Saara Ahmed

Saara Ahmed

Italy’s vaccination turnaround raises questions about state’s role in public health

24 July 2018

children drawing with chalk on green board with Italy shown

Italy has changed its policy around childhood vaccination, provoking debate about the role of the state in enforcing public health measures.

Italy has relaxed the requirements for parents to provide evidence of their children’s vaccination history on enrolment in state-run schools.

The new rule, announced by Giulia Grillo, Italy’s health minister, requires only parents’ assurance – as opposed to a doctor’s note – that their children are immunised before they can enrol in state‑run schools this September. The country’s new populist government aims to simplify enrolment procedures and enable school participation for all, including children whose parents do not yet have their paperwork in order. However, critics fear that this move will lead to a drop in compliance with vaccination programmes.

Vaccination in Italy

A 2017 law had made 10 vaccines mandatory for Italian schoolchildren. The law was introduced to raise the country’s immunisation coverage after a measles outbreak in Europe that saw more than 3,300 cases in Italy. Only Romania had more cases of measles during the outbreak. The two parties that now comprise Italy’s government – the Five Star Movement and the far-right League – have repeatedly expressed scepticism about the benefits of vaccines, and are seeking to revise this law alongside their new ruling. The Five Star Movement has asserted that vaccinations may be linked to cancer, allergies, inflammation and autism – despite the abundance of robust evidence to the contrary.

Critics of the new ruling are worried that it will encourage a lax attitude towards vaccination – and that the number of children being vaccinated will drop.

While there are certainly benefits to rapid enrolment into school, critics of the new ruling are worried that it will encourage a lax attitude towards vaccination – and that the number of children being vaccinated will drop. This has repercussions including risk of outbreaks of infectious disease, and especially high risk of infection for children with autoimmune diseases who rely on others being vaccinated to protect them via herd immunity.

The practical ramifications of the ruling, meanwhile, are unclear: no plans have been announced for how the government will detect whether parents are telling the truth. Moreover, critics argue that a rule that contradicts the general scientific consensus might erode public faith in science.

Those who oppose the rule are now looking to other countries. In 2017, Germany began to crack down on parents who refuse to vaccinate their babies before enrolling them in kindergarten, while France has introduced fines for noncompliant parents. In some states of Australia, childcare centres can be fined thousands of dollars for admitting an unvaccinated child.

The state’s role in health promotion

The debate over Italy’s latest policy goes further than questioning the benefits of vaccines. It also questions the role of the state in medical interventions – and the responsibilities of the population for maintaining public health. The European Commission has proposed a Council recommendation on strengthened cooperation against vaccine-preventable diseases, aiming to increase vaccination coverage across Europe. But should public health advice be enshrined in national laws?

There are many arguments to encourage state intervention to benefit public health, which can be roughly divided into practical issues, promoting social justice and an obligation of care.

The practical arguments for state intervention include preventive protection against future outbreaks, which would put unseen and excessive strains on the health system. The foundation of preventive care is knowledge of risk – if authorities cannot accurately estimate the risk of public health hazards, they cannot determine how to allocate resources for a potential outbreak. A government needs to be able to plan and budget appropriately to provide public services efficiently.

Many believe that to promote social justice, governments should champion individual autonomy – and that making vaccinations mandatory encroaches on that autonomy. However, a 2012 position statement from the British Medical Association points out that this criticism of mandatory vaccinations oversimplifies the debate into ‘individual autonomy versus a paternalistic state’. Instead, we should recognise that the state, in order to promote individual autonomy, needs to create a reasonably healthy environment in which ‘freedom’ can have real meaning. In the context of the vaccine debate, governments need to be able to ensure a healthy population so that individuals can make decisions and be free from illness in order to pursue the lifestyles they want.

In light of these arguments, it is clear that there is a greater debate to be had surrounding mandatory vaccinations and the role of the state, which may address some of the criticisms the Italian government is currently facing. Whether relaxing legislation around vaccination has a negative effect on uptake remains to be seen, but will surely form a crucial element of this debate for years to come.


Saara Ahmed is a former Researcher for The Health Policy Partnership.


The opinions expressed in this blog are those of the author and do not necessarily represent the views of The Health Policy Partnership.