Even a cursory look at the resume of Dr. Johan Bester, director of bioethics at the UNLV School of Medicine, helps you understand why the national media frequently calls on him to explain the reasons vaccine-preventable measles has come roaring back in the U.S. and around the world.
The title of his doctoral thesis? “Ethical Concerns in the Debate about Pediatric Vaccinations, with Special Reference to MMR (Mumps, Measles and Rubella).”
The increased public interest in pediatric vaccinations is certainly understandable, given that measles cases — thought eliminated in the U.S. almost two decades ago — are now surging. Last year, the U.S. recorded more than 1,200 cases of the disease. In 2018 measles outbreaks cropped up around the globe, killing 140,000 people, according to the World Health Organization. In the South Pacific nation of Samoa in 2019, 65 people, most of them babies or small children, died from the highly contagious disease.
False information that can be found on the internet and social media has much to do with people shunning vaccinations for their children, Bester said. He points out a 1998 British research study proposing a link between the measles vaccine and autism “exploded in the media.” Though it was found to be fraudulent — data was made up — and the paper was retracted and completely discredited, Bester said “the idea of a link has persisted among those skeptical of vaccines. There have been over 40 studies...involving millions of children on this issue, and it is clear that there is no link between the measles, mumps, and rubella vaccine and autism.”
In Samoa, where measles was spreading rapidly last year, it was the circulating of misinformation following a tragic accident that caused vaccination rates to plummet to 32 percent, far below the 95 percent immunization rate that public health officials say is necessary to prevent a disease from spreading through the community. It turned out a nurse had mixed the vaccine powder with an expired muscle relaxant instead of water. Two children died shortly after being injected. Though the nurse and another colleague were sent to prison for negligence, anti-vaccination zealots spread a false narrative on the internet and through social media that the vaccine alone is toxic. It did not matter that years of data and scientific study confirmed the vaccine is safe.
Bester, who received his MD in 2002 and completed his doctorate in applied ethics in 2016, realized as he was finishing his medical education that some people were looking at vaccinations far differently from those in the medical community were.
“I became aware that some friends and acquaintances were vehemently opposed to vaccinations,” he said. “These were people who were in all other respects reasonable people, but their views on vaccines diverted markedly from what I was taught in medical school. This made me curious — was the science about vaccines really settled? What is the evidence behind vaccine effectiveness and safety? I wanted to find out for myself.
“Reading around these questions launched me into a project of study that continues to this day. Measles vaccine seemed the most controversial, so that was where I started, and eventually remained. I read about the history of vaccines, the studies done, the evidence behind it. I read about public policy in different places, and then eventually realized there are serious ethical questions related to vaccination. It therefore became a natural focus of my Ph.D. dissertation. The ethics of measles vaccination is so interesting because it ties together a whole set of ethical questions — the balance between public health and the individual’s rights, questions about parental authority and the relationship between society/state and parents, the moral status of children, and what physicians (and society) owe children.”
A native of South Africa, Bester completed his medical training there and practiced family and emergency medicine for 12 years in a variety of settings, including South Africa, the United Kingdom, and Canada. During this time, he finished a master’s degree in applied ethics and eventually completed a doctorate in the discipline with a focus on bioethics. “I came to realize that bioethics (the application of ethics to the field of medicine and health care) is where my real interest lies.”
Before joining the UNLV School of Medicine in 2017, Bester completed a year of fellowship training in clinical ethics at the Cleveland Clinic in Ohio and spent an additional year on staff as a clinical ethicist. His peer-reviewed articles, which range from the ethics of parental refusal of blood transfusions and vaccinations for their children to ethical discussions of organ donation and circumcision, have appeared in journals that include the American Journal of Bioethics, the Journal of Medical Ethics, and the AMA Journal of Ethics. He has also been published in noted medical journals such as JAMA Pediatrics.
Bester, who teaches bioethics to UNLV medical students whom he describes as “very idealistic and very engaged with ethical issues,” said there are two different ways questions of vaccine ethics can be approached.
“One is to consider it from the perspective of vaccination being a medical decision, where a parent and a physician together try to decide what is best for the child-patient. Here the ethical guideline we use is the best interest standard: In decisions about the child, the available option should be chosen that best protects or promotes the well-being of the child. When you look at measles vaccination, it is clear that it is best to have the child vaccinated rather than unvaccinated… Many discussions on vaccine ethics start with the question of the parental role, in other words, what society owes parents,” he said.
“Another way of thinking about vaccine ethics is to ask what is owed children by society. This is a new perspective I’ve brought to vaccine ethics in my work on these issues starting with the moral obligations society owes children rather than starting with the question of what is owed parents,” Bester said. “I argue that society is obligated to protect children against preventable diseases that can impact the well-being of children, and therefore that society has the obligation to guarantee measles vaccinations for children.”
Bester noted that not everyone can be vaccinated. Some may be allergic to components of the vaccine and for others it does not work. “So there is always a small percentage of the population that remains susceptible to measles even if you vaccinate as many people as you can. These people depend on “herd immunity” for protection — if enough people in society are protected, measles does not spread and those who are susceptible are relatively protected.
“Some people think they can forego vaccination and instead rely on herd immunity, but this is a mistaken way of thinking. We need to vaccinate about 95 percent of the population to protect the 5 percent who are vulnerable because they do not derive benefit from the vaccine, so there is very little wiggle room for refusals. If you are not vaccinated, you still are susceptible to getting measles through imported cases from elsewhere, a measles outbreak, or if the vaccination rates drop. Herd immunity can have holes in it, and herd immunity can go away if vaccination rates drop.”
Bester thinks the rate of vaccinations can be increased.
“The best thing we can do is to try and foster trust relationships between community medical providers and parents,” he said. “It has been shown, convincingly, that if parents have a trusting relationship with their primary care provider and other health care professionals, that relationship can help parents resist anti-vaccination messaging.”