research on vaccination has tried to understand the behavior and beliefs of those opposed to it (see Kata 2012; Krishna 2018; McCoy 2018; Reich 2016). While it is important to explain why some people resist vaccination, it is equally important to understand how industrialized nation-states achieve compliance from the vast majority of their populations. In 2014, for example, the vaccination rate for measles was 93% in Australia, 93% in Britain, and 91% in the United States (OECD 2015). Do citizens in these three countries simply believe in and support the practice of vaccination? No. Over half of Australian parents have concerns about vaccinating their children (Hagan 2013), nearly 1 in 5 Britons think that vaccines might not be safe (Larson et al. 2016), and over a quarter of Americans think that vaccinated children have a higher risk of developing autism (Kahan 2014).
How do these nations achieve such high vaccination rates when a sizeable portion of each country's population is wary of it? This is achieved through policies that, to varying degrees, coerce citizens to get vaccinated. By focusing on the power that industrialized states have gained to immunize their citizens, the compliance of most citizens is not viewed simply as a normal form of behavior that needs no further explanation, but rather as a historical achievement of industrialized states to gain a certain degree of control over the biological lives of their citizens that now appears natural. By examining the development of vaccination policy in Britain, the United States, and Australia, we can begin to understand the range of coercive techniques that industrialized nations more generally utilize to manufacture vaccination compliance.1
While these countries have reached similar vaccination outcomes, they have not achieved them in the same way. As vaccination is voluntary in Britain, state agencies achieve compliance through persuasion, routinization, and financial payments to general practitioners. The United States relies on a more compulsory approach of requiring vaccination for school attendance and, in most states, daycare. Australia has instituted a compulsory “all of the above” approach. By utilizing a mix of policies that includes regulations for school attendance and childcare services, financial payments to doctors, and a substantial tax penalty for families of unvaccinated children, Australia has developed the strictest vaccination policy of the three countries. How did these three nations develop vaccination policies with different degrees of coercion?
Performing a comparative-historical analysis, using a combination of secondary and primary sources, I find that each nation institutionalized a distinct style of vaccination through a long process of responding to noncompliance from civil society and adapting the coerciveness of its vaccination policy. As they developed their country's policy, health officials encountered two problems: passive noncompliance (apathy from lax parents) and active resistance (opposition from civil society groups). Over time, each nation has moved up and down a continuum of coercion, searching for a vaccination policy compulsory enough to overcome passive noncompliance yet not so severe that it engendered active resistance. Achieving this fine balance was unique to each country and occurred over an extended period of time. The current vaccination policies of Britain, the United States, and Australia are now more or less coercive because they have arrived at different balancing points between these two objectives.
The differences in their vaccination policies thus need not only be explained through an examination of their contemporary macro-level differences, but also through a comparative-historical observation of the different ways that the state and civil society reacted to each other's actions. The main parts of this interactive process are policy action, civil society response, and then state adaptation. This research thus highlights (as previous research has explored—see Alford 2002; Gofen 2015; Gofen et al. 2019; Jacobs and Weaver 2015) the role the public plays in shaping public policy. Each country's approach to vaccination was not just created top-down by the state but also through a process of response and adaptation between civil society and the state.
The continued existence of anti-vaccination movements in the contemporary era shows that this process is ongoing. As described by Tuohy (2018), vaccination policy is what social policy scholars call a “wicked problem”—a complex problem requiring the integration of multiple divergent issues which has no final solution. As a policy that achieves full vaccination compliance “once and for all” is impossible, the three states under consideration will continue to increase or decrease the coerciveness of their policies in response to the ongoing apathy for or resistance to vaccination from civil society.
Possible Structural Explanations and the Approach of Path Dependency
To explain the current differences in the vaccination policies of Britain, the United States, and Australia, it is tempting to look for some contemporary macro-level difference between them. For instance, for most of the twentieth century Britain has had a nationalized system of healthcare, while the United States has not.2 One could argue that this structural difference explains the difference in how coercive their vaccination policies are. Having a national healthcare system, Britain has the state resources to make vaccination routine and so does not have to resort to compulsion. As the US state is less involved in its citizens' health, it has to rely on more compulsory measures.
While below I argue that a national healthcare system did help Britain institute a less compulsory vaccination system, the main problem with this argument is Australia. Australia also has a government-funded system of healthcare and so also has,3 theoretically, the organizational resources to persuade rather than compel its citizens to get vaccinated. Yet, as we shall see, Australia has developed the most compulsory system of vaccination of the three countries. If the existence of a national healthcare system explains why Britain enacts a relatively lenient vaccination policy, it fails to explain why Australia enacts a very strict one.
Alternatively, we might appeal to cultural differences. A classic biomedical example of this approach is Titmuss's (1971) study of the distinct ways that Britain and the United States provide blood for medical procedures based on the way each country values community and conceives of the obligations citizens have to one another. We might similarly examine how the cultural values of Britain, the United States, and Australia guide their vaccination policies. The problem here is the United States and Australia. America's presumed libertarian political culture (see Hartz 1955; Lakoff 2005) is at odds with the coercive mechanisms that US states utilize to vaccinate their citizens. Likewise, although Australia is described as also possessing an ideology of “cultural liberalism” (Melleuish 1995), it has, as mentioned, enacted a very strict system of vaccination.
Maybe there is a difference in how compliant citizens are in each country? Hood, Rothstein, and Baldwin (2001) describe three different cultures of compliance: in compliant cultures official bans or warnings are sufficient to produce policy compliance; in opportunistic cultures behavior must be monitored and sanctioned so that regulatees can see the benefit of complying; and in defiant cultures sanctions may actually produce greater resistance. Maybe the classically liberal culture of the United States and Australia encourage citizens to be opportunistic or even defiant, requiring state organizations to enact coercive mechanisms to produce vaccination compliance? The problem with this argument is now Britain. In regard to vaccination, we shall see below that during the nineteenth century and right up until the 1940s there was a strong and very “defiant” compliance culture in Britain. Yet, in the twentieth century British health organizations have managed to achieve mass compliance with the least coercive vaccination system.
Although one could continue to search for (and possibly find) contemporary structural differences between Britain, the United States, and Australia, I believe it is more fruitful to examine the historical development of vaccination policy. Previous work (e.g., Abiola, Colgrove, and Mello 2013; Colgrove 2006; Pacheco and Boushey 2014; Salmon et al. 2006) has examined the development of vaccination policy in these countries, yet what still needs to be understood is how they developed vaccination policies with different levels of coercion. To explore this question I adopt the comparative-historical approach of path dependency. Path-dependent approaches examine how a sequence of historical events can produce long-term institutional patterns. At some point in the past a social actor, like the state, has a range of options. Once taken, the field of possible future actions narrows until a critical point is reached and a style of action becomes institutionalized (Mahoney 2000; Pierson 2003).
An important part of this approach are self-reinforcing and self-undermining feedback effects. Reinforcing feedback loops occur when policy actions create further conditions for the maintenance and even expansion of the policy which can “lock in” a state actor into a certain policy approach (Pierson 2003). Self-undermining feedback loops gradually weaken support for the policy, making it more difficult to carry them out. Jacobs and Weaver (2015) describe three kinds of negative feedback loops: (a) policy actions that create unanticipated loses for mobilized social interests, (b) the loss of public support because of cognitive effects of policy, and (c) when the range of policy tools are broadened rather than narrowed.
Researching health policy, Tuohy (2018) argues that when a policy creates countervailing positive and negative feedback effects, a state can begin to cycle through its repertoire of policy instruments in an attempt to balance and then rebalance the persistent tension between them. Adjustments made to counteract negative-feedback effects and achieve equilibrium again can create a whole new set of negative feedback effects that need to be balanced once more. Empirically, Skogstad (2017) shows how a shift in the balance from self-reinforcing to self-undermining feedback effects eventually encouraged the European Union to weaken its biofuel policies.
The different vaccination policies of Britain, the United States, and Australia can be explained through the distinct path-dependent sequence of events that each country went through. During a critical period, state organizations in each nation took coercive policy actions to compel citizens to get vaccinated. These policies produced self-reinforcing, but also self-undermining feedback effects in the form of fomenting mass resistance movements (a negative feedback effect similar to the creation of unanticipated losses for mobilized interests). In Britain and the United States, the balance tipped toward self-undermining effects and they were forced to give up on a strictly coercive approach to vaccination. Over the course of the twentieth century, the two nations cycled through more and less coercive policy alternatives in order to achieve a balance between producing sufficient compliance without fostering excessive resistance. While Australia also experienced resistance, it was not so great as to alter its approach to vaccination. Instead it has only increased the coerciveness of its vaccination policy. Let me develop this analysis.
Adapting Coercion in Response to Civil Society Noncompliance
The Continuum of Coercion
Public policy has been described (Schneider and Ingram 1990) as the utilization of state tools to compel or enable people do things they might not otherwise do. A key part of public policy is thus what are called “compliance regimes”: “The instrument or instruments that governments use to secure compliance, the settings on those instruments, and the targeting of those instruments” (Weaver 2014: 252). This research examines how the three countries under consideration created distinct compliance regimes to vaccinate persons who might not have otherwise. Policy analysts have developed a number of ways to categorize policy designs (for an overview, see Howlett 2010). As well as older typologies, such as Hood's NATO model, policy designs are now categorized by how many tools are used to carry out an objective, how integrated these tools are (i.e., how well they work together), the degree of freedom there is to develop or alter policy, and the different policy styles (i.e., legal, corporate, market, and network governance models) states utilize (Howlett and Rayner 2013).
Recognizing the amount of conceptual work on typologies that has been done, this research restricts itself to a typology of how coercive a compliance regime is. Howlett (2010) describes, as well as criticizes, a number of typologies that place policy instruments along a continuum of coercion. I utilize Vedung's ( 2011) typology of “sermons,” “carrots,” and “sticks” that possess what he calls increasing degrees of “authoritative force.” The least compulsory are sermons: policy instruments that influence behavior through the transmission of information and techniques of persuasion. More compulsorily are carrots: economic instruments that provide either cash-related incentives or penalties that make it cheaper or more expensive for citizens to follow a course of action. Sticks have the greatest authoritative force: regulations that obligate citizens to follow a certain course of action through the enforcement of rules. Regulations are more compulsory than carrots because whereas economic benefits or penalties only incentivize or disincentivize a course of action, regulations obligate citizens to act in a certain way.
The concept of “policy mixes” can be added to this typology. Policy mixes are the complex arrangement of policy tools and goals that can be organized in a more or less systematic way to carry out a policy objective (Howlett and Rayer 2013). The exact tools within this mix can thus be a combination of more and less coercive instruments. Only by observing the combination of tools within the vaccination policy mixes of Britain, the United States, and Australia is it possible to ultimately say where along a continuum of coercion their compliance regime falls.
As Britain's policy mix mainly utilizes informational instruments, it is situated at the bottom of this continuum of coercion. Even though the United States uses regulation in the form of school and daycare vaccination mandates, it is located between Britain and Australia. Australia's policy portfolio includes sticks in the form of vaccination requirements for preschool and childcare, sermons in the form of vaccination health campaigns, and carrots in the form of financial benefits for doctors and a sizeable tax penalty for non-vaccinating parents. As multiple forms of state coercion are utilized (including regulation), Australia's vaccination policy is located at the top of this continuum of coercion.
Overcoming Passive Noncompliance and Avoiding Active Resistance
How did these three countries create compliance regimes located at different points along this continuum of coercion? In developing vaccination policy, each nation has faced an enduring political dilemma: how to balance protecting the public's safety with the demand for individual rights by citizens. The solutions they came up with to this problem were not the result of an abstract discussion of political theory but were the outcome of an ongoing social process of adapting coercion to the actions of civil society.
Specifically, each country encountered two problems: (a) passive noncompliance—apathy from some of the citizenry who were either uninformed or simply uninterested in the benefits of vaccination, and (b) active resistance—deliberate civil society opposition to the state's vaccination policy. These problems became interrelated. When the states encountered passive noncompliance, they developed policies to compel indifferent parents to vaccinate their children. Yet, in enacting more compulsory measures the state encouraged active resistance from civil society groups that did not want the state interfering with their bodies. If the state gave in and reduced the level of compulsion, it once again experienced more passive noncompliance. The problem here is the target population for vaccination policy is not homogenous (Weaver 2015). The coercive policy instruments used to make one segment of the population (i.e., the lax) comply produced noncompliance in another segment (i.e., the resistant). States had to thus design a finely balanced compliance regime; one that was compulsory enough to overcome passive noncompliance but was not so strict that it fostered active resistance.
The main argument of this article is that finding this balance was an interactive historical process. When the response of civil society to the state's vaccination policy tipped the balance from self-reinforcing to self-undermining feedback effects, the compliance regime of the state was forced to move back down the continuum of coercion. When too much passive noncompliance occurred the state had to find ways to move back up. In this way, Britain, the United States, and Australia have, over time, moved up and down the continuum of coercion, adjusting and readjusting their policies to be more or less compulsory, until they each found an approach that was (more or less) able to achieve this fine balance. Importantly, the different degree of coercion that now exists in each system shows that the current balancing point between overcoming noncompliance while avoiding resistance is not the same for all three countries.
Vaccination in Britain, the United States, and Australia
In comparative-historical analysis, the cases being considered should ideally vary along the variable the researcher is interested in, but in other ways remain similar. This allows the researcher to narrow down the list of potential factors that might explain the divergent outcome (Smelser 1976). Although Britain, the United States, and Australia have different vaccination policies, they otherwise share a number of common features (industrialized economies, liberal-democratic political systems, a common language, and shared cultural history as the United States and Australia are both former colonies of Britain) that make them suitable for comparison.
In Britain, vaccination is voluntary (see the Department of Health's “green book,” Immunisation against Infectious Disease) (Salisbury, Ramsay, and Noakes 2017). As explained by Public Health England (PHE 2014), “Parents are free to choose whether to protect their children, as no vaccination is compulsory in the UK.” Instead of explicit compulsion, compliance is produced through two interconnected mechanisms: the routinization of vaccination (a process in which vaccination becomes a normal part of a citizen's interaction with a state-run healthcare system) and manufactured consent (a process in which citizens are persuaded to vaccinate their children by government officials and public health marketing).
British health agencies use carrots (economic instruments) and sermons (information instruments) to produce compliance. First, vaccination is offered free of charge as part of the British healthcare system (Salisbury, Beverley, and Miller 2002). By having a centralized state-run system of healthcare, Britain is able to provide immunizations economically to all citizens and ensure there are no shortages. The vaccination becomes part of the government's overall involvement into citizens' health (Freed 2005). This is an example of the power of “leverage points”—how significant compliance gains can be achieved efficiently by using the existing state structures to reduce the cost of compliance and simplify the process of complying (Weaver 2015). As British citizens already interact with a government-run healthcare system, health officials are able to leverage this structural aspect of the British state apparatus to increase the rate of compliance for vaccination at little cost and without resorting to more coercive methods.
Moreover, when parents bring their child to their general practitioner (GP), these state-employed doctors advocate, on behalf of the government, that the child be vaccinated. GPs are given a financial incentive to do this as they receive bonuses when their communities achieve optimal rates of vaccination. For example, in England, GPs are paid £9.80 for every patient in their community who is immunized on time (NHS Employers 2016).
Health visitors are also an important tool of persuasion. Health visitors are public health nurses that visit the families of newborns to provide information about the proper care of infants, including the importance of vaccinations. As part of the Healthy Child Programme (HCP), health visitors are tasked with identifying a child's immunization status and then advocating for any necessary vaccinations (NHS—England 2014). As a Department of Health (2009) document recommends, “At every contact, members of the HCP team should identify the immunisation status of the child” (24) and “Every contact should be used to promote immunisation” (25). Parents are also asked if they consent to having their child's health information entered into the national Child Health Information Services (CHIS) IT system. This allows the immunization status of all consenting British children to be tracked and monitored (NHS—England 2015).
Public health education campaigns are another tool in Britain's vaccination policy portfolio. For example, in 2013 Britain's Department of Health launched a £20 million campaign that sought to have 10- to 16-year-olds get caught up with their measles, mumps, and rubella (MMR) vaccinations by generating demand for the vaccination through print media ads, Facebook advertising, and a Twitter hash-tag: “#getthemmr” (Boseley and Meikle 2013).
The previous director of immunisation at the Department of Health, David Salisbury, provides a good summary of the whole process of vaccination in Britain:
No immunisations are compulsory. When a child's birth is reported, the local health authority is alerted and allocates the child to a general practitioner (GP). This process enrols the child onto the local health authority computerised database that will schedule the immunisations, calculate local coverage, identify defaulters and arrange payments for the GPs. By the time that an infant is 10 days old, the health visitor will have visited the parents. The health visitor discusses immunisation arrangements and seeks parental consent for the child to be entered into a computer-based programme. Consent is almost universal (Salisbury, Beverley, and Miller 2002: 202).
While the administration of immunization has become more fragmented and localized after the passage of the Health and Social Care Act in 2012 (Chantler et al. 2016), the core aspects of vaccination in Britain remain as described above (see PHE 2017).
Thus, while vaccination is not per se compelled, neither can it be called simply voluntary. British parents consent to having their children vaccinated, but only after it is presented to them and advocated for by health professionals. Health agencies intervene to make the practice of vaccination a habitual, even mundane, part of raising one's child within a state-run system of healthcare. The universal consent the state lauds is something the state produces.
In this way, British health officials more or less solve the problem of overcoming passive noncompliance while avoiding active resistance. By making vaccination voluntary, the state eliminates a key aspect of a vaccination policy that might engender resistance, but by routinizing the practice the state, aided by pressure from GPs and health visitors, is able to overcome passive noncompliance by essentially manufacturing consent.
How did these subtle techniques of persuasion and routinization come to be the main tools in Britain's contemporary vaccination policy mix? To understand this, we have to go back to Britain's experience with compulsory vaccination in the nineteenth century. Three years after a massive outbreak of smallpox in 1837, Britain passed its first vaccination act. The Vaccination Act of 1840 tried to use the carrot of free vaccinations for the working classes to increase the rate of immunization in the populace. When most of the working class were still not getting immunized, vaccination for all infants was made mandatory under the aptly named Compulsory Vaccination Act of 1853. In 1871, an updated version of the act allowed for multiple prosecutions; this increased the compulsory nature of the act as now parents could be fined repeatedly until they complied (Brunton 2008).
In response, a strong anti-vaccination movement emerged. In the 1860s and 1870s a number of civil society organizations formed: the National Anti-compulsory Vaccination League, the Anti-compulsory Vaccination and Mutual Protection Society, and the London Society for the Abolition of Compulsory Vaccination, to name just a few. Many of these organizations had strong support; by 1870, the National Anti-compulsory Vaccination League had 103 chapters and claimed to have 10,000 members. These organizations published journals (e.g., The Anti-Vaccinator) and held well-attended marches. In 1885, a demonstration in Leicester was attended by somewhere between 80,000 and 100,000 people (Durbach 2005). Essentially, Britain's coercive vaccination policy produced a significant negative feedback effect of engendering active resistance to the policy.
By the end of the century, the government relented and made vaccination less compulsory. In 1898, the Royal Commission on Vaccination called for the inclusion of a conscientious clause that would allow persons to opt out of the state's compulsory vaccination policy. To explain this new policy, the commission's report stated,
The irritation which these repeated convictions create . . . and the agitation and active propaganda of anti-vaccination views which they foster tend so greatly to a disuse of the practice that in the result the number of children vaccinated is less than it would have been had the power of repeated prosecutions never existed. The ultimate object of the law must be kept in view . . . to secure the vaccination of the people. If a law less severe, or administered with less stringency, would better secure this end, that seems to us conclusive in its favour (Royal Commission on Vaccination 1898: 298)
In this statement, and many others like it, we observe how, in crafting a less compulsory vaccination policy, officials are adapting policy in response to resistance from civil society. Elsewhere in the report we see the commissioners trying to achieve that fine balance between overcoming “neglect” and “indifference” while also avoiding active resistance. The commissioners state that a compromise policy of conscientious objection is put forward because,
If no penalty were attached to the failure to vaccinate, it is, we think, certain that a large number of children would remain unvaccinated from mere neglect on the part of the parents, or indisposition to incur the trouble involved, not because they thought it better in the interest of their children . . . if a scheme could be devised which would preclude the attempt (so often a vain one) to compel those who are honestly opposed to the practice to submit their children to vaccination, and, at the same time, leave the law to operate, as at present, to prevent children remaining unvaccinated owing to the neglect or indifference of the parent (Royal Commission on Vaccination 1898: 299–300).
Although the British government now allowed parents actively opposed to vaccination to be exempt, parents still had to go before a judge to get approval of their conscientious objection. Many judges refused. This changed in the early twentieth century. The Vaccination Act of 1907 allowed parents simply to sign a form declaring that vaccination was against their conscience (Durbach 2005). Once more this policy change was motivated by civil society resistance.
The anti-vaccination movement was able to exercise its political might in the 1906 general election and get over a hundred anti-vaccination supporters elected to office (Salmon et al. 2006). Liberal MP and anti-vaccination supporter, Arnold Lupton, warned that the anti-vaccination movement would be displeased if changes were not made to the vaccination law, and it would “go hard with the Liberal Party at the next election” (quoted in Durbach 2005: 189). The anti-vaccination movement called for a complete abolishment of vaccination laws, but the parliament proposed the compromise of making it easier for vaccination opponents to opt out. Here again we see the process of negotiation between state and civil society actors. After the act was passed, the number of persons applying for certificates tripled and there was a substantial drop in the rate of vaccinated children (Durbach 2005).
All vaccination requirements were repealed in 1946 with the passage of the National Health Services Act. By this time, in many parts of Britain over half of parents were applying for certificates of exemption (Salmon et al. 2006) and so instead of compelling vaccination, the newly formed National Health Service (NHS) decided it would make vaccination voluntary and free of charge to all citizens. Citizens then began to accept the practice of vaccination as part of the bargain of having “free” government-funded healthcare (Gilbert 1966).
A 1944 Ministry of Health white paper explains the reasoning for the change. It notes that with sustained resistance from the anti-vaccination movement, the previous compulsory vaccination acts were proven to be ineffectual. Any effectiveness they had was eroded by the increasing use of the conscientious clause in the twentieth century. Moreover, the government's success in immunizing the populace against diphtheria in the 1940s with free vaccinations and advertising in the form of posters, radio talks, and newspaper ads showed that noncompulsory forms of vaccination could work (Pollock 2003). The Ministry of Health report thus concluded,
It is probable that the time has come to amend the law, and to substitute for compulsory vaccination, a system of free vaccination for all through the family doctor, the clinic services, or otherwise. This is the method adopted during the present war in organising the immunisation of children against diphtheria. Supplies of the necessary toxoid have been provided free, and immunisation has been performed normally without charge to parents, while every method of publicity has been used to encourage them to take advantage of the facilities provided (Ministry of Health 1944: 58)
Britain tried to travel down a compulsory path, but because of the negative feedback effects of that policy found the way blocked. In the mid-twentieth century, Britain switched course and “cycled” (Tuohy 2018) to a policy of free voluntary vaccinations encouraged by publicity. The British state put away its sticks and began to travel down a path of carrots and sermons.
Health visitors became a part of this new strategy. By the 1920s, health visitors were established as a state service that provided mothers with childcare information and checked on the health of newborns. In this way, they became a paternalistic tool that allowed the state to shape the health behaviors of mothers (Abbott and Wallace 1998). By mid-century, health visitors were used to advising new mothers about vaccination and enrolling newborns into a national vaccination registry (NHS—England 2014). Health organizations also began to publicize the benefits of vaccination. The Health Education Council, formed in 1968, produced television and print advertisements that advocated that citizens get vaccinated. One print ad declared that “Measles Is Misery” and that vaccination is free for all citizens up to age 15 (Pollock 2003).
In 1963 the British state established the Joint Committee on Vaccination and Immunisation (JCVI) to oversee the implementation of new vaccines, and in the 1980s the JCVI, along with the Department of Health, developed the practice of providing GPs with financial reimbursements for fulfilling vaccination requirements (Alderson et al. 1997). In this way, Britain was able to achieve high rates of vaccination by the end of the twentieth century without resorting to compulsory measures. However, this has not meant that resistance to vaccination entirely went away. During the 1970s and 1980s the Association of Parents of Vaccine Damaged Children waged a fierce campaign against the whooping cough vaccine after some children were brain damaged (Berridge 1999) and even in present-day Britain there are civil society groups like Arnica that still resist vaccination and support “natural immunity” (Speed 2015).
From this brief history of vaccination, we can see the interactive process the British state went through to adapt coercion in response to civil society actions. In a path-dependent series of events, the state first tried to vaccinate the populace through the use of economic subsidies, that is, providing free vaccinations to the working classes. When this was not effective because of too much passive noncompliance, the state moved up the coercion continuum and regulated that all infants be vaccinated. This produced a significant negative feedback effect in the form of fomenting active resistance from civil society. The state relented and moved back down the continuum of coercion by offering a way to opt out of compulsory vaccination. This again produced too much passive noncompliance. By the late twentieth century, the British state seems to have, more or less, “solved” the problem of vaccination by using routinization, advertising, and persuasion. This approach is institutionalized as it is able to produce a sufficient degree of vaccination compliance by overcoming indifference to vaccination while also avoiding the cost of fostering (too much) civil society resistance.
Crossing the Atlantic, the vaccination policy portfolio of the United States is a mixture of carrots (economic instruments) and sticks (regulations). Carrots come in the form of government vaccine purchases for low-income families; the US federal government provides cost-free vaccinations through federal entitlement programs like the Vaccination Assistance Act of 1963, the 2002 Vaccines for Children Program, and Medicaid, which began to reimburse beneficiaries for vaccines in 1981. In the twenty-first century, the federal government pays for 57% of all childhood vaccines (Hinman, Orenstein, and Rodewald 2004).
The main tool of the United States is the regulation that children be vaccinated in order to attend school. This policy is instituted in all states and in most includes daycare and applies to both public and private schools (CDC 2015). As the United States is a federal system, vaccination laws vary significantly by state; the best example of this are laws on vaccination exemptions. All states allow medical exemptions, forty-seven states allow exemptions for religious reasons, and eighteen states provide a philosophical exemption in case vaccination contradicts someone's personal beliefs. States also differ in how hard it is to obtain these exemptions. In some (e.g., Alaska) a person has to be a member of recognized religious group opposed to vaccination, in others (e.g., Oregon) a person is required to receive information on the benefits of vaccination and the risks of remaining unvaccinated, while in others (e.g., Iowa) a citizen simply has to declare on a form that it is against their religious or personal beliefs. Twenty-eight states have laws in which exempted students can be excluded from school during an outbreak (CDC 2015).
Through this mechanism of school mandates, US health agencies try to balance overcoming passive noncompliance with avoiding active resistance. By requiring vaccination for school and daycare, the states help ensure that even apathetic parents vaccinate their children. Yet, by ostensibly giving parents a choice—vaccinate your children to gain access to a public good (e.g., education) or choose not to vaccinate and lose it—health officials hope to give the appearance of choice and thus defuse active resistance. This argument was explicitly made by the future director of the Centers for Disease Control and Prevention's (CDC's) Immunization Program, Walter Orenstein. Recalling when school vaccination requirements were instituted in Los Angeles in 1977, he stated, “The school mandate [in Los Angeles] really changed everything. That set the precedent for no shots, no school. The beauty of the school laws is that we didn't have policemen forcing people against their will to be vaccinated. We just said if you are unwilling to be vaccinated, you can't go to school” (quoted in Offit 2015: 139).
Exemptions also help achieve this balance. States make it possible for children to attend school unvaccinated, but also create barriers to this choice. The ability to opt-out defuses active resistance to the policy (those that are avidly opposed may not have to comply), but by creating a burden to opting-out it ensures that simply negligent parents will still conform.
How did the United States come to rely so heavily on school mandates? In the late nineteenth century, various states tried, unsuccessfully, to implement compulsory community-wide vaccination. For example, in response to the nationwide 1893–94 smallpox outbreak, the Brooklyn Health Department deployed vaccinators to forcibly vaccinate residents. Residents fled when vaccinators appeared or simply refused to comply. Similar acts of defiance occurred in Illinois, Minnesota, Wisconsin, Indiana, and Rhode Island and happened again in the smallpox outbreak of 1901–02 (Colgrove 2006). It was not just random acts of disobedience; states also experienced organized civil society resistance. Various anti-vaccination groups formed (e.g., the New England Anti-compulsory Vaccination League, the Anti-vaccination League of America, etc.). They published journals (e.g., The Liberator), printed books (e.g., The Facts against Compulsory Vaccination), held marches, and flooded state legislatures with petitions calling for the abolition of compulsory vaccination. They used the rhetoric of “medical liberty” to argue that the government did not have the right to interfere with the health of private citizens (Colgrove 2006). As in Britain, compulsory vaccination produced a significant negative feedback effect of engendering a mass resistance movement.
While at the start of the twentieth century various states, such as New York and Massachusetts, still had compulsory laws on the books, these laws were constantly under attack by anti-vaccinationists and thus rarely enforced. Other states, like Wisconsin and Washington, actually repealed their vaccination laws. Resistance from civil society groups and the public at large made it impossible for states to carry out compulsory policies of community-wide vaccination (Colgrove 2006).
In the 1920s, health agencies moved away from compulsion and tried persuasion and education. The idea of selling vaccines to the public was first tried with the diphtheria vaccine; New York produced an advertising campaign with posters, postcards, and lectures. Similarly, the United States Children's Bureau distributed pamphlets on the importance of the vaccine to homes all over the country. The confidence in the power of persuasion was broken in the 1930s. While cases of diphtheria were now much less common, it also meant that the threat was less real. Fewer and fewer children were vaccinated; in New York City less than two-thirds of children received the diphtheria vaccination (Colgrove 2006).
In the 1960s a similar experience occurred with measles. When the measles vaccine was developed in 1963 the country saw a significant decrease in cases through most of the decade. But even with a free and highly publicized vaccine, by 1968 the number of measles cases started to rise. As the level of passive noncompliance steadily increased, states decided persuasion was no longer enough. States cycled back to compulsion—in the form of a vaccination requirement for school attendance—in order to once more find a balance between compelling lax parents to vaccinate while avoiding active resistance from defiant parents (Tuohy 2018).
The legal basis for school mandates was a 1905 Supreme Court case. During an outbreak of smallpox, Cambridge, Massachusetts resident Henning Jacobson refused to comply with a city ordinance requiring vaccination. In Jacobson v. Massachusetts (197 US 11 ) the US Supreme Court upheld the city's actions, arguing that certain liberties can be curtailed during an outbreak in order to protect the public's safety. This case became an important precedent for later cases and helped empower states to institute vaccination requirements for school attendance. It was cited in the 1922 case of Zucht v. King in which the Supreme Court upheld a Texas city ordinance that required schoolchildren to be immunized against smallpox and again in the 1968 New York Supreme Court case of McCartney v. Austin in which the court declared that the state's vaccination law did not interfere with Roman Catholics freedom to worship (Gostin 2008).
Widespread use of school mandates began in the 1970s. With the passage of the 1962 Vaccination Assistance Act, there was a renewed push for the mass immunization of the populace. In 1966, the CDC was put in charge of coordinating nationwide immunization efforts and adopted a new approach to infectious disease control: the complete eradication of targeted diseases. It outlined a plan for the elimination of measles through the use of school vaccination mandates (Conis 2015). At the start of the 1970s, a few states adopted the practice, but by 1981 all states made vaccination against a set of infectious disease mandatory for school attendance (Orenstein and Hinman 1999). Why did this policy spread so quickly and so wide?
Two reasons. First, the use of school mandates was shown to be effective: states that adopted the policy observed significant increases in their rate of vaccination (Conis 2015). For example, Alaska experienced an outbreak of measles in 1976 and health officials quickly moved to enforce vaccination requirements for school attendance. After the policy was implemented, government research (see Middaugh and Zyla 1978) showed a dramatic increase in the rate of vaccination among schoolchildren. At one school, within one month of the order there were only fifty students that did not have a certificate of vaccination. Various studies began to show that states with school mandates had much higher vaccination rates and no outbreaks (Gostin 2008).
Just as importantly, states experienced no widespread community resistance. For instance, Los Angeles County experienced an outbreak of measles in 1977 and the county health director declared that all students had to provide a measles vaccination certificate. Within a few days nearly all students returned to school with a vaccination certificate. Just as important, government officials found that there was a complete lack of organized resistance to the program (see Orenstein and Hinman 1999). Orenstein later recalled that strict enforcement of vaccination requirements was completely acceptable to most parents in Los Angeles (Allen 2007). He stated: “It wasn't forcing vaccination on people that opposed it. It was making vaccination a priority for people who didn't have it as a priority. And the feeling was that if you can do it in Los Angeles, you can do it anywhere” (quoted in Allen 2007: 246).
This belief was confirmed by the experience of school mandates in Alaska. In their research on the impact of school mandates in Alaska, co-funded by Alaska's Bureau of Epidemiology and the CDC, Middaugh and Zyla (1978: 2130) note:
The entire program was surprisingly well received. An adverse reaction to the mandatory immunization program was expected but never materialized. The program received full support and cooperation of the community.
After the first few states met no resistance, other states saw that they could institute such a policy without opposition (Gostin 2008). As Alan Hinman (1979: 694–95), the CDC's director of the Immunization Division, noted, “Numerous examples [now] exist, demonstrating that the public is willing to comply with laws or regulations which require immunization as a condition of school entry or school attendance.”
Once a policy of school mandates was shown to work, the federal government began to connect education funds to a state's use of school mandated vaccination. Thus, even though the United States is made up of a number of individual states that could each create their own vaccination policy, through holding the “power of the purse” the federal government was able to produce a degree of uniformity (Orenstein and Hinman 1999). Overall, school mandates spread around the country as it was a policy that was strict enough to compel indifferent parents to vaccinate, but not so compulsory as to elicit active resistance. Opposition that did exist was suppressed by allowing exemptions. The medical, religious, and philosophical exemptions were put in when states first created their laws. For example, when New York State first instituted a policy of vaccination requirements for school attendance it included a waiver for children whose parents were from a recognized religion that objected to the practice (Colgrove 2006).
The historical process of policy action, civil society response, and state adaptation is ongoing. Even though most US citizens accepted the policy of school mandates, an active anti-vaccination movement developed. Some groups like the National Vaccine Information Center (NVIC) were born in the 1980s over concerns about the diphtheria, pertussis, and tetanus vaccine, while others, like SafeMinds, arose in the 1990s out of concerns about the MMR vaccine and autism (Kirkland 2016). In the last decade, a new and energized anti-vaccination movement has formed in the United States. In addition to concerns over autism, current activists cite a general concern over vaccine safety, fear of intestinal problems, and a general right to personal medical liberty. By 2014 some wealthy school districts in Los Angeles, California, had vaccination rates lower than developing countries such as Chad and the Sudan; 60% to 70% of parents were filling out personal belief exemption forms for their children (Krishna 2018).
This renewed resistance eventually produced increased state enforcement of vaccination policy. When a nationwide outbreak of measles started in California at the end of 2014, states adapted the coerciveness of their policies. California eliminated both its philosophical and religious exemption, Vermont eliminated its philosophical exemption, and Colorado made it more difficult to obtain an exemption (Sandstrom 2015). After another outbreak of measles in Washington State in 2019, bills to remove its personal exemption have advanced through the state house and senate (La Corte 2019). As vaccination is a “wicked problem,” state organizations will likely never achieve total compliance and civil society groups will likely never completely give up. Instead, state and civil society will continue to react and respond to the moves the other makes, locked in a never-ending negotiation of response and adaptation.
Above we see how the United States has traveled down its own path-dependent sequence of events. Like Britain, the United States first tried to implement a compulsory style of vaccination, but after facing stiff opposition was forced to back down. US health agencies then tried to rely on persuasion to vaccinate the populace, but with the persistence of diphtheria in the 1930s and measles outbreaks in the 1960s persuasion was not enough to overcome passive noncompliance. Drawing on early legal victories, US states moved back up the continuum of coercion by utilizing the approach of limited compulsion in the form of vaccination requirements (with exemptions) for school attendance. Once again, it is an approach that seems—more or less—to have achieved a high rate of compliance combined with a limited degree of opposition.
Australia has the strictest vaccination policy of the three countries under consideration. Australia uses an “all of the above” approach comprising most of the policy tools described above and some additional ones. First, Australia operates a government-run healthcare system called Medicare through which vaccinations are provided free of charge through the National Immunisation Program (ATAGI 2017). The immunization status of every person enrolled in Medicare is tracked through the national Australian Immunisation Register; this allows the federal government to track coverage rates and send reminders to parents whose children are behind in their immunizations (Ruff, Taylor, and Nolan 2012). Thus, in Australia vaccination compliance is, like in Britain, partially achieved by the state leveraging the fact that it operates a national healthcare system to simplify the process of compliance and monitoring compliance (Weaver 2015).
Starting in the 1990s, Australian doctors were given a financial incentive to vaccinate their patients. Originally doctors were provided with a fee of six dollars for each notification of a completed vaccination and then in 2014 that was doubled to twelve dollars (Medhora 2015). Also, Australian health officials have tried to persuade citizens to get vaccinated through the use of public health advertising campaigns. Most recently, in 2017 the Australian federal government launched a $5.5 million three-year advertising campaign, including a “Get the Facts” 30-second video advertisement, to encourage parents to vaccinate their children (Hunt 2017).
To increase compliance, the federal government has also turned to the tax code. The annual Family Tax Benefit of $726 per child is withheld three times if parents do not meet the vaccination schedule for their children, amounting to a total tax penalty of $2,178 per child. Then there is the annual Child Care Rebate, which covers 50% of a family's out-of-pocket childcare expenses up to $7,500, and the Child Care Benefit, which provides a tax rebate for the amount of childcare services a family utilizes up to $10,000. Again, both of these rebates are withheld if a child remains unvaccinated. In 2015 the national government removed all exemptions from this regulation except for medical reasons (Medhora 2015). This policy, now labeled the “No Jab, No Pay” approach, produces a strong economic disincentive for parents to vaccinate their children (ATAGI 2017). Moreover, by utilizing the national tax code, the federal government is able to produce a uniform policy of vaccination across multiple states and territories.
Finally, like the United States, Australia has instituted various vaccination laws involving school attendance and childcare. As Australia also has a federated political system these laws vary by state and territory. Victoria, Queensland, and New South Wales require a certification of vaccination in order for a child to attend daycare or preschool. At the end of 2018, Western Australia introduced legislation that would similarly require children to be vaccinated to attend kindergarten or daycare (Davidson 2018). While the remaining states and territories do not have such requirements, all states exclude unvaccinated children from daycare and public school if there is an outbreak of infectious disease (NCIRS 2016). In 2017, former Prime Minister Turnbull proposed a policy of excluding all unvaccinated children from all childcare centers and preschools across Australia; the only exemption allowed would be a medical condition (England 2017).4
Australia's vaccination policy is thus situated further along the coercion continuum than the other two countries. Although its vaccination policy mix contains many of the same tools as Britain and the United States, by combining them together and adding a substantial tax penalty for families with unvaccinated children, it enacts a highly compulsory form of vaccination policy. If Britain tries to evade resistance by making vaccination technically voluntary, and the United States takes a middle-ground approach by relying on school mandates, Australia tries to force both indifferent parents and those actively opposed to vaccination to comply with the law.
How did Australia come to develop a more compulsory style of vaccination than either Britain or the United States? In developing its approach to vaccination, Australia faced a different problem than either of these two countries. Instead of active resistance, for much of the twentieth century Australia experienced widespread passive noncompliance. Free vaccinations have been offered as part of Australia's National Health Service since its creation in the early 1950s. The government started to purchase vaccines for measles, rubella, and polio as early as 1953 and voluntary mass vaccination programs were performed in Australian schools starting in the 1940s (Gidding, Burgess, and Kempe 2001).
Nevertheless, over the course of the twentieth century, Australia persistently experienced low vaccination rates; in the 1980s, government surveys showed that only 53% of Australians were adequately vaccinated (Department of Health 2013) and even in 1997 the vaccination rate at 12 months was only 75% (Hull et al. 2003). The low vaccination rate meant that over the years Australia has experienced various outbreaks of infectious disease; even into the 1990s there were outbreaks of whooping cough and measles (Feery 1997). Public health research at the time (see Hanna et al. 1994; Hawe 1994) suggested that the reason for the low rate of vaccination was not deliberate refusal, but rather disinterest and a lack of information from the public.
Starting in the 1990s the government developed a more compulsory approach. In 1993, Australia announced the creation of its National Immunisation Strategy. In 1996 the Australian Childhood Immunisation Register (ACIR) was created and doctors were given payments to boost vaccination rates. In 1997 the federal government instituted its seven-point “Immunise Australia” plan and began to limit tax credits for families with unvaccinated children (Department of Health 2013). At the time, the Minister of Health, Dr. Wooldridge, argued that for the plan to work a strong commitment was needed not just from the government or the medical community, but, “most importantly, from parents whose job it is in the end to see that their children's immunisation is complete” (ACT 1997: 1180). In a media release on the plan, the minister claimed that making family tax credits dependent on the immunization status of children was a way to manufacture that commitment (Wooldridge 1997).
Furthermore, as the plan was being debated, members of parliament discussed the need for the policy to be compulsory enough to encourage indifferent parents to vaccinate, but not so strict that it overly penalized parents actively opposed to vaccination. For this reason, parents were originally allowed to get a “conscientious objection.” As the Labor MP, Mr. Lee, stated at the time: “I think the minister in many ways has struck a balance between incentives and penalties while also respecting the rights hopefully of that small percentage of parents who do not want their children immunised for medical reasons or because they have conscientious objections” (ACT 1997:1182). We see here state officials seeking to navigate Australia's vaccination policy between passive noncompliance and active resistance.
Over time, the federal government progressively increased the compulsory nature of its vaccination policy. The tax penalty steadily increased: in 2000, the Child Care Benefit was limited to families with vaccinated children, and then in 2012 the Family Tax Benefit became dependent on immunization status. In 2015, the federal government removed the option of conscientious objection and eliminated the exemption for Christian Scientists. Why has Australia moved steadily up the coercion continuum when Britain and the United States have, since the nineteenth century, made their vaccination policies less compulsory?
There are a few reasons for this. First, as the policy was made more compulsory, the Australian government observed that it was effective in producing higher rates of vaccination compliance. From 1997 to 2003 the coverage rate for vaccination at twelve months rose from 75% to 94% (Hull et al. 2003). Similarly, when the government introduced its stricter No Jab, No Pay tax policy in 2016, the vaccination rate for 1- to 5-year-old children went from 90% to 93% in the same year (Doran 2016). The government learned that compulsion was effective in overcoming passive noncompliance and boosting the vaccination rate.
Next, the government believed that it had to reach a 95% vaccination rate to achieve “herd immunity”—a situation in which the population as a whole is protected because there are so few unvaccinated bodies for viruses to circulate between (Fine, Eames, and Heymann 2011). The relative novelty of this concept is, most likely, part of the reason Australian health officials have pursued a more coercive vaccination approach as compared to Britain and the United States. Although coined in the 1920s, herd immunity did not gain wide currency until the 1980s (Fine, Eames, and Heymann 2011). While this was after Britain and the United States had already established the framework of their vaccination policies, in Australia the idea was coming into vogue just as it was forming its policy in the 1990s. In order to reach the high rate of compliance required by herd immunity, a compulsory approach was thought necessary (see Department of Health 2013). For example, Christian Porter, the Social Services minister, defended the government's “No Jab, No Pay” policy by stating, “We were facing a situation where the medical community were telling us that ‘herd immunity rates’, as they call it, need to be 95 per cent. . . . We would've liked to have gone about this some other way, but this was the most practical and effective” (Doran 2016: 1).
Third, over time health officials became more focused on parents who intentionally do not vaccinate their children. For instance, the minister of health in 2015, Susan Ley, explained the removal of conscientious objection from the law by claiming that the remaining pockets of unvaccinated children are caused by parents intentionally not vaccinating their children. The minister thus concludes, “In this area a stick as well as a carrot is needed. We know that the responsibility [for vaccination] does rest on parents, and sometimes when you connect that responsibility with a payment, such as family tax benefit, people's approach might change” (ACT 2015: 7144).
Perhaps the most important reason that Australia's vaccination policy has become more compulsory over time is that Australia has not yet encountered enough organized resistance from civil society to produce a self-undermining feedback effect to its policy. When Britain and the United States started to develop their vaccination policies in the nineteenth century, they too began with compulsory approaches and only moved back down the continuum of coercion when they met strong opposition from civil society. As the Australian government has not yet encountered this kind of intense resistance it continues up its compulsory path.
Indeed, evidence suggests that the anti-vaccination movement of Australia has actually grown weaker over the last decade. Australia's main anti-vaccination group, the Australian Vaccination-Skeptics Network (AVN), lost strength over the 2010s. Formed in 1994, when the government first began to develop its more compulsory approach, it reached a peak membership of 2,042 members in 2011. Yet, by 2013 that membership had fallen to 418. Similarly, by 2012 its income sources had fallen from $281,885 to just $65,534 (Safi 2015). The organization has grown weaker, in part, because it has been effectively neutralized by the Australian government. In 2012 the New South Wales Office of Fair Trading forced the group to change its original name (Australian Vaccination Network) because it was deemed to be misleading and then in 2014 the group lost its official status as a nonprofit charity. Also in 2014, the Health Care Complaints Commission (HCCC) published a warning statement about the organization accusing it of spreading medical misinformation (Safi 2015). Here we see state agencies utilizing sticks (regulations) to not only produce vaccination compliance, but to also quell dissent against its vaccination policy.
Although it is still possible that a strong Australian anti-vaccination movement might emerge, at present, no such organized civil society opposition to the government's policy exists. As the Australian state has not yet experienced a strong response by civil society it has not been forced to adapt its policy. Indeed, officials are now focused on making even those actively opposed to vaccination comply. In regard to vaccination, it seems there exists in Australia an inertia of compulsion and officials will continue to move up the continuum of coercing, enacting an increasingly strict vaccination policy portfolio, until either strong resistance is encountered or officials achieve a vaccination rate they are satisfied with.
This article has examined the different vaccination policy paths that Britain, the United States, and Australia have traveled. I have argued that their comparable high rates of vaccination compliance are not a natural outcome of citizens' belief in vaccination but is rather manufactured by state policies. Each nation faced the same problem: how to create a policy coercive enough to overcome passive noncompliance, but not so coercive that it fostered active resistance. The different policy approaches each country took to balance these two objectives was not something that could be achieved overnight but rather developed through a long path-dependent process of adapting the degree of state coercion in response to civic society resistance.
The continued presence of an active anti-vaccination movement in each country shows that what has been described is not a completed social process. As vaccination policy is a “wicked problem,” the long-term societal negotiation between state health agencies and civil society groups is ongoing and, likely, never-ending. Civil society groups will continue to resist vaccination and press for less compulsory laws, and state agencies will continue to adjust and readjust their policies in order to overcome indifference and defuse resistance. The state and civil society will carry on traveling down this path together.
Recent public policy research has tried to show the role that citizens and civic society groups—the “regulatees”—play in shaping public policy. Braithwaite (2011) has described how engaging with and listening to those opposed to policy is a key part of responsive regulation. May (2004) has described policy as a social contract between the state and citizens based on a shared commitment to a public goal (e.g., protecting citizens' health). And Alford (2002) has examined the way the state can interact with civic groups to “coproduce” policy. Even vaccination research (see Gofen et al. 2018; Gofen and Needham 2015) has examined how policy is influenced by those opposed to vaccination. Similarly, this research has tried to show how civil society resistance to vaccination policy has shaped that very policy and how coercive it is. This research thus aligns with Gofen's (2015: 5) approach of seeing policy formation as an ongoing interactive process that is shaped by “individual citizens' noncompliance with policy and the following governmental response.”
This research also highlights the role that negative feedback effects can have in shaping public policy. Jacobs and Weaver (2015) described three different types of negative feedback effects; this research suggests another. Failing to enact a balanced policy that is coercive enough to produce compliance, but one not so coercive as to engender resistance, may in the long run produce a negative feedback effect that undermines that policy. By either overshooting (producing a policy that is too coercive) or undershooting (producing a policy that is not coercive enough), over time the effectiveness of the policy is weakened to such an extent that it is no longer effectual. Yet, states recognize these negative feedback effects and attempt to rebalance until an optimal level of policy coerciveness is achieved.5 In the end, negative feedback effects may not just weaken a public policy, they may also help adapt it.
An analysis of these path-dependent processes helps explain, I believe, the differences in the coerciveness of the vaccination policies of Britain, the United States, and Australia; yet, it need not be the entire explanation. Many other factors (e.g., geography, organizational capacities of the states, disease prevalence, etc.) were likely at play in shaping the vaccination policy of these three countries. This research has tried to highlight how each nation's vaccination policy, and how coercive it is, is shaped by the historical process of interaction between the state and civil society. By comparing their different approaches to manufacturing compliance, we can begin to understand how industrialized nation-states more generally have acquired, over a long period of time, the power to vaccinate their citizens.
I would like to thank Gulay Turkmen, Elizabeth Onasch, and two anonymous reviewers for reading early versions of article and for offering valuable insight and suggestions.
Among industrialized nations, the coerciveness of vaccination policies varies significantly: Italy requires vaccination for school attendance; France requires all children get 11 mandatory vaccinations to receive any state-funded child service; in Canada, policy varies by province—some provinces (e.g., Ontario) require vaccination certificates to attend preschool, while others (e.g., Alberta) just assert the right to exclude children during an outbreak; and in Germany, parents of preschool children are required to receive counseling about vaccinations (Scutti 2018).
In Britain, the National Health Service was created in 1948, and while Medicare and Medicaid were created in 1965 and the Affordable Care Act (ACA) was passed in 2010, even today most US citizens (67.1%) are covered by private health insurance (Barnett and Berchick 2017).
After the creation of Medicare in 1974, most Australian hospitals are now state run, doctors are heavily regulated by the state, and most of doctors' incomes come from the government. See Biggs 2004 for a further description.
As Malcolm Turnbull is no longer prime minister, the future of this proposal is uncertain.
I would like to acknowledge and thank anonymous reviewer 2 of this article for helping me formulate this idea.