Policy Feedback and the Politics of Childhood Vaccine Mandates: Conflict and Change in California, 2012-2019.

CONTEXT: In 2012, California instituted a new requirement for parents to consult with a clinician before receiving a personal belief exemption to its school entry vaccine mandate. In 2015, the state removed this exemption altogether. In 2019, legislators cracked down on medical exemptions to address their misuse by vaccine refusers and supportive clinicians. This paper explores these political conflicts using 'policy feedback theory,' arguing that personal belief exemptions informed the emergence and approaches of two coalitions whose conflict reshaped California's vaccination policies. METHODS: We analysed legal, policy, academic and media documents; interviewed ten key informants; and deductively analysed transcripts using NVivo 20 transcription software. FINDINGS: California's long-standing vaccination policy inadvertently disseminated two fundamentally incompatible social norms: vaccination is a choice; vaccination is not a choice. Over time, the culture and number of vaccine refusers grew, at least in part because the policy state-sanctioned the norm of vaccine refusal. CONCLUSIONS: The long-term consequences of California's 'mandate + PBE' policy - visible, public, and socially sanctioned vaccine refusal - undermined support for it over time, generating well-defined losses for a large group of people (the vaccinating public) and specifically for the parent activists whose experiences of personal grievance drove their mobilisation for change.

Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates.

BACKGROUND: Vaccine hesitancy is a global problem with diverse local policy responses, from voluntaristic to coercive. Between 2015 and 2017, California, Australia, France, and Italy increased the coerciveness of their childhood vaccine regimes. Despite this apparent convergence, there is little evidence of imposition, policy learning, or diffusion - the drivers that are usually discussed in scholarly literature on policy convergence. The fact that the four governments were oriented across the political spectrum, with quite different political and institutional systems, further indicates an empirical puzzle. METHODS: To better understand the drivers of enhanced vaccine mandates, a crucial issue during the coronavirus disease 2019 (COVID-19) global rollout, this article engages with four case studies assembled from qualitative analysis of semi-structured in-country interviews and document analysis between November 2018 and November 2020. Key informants had specific expert knowledge or played a role in the introduction or implementation of the new policies. Interview transcripts were coded inductively and deductively, augmented with extensive analysis of legal, policy, academic and media documents. RESULTS: The case analysis identifies two key and interacting elements in government decisions to tighten vaccine mandates: functional and political pressures. Policy-makers in Italy and France were primarily driven by functional challenges, with their vaccination governance systems under threat from reduced population compliance. California and Australia did not face systemic threats to the functioning of their systems, but activists utilised local opportunities to heighten political pressure on decision makers. CONCLUSION: In four recent cases of high-income jurisdictions making childhood vaccination policies more coercive, vaccine hesitancy alone could not explain why the policies arose in these jurisdictions and not others, while path dependency alone could not explain why some jurisdictions with mandates made them more coercive. Explanation lies in restrictive mandates being attractive for governments, whether they face systemic functional problems in vaccine governance, or political pressures generated by media and activists. Mandates can be framed as targeting whole populations or localised groups of refusers, and implemented without onerous costs or policy complexity.

The promises and pitfalls of polysemic ideas: 'One Health' and antimicrobial resistance policy in Australia and the UK.

Recent scholarship posits that ambiguous ('polysemic') ideas are effective for coalition building between diverse stakeholders: their capacity to be interpreted differently attracts different interests. Hence, in search of political solutions to 'wicked' and similarly complex problems, deploying polysemic ideas would be critical to effective policy-making. This paper scopes the policy-making potential of polysemic ideas by examining the impact of an ambiguous concept known as 'One Health' on responses to antimicrobial resistance (AMR) in Australia and the UK. It offers two primary arguments. Firstly, polysemic ideas can help mobilise broad attention to complex problems: since One Health became associated with AMR, political and administrative attention has grown more intense and coordinated than previously. Secondly, however, a polysemic idea alone may be insufficient to generate effective action: the contrast between Australian and UK AMR policies illustrates that polysemic ideas do not suspend interests, institutions, or ideas that can be readily deployed.