Thinking Locally, Acting Legislatively: California Suppresses a Measles Outbreak with a Law

Communicable Diseases 681 views

As the federal overseers of American public health are “turning on” science, California legislators have turned to statistics and politics to stamp out measles.

Two months ago we ran a post about worrying measles outbreaks. Predictably, some of the reported outbreaks were in countries in which conflicts ranging from corruption to all-out war were raging, too. Conflicts of any kind famously disrupt vaccination programs, and in the case of measles, there is an effective vaccine but no known effective treatment for someone already infected.

It’s a story that repeats itself with numbing regularity. Often, outbreaks of infectious diseases take place in “poor countries,” whose stories don’t get much traction until they threaten countries like the U.S., where an already educated population with easy access to any necessary vaccine is further protected by informed travel advisories.

By contrast, war-ravaged countries like Yemen, which has become a bombed-out petri dish of all the pestilences known to man and to which no educated person would go without phenomenally large hazardous-duty pay, instead host infectious diseases of every imaginable kind. In the case of the air-borne ones, one would be lucky merely not to be downwind. Don’t look for meaningful statistics out of Yemen.

Measles got the news because the outbreaks were in the U.S., in the state of Minnesota in particular. There also was a disturbing uptick in state such as Oregon, where anti-vaccination politics were breeding faster than microbes.

Add to that a federal government that has become aggressively, explicitly, non-science, even anti-science, and, well, it gets harder to peg the source of a measles outbreak on Asian visitors to Disneyland unless you’re the Department of Health and Human Services, working in tandem with the U.S. Homeland Security immigration police.

So, what got reported in a “After a Debacle, How California Became a Role Model on Measles,” a superb New York Times feature on January 16, takes on more importance than even its appearance on the front page of The New York Times provokes.

The report

The information in the well-reported and -constructed Times article, clearly targeted at lay readers, albeit lay readers of the The New York Times, did not come from scientists, including epidemiologists. Instead, the facts came from the typically unflashy and often arcane world of government statistics and the analyses of observant experts on the political scene.

We encourage you to read the article in full. It is replete with facts and figures, charts and graphs, and time-lapse public-health reports, which we will make no attempt to repeat in full here. Our goal is to provide what we consider the salient ones and hope that they will lead you to the full story.

The bit that may take a bit of explaining for non-Americans is that, in continuation of the leading public-health work it has been doing for decades and in direct, explicit opposition to the science-bashing work of the Trump Cabinet, California has increasingly become a state responding to what it regards as a state of siege from the Republican Party—by contrast a true “welfare state,” not the kind the feds are making war on but one in which “welfare” stands for the welfare of its people one and all.

So, to jump to the punch line here, in 2016 it passed a law, Senate Bill 277.

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Senate Bill 277

The law basically decided that Washington, D.C., could be its own Disneyland if it so chose, but California’s laws on school vaccinations were going to get tough, and pronto. In a sentence, about all the new law didn’t do was eliminate medical exemptions to vaccinations for the very small sub-population of students wishing to study in California’s schools with legitimate reasons not to have the vaccination -- in short, more than a note from your mother.

What the law did was to put the screws on the practive of “conditional” school admissions, that is, admissions of student who were not up to date on their vaccinations. It required that they show hard proof that those vaccinations would be given promptly, the unit of “prompt” to be proved by certificate of vaccination in days rather than “sometime this century. Promise.”

As important, many would say more important, it eliminated the “personal belief exemption,” that being the one allowing parents to say that they would not vaccinate their children because of their—the parents’—beliefs that vaccinations were harmful. Effectively, the state said, “You have a right to your beliefs and it comes with a concomitant necessity to home-school your children. And don’t go testing us on matters of public playgrounds.”


Again, for non-Americans, it’s necessary to know that conservative forces in the rest of the country have always considered California a raving nuthouse, at best a figment of Hollywood’s imagination. This “explains” why it is the nation’s most populous state, growing at a rate that may be its biggest problem apart from the Big One (the dreaded earthquake), and the world’s third largest economy. Its reputation as a universally liberal state is arguably the nuttiest thing about it. Richard Nixon, from San Clemente, all of Orange County except the vagrants—we could go on, but we would be digressing needlessly.

Some California beaurocrats thought to look at those boring public statistics. It turned out that arguably the least interesting fact about the measles outbreak that occurred in late 2014 was that it could be traced to Disneyland. (And our single quibble about the Times story is that it was illustrated by a photo of the celebrants of its Disneyland's 60th anniversary, every one of whom looked Asian; but we’ll go on with their story anyway.)

Another apposite bit of extra-California information: Measles is the kind of disease that could be, for all intents and purposes, be eliminated worldwide. The WHO set a target of 2020 for that to happen. The critical figures here are 90% and 95%, which define the portions of a population that have to be vaccinated for there to be what epidemiologists, not meaning anything derogatory with the term, call “herd immunity.” If a minimum of 90% of a population, and ideally 95%, are immune from an infections disease (which in the case of measles almost exclusively means vaccinated against it), any spread is minimal enough to prevent an epidemic, or even a significant outbreak.

The "numbers types" then noted that in 2014, the immunization rate for California students starting kindergarten (for non-Americans, about age 5) averaged 93%. But what quickly became clear was that the average occluded the figure for local rates, the keys to herd immunity. Looked at again, it turned out that 70% of that subset of children lived in California counties with lower than 95% immunization, and 36% were in counties with lower than 90% rates.

That in turned prompted the realization that two patterns characterized the schools that admitted un-immunized students: “conditional” admissions and “belief-based” exceptions.

It’s at this point that the statistics in the article start coming thick and fast, but the Times is generous in its graphics helping make sense of them. There not at all hard to follow.


We can’t improve on the Times’ conclusions, so we’re providing them here verbatim:

  • “In the end, the effect of the [California] law was simple: More children were vaccinated, and the risk of disease outbreaks has gone down.”
  • “From a policy standpoint, these findings offer a ray of hope for vaccine proponents. Maybe changing minds isn’t so important. People may not have altered their attitudes about vaccination, but the fact is that these laws actually changed behavior.”


Supporting information: (the law, including the bill in toto) (about California’s “tough new law”)



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