There is considerable nostalgia among health officials in the former Soviet bloc for the good old days. The coverage for vaccination always used to appear on the records as 100%, a boast matched by few other countries. If you failed to have your child inoculated against childhood illnesses, your employer would summon you in to account for yourself. And since there was also full employment, disease control was wonderfully effective. All that collapsed with the fall of the Soviet Union; coverage rates plummeted, although they are now creeping back up again as people begin to choose for themselves the value of protection. In a modern democracy it is much more difficult, as our own department of health is finding. You cannot override people's dissent.
MMR (measles-mumps-rubella) vaccinations have fallen dramatically below the 95% required to maintain "herd immunity", to only 85% across Britain. Many parents have been unimpressed by the department's 3m pounds reassurances that MMR is safe following recent scares about a link with autism and bowel disorders. Denied the possibility of having separate jabs on the NHS, a group of them have found a way of bypassing the government blocks and invited a doctor, Peter Mansfield, to give single-dose vaccinations privately.
Clumsy efforts to cut off their choice this week by hauling the former GP before the General Medical Council, which has the power to strike him off, look likely to backfire. If he wins his case, more doctors will probably follow his initiative, and the government policy on vaccination could be left in tatters. Those who are articulate and wealthy enough will be able to chose one form of care; others will be denied the choice and many will continue to refuse what is on offer.
The great public health initiatives of the past depended on general compliance with the politician's or expert's view of what was good for us - and how much should be spent providing it. That compliance can no longer be relied upon. Instead, people are voting with their feet and pursuing their own rights.
A new phenomenon with parallels to the MMR case is currently giving the department of health further headaches. A recent ruling by the European court of justice in a Belgian case said that patients had the right to have their treatment paid for abroad if they faced undue delay in their own countries. In the past, patients might have accepted waiting lists as an inconvenient, but inevitable, form of rationing of limited resources, but not now.
A group of British patients who feel they have been denied their right to treatment are preparing to take the government to the European court. Frank Field, the former social services minister, has been advising them. The first cases will be ready soon. As he points out, the wait for the European court is less than six months, so it should be possible to go through the whole process of getting legal aid, obtaining a ruling and going for treatment abroad in less time than it takes to get to the top of the NHS queue.
As with the MMR problem, the department of health reaction is classic ostrich behaviour. The department says it is still considering the legal implications of the European ruling. But the signs are it will try to fight any attempts to use foreign facilities.
The Crawley primary care group, in West Sussex, has explored using spare capacity in Germany to cut waiting lists. It had got as far as drawing up contracts with GerMedic, an organisation which promotes the use of German hospitals abroad, to have up to 50 NHS patients treated. But the West Sussex health authority, which would have to approve the funding, has decided against it, and is, according to a spokesperson, waiting for further guidance from the department.
Unimpressed with the rhetoric on reducing waiting times and unofficial rationing, people are increasingly finding their own ways round them. Several people have exploited what are known as E111 and E112 forms. EU countries have reciprocal arrangements to provide emergency care to travellers taken ill abroad or care that is not available in the home country. English patients are increasingly showing up in foreign hospitals, using an E111 to get emergency treatment for long-standing complaints. Doctors can also refer patients for non-emergency treatment using E112s. In 1995, 500 patients were treated this way; the number is now said to be 900 a year.
It is not just individuals prepared to fight through the legal route. The national institute for clinical excellence - which was supposed to take the politics out of drugs rationing - may have its decision that certain MS drugs should not be available on the NHS tested in the courts by the Multiple Sclerosis Society. The drugs cost between 7,000 pounds and 10,000 pounds a year for each patient, and only 2 to 3% of MS sufferers receive them in the UK, compared to 12-15% in other countries.
We are witnessing what appears to be the breakdown of any collective commitment to social action and consensus on the distribution of public resources. We have all become more isolated, asocial and selfish, according to communitarian philosophers. Preoccupied by our own private good, we no longer recognise an obligation to pursue a common good that transcends personal interest. So, if there is any risk that my child might suffer damage from a vaccine, I won't give it to them, even if it means the community loses its immunity. If I can find a way round the waiting list that has kept me in pain for months and jump the queue by going abroad, I have a right to do it.
It is certainly true that there has been a huge shift in attitude towards public services. Encouraged throughout the Thatcherite 1980s to apply the laws of the market to all institutions, we learned to treat services as commodities. Everything, including health, was reduced to an anonymous financial rela tionship between a buyer and a seller, public services became something to consume, just like other goods - and that has meant demanding your rights.
But this "we're all too neo-liberal" view won't really wash. Vaccine refuseniks often have a highly developed sense of social responsibility. They expect to play their part in working for the common good; they are just not prepared to accept the medical establishment and government's limited prescription of how that should be obtained.
In fact, there have always been problems with calls to the common good. Historically such visions, whether Marx, Calvin or Rousseau-inspired, have often come to be associated in practice with oppression. It was Aristotle who argued that the difference between a master and a slave was that the master had a superior ability to understand the common good to the poor slave who couldn't be trusted to recognise it. The modern-day metaphorical slaves are rebelling.
At the heart of the rebellion is a refusal to accept the expert's superior ability to judge on their behalf. People are not prepared to accept that exhaustive reviews of the evidence show no link between MMR and autism. They mentally substitute beef and vCJD, or food additives and allergies. They know that epidemiological studies which fail to find correlations are not the same as empirical evidence. Governments have too often given assurances, only to admit a problem later. And even if the risks are small, they know there are alternatives.
What rankles about so much of government policy is its obsession with command and control - on vaccination, that it is driven top-down by the economics of mass disease control, rather than bottom-up by what serves the health of each child; on waiting lists, that the government appears to be in denial about the scale of the bed crisis.
So the social scaffolding has gone. With good reason. It was often remote, unaccountable and paternalist.
But how do we move on? In a society of sophisticated consumers of information, the arguments have to be won by persuasion; and that needs much greater honesty about the limits of knowledge and resources - and the difficult choices that distributing them entail.
