Dr. Ashish K. Jha is a senior fellow at the Belfer Center at Harvard Kennedy School and a contributing Globe Opinion writer
Turn on your kitchen tap and water comes out. You don’t test it. You don’t decide each morning whether it is safe to drink. Someone has already made those decisions, upstream, at a treatment plant you will probably never see, so that you wouldn’t have to
That is one of the things a good public health system does. It takes interventions we know work and builds them into everyday life: treated drinking water, pasteurized milk, fortified flour, routine childhood vaccination. People can always opt out, but getting the health benefit requires little effort
Other health decisions appropriately remain more individual. A mammogram and a colonoscopy, for example, still require a patient to decide whether and when to have the test. Public policy can remove obstacles surrounding that choice. That is the logic behind the Affordable Care Act’s requirement that many preventive services be covered without copays or deductibles. There is no default choice (patients aren’t automatically scheduled for a mammogram) and the decision to test remains with the patient, but cost is less likely to be a factor in their decision.
Some people might find this paternalistic. Who gets to decide which care should become routine and which should remain proactive choices? That is an important question. But no one designs these systems from a blank state. Someone decides how many medical visits are required, which vaccines are combined, what insurance covers, and what clinicians routinely recommend. Every system therefore creates defaults and obstacles. The question is whether those choices reflect strong evidence and make it easier for people to act on the measures that keep them and their families healthy.
The stronger the evidence, and the more the benefit extends beyond the person deciding, the stronger the case for a simple, protective default. When the evidence is uncertain or values genuinely differ, individual choice should play a larger role
Which brings us to childhood vaccination
A White House executive order signed this month calls for moving toward administering measles, mumps, and rubella, currently delivered in a single combined vaccination, as three separate vaccines. It also mandates that, “to the maximum extent feasible,” childhood immunizations should be given at separate medical visits
Stand-alone measles, mumps, and rubella vaccines are not currently available in the United States, and developing and licensing them would probably take years. But the direction of the policy matters now because it reverses one of the basic principles that has made childhood vaccination successful: make it easy for families to complete the recommended schedule
The practical burden would fall overwhelmingly on parents who already intend to vaccinate. A parent determined to refuse vaccination will refuse whether or not the schedule requires one visit or three. For everyone else, additional visits create additional barriers regarding work, child care, and ease of scheduling appointments
Confusion creates its own obstacles. TheCenters for Disease Control and Prevention’s website states plainly that no published scientific evidence shows a benefit from separating the combined MMR vaccine. Yet administration officials have publicly encouraged manufacturers to produce separate vaccines, while a Health and Human Services spokesperson suggested that stand-alone shots might reduce side effects, a wholly evidence-free claim. Parents trying to do the right thing are now left sorting through conflicting signals from their own government. Some will postpone vaccinations while they figure out whom to believe. Some may never return to the question.
Critics of the childhood vaccine schedule have spent years arguing that children get too many shots. Yet splitting MMR would turn two injections into six
Japan offers a useful lesson. It withdrew its MMR vaccine in 1993 after a safety problem involving the mumps strain used there. Even after Japan switched to a safer strain, coverage remained low, and the country experienced recurrent mumps outbreaks. The splitting was a major cause of the decline in vaccination. This May, Japanese regulators approved a new combined MMR vaccine
None of this means combination vaccines should be immune from scientific scrutiny. They should be continuously evaluated, just like every other medical intervention
But here’s the key point: Strong evidence can persuade people to do the right thing. But good intentions compete with a missed bus, a sick sibling, an emergency shift at work. A parent can fully intend to vaccinate and still miss an appointment
That principle reaches far beyond vaccines. Pharmacies default to child-resistant caps on prescription bottles so children are protected. It is possible for a customer to request a non-safety cap if they choose to but almost no one does, making children safer because the protection is already built in. We fortify foods rather than requiring people to purchase vitamins separately. We eliminate copays for preventive care because even small barriers keep people from getting care they already want
Good public health becomes invisible. The healthier choice is built into the world around us
We don’t ask parents to test their tap water each morning. A parent who has already decided to protect their child against measles, mumps, and rubella shouldn’t have to make many visits just to see it through
