In late 2015 a Senate Inquiry was held into the planned introduction of the Federal No Jab No Pay bill, which would deny a childcare rebate and a tax benefit for those on low incomes to parents whose children were not fully vaccinated. The public were invited to make submissions and some 2,500 were received, though only 550 were published .
The bill was passed in November 2015 and enacted January 1 2016. It was recommended to assess the immediate impact of the Bill after 12 months and a full evaluation of the impact and effectiveness of the Bill after three years of implementation. More than 3 years later, and we still don’t have either.
Yet, Doctors groups, prominent health officials, lawyers and other well-regarded Australians have expressed concern over Australia’s No Jab No Pay/Play laws. They are from the following:
- Royal Australasian College of Physicians (RACP)
- Australian Medical Association (AMA)
- Professor Julie Leask, Visiting Senior Research Fellow at the NCIRS
- Dr. Jenny Royle, Immunisation Paediatrician at Royal Children’s Hospital
- Dr Frank Beard, Executive of NCIRS
- Law Institute of Victoria (LIV)
- Australian Council of Social Service (ACOSS)
- Australian medical ethics academics
- Liberty Victoria
- Professor Paula Gerber
- Jennifer Rivarovski, Education Consultant
- Professor Peter McIntyre
- Professor Robert Booy
- Association of American Physicians and Surgeons
1. Royal Australasian College of Physicians
The Royal Australasian College of Physicians (RACP) is the professional medical College of over 17,000 physicians and 8,000 trainee physicians, often referred to as specialists, in Australia and New Zealand. A quote from their submission :
“The RACP is a strong advocate of vaccination, vaccination programs, and other initiatives to promote high compliance rates of immunisation for vaccine-preventable diseases. However, the RACP does not support routinely denying children or their family’s access to social benefits. Denying access to these payments has the potential to entrench a child’s disadvantage.”
More recently, the RACP have written to the NSW, SA and WA governments expressing concern over their plans to introduce No Jab No Play, which denies unvaccinated children access to childcare and kindergarten . Excerpts:
“The RACP is very concerned about section 96C of the draft amendment which proposes to deny attendance not only to child care, but also to pre-school, to children who do not meet Australian immunisation requirements. In the older preschool group, any incremental benefit from this proposed measure in strengthening protection against vaccine-preventable diseases (VPDs) is minuscule, as Australia has high overall rates of immunisation and children over 2 years of age have received most vaccines and boosters. This means any increase in protection for other children from exclusion of incompletely immunised children from pre-school is negligible, whereas that the detrimental effects of lack of access to early childhood education and care on a child’s long-term development are potentially very large.
As paediatricians who advocate for the welfare of children, we are bound to draw attention to the enormous body of research demonstrating the benefits of childhood education before school commencement, especially in disadvantaged households. Denial of this access is a serious matter, with likely long-term adverse consequences for the healthy development of the children involved. In this context, the risk of VPDs to fully vaccinated children from children who are under-vaccinated is often exaggerated.”
The RACP have also responded to law proposals in NSW  and WA .
2. Australian Medical Association
The Australian Medical Association (AMA) is effectively a doctors’ union, set up to represent doctors’ interests. In 2016 the AMA had a membership of 29,425 doctors, which was 27% of doctors . In their submission , the AMA are strongly supportive of the Bill. However they also have some reservations, outlined in the following statements:
“While the AMA is generally supportive of the intent of the Bill, in terms of encouraging parents to reconsider their choice not to immunise their child, disadvantaged or at risk children may be disproportionately affected by the measure in terms of it potentially reducing their access to childcare (via reductions in childcare related fees or payments). Vulnerable children, or children deemed to be at risk, can gain significant benefits from engaging in quality childcare and preschool activities. In some instances, regular childcare and preschool participation can reduce the impact of problematic and unstable home environments. High rates of immunisation among all groups of children, including those that are vulnerable, is critical, but it is also essential that the impacts of the Bill are monitored to ensure that vulnerable, or at risk, children are not being increasingly disadvantaged in terms of reduced access to quality childcare and preschool.
The Government must also remain alert to the possibility of unintended consequences, including higher rates of children not being immunised in areas associated with higher incomes, and disadvantaged children having reduced access to childcare and preschool.”
3. Professor Julie Leask
Professor Julie Leask is a behavioural scientist and professor in the Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney. She works with a team of postdoctoral and PhD researchers with a shared focus on improving public health policy, programs and practice with a focus on vaccination and environmental health. In 2018, Julie was appointed chair of a working group on data for vaccine acceptance and demand convened by WHO, Geneva office. Quote from submission Julie Leask PhD, MPH, Dip Health Sci & Kerrie Wiley, PhD, MScMed, BSc :
“While vaccination is well supported by research, the proposed amendment is not grounded in evidence from the behavioural sciences and brings a series of unintended deleterious consequences. This submission urges government take a more rational and considered approach to increasing vaccination rates consisting of comprehensive, multifactorial approaches that amount to firm but fair policy and continue to hold vaccine refusers to account. In addition, shutting out the unvaccinated from childcare by removing its affordability will not shut out the risks from vaccine-preventable diseases.”
In June 2018 Professor Leask gave a presentation at the 16th National Immunisation Conference, held in Adelaide. Watch her talk  At 5:45 minutes she describes how the laws came about:
“How did we get to No Jab No Pay? Well we had sudden national awareness of differences in regional vaccination rates in 2013 with the release of the National Health Performance Authority Report and immediately the problem was framed as an objector problem. And the script was written, certainly the Sunday Telegraph, a Sydney tabloid [Murdoch] newspaper, they immediately leapt into a campaign which they called No Jab No Play. So that’s where the name of the policy comes from.
They were calling for state governments to amend their legislation and the federal government to get rid of the loophole which was the granting of conscientious objection exemption.
The media frequently framed our vaccination rates as declining, Tony Abbott in May 2013 said they were even plummetting, or was quoted as saying so, and you even had those strident comments about parents who don’t vaccinate being anti-vaxxers and baby killers. And this painting of the stereotype of the irresponsible, selfish hippie.”
She goes on to talk about the politicalisation of the issue, the introduction of No Jab No Play, and she explains that vaccination rates were not going down, and looks at what improves vaccination coverage according to evidence. Regarding the vaccine preventable diseases (VPD) risk in childcare, which was part of the promise of the policy, she says:
“we know about the dynamics of pertussis (whooping cough): transmission can be in the vaccinated, and up to 50% of infants hospitalised with pertussis contracted it from a parent or sibling …”
Professor Leask also says that what is needed now is that governments should carefully weigh potential benefits against known risks of removing early childhood education, and she calls for Australia to introduce a no-fault vaccine injury compensation scheme. She says that particularly in light of the level of requirement of the laws now in place, we need to look after the very few who are injured by a vaccine and need compensation. A quote from her article ‘No Jab No Play: vaccination rules should be fair to all children’ .
“Removing the vaccine objection exemption:
Punishes the children for the decisions of their parents by denying their right to education. It contravenes the National Partnership Agreement signed by Commonwealth and the states and territories that “All children have access to affordable, quality early childhood education in the year before formal schooling”.
Is not a panacea for disease control because others too spread disease and need boosters – parents, childcare workers, travellers and health care workers. One review found that up to 50% of infants hospitalised with pertussis [whooping cough] contracted it from a parent or sibling. Staff in childcare centres also spread disease and a NSW study of 319 childcare centres containing 3574 workers found that only 29.4% were fully vaccinated.”
4. Dr. Jenny Royle
Dr Jenny Royle  is an Immunisation Paediatrician who has 15 years experience working at the Immunisation Service of the Royal Children’s Hospital (RCH), Melbourne, providing clinical immunisation advice for parents and staff, Community Immunisation Providers and the Victorian Department of Health.
In 2018, Dr Royle strongly criticised the Victorian No Jab No Play law during a panel discussion at the 16th National Immunisation Conference held in Adelaide SA. She said :
“I vehemently oppose the Victorian law, No Jab No Play. … I don’t want people to be disadvantaged by strategies to increase immunisation coverage, and the Victorian law, No Jab No Play, disadvantages children and their families. I think denying a child entry into kindergarten is wrong. I think it’s a disproportionate response to the risk that a fully immunised child has in being in a kindergarten with a very small number of children who aren’t 100% up-to-date with their immunisations, and that risk is disproportionate to the punishment.”
5. Dr Frank Beard
Dr Frank Beard  is an executive of the National Centre for Immunisation Research & Surveillance (NCIRS). He is a public health physician who heads up the coverage, evaluation, surveillance and social research team at NCIRS and has a conjoint academic appointment as Senior Lecturer in the University of Sydney School of Public Health.
Dr Beard was a panelist in a NJNPay/Play discussion at the 16th National Immunisation Conference 2018 . Dr Beard first outlines successes of the laws, then he says:
“I do have ongoing concerns about some of the issues that have been raised by other speakers: equity, ethical issues, coercion …
I have concerns about the removal of the vaccine objection exemption completely rather than being in a strict exemption process and I do wonder whether this will potentially come back to bite us down the track. I think that at minimum we should be advocating, as other speakers have called for, for a full evaluation of No Jab No Pay, potentially through conference resolution tomorrow.
I have particular concerns about No Jab No Play policy, and Jenny [Royle] has outlined a lot of the issues where it’s much more debatable whether the benefits outweigh the potential negative impacts. And I do worry – I do think we have a window of opportunity for advocacy in terms of No Jab No Play given that it hasn’t been rolled out nation-wide, and so again we’d be arguing as I think Margie [Danchin] suggested yesterday for an evaluation of the Victorian policy.
And I do worry about whether this is all a bit of a slippery slope that we’re going to end up with a Californian situation of mandatory school entry vaccination and vaccine refusers having no option except to home school. And before people dismiss that as hyperbole, I think it’s a very realistic prospect given the context that No Jab No Pay and Play have come in on, as Julie [Leask] presented, a bit of a moral panic about the supposedly plummeting vaccine rates which we know is not correct, and the context of poor general understanding of some of the principals of herd immunity, and disease control and risk management. And too much focus on this 95% coverage target which is somewhat arbitrary, and too much focus on children and not looking at some of the other under-immunised groups such as adults.”
6. Law Institute of Victoria
The Law Institute of Victoria (LIV) is Victoria’s peak body for lawyers and those who work with them in the legal sector, representing 19,000 members. Some excerpts from their submission :
“The LIV supports the purpose of the Bill to encourage the uptake of childhood vaccinations; however, we have a number of concerns with the way in which the Bill seeks to achieve this aim.
a) The Bill does not promote the best interests of the child
The LIV is concerned that this policy is not in the best interests of the child. The United Nations Convention on the Rights of the Child provides in article 3 that:
In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.
The fact that the Bill takes a punitive approach to encouraging vaccinations, and contains penalties for children and their families who may have a range of reasons for not being vaccinated strongly suggests that the legislation has not been designed with the best interests of the child in mind.
b) The Bill will have a negative effect on disadvantaged families
The ‘no jab, no pay’ law would have an unfair punitive effect on those families that rely more heavily on government payments. Some families may not be able to afford to send their children to childcare without these subsidies, which would be a serious undesired consequence of the Bill. This potentially discriminatory outcome of the Bill does not appear to be consistent with the best interests of the child.
This punitive approach is also unlikely to influence the completely committed vaccine objectors and would seem unlikely to greatly influence choices of wealthier families, who do not depend or qualify for the relevant government payments.
c) There is insufficient evidence about the effectiveness of the Bill’s approach
Will aby notes that research and experience indicate that about half of under-immunisation in Australia is due to lack of access. The ‘no jab, no pay’ does not address this issue and may further entrench existing disadvantage. A policy that focused on the best interests of the child would include measures that make it easier for parents to vaccinate their children, especially for those in regional and remote areas.
The expected and significant financial savings to be made from this Bill themselves suggest that the Bill is likely to be ineffective in raising vaccination levels (if the Bill was completely effective, there would be no budgetary savings, as no welfare payments or benefits would be cut). This suggests that the best interests of the child may not have been the primary consideration in the formulation of this Bill.
[Then] Australian Medical Association (AMA) President, Associate Professor Brian Owler has noted his concern that such large savings were expected:
it indicates that a number of people aren’t going to vaccinate their children. What we should be saying is we need to make sure that we do get all those children vaccinated and we should be aiming to actually continue to spend the same amount.”
Incidentally, Brian Owler is the Australian Labor Party’s candidate for the Sydney seat of Bennelong for the 2019 Australian federal election.
7. Australian Council of Social Service (ACOSS)
The Australian Council of Social Service (ACOSS) is a national advocate for action to reduce poverty and inequality and the peak body for the community services sector in Australia. In September 2017 ACOSS published a policy statement about No Jab No Pay . Some excerpts from the statement:
“The government’s No Jab No Pay policy, by definition, targets families on lower incomes who receive Family Tax Benefit.
Higher-income families are unaffected by No Jab No Pay because they do not receive Family Tax Benefit.
The policy of No Jab No Pay should also be transparently reviewed with participation by health experts in order for parliamentarians to make fully informed decisions.
We do not support a social security policy that places additional pressure and stress on lower income families, unfairly targeting a group who already have higher rates of immunisation without evidence of its effectiveness. Social security provides essential income support to lower income families struggling to make ends meet.”
8. Australian medical ethics academics
A group of 4 academics who work in the fields of public health and medical ethics have published a research paper that looks at Australia’s No Jab No Pay and Play laws. Their paper examines “the impact of coercive approaches to childhood vaccination such as these and raises the question of the ethical justifiability of health policy initiatives based on coercion.” It is published in Journal of Bioethical Inquiry, 2018, ‘Raising Rates of Childhood Vaccination: The Trade-off Between Coercion and Trust in the journal Bioethical Inquiry’ . Some points they raise:
The Australian Immunisation Handbook states that vaccination should only be given in the presence of valid informed consent and that consent must be given voluntarily in the absence of undue pressure, coercion or manipulation (Australian Government 2013, revised 2017).
We conclude that the evidence does not support a move to an increasingly mandatory approach that could only be delivered through paternalistic, coercive clinical practices.
Approaches are available that tighten procedures for registering objection while simultaneously enhancing consumer autonomy, improving access to healthcare, and removing barriers to information and vaccination. Such approaches are preferable to ensure adequate protection for the community while avoiding the risks and potential negative social effects of punitive policies.
9. Liberty Victoria
Liberty Victoria  is one of Australia’s leading and longest-standing civil liberties organisations. They work to defend and extend human rights and freedoms. They have produced a policy on Victoria’s No Jab No Play law , Their comprehensive policy includes the following:
“Liberty Victoria does not support the “No Jab, No Play” provisions as set out in the Act. Liberty prefers the “no form, no play” policy adopted in NSW. Such a policy requires registration of a child’s vaccination status before enrolment at childcare or Kindergarten facilities while still allowing for conscientious objections. The NSW provisions strike a better balance between the opposing values of promoting the public’s interests and respecting individual autonomy.
In conclusion, we simply note that there is something deeply unpalatable in using compulsion, whether direct or indirect, to force parents to subject their children to preventative medical interventions when they believe such interventions may be harmful to their children. It is certainly not an approach favoured by medical ethics and, in our submission, is an approach that should not be favoured by civil libertarians. Even more objectionable is the fact that the “no jab, no play” provisions in Victoria may have the effect of visiting additional deleterious consequences on young children due to parental decisions not to vaccinate.”
10. Professor Paula Gerber
Professor Gerber has been an academic in the Monash University Law Faculty since 2004. As a Professor, Gerber researches, teaches and performs leadership roles across the university, the Law Faculty and the Castan Centre for Human Rights Law. In 2013 Gerber wrote an article ‘Bringing a human rights perspective to the debate surrounding the vaccination of children’ . Some excerpts:
“Australia ratified the United Nations Convention on the Rights of the Child well over a decade ago. This means that we have agreed that, In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.
So when the New South Wales parliament is considering allowing schools and childcare centres to ban a group of children (those who have not been vaccinated), its decision needs to be informed by what is in the best interests of children.
There is no doubt that more needs to be done to increase the number of children being immunised. However, discriminating against children whose parents have decided not to vaccinate them, by withholding access to education, is not an appropriate way of achieving this. It is not in the best interests of children to try to increase one right (health) by denying access to another right (education).”
11. Jennifer Rivarovski
Jennifer Rivarovsk is an education consultant and here she discusses concerns teachers and educators have about unvaccinated children being denied education .
12. Professor Peter McIntyre
Professor Peter McIntyre  is Professor of Child and Adolescent Health and the School of Public Health, University of Sydney. He is qualified as a paediatrician, specialising in infectious diseases, and an epidemiologist, specialising in vaccine-preventable diseases and a public health physician. Professor McIntyre was Deputy Director of Australia’s National Centre for Immunisation Research and Surveillance of Vaccine-Preventable Diseases (NCIRS) from 1997-2004, Director from 2005-2017 and continues to be a Professorial Fellow with NCIRS.
In May 2017 McIntyre was interviewed for the Medical Journal of Australia (MJA) podcast series . The interviewer asks whether the No Jab No Pay and Play laws are keeping babies safe, and he says the laws have increased vaccination rates, but points out this needs to be balanced with accessibility to education:
“It’s terribly important to evaluate this carefully… there are people there who just worried, concerned about well, just fearful about some aspects of vaccines and who for whom the dollars are really important. That could mean that a child who would otherwise benefit from early childhood education and child care or pre-school misses out…we know that a child missing out on early childhood educational opportunities, we know that that is really bad, in terms of your subsequent educational progression.”
McIntyre also debunks the community’s main argument for the laws, the idea an unvaccinated child is a risk to a vaccinated one. He says:
“But it is a bit of a myth that there’s this terrible disease risk that other children or other parents doing “the right thing” are exposed to by these unimmunised children, particularly when you’re talking about older kids in pre-school. Conversely, with an older kid in pre-school, that’s when you’re really missing out on your kickstart for school, if you’re excluded from participating in that.”
Early in the interview, McIntyre attributes the initial drive for the No Jab No Pay law to the media:
“No Jab, No Pay, I guess, was particularly initially driven by the fact that for the first time via the then National Health Performance Authority, at that time was the first kind of, I guess, authorised way to make available the detailed information at postcode level and that really spurred a lot of media coverage around areas, particularly, I guess areas that might be considered a bit more affluent or trendy in cities, where these rates were said to be low and potentially a problem. And that sort of coincided, I guess, with all the concern about pertussis [whooping cough] and pertussis deaths from a young infant, and the two are not necessarily related, but they sort of got related in the media messaging around all of this.”
In other words, according to McIntyre the fear of the unvaccinated spreading pertussis was the result of hype by the media and not based on facts, and this was the initial drive for No Jab No Pay.
13. Professor Robert Booy
Professor Robert Booy is Head of the Clinical Research team at the National Centre for Immunisation Research and Surveillance (NCIRS), having joined in March 2015. He is a medical graduate of the University of Queensland (1984), trained in paediatrics at the Royal Children’s Hospital in Brisbane and has held a range of positions in the UK. Like Professor McIntyre, Professor Booy appears frequently in the media promoting vaccination. He was interviewed on ABC radio Sydney by Richard Glover about Australia’s ‘No Jab’ laws. Listen to the interview below: Richard Glover interview on Drive with Professor Robert Booy on vaccination .
Booy clearly expresses his discomfort over the laws, as well as pointing out there has been very little change in the vaccination rates since the laws were introduced, that the herd immunity figure of 95% does not really mean a great deal and there are better ways of increasing vaccination uptake than coercion. At 7:45 minutes, Booy is asked if the laws are important.
Booy: Look they’ve made a contribution, but the only measurement we have is that it has gone up by about 1.4% overall.
Glover: I keep on hearing these figures of 94%, 95%, something like that, that gets you herd immunity, so the difference between 90 and 95 might be everything!
Booy: Well, there isn’t a magic tip-over point … to imagine that if we could only go from 94 to 95 would make a massive difference is not a truism, it’s not correct. Actually, we are already getting good herd immunity at 90-91-92, we are just improving each time. We might be able to argue there’s a tipping point but then new babies are born who are not immune and it changes immediately.
Glover: Mandatory [vaccination], absolutely hard line – you gotta do it.
Booy: The mandatory approaches have been tried on and off for 150 or more years, and it does create opposition, so it’s not always the panacea you are looking for, it can actually be problematic. I worked in the UK for 15 years, I ran a study which vaccinated 20,000 children in the Oxford community, we got 95% uptake with an unlicensed vaccine. Why? Because the nurse and I went round and listened to people and educated them and – this was in the 90s, so maybe things have changed – but just simple information, providing information that is credible … we got great uptake.
Glover: Are you an opponent of the No Play, No Pay? You sound as if you’re kinda unsure about it.
Booy: Yeah I’m a bit on the fence. I’ve always felt that caring about people and the information you provide was the key, and then the No Pay No Play might add a little bit.
14. In the United States - Association of American Physicians and Surgeons
The Association of American Physicians and Surgeons (AAPS) represents thousands of physicians in all specialties in the United States. The AAPS was founded in 1943 to protect private medicine and the patient-physician relationship.
In the US vaccine laws are a state matter, but the federal government are considering introducing vaccine mandates. The AAPS has written the following letter to relevant federal committees . From the letter:
“Governmental preemption of patients’ or parents’ decisions about accepting drugs or other medical interventions is a serious intrusion into individual liberty, autonomy, and parental decisions about child-rearing.
Issues that Congress must consider:
- Manufacturers are virtually immune from product liability, so the incentive to develop safer products is much diminished. Manufacturers may even refuse to make available a product believed to be safer, such as monovalent measles vaccine in preference to MMR (measles-mumps-rubella). Consumer refusal is the only incentive to do better.
- There are enormous conflicts of interest involving lucrative relationships with vaccine purveyors.
- Research into possible vaccine adverse effects is being quashed, as is dissent by professionals.
- There are many theoretical mechanisms for adverse effects from vaccines, especially in children with developing brains and immune systems. Note the devastating effects of Zika or rubella virus on developing humans, even though adults may have mild or asymptomatic infections. Many vaccines contain live viruses intended to cause a mild infection. Children’s brains are developing rapidly—any interference with the complex developmental symphony could be ruinous.
- Vaccines are neither 100% safe nor 100% effective. Nor are they the only available means to control the spread of disease.”
- https://www.armchairmedical.tv/immunisation-2018/videos/no-jab-no-pay-play-is-the-juice-worth-the-squeeze-associate-professor-julie-leask; https://youtu.be/3ole375H-cQ
- https://www.armchairmedical.tv/immunisation-2018/videos/panel-discussion-no-jab-no-payplay; https://youtu.be/8MiCOL9WglE
- https://www.mja.com.au/podcast/206/9/mja-podcasts-2017-episode-24-vaccination-rates-and-incentives-prof-peter-mcintyre; https://youtu.be/5QOqA9sB1N0
Note: information for this press release was sourced from 'For Legislators: Opposition And Concern Regarding Australia’s No Jab No Pay/Play Laws' https://avn.org.au/information/vaccine-laws/for-legislators-opposition-and-concern-regarding-australias-no-jab-no-pay-play-laws/