Introduction
Vaccinations constitute one of the most important medical and public health developments in human history, preventing up to 5 million deaths each year.[1] However, as the prevalence of vaccine-preventable diseases decreases due to widespread vaccine use, concerns about the safety and necessity of vaccines have emerged.
Anti-vaccine rhetoric is not new, with some early incidents dating as far back as the 1800s when the first vaccines were distributed.[2] Scholars have linked vaccine hesitancy to questions about vaccine safety, low perceived risk of the vaccine-preventable disease, influence from nonmedical sources of information, lack of trust in the medical community, and religious objections.[3] Often the arguments for and against vaccines can be contextualized as a clash of ideals—such as the communal health benefits of vaccination versus the individual right to decide medical interventions for oneself or one’s children (often referred to as “medical freedom”).[4]
Unfortunately, the COVID-19 pandemic has perpetuated fears about vaccines more broadly, even before the COVID-19 vaccines were available.[5] Public polling indicates that around one out of every four Americans has chosen not to receive a COVID-19 vaccine despite the Pfizer and Moderna vaccines receiving full approval from the U.S. Food and Drug Administration (FDA).[6] This hesitancy has been linked to the politicization of the vaccine and concerns about its safety, which has manifested into high levels of public distrust in the government and scientific institutions—especially among the uninsured under 65, Republicans, and rural residents.[7]
In this brief, we review myths and arguments presented against vaccines and vaccine mandates in the 2021 Texas Legislature. Specifically, the focus will be on five hearings that discussed bills related to transparency and mandates, major themes that emerged from anti-vaccine testimonies, and the implications of these discussions as we look forward to the 2023 Texas legislative session.
2021 Texas Legislative Session
The state of Texas requires the Legislature to meet biennially on odd years for 140 days starting the second Tuesday in January. In addition, the state governor can request the Legislature to meet to discuss specific issues in special sessions for up to 30 days. In 2021, the Texas Legislature met from January 12 to May 31 and for three shorter special sessions over the summer and fall (July 8 to August 6; August 7 to September 2; and September 20 to October 19). During these sessions, the Legislature held hearings for five bills related to vaccine mandates or transparency (Table 1).
Table 1 — Vaccine-Related Bills Filed in the 2021 Texas Legislative Session That Received Hearings
In total, the five bill hearings included more than 15 hours of testimony and received 171 witness statements by 128 individuals. Eighty-four witnesses who made 102 statements were categorized as “anti-vaccine” based on how they identified themselves in the testimony (for or against a bill) or on the witness list. The testimonies from the anti-vaccine witnesses were reviewed to identify recurring topics and ideas among witnesses and sessions.
Overall, several major themes emerged from the anti-vaccine testimonies, including medical freedom arguments, claims of discrimination based on vaccine status, and references to scientific data (Figure 1). Only a few witnesses indicated that they were opposed to all vaccines or vaccine mandates. The majority of the testimonies focused on the COVID-19 vaccine mandates as well as the risks of the vaccine and why they thought employers should accept employee vaccine exemptions. In addition, several witnesses testified at multiple hearings, with one individual testifying against vaccines at all five.
Figure 1 — Major Themes from Anti-Vaccine Testimony During the 2021 Texas Legislative Sessions
Medical Freedom
One of the most prevalent arguments, especially during the three hearings related to vaccine mandates, was about an individual's right or freedom to make medical decisions for themselves or for those under their guardianship, such as children. This concept is often referred to as “medical freedom,” a term also used by many witnesses. Arguments for medical freedom are not new, nor are they limited to vaccine policies. Right-to-try laws passed from 2015 to 2018 were also centered around the idea of giving individuals the right to try new and experimental treatments that are not approved by the FDA.[8] In addition, anti-vaccine advocates used this argument during the 2017 session when promoting a bill to make obtaining vaccine exemptions easier (HB 1124) and arguing against a bill (HB 2249) similar to the 2021 bill SB 636-R, which would have allowed increased information on vaccine exemption rates at the school level instead of the district level.[9]
During the 2021 session, witnesses often framed their rejection of either vaccines or vaccine mandates in terms of their rights and freedoms. Witnesses used the phrase “medical freedom” in their testimony, described the government’s role to protect citizens’ autonomy, and argued that they had the right to choose not to vaccinate. For example, witness RF6822[*] centered their claims around the rights of citizens and individuals and argued that “One of the primary purposes of the government is to protect individual rights. ... This should extend to protecting individuals’ rights to make medical decisions for themselves.” Other witnesses evoked constitutional protections and even represented the founding fathers as “pledg[ing] their lives, their fortune, their sacred honor to secure our unalienable rights from tyrants” (RF57352).
In addition, when discussing medical freedom, many witnesses discussed these rights as being part of Texas culture. This idea implies that in Texas residents uniformly enshrine individual rights and freedoms above all else and reject large government interference such as public health mandates. Some mentioned “Texas pride,” while others compared Texas to various states, and even countries, that they believe to be more liberal and restrictive. To this point, several described immigrating from other countries or migrating from other states to avoid liberal policies: “I represent [the] massive migration of people that are moving from California to Texas; we're leaving tyranny, total control over our lives” (AU9519).
Discrimination Claims
The testimonies often depicted incidents where individuals faced limitations based on their vaccine status, especially related to vaccine mandates during the third special session. Several described losing their jobs or receiving notices to obtain the COVID-19 vaccine under penalty of losing their job in the future. Witnesses also discussed medical reasons for not complying that were not honored by their employers. Others had conscientious objections stating the vaccines were dangerous, unnecessary, ineffective, or too experimental and in need of more data. However, in most cases the vaccines in question had already been fully approved by the FDA—the Pfizer COVID-19 vaccine in August 2021 and the Moderna vaccine in January 2022.
Witnesses also described being bullied for not complying to vaccine mandates or for obtaining a vaccine exemption. Many of these examples were more hypothetical in nature, suggesting mandates would “create hostile school environments” (HU4521). One witness, SA0918, suggested a dystopian future if legislators allowed vaccine mandates: “The committee will either advance Texas as a state that protects the liberty of its citizens, or it will oversee the creation of a permanent group of second-class citizens: the unvaccinated.” However, not all examples were hypothetical. Witnesses also described specific instances of children being “terrorized ... due to the lawlessness and tyranny” (DA 9935). They also faced limitations in participating with society, such as their ability to travel to Europe or “go into certain restaurants [or] do certain things” (FW1219).
Referencing Science
Another major theme within the testimonies was the safety and efficacy of vaccines. More than three-quarters of anti-vaccine witnesses questioned whether the COVID-19 vaccine or all vaccines were safe, necessary, or effective. Witnesses also asked that more information and data be collected on vaccines and their side effects. In general, most challenges focused on the COVID-19 vaccine, stating it was dangerous, unnecessary, or ineffective.
Many witnesses predicated their perspectives on scientific data, quoting scientists and experts or referencing scientific agencies and their data to justify their arguments. Some witnesses presented vague data that could not be validated or appeared to originate in their own online research. Such was the case of witness SA6537, who claimed to have “read articles where there’s a 400% increase in miscarriages [from the COVID-19 vaccine].” Others provided specific references. SA4471 noted, “In the STOIC [steroids in COVID-19] trial, they found that 90% of hospitalizations for COVID patients could be prevented ... with one medicine, inhaled budesonide.” The witness interpreted the findings of a 2021 paper published in The Lancet Respiratory Medicine from a group at Oxford who presented data from a small-scale phase 2 clinical trial and found that the use of the steroid budesonide early in the infection reduced the likelihood of the patient needing urgent care and reduced the time to recover.[10] While promising, this was not a phase 3 trial, and the intervention was only effective in reducing some side effects, not eliminating them.
Other witnesses mentioned data or experts from the U.S. Centers for Disease Control and Prevention (CDC), U.S. National Institutes of Health (NIH), and the Texas Department of State Health Services. Some alluded to the institutions’ recommendations provided in their specific cases, claiming, for example, that “the CDC itself says people like me should not get the vaccine” (FW2739). Others disputed the authority of such institutions altogether, condemning, for example, “the corruption of this entire pandemic that goes directly to the CDC and the NIH” (RF7564).
Many more witnesses mentioned the Vaccine Adverse Events Reporting System (VAERS). Some believed VAERS was an attempt by the government and pharmaceutical companies to hide vaccine injury data, whereas others referenced VAERS data to prove vaccines were harmful. DA5215 presented VAERS data to prove the harms of the COVID-19 vaccine: “[The number of vaccine-related adverse events] will be over 800,000 by the weekend. The numbers have consistently gone up 25,000 each week. We are at 16,310 deaths in only 291 days.” These statements, however, seem to overlook the CDC’s explicit disclaimer that reported adverse effects do not indicate that “the vaccine caused or contributed to the adverse event.”[11]
Repeated Testimony
Of the 128 witnesses, 18 testified in more than one hearing, one individual testified in all five hearings, and three others testified in four of the five hearings. Of the individuals who testified in either four or five of the hearings, all were anti-vaccine advocates with affiliations to a known anti-vaccine lobbying group. A review of their testimonies, by session, demonstrated that several anti-vaccine advocates adjusted their argumentation strategy depending on the bill’s focus. A side-by-side review of their arguments on different topics reveals contradictory lines of reasoning and logical inconsistencies at times. The only commonality was that in the end, they opposed the use of vaccines by and large. For example, in their testimony for SB 1310-R, a bill requiring detailed informed consent documentation for all vaccines, even those with FDA approval, R5966, among other anti-vaccine advocates, argued for data being made publicly available on grounds that “an individual has a right to analyze all of the risks and benefits of a proposed medical intervention.” However, when testifying on SB 636-R, which would have expanded data availability on vaccine exemption rates to the school level (currently only available at the district level), arguably improving informed decision-making, R5966 and other anti-vaccine advocates suggested more data would “[provide] a false sense of security,” but “not actually help parents make sound medical decisions for their children.” R5966’s testimony stressed the importance of publicly accessible data for an individual’s decision-making process (for SB 1310-R) but then discouraged public access to data related to school exemption rates (for SB 636-R).
Conclusions
In 2020 and 2021, anti-vaccine activists strengthened their presence in the United States by joining forces with anti-government, anti-mask, and anti-mandate activists.[12] Under the guise of medical freedom and personal rights, they relied on common arguments previously used against childhood vaccinations to push back against adult vaccine requirements, including employee requirements by private businesses.[13]
Politicization of vaccines and other health measures during the past two years will have dire consequences for current and future public health measures.[14] Many scholars are concerned that anti-COVID-19-vaccine sentiment could impact routine childhood and adult immunization rates over time. Reports are already finding lower routine childhood vaccination rates in the United States and abroad: 25 million children were missing their routine immunizations in 2021 alone.[15]
While the majority of Americans agree with public health experts that vaccines save lives, increasingly influential individuals and special interest groups oppose their use and spread misinformation to sow doubt and distrust in public health and governmental institutions. If these groups align with individuals seeking or holding power at the state level, they will continue to find ways to subvert immunization programs.
Given the politicization of vaccines during the pandemic, vaccine advocates should be mindful of controversial vaccine issues, especially nonmedical exemptions and vaccine mandates, in state legislatures. Rather than feeding into a fabricated controversy, it would perhaps be more advantageous to identify potential bipartisan topics, such as increasing vaccine information or improving access to vaccines to promote incremental improvement in public policy and health. Previous research has found that vaccine-related policies can be collaborative and promote increased immunization rates in a state with a conservative majority in power such as Texas.[16] This data is promising and should be used to encourage bipartisan cooperation on vaccine issues.
Acknowledgments
The authors would like to thank the staff and students who helped transcript hearings, code testimony, and review manuscript drafts including Baker Institute staff Daniel Morali, Jacquie Klotz, and Flora Naylor; Baker Institute CHB interns Neha Kalakuntla, Hallie Trial, and Neha Tallapragada; and Baker Institute EMERGE scholar Tietchan Dang. The authors would also like to thank the staff at The Immunization Partnership for their help with the Baker Institute Vaccine Project. This article is part of the 2022 Vaccine Policy Symposium. Support for dissemination of this report and other vaccine policy research was generously provided by a “Bridging Bioethics Research & Policy” grant from The Greenwall Foundation. For more information and other related research, visit the Baker Institute Vaccine Project webpage at https://www.bakerinstitute.org/vaccine-project.
Endnotes
[*]All state hearings were public, webcast, and recorded. Witnesses identified themselves prior to testifying. However, to respect personal privacy, this paper will use randomly generated IDs in place of names.
[1] U.S. CDC (Centers for Disease Control and Prevention), “Ten Great Public Health Achievements – United States, 1900-1999,” Morbidity and Mortality Weekly Report, April 2, 1999, https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm; WHO (World Health Organization), “Immunization,” December 5, 2019, https://www.who.int/news-room/facts-in-pictures/detail/immunization.
[2] Martin Kaufman, “The American anti-vaccinationists and their arguments,” Bulletin of the History of Medicine 41, no. 5 (1967): 463-478; Lucas B. Stolle et al., “Fact vs Fallacy: The Anti-Vaccine Discussion Reloaded,” Advances in Therapy 37, no. 11 (2020): 4481-4490, https://doi.org/10.1007/s12325-020-01502-y.
[3] Jiana L. Ugale et al., “‘It’s Like 1998 Again’: Why Parents Still Refuse and Delay Vaccine,” Global Pediatric Health 8, August 27, 2021, https://doi.org/10.1177/2333794X211042331.
[4] Peter J. Hotez, “America’s Deadly Flirtation with Antiscience and the Medical Freedom Movement,” The Journal of Clinical Investigation 131, no. 7 (2021), https://doi.org/10.1172/JCI149072; Melody Tan and Kirstin R.W. Matthews, Scientific Misconceptions and Myths Perpetuated in the 2017 Texas Legislative Session, Issue brief no. 10.23.18, Rice University’s Baker Institute for Public Policy, October 23, 2018, https://doi.org/10.25613/wsgx-df24.
[5] Philip Ball, “Anti-Vaccine Movement Could Undermine Efforts to End Coronavirus Pandemic, Researchers Warn,” Nature 581 (May 21, 2020): 251, https://doi.org/10.1038/d41586-020-01423-4; Hotez, “America’s Deadly Flirtation.”
[6] Lunna Lopes, Liz Hamel, Grace Sparks, Alex Montero, Marley Presiado, and Mollyann Brodie, KFF COVID-19 Vaccine Monitor: July 2022, Kaiser Family Foundation, July 26, 2022, https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-july-2022/.
[7] Rupali J. Limaye, Molly Sauer, and Shaun A. Truelove, “Politicizing Public Health: Powder Keg of Rushing COVID-19 Vaccines,” Human Vaccines and Immunotherapy 17, no. 6 (December 17, 2020): 1662-1663, https://doi.org/10.1080/21645515.2020.1846400; Lopes et al., KFF COVID-19 Vaccine Monitor.
[8] Michelle J. Rubin and Kirstin R.W. Matthews, The Impact of Right to Try Laws on Medical Access in the United States, Policy Report no. 66, Rice University’s Baker Institute for Public Policy, May 17, 2016, https://www.bakerinstitute.org/research/right-try-unproven-drugs/.
[9] Kirstin R.W. Matthews and Melody T. Tan, Medical Freedom, Privacy, and Fear of Discrimination: The 2017 Texas Legislative Session Anti-Vaccine Arguments, Issue brief no. 10.22.18. Rice University’s Baker Institute for Public Policy, Houston, Texas, October 22, 2018, https://doi.org/10.25613/4157-c610.
[10] Sanjay Ramakrishnan et al., “Inhaled Budesonide in the Treatment of Early COVID-19 (STOIC): A phase 2, open-label, randomised Controlled Trial,” The Lancet Respiratory Medicine 9, no. 7 (April 9, 2021): 763-772, https://doi.org/10.1016/S2213-2600(21)00160-0.
[11] U.S. CDC, “Vaccine Adverse Event Reporting System (VAERS),” 1990 - 07/29/2022, CDC WONDER On-line Database, http://wonder.cdc.gov/vaers.html.
[12] Susan Pulliam, Betsy McKay, and Kris Maher, “Vaccine Skeptics Join Forces with Antimask Advocates,” The Wall Street Journal, February 2, 2021, https://www.wsj.com/articles/vaccine-skeptics-join-forces-with-antimask-crowd-11612284890.
[13] Rishi Goyal, Arden Hegele, and Dennis Tenen, “How ‘My Body, My Choice’ Came to Define the Vaccine Skepticism Movement,” The Los Angeles Times, May 22, 2021, https://www.latimes.com/opinion/story/2021-05-22/vaccine-hesitancy-language-covid; Matthews and Tan, Medical Freedom, Privacy, and Fear of Discrimination; Tish Harrison Warren, “The Limits of ‘My Body, My Choice,’” The New York Times, September 26, 2021, https://www.nytimes.com/2021/09/26/opinion/choice-liberty-freedom.html.
[14] Joshua M. Sharfstein et al., “Uncoupling Vaccination from Politics: A Call to Action,” The Lancet, 389 (September 16, 2021): 1211-121, https://doi.org/10.1016/S0140-6736(21)02099-7.
[15] Giorgia Guglielmi, “Pandemic Drives Largest Drop in Childhood Vaccinations in 30 Years,” Nature 608 (July 26, 2022): 253, https://doi.org/10.1038/d41586-022-02051-w; Bhavini Patel Murthy et al., “Impact of the COVID-19 Pandemic on Administration of Selected Routine Childhood and Adolescent Vaccinations—10 U.S. Jurisdictions, March-September 2020,” Morbidity and Mortality Weekly Review 70, no. 23 (June 11, 2021): 840-845, http://dx.doi.org/10.15585/mmwr.mm7023a2; Jeanne M. Santoli et al., “Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration – United States, 2020,” Morbidity and Mortality Weekly Review 69, no. 19 (May 15, 2020): 591-593, http://dx.doi.org/10.15585/mmwr.mm6919e2.
[16] Sarah Lasater, Rekha Lakshmanan, Kirstin R. W. Matthews, Vaccine Legislation in Texas and the Rise of the State Anti-vaccine Movement: A Survey of Vaccine-related Bills Filed and Passed in the Texas State Legislature From 2009 to 2019, Baker Institute research paper, Rice University’s Baker Institute for Public Policy, Houston, Texas, 2020, https://www.bakerinstitute.org/research/vaccine-legislation-texas-and-rise-state-anti-vaccine-movement.
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