February 4, 2021
I try to have patience when parents hesitate to vaccinate their children. I have to imagine that the hesitance comes from a place of love: all parents want their children to be happy, to be healthy, to thrive. And in fairness, particularly when considering diseases of presently low incidence in the USA, such as rubella and polio, it’s not too hard to understand why the fear of any adverse reaction – even a reaction that is exceptionally rare (I’m looking at you, Guillain-Barre syndrome after the flu vaccine) or more common but rather mild (low-grade fevers, muscle soreness) – in the here in now outweighs the perceived future risk of a rare disease, or really any disease for which a layperson may not understand the severity. Indeed, in all honesty, I didn’t know that “hepatitis” meant damage to the liver until I was studying for the MCAT, so when a parent asks me why we have to give so many vaccines at the 2-month visit, how do I concisely explain the need for immunization against haemophilus, pneumococcus, polio, diphtheria, tetanus, pertussis, hepatitis B, and rotavirus all at the same visit? She hasn’t seen the family mourning their child who lost all meaningful neurologic function due to pneumococcal meningitis. He hasn’t seen an infant cough so hard that air became trapped between her chest wall and her heart from pertussis. The chief irony, of course, is that these diseases would not be so rare but for the tremendous success of widespread childhood vaccination.
And thus arises the tradeoff, a sort of tragedy of the infectious commons, a balancing of the desires of the individual versus the needs of the community, a reiteration of the unflappable American prioritization of the rights of the individual over the needs of the collective. A given set of parents who choose not to vaccinate their children at the 2-, 4-, and 6-month visits is unlikely to see their child suffer any adverse consequences of this action. But of course, this privilege is predicated on the immunity of the masses – on herd immunity. Were it not for widespread vaccination against these pathogens, seeing children with haemophilus epiglottitis, acute flaccid paralysis from poliomyelitis, and subacute sclerosing pan-encephalitis from measles would be tragically routine. That the obtuse titles of these pathogens hardly qualify as household names any longer speaks to the enormous efficacy of prior vaccination campaigns. But on the individual level, it is easy to see how the misguided mindset of anti-vaxxer rhetoric takes root: “I didn’t vaccinate my child, and they’re fine! I don’t want those ‘toxins’ in my child. Only natural substances.” I have two reflexive retorts to this. First, could you take two fingers on the smartphone display of your life and squeeze them together, zooming out to view the broader context here? Whether or not you choose to ignore it, you live in an interconnected world, and your decision to vaccinate your child does have an impact on the health of other children, however seemingly infinitesimal. Second, may I remind you that feces and HIV are both “naturally occurring” substances? I’m rather certain we can agree that “natural” does not equate with “good”, so let’s drop the charade.
And then, of course, bring on autism. While any pediatrician or expert in child development knows that meaningful signs of autism become first apparent between a child’s first and second birthdays – hence the routine screening for autism at the 18- and 24-month visits – conveniently 6 to 12 months after the first dose of the measles, mumps, and rubella vaccine. Anyone who’s come within six virus-spitting-feet of a statistics classroom can render the hoary chestnut that correlation does not equal causation. Indeed, in one of my favorite xkcd comics, membership in Wicca is shown to correlate strongly with total downloads of the Firefox internet browser. Few among us, however, would claim that steering from the ever-more-hegemonic grip of Google Chrome would constitute apostasy. Nevertheless, this did not stop Andrew Wakefield from seizing on this correlation – that is, the completely coincidental onset of symptoms of autism in the months following the MMR vaccine – to grab his fifteen minutes of medical fame, however redacted they now are. The damage was done and the myth persists. A myth founded on anecdata now impervious to falsification with genuine, rigorous, longitudinal data disproving the link between autism and vaccination. Excellent. And so I sigh and brace myself for the next measles outbreak to deplete our seemingly ever-dwindling supply of N95s.
Moreover, some vaccines do provide tremendous individual benefit even beyond the community benefit. The HPV vaccine has been tremendously successful in preventing cervical cancer, oropharyngeal cancers, and genital warts – but of course, acknowledging the need for this vaccine would imply a recognition that humans are sexual beings, as the very continuation of human life on earth reminds us each day. In the majority of cis-hetero relationships, sex was a part of bringing the child into the world, so can we cut the pretense that this child will be asexual? But no! “My child’s not a slut. That vaccine won’t be necessary.” How dare I suggest that your ostensibly eternally chaste child be protected against malignancies in the untoward event of sexual assault. How dare I.
But of course, that is my internal dialogue. I never share those less generous thoughts with families outright, because while writing them – even thinking them – can be cathartic, stating them aloud won’t do anything but erode the potential for a therapeutic relationship to materialize. How, then, can we communicate the safety and efficacy of vaccines in a way that actually drives behavior change? If our end goal is preventing disease through broader uptake of immunizations, then how do we convince the hesitant parent? The student of motivational interviewing knows that open-ended questioning, non-judgmental dialogue, and elicitation of fears and barriers to uptake can gradually lead patients – or parents – to changing their mind while making them think that it was their idea to do so all along. The trouble with motivational interviewing, however – besides the fact that it requires emotional energy and time, which can be scarce during busy clinic days – is that it is predicated on the existence of a common epistemological plane between the interviewer and the interviewee.
That is, I have found great success in using motivational interviewing with parents who have reasonable questions or concerns, or simply want more information prior to a vaccination. The breakdowns in communication are the most profound when the chasm between our worldviews is so wide that our fundamental understanding of the etiology of infectious disease is not the same. I simply do not have tools in my interpersonal toolbox to argue the benefit of vaccines to someone who believes that viruses do not cause disease, but rather that mysterious entities called exosomes dictate human health and well-being. A belief, mind you, founded on the arguments found in a 9-minute YouTube video rather than the enormous corpus of falsifiable and robust scientific evidence on the topic. Lovely.
Indeed, with the democratization of communication brought about by the internet there has been a simultaneous erosion of respect for the notion of “expert opinion” on a topic. In many cases this is healthy, and allows for outdated ideas – often racist, sexist, homophobic, transphobic, ageist, or otherwise historically privileged ideas – to be challenged in open fora, for old norms to be challenged by fresh ideas. But the ever-present danger of such a devaluation of expertise was exemplified no more prominently than by he-who-shall-not-be-named, our 45th President, whose insistent, consistent, and persistent disregard for the recommendations of epidemiologists and other public health experts indubitably contributed to the astounding number of Americans dead due to COVID-19, over 400,000 at the time of this writing. Perhaps in addition to jennymccarthybodycount.com we need a 45covidfailures.com. Perhaps.
Yes, at this juncture, here we are in the midst of a pandemic, with a new vaccine – or rather a panoply of related vaccines – that show truly remarkable promise in getting our society back to normal. To the surprise of no one, anti-vaxxers have been no less prominent with this vaccine than any of the dozens their lies have libeled in the past. And yet, the urgency in speaking out against despicable anti-vaxxers has never been greater. Courageous mothers who receive the vaccine while pregnant, hoping to protect their babies from the untoward effects of maternal COVID-19 on the fetus (i.e., low oxygen levels from COVID are probably not great for a baby’s brain development in utero), are maligned on Twitter as reckless murderers. It is true that by virtue of its novelty, we cannot yet speak regarding the long-term effects of the vaccine, though we have little scientific reason to think there would be any. We can, on the other hand, speak at great length about the deleterious short- and long-term effects of COVID. With the exception of anaphylaxis, which thankfully remains a rare occurrence (and one for which we are monitoring with exceptional vigilance, particularly those with an allergic/atopic history), the vaccine has been proven to be remarkably safe and remarkably effective, an unbeatable combination. Yes, you may get a fever for a few hours after the vaccine, or have diffuse body aches. Beats having blood clots in your lungs from COVID. While we can never quantify every risk of a medical intervention, the risk of the intervention must always be weighed against the risk of the counterfactual – i.e., the risk of getting and/or spreading COVID. And in this case, there are strong arguments on both the personal and individual levels in favor of getting the vaccine just as soon as it is available to you.
So please. If this post hasn’t convinced you, and we share the common understanding that viruses do indeed cause disease but you have further questions, don’t hesitate to reach out. We need to get past this pandemic together, and that means as many vaccines as possible, as soon as possible.
And that’s all I have to say about that.
For now.
Dr. Rhodes Hambrick 