No Jab, No Pay–Now the Australian Way: Interview with Julie Leask
December 8, 2015
The Australian federal government’s no-jab-no-pay laws will remove childcare benefits, rebates, and the end-of-year Family Tax Benefit A supplement from parents who don’t immunize their children.
After legislation was passed by the Senate, the changes will start on from the 1st January next year, with exemptions for medical reasons.
After she wrote a detailed blog post in response to the news, I asked an Immunisation expert from the University of Sydney, Associate Professor Julie Leask, on what is new and what remains the same with these laws.
Julie Leask: Well, they are and they aren’t. We already have this requirement. Children have to be up to date with their vaccinations in order to receive these family assistance payments, and that’s been the case since 1999. What’s changing now is that while previously if the parents refused vaccination and lodged an exemption form called the so-called conscientious objection, they could still get the payments, and this revision of the policy removes their capacity to get those payments.
Kylie Sturgess: There’s an estimated 7 percent of parents who don’t vaccinate their children but they’re not registered conscientious objectors. Will these changes make much of a difference in your opinion?
Leask: They will to a certain extent; the main part of the policy is the one I describe, the removal of conscientious objection capacity, and that I’d say is the main course. Then there are these side dishes that come along with the bill, and they’re what I think will probably make a difference, because they actually touch that 7 percent. The conscientious objectors, by now they’re 2 percent, they’re 1.5 percent.
Then there’s this 7 percent who don’t lodge their objection. They’re still not up to date, so they’re not actually getting their payments at the moment. The new policy isn’t in theory going to touch that group, because they need something else, because the removal of capacity to object, they’re not objecting anyway.
What’s coming along with the new policy is a yearly requirement. Instead of just being reminded, “Hey, your kid’s not up to date,” when they turn twelve months, two years, and five years, which is what happens now, it’ll be every single financial year. “Hey, your kid’s not up to date. You, this year, will lose these payments unless you get them up to date.” I think that extra nudge every single year will make a difference.
They’re extending the requirements; they used to finish at age five, and now they go right up to age nineteen. If you have, for example, a twelve year old and you’re eligible for one of these payments and they weren’t up to date for their baby vaccines and we still haven’t got them up to date, then you will be warned that you’ll lose those payments and you need to get them up to date.
Sturgess: We’re talking about very small numbers here. Even if we add up those little percentages, it’s less than 10 percent overall of people who aren’t vaccinating their kids. So, what are some of the barriers for these people, and what makes it such a big concern?
Leask: First of all, that’s a national average, and averages mask differences in regions and particular population groups, like aboriginal and Torres Strait Islander children, children born overseas, and then the regions where you have more alternative practices and more people who are actively refusing vaccines. There you can see lower vaccination rates and higher rates of vaccine objection.
I must qualify that among the families that have children born overseas and the aboriginal and Torres Strait Islander families, they’re not objecting. They’re not getting around to it. They want to vaccinate their kids, they’re motivated; it’s just an issue with accessing the services and getting to those appointments and having culturally appropriate, safe services that are available to them so that they can use those services.
They’re very different groups. I think also we’ve got to remember that we’ve got 92 percent of children fully vaccinated now. We’ve been able to come from a 53 percent vaccination rate in the ‘90s to that 92 percent all with these requirements, with these incentives, with these “you must be vaccinated or lodge an exemption or you’ll lose your payments,” with other reforms like paying health professionals to get children up to date. They’ve all made a difference. I think regulation is really important with changing behavior, as it is in many areas of public health, but then you reach this point where you’ve got in Australia today this last 8 percent who need something different, because the regulation hasn’t worked. The “no jab, no pay” works on those objectors by saying, “Well, you can’t get your objection signed anymore and get the payments. You just won’t get the payments at all now.” As I said, they’re now 1.5 percent, and there’s that other 7 percent who need other things.
In fact, for the objectors I think there are better ways to address that group, but we’ve got the legislation now. We have to make the best of it and advocate for some other reforms that will strengthen our immunization programs.
Sturgess: You’re not fully on board? You’re saying “making the best of it,” as it were.
Leask: Yes, I’ve always been very concerned about the strategy of tipping over from an incentive scheme to a sanction scheme, which is essentially what this is, because these are quite large payments. For a very low income family with a child in full-time child care, they can be up to $15,000 if you include the child care benefit and the rebate and the family tax benefit payment. That could represent hardship for families. It’s the first time we’ve ever linked family assistance payments to a particular health behavior.
I guess the question then is, if parents smoke in their car with their kids, should we be also stopping them getting their payments? Where should it stop? Asking, “Well, what makes us focus on vaccination?” I think when you ask that question you see that people are rightly concerned about spread of diseases, rightly concerned about high vaccination rates, but also there’s a fair amount of community outrage about people who refuse vaccination.
I guess the job that I’ve seen I’ve needed to do is to raise awareness of these other groups who aren’t fully vaccinated among children and adults and say this is a bigger problem, and to address it effectively we need these multifactorial, supportive strategies that address the actual problems that we know are there rather than this fairly punitive strategy, which is brilliant politics, but I don’t think necessarily great policy. Many other people in vaccination programs share my views.
Sturgess: These changes are meant to improve immunization rates for children. What about adults?
Leask: That’s one of the areas where we’ve tried to shed a light on a very serious problem, which is that vaccines, we get the primary course in childhood, and then our immunity can wane with some of these and we can need boosters. Very many adults are not getting boosters for various reasons. Often it’s unwitting, but we need to really focus on adult vaccination and make sure that those vaccination rates are high as well. We’ve got 92 percent of children in Australia fully vaccinated. For adults, you can see rates as low as 30 percent for some of the recommended vaccines.
An example would be that for a number of years pregnant women have been recommended an influenza vaccine. That vaccine will help protect her from serious influenza, which will help protect her from getting very sick from influenza during pregnancy and if it happens can affect her and the baby. We want better than 30 percent vaccination rates in those moms. I’d love to see a bit more attention on those problems as well as the vaccine refusers and the people who lack access and opportunity to get fully vaccinated with their children.
There are some adults who are recommended flu vaccine every year, and they’re not getting it. Some other adult groups, those with a chronic disease for example, children with a chronic disease, they’re recommended a free flu vaccine, and we see some quite low vaccination rates among those children. There are children getting influenza, going to hospital, and getting very sick and even dying from a disease that they could’ve been protected against. I’d love to see some more focus on these areas where there are very low rates, and a lot more needs to be done.
Sturgess: You also spoke at the Commonwealth Senate Inquiry into the “no jab, no pay” amendment to social services legislation when it first got underway. What was the experience like? There were a lot of people speaking up…
Leask: It was really interesting! This was my first time in presenting, submitting a paper to the federal senate, and then being called as a witness to an inquiry.
It’s been a real learning curve for me as a researcher. We had a week’s notice. I was called a week beforehand and asked if I would present as a witness to the hearing. That was based on I think a seven-page submission that I had written with a colleague, Dr. Kerrie Wiley, about the amendment bill.
The weekend before I spent a lot of time agonizing over my four-minute preliminary speech of what to say, and eventually wrote something out. Then the morning before at the airport I was able to talk to a former senator who I got some advice from about how to broach this issue with this committee. She made me, basically caused me, to have to toss my speech in the bin and completely rewrite it!
In the end, we knew that this bill would be passed. All the writing was on the wall. What we had to focus on was what other things we can draw attention to if the bill is passed, and they included the need for Australia to bring in a no-fault vaccine injury compensation scheme, the need to continue monitor vaccine acceptance and opinion in Australia so that we can get a sense of where that’s going, because we’ve lost that capacity now that we’re not making people register their objection, the need for review of this policy and its impacts a year and then two years into its implementation so that we’re keeping abreast of how this is affecting families.
Fortunately, all of those things were put as recommendations along with the recommendation that the bill be passed. We were really pleased with that outcome, given that we accepted that “no jab, no pay” would likely be passed through the senate, just to see those issues put on the national agenda.
Now our focus will be very much on continuing to call attention to the fact that, unlike nineteen other countries, Australia doesn’t have a compensation scheme for people who are injured by a vaccine. This is a very, very small group, and it’s very rare because vaccines are largely very safe and very important and effective. Like any medicine, there can be rare serious side effects, and some people may need to be compensated for those side effects. Australia, now that it’s ramping up the level of the mandate to vaccinate even more, we need to have a scheme that looks after those individuals who might be injured who are doing the right thing by the community. We are going to keep that on the agenda.
Sturgess: Speaking of opinion, debates about vaccinations and immunization are often heated. It seems for example on social media you can get people who are equally completely for vaccination or completely against it, and often they have similar rhetoric and similar tone. It’s quite funny. Even though they’re on different sides, they can sound the same. Do you think that there’s a need for a more middle ground in terms of voices? How do you think that could be encouraged?
Leask: It’s been really interesting, because I started in this area looking at ... I did my PhD on the anti-vaccination lobby in Australia and how they behaved and how they constructed their arguments. I saw a number of different typical biases that they exhibit, and strategies and formed some views about what to do about them. I think what it taught me … my mum said to me all through my childhood, “All things in moderation,” which is a bit of a contradiction in terms, I know, but I’ve really held to that!
My mom grew up with an anti-vaccination mother herself, so my grandmother was against vaccination. Mom turned from that. She got all of us immunized and she kind of rebelled. I’ve really respected my mom’s approach to this issue, which is just to be moderate about things in life. It’s taught me to constantly be aware of my own biases and try to keep being objective about things. When we’re very passionate about something, whether it’s against vaccination or for vaccination, it can sometimes be genuinely difficult to think rationally.
I think all of us need to guard against being irrational in our thinking, and what Dan Kahan calls “motivated reasoning.” We want an outcome, we want to see something in a certain way, and so we reason away stuff to suit that argument. I think watching the very strident views that particularly occur on the anti-vaccine side of things, but you do see them on the very pro-vaccine end of the spectrum where I’m generally located, that it’s just so important for us to try to be balanced and measured and rational. We need that in science, and we need it when we’re thinking about the science of vaccine communication and vaccine-related behavior.
As a researcher, I’m committed to encouraging us to think rationally and calmly about the problem of vaccine refusal and non-vaccination and partial vaccination among children and adults, and how we can address that in ways that are evidence based and ethically sustainable at the same time.