How Mississippi Got to Be First in Something Good

First in teen pregnancy. First in obesity. First in childhood immunizations?

Mississippi is better known for scoring high on lists of bad health indicators than good ones. But with the measles outbreak drawing attention to states and communities with especially low immunization rates, Mississippi stands out for its especially high rates: at least 99.7% of its kindergarteners are fully vaccinated. Nationwide the rate is 94.5%. Colorado’s rate is 81.7%.

So how did Mississippi achieve near-universal immunization rates? Faulkner’s famous line, “The past is not dead. It’s not even past,” holds some truth here. As a poor, rural state in the hot, humid south, Mississippi historically has been more prone to infectious disease outbreaks than many other states and less prepared to address them through private-market health care. As a result, the state has a century-long history of public health efforts to combat the spread of communicable diseases, supported by the state health department and the state legislature.

In line with this history, when states began passing legislation in the early 1970s requiring children to be vaccinated before attending school, Mississippi passed a particularly strong law: it required children planning to attend public or private school to have the required vaccinations, allowed for medical exemptions only when the local health officer determined that the exemption would not cause undue risk to the community, and had a strict religious exemption policy. Only parents who were “bona fide members of a recognized denomination whose religious teachings require reliance on prayer or spiritual means of healing” could qualify, with a statement of support from an officer of the church.

This religious exemption policy was challenged by a father who sought to expand it to encompass parents’ personal beliefs against vaccinations, in line with the policies currently in place in 20 states. The father appealed his loss in a lower court to the state’s Supreme Court, which not only affirmed the lower court ruling but went much further: The court decided that the law’s religious exemption was itself unconstitutional. First, they determined that the exemption was not required by the First Amendment, asking, “Is it mandated by the First Amendment to the United States Constitution that innocent children, too young to decide for themselves, are to be denied the protection against crippling and death that immunization provides because of a religious belief adhered to by a parent or parents?” and answering no. Second, they found that the exemption violated the 14th Amendment, “which provides that no state shall make any law denying to any person within its jurisdiction the equal protection of the laws, in that it would require the great body of school children to be vaccinated and at the same time expose them to the hazard of associating in school with children exempted . . . who had not been immunized.”

With that decision in 1979, Mississippi – one of the nation’s most religious states and one in which equal protection has too often been denied – became one of only two states to disallow religious, as well as personal belief, exemptions (West Virginia is the other).

Mississippi backed its mandate with policies that made vaccinations available to all, regardless of income, race, or location. The head of the state’s Department of Health, Alton Cobb, made vaccination accessibility a top priority, and he held his post for 20 years, from 1973 to 1993.

This history largely accounts for Mississippi’s – and to a large degree West Virginia’s – high kindergarten vaccination rates. But West Virginia’s immunization rate for younger children is among the nation’s lowest, and Mississippi’s again the highest. Here Mississippi again built on past policies, expanding the state’s vaccination commitment to infants and toddlers. In 1994, the state legislature passed the Mississippi Child Immunization Act, which directed the state health department to “focus on children receiving all recommended immunizations by twenty-four (24) months of age.” The legislation required the department to “improve parent compliance,” and took as hard a stance against doctors’ discretion as parents’: it specifically states that “The administration of vaccine shall not be delayed due to a reluctance of the health-care provider to administer multiple immunizations in a visit.” The Act also charged the health department with creating a statewide childhood immunization registry.

The Mississippi Child Immunization Act of 1994 was passed five years before Andrew Wakefield’s widely influential study purporting a link between the Measles-Mumps-Rubella (MMR) vaccine and autism, which sparked a backlash especially against the vaccination of infants and toddlers. Those years had given the state’s policies time to become well enough established that they were not rolled back in the wake of the vaccine-autism controversy.

Mississippi’s immunization policies aren’t just strong on the books; they are backed by strong and competent administration by the Department of Health. This I know from personal experience. When my daughter was two, I had her enrolled in a privately run, state-licensed childcare center. By law, her vaccinations had to be up-to-date for her to be in care. One day I got a notice that a records inspector from the Department of Health had visited the center and discovered that one of my child’s vaccinations (received abroad) had been given several months before Mississippi’s age guidelines stipulate, and that she’d need an additional vaccine to be in compliance. That inspector looked at a hundred children’s records at that center, and each one had approximately 20 vaccinations. My daughter’s vaccination wasn’t missing; to discern the problem the inspector had to compare my child’s birthdate to the vaccination date, calculate her age at vaccination, then compare that to the state guideline. No one in the pediatrician’s office had caught it. In a state not known for its administrative capacity, this is impressive.

For once, Mississippi is first in something good. But the father who lost in the state’s Supreme Court in the 1970s wasn’t the last person to challenge the state’s strong pro-vaccination policies. Bills to allow religious and personal belief exemptions have been introduced, with the backing of high profile legislators like Tea Party Republican state senator Chris McDaniel. To date, none of these bills has made it out of committee. We’ll have to see whether Mississippi’s strong policy history, bolstered by the reality of measles outbreaks in less well-protected states, will continue to protect a state where the “I’m not trusting President Obama to tell me whether to vaccinate my kids” sentiment resonates so well. This time, I think the weight of history is on Mississippi’s side.

Melissa Bass and Austin Vitale

Melissa Bass and Austin Vitale are both from the University of Mississippi. Melissa Bass is an assistant professor of Public Policy Leadership and Austin Vitale is a senior Public Policy Leadership major, writing his undergraduate honor’s thesis on vaccine policy.