Vaccine Vexation

Climate change is fully upon us here in the lush green mountains of West Virginia, with roller-coaster temperatures. The day before had been a beautiful day in mid-May, the temperature in the 70s; on this day it was about 35 degrees. The night promised frost. Folks were covering their newly-planted tomatoes, and the buds on some of the fruit trees were at risk.

As a pediatrician on this Friday afternoon I had no such worries: I was in the clinic seeing patients and getting ready to do a well-child check on a four-month-old boy, an exercise I thoroughly enjoy. I usually start off by going over the baby’s height, weight and head circumference with the parents. On this occasion, we were talking a bit about the family’s’ plans for this summer, their planned travel as well as some strategies for making air travel more tolerable for everyone, particularly the baby.

On this afternoon, the vaccine consent form was on top and I started with that. I try to make sure that the experience of vaccination causes as little discomfort for the baby as possible and as little anxiety for the parents too. To that end, I talk about the importance of vaccination – probably the most important thing I do in the clinic as a pediatrician. I note the care which has gone into the development and manufacturing of vaccines, and the attentiveness of the medical community to the concerns voiced at various times by parents and others regarding vaccine safety. This was a young couple with their first child; at the two-month visit I had given the vaccine talk and we had vaccinated the baby with the two-month regimen.

Today the family resolutely refused any of the scheduled vaccines.

When this occurs I pause and go slowly and – in non-judgmental terms – explain the importance of vaccination in community health, touching once more on the studies showing vaccine effectiveness and safety. In particular, I discuss the decreased use of mercury in vaccine and the large meta-study concluding that the twelve-month vaccination with MMR does not cause autism.

Often a family’s reluctance to vaccinate has to do with the tremendous amount of misinformation in circulation concerning the administration, components, scheduling and production of vaccines. This misinformation instills apprehension in parents who have the best interests of their children at heart and who begin to believe that there is more risk than benefit associated with vaccines. Through reasoned, calm discourse in a dialogue with good give-and-take, I’m usually able to alleviate parents’ fears. I share sound scientific data and its sources so that the families are able to confirm on their own what we’ve talked about in the clinic.

As we talked – or I should say, as I talked, for I realized this was becoming not a dialogue but a monologue on my part – I extolled the value of vaccination and documented the safety record and the lack of significant side effects from vaccines. It was a talk appropriate for a senior high school class, underlined and footnoted and it was getting no traction. I gradually realized that I did not understand – since I had not yet asked – why this couple was averse to vaccinating their four-month-old. I pulled the plug on what had become quite the impassioned statement, not to say a diatribe, to ask the couple why they didn’t want their child vaccinated.

Their objection to vaccination was typical of those I usually encountered. They had heard vaccine-negative information and they worried the vaccines could be harmful for their baby. In addition, it turned out that as they didn’t ‘believe in’ science or scientific theory, my well-constructed argument was not relevant for them – in fact they didn’t ‘believe in’ evolution. They couldn’t see any reason to vaccinate. I really didn’t have anything else to offer at that point, so I took a breath and we carried on with the well-child visit.

The rest of the encounter went well; the couple had good questions concerning some minor problems of their young son. It was clear that they loved him very much and wanted to do anything they could understand to keep him healthy. At the end of the visit I felt I still had a good relationship with the couple.

And yet he was not vaccinated – what to do? I sat down with a colleague for a talk.

Some physicians refuse to see unvaccinated patients. Years ago when I first ran into this problem of families refusing vaccinations I determined that I would not abandon them. This is a rural mountain community in eastern West Virginia and there were only two pediatricians within a hundred-mile radius; now there is one. I therefore continued to work with families, but also to make what I felt were cogent arguments in favor of having their children vaccinated.

One of the points I began making had to do with “herd immunity” on which these parents who were not vaccinating their children were relying. I would explain herd immunity and tell families to thank their friends who were vaccinating their children because they were in fact protecting the unvaccinated children from illness.

On this occasion as I sat down with my colleague we explored the problem in a bit more depth. We talked about how each situation is different, and how the approach needs to be individualized to the belief system and the kind of information to which the parents had been exposed. There are, however, certain components in our revised approach which promise universal efficacy.

My response as a physician can begin to be emotional when confronted with parents who refuse to take my advice about vaccinations; they are both denying my hard-earned expertise and the validity of one of my core beliefs. First, in any situation in which a parent disagrees with me, whether concerning vaccinations or other advice, it will be important to state emphatically our common ground: that as a pediatrician my primary interest is the well-being, health and happiness of the child, and that I certainly recognize this as the case for the parents as well. This statement will help to avert an adversarial tone in our discussion.

Second, during my talk about vaccines it will be important to avoid any negative buzz words which can raise red flags for the parents, put them on the defensive and turn them off to hearing the information I am giving. Words like ‘science’ and ‘fact’ may need to be avoided in future, and certainly words such as ‘meta-studies’, ‘statistics’ and ‘data’. These words might identify the pediatrician as a purveyor of suspect information, as someone not to be trusted; and trust is critical to maintaining the relationship with a family. It may seem somewhat Orwellian, but I am considering using neutral non-judgmental words, such as ‘rumor’ for misinformation and ‘accurate account’ for scientific study. It will be preferable that a family continues to be comfortable with a trusted clinician when care for their children is needed, and still be able to discuss the pros and cons of vaccination.

My way of working with families is continuing to evolve. I’ll let you know how it goes.