First published by Crikey, 13 July 2015

Mullumbimby, a hippie heartland since the 1970s, is one of those places where all the contradictions of rural life bump up against each other in the most incongruous of ways. To get there you pass through Queensland’s sugar cane belt from the north, or the dairy and cattle farms of the NSW coast from the south. But once you land on the main street, it’s all sugar-free, vegan “raw bliss balls”, a town where the old bank building has been turned over to an organic grocer and juice bar selling acai smoothies, a folk singer busking out the front.

Peruse the noticeboards and you can enrol in a Tigress yoga workshop, or organise an inspection of a demountable yurt (“$35,000 ono”). Or you could, like me, go straight to the conflict zone and meet with the Northern Rivers Vaccination Supporters (NRVS) – a voluntary group of locals, many of them doctors and other health professionals, who are trying to turn around the area’s reputation as having the lowest immunisation rates in the country.

“Fifty percent of kids here under five are not vaccinated,” says Dr Rachel Heap, over a chai tea in one of the inner city-meets-hippy cafes on the town’s main street. Heap, an intensive care specialist, has seen more vaccine-preventable diseases on the NSW north coast than anywhere else in 10 years working in regional and remote areas, including Alice Springs. In recent months she’s seen whooping cough, chicken pox and at least three cases of epiglottitis – a potentially life-threatening infection that can cause your windpipe to swell, blocking off your airway. “It used to be a nightmare 20 years ago. Thank god the vaccine came in and it vanished [elsewhere].”

For doctors such as Heap the horror scenario is a bus coming through town from Byron Bay, carrying a backpacker just in from Bali, where measles is endemic. “That bus is infectious for two hours after that backpacker leaves. It’s a chink in the armour.”

She says about half of the region’s non-vaccinated children are registered as conscientious objectors – a category Social Services Minister Scott Morrison announced back in April would be scrapped from January 1 next year. Under the No Jab, No Play, No Pay policy, non-immunising families who can now register as conscientious objectors, thereby allowing them to bypass immunisation rules for collecting childcare subsidies and the family tax benefit Part A, stand to lose thousands of dollars (exemptions will still apply to children who can’t be immunised for medical reasons).

The policy – and the scrapping of the exemption for “religious” objectors a few days later – was widely reported. But far less attention was paid to the item in the May budget, just a few weeks later, which claimed the measure would recoup savings of half a billion ($508.3 million) over five years. It begged the question – is the policy designed to promote potentially life-saving vaccinations, or is it merely a cost saving attempt?

If the policy is beginning to turn around anti-immunisers in Mullumbimby – who range from the clearly-misguided-but-you-can-almost-understand-them crowd who believe bare feet, vitamin C and healthy air affords all the disease protection a child needs, to those who spend their days in the internet hinterland sharing their theories about big pharma attempts to exert mind control over the world’s population – then surely it’s working everywhere, I reasoned?

“Pharmacists and immunisation providers up here reported that there was a big increase in vaccination uptake around the time of the announcement,” says Heap. Immunisation nurse Debbie Procter, who has just come back from a baby expo in Brisbane, chimes in to say nursing colleagues were talking about a “big uptake” in immunisation (although the policy starts next year, full immunisation can’t be done in one doctor’s visit – the catch up process take time).

But it’s hard, they say, to pinpoint a single cause. Around the same time as the No Jab policy was announced, the widely-reported death of Perth baby Riley John Hughes led to a spike in whooping cough awareness, and funding also became available for third trimester booster shots for pertussis (whooping cough). “It was a perfect storm of three things that came together,” Heap says.

Through the NRVS I’m put in touch with Dr Sue Page, a north coast GP who tells me “more people are coming in and getting more information, and more people are getting catch-up vaccinations. The biggest impact [of the policy] is it’s opening up the dialogue.” Page has spent the best part of three decades in the region trying to counter anti-vaccine groups – groups that have advertised alongside doctors in the yellow pages, and who’ve relentlessly promoted links between vaccination and autism, cot death and arthritis.

Now, the “money factor” seems to be kicking in, she says. Often couples will be divided on the issue, and the one who has “felt most strongly about the issues has held sway”. The money has “given the other person another argument, it’s changing the dynamic between parents,” says Page, who has tried everything – mobile clinics, creating a shopping centre immunisation mascot, an echidna called “Spike”, hand-delivering information packs to journalists.

The anti-immunisation mindset is clearly a problem, she says, but so is the disorganised or disenfranchised mindset: one of the biggest non-vaccinating groups are families with more than three children, where one of the adults has a chronic illness. And here’s where, the more you talk to experts, the more the problem starts to look like one of those lenticular books, where the picture keeps changing depending on the angle you’re looking from.

Back in Sydney I talk to Dr Julie Leask, a public health researcher at the University of Sydney and an expert in immunisation behaviour. She’s no apologist for anti-immunisers, but she has a number of reservations about the No Jab policy. Not the least of which is that while nation-wide immunisation rates are at around 92%, the conscientious objectors represent less than 2% of non-immunised children aged 6 and under (as of December last year, 39,523 children were on the register).

Of the remaining 6% of families who are neither immunised nor recorded as conscientious objectors, about 2% are up-to-date, but their immunisation hasn’t been registered – perhaps “the doctor has simply not put the right forms in”, Leask says. The remaining 4% are those families who face various “barriers” – economic or social barriers, or they’ve been given incorrect medical advice, and so on.

That larger group of non-immunised children currently aren’t receiving the relevant benefits – and the new policy will do nothing to affect them, says Leask. At best, it has the potential to “publicise” the financial benefits people could receive if they fully immunise; but she thinks any positive effect of the policy has to be weighed up against the downsides, including the potential to “radicalise anti-immunisers”.

Registering as a conscientious objector requires parents to have a conversation with a doctor who must sign a form to say immunisation has been discussed. Doing away with a conscientious objector status “removes the opportunity for that conversation”, she fears. It could see some families go off the grid, medically speaking (and rumours of pop-up childcare centres for non-immunised children are already circulating).

At the moment, conscientious objectors only have to visit the doctor once. “It would be fairer to have vaccine objectors have to submit a form at the 1-, 2- and 5-year-old milestones, not just once,” she has written. Leask also wonders, too, if it’s fair to introduce what “amounts to a form of mandatory vaccination for lower income families” without an accompanying “no-fault vaccine injury compensation system”. And there is no comparable welfare benefit that requires a particular health behaviour, she notes.

Failing to understand anti-immunisers will only produce “anger-based policy not evidence-based policies,” Leask says. In the meantime, no-one seems to be able to say for sure what’s working: the data showing whether vaccination rates are indeed up will take a while to come in, say health department officials I contact. Calls to Scott Morrison’s office – to ask how many conscientious objectors were expected to immunise as a result of the new policy – were not returned.

It’s easy to find yourself nodding in furious agreement whomever you speak to (on the pro-immunisation side) in this debate – whether it’s those who talk about the responsibilities that come with rights, or the intensive care doctor Heap, who has nursed a baby struggling to breathe, who is concerned for a friend with cancer who’s vulnerable to a child with measles, and who quotes the $10,000 per day it costs to maintain an intensive care bed.

Communication and accurate information are the touchstones of this issue. Yet guardedness is everywhere, and the line between scepticism and suspicion is blurry. People want to know where you’re coming from. Before meeting with the NRVS, I had to confirm they wouldn’t be sitting with a group of anti-vaccinators: “In Mullumbimby that just has the potential to turn nasty very quickly,” a spokeswoman writes to me before I arrive. Someone else warns me that if I speak to anti-vaccination parents, the Murdoch press will jump on me for “false balance”.

I finish my chai tea and farewell Heap and her NRVS colleagues, but I’m still curious about what goes on in the anti-vaccination mind. At the rainbow-signed Mullumbimby Herbals, a homeopathy “dispensary”, I ask if they help people who want alternatives to vaccination. The clearly flustered assistant heads to the back of the shop, returning with the manager. “We don’t comment on that,” the lady manager says, still smarting from a recent visit from Channel 7 who “misquoted us”.  Pressed, she just says: “We support choice”.

As I drive out of Mullumbimby I detour to the town’s “museum”. The old post office building is locked up, but it’s surrounded by a paddock of outdoor exhibits, displayed like some sort of rural sculpture by the river: an old dray, a rusty plough, an outdoor dunny. It’s as if history starts and ends with white settlement. Mullumbimby might be a place where it’s possible to believe in almost anything, but it’s also more than possible to forget almost everything here too. To forget that – and there’s no subtle way of putting this – it was once home to a Bundjalung people, before diseases such as smallpox, measles and whooping cough did their deadly work.

And the vaccination rates of the Indigenous community now? Up at the 90 per cent levels and above, they are sky high, says Heap. Some groups, it seems, can’t afford to forget.

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