What I've learned from COVID anti-vaxxers

Let’s start this newsletter with reiterating my opinion on the COVID vaccines: these are true scientific miracles.

I signed up to get vaccinated as quickly as I could. I recommend that anyone who asks me gets vaccinated because the data on these vaccines are so amazing. My family is vaccinated. I recommend vaccination unequivocally to all of my patients.

These vaccines are slam dunk medical decisions - very little of what your doctor prescribes has such an impressive risk/benefit calculation. I regularly prescribe medications and send patients for procedures that aren’t as safe or as effective as the COVID vaccines.

I ask every patient I see about their vaccination status, the same way I ask them about their medication allergies or whether they smoke.

When the vaccines were first approved, I noticed that the vast majority of my patients had been vaccinated or signed up.

As time has gone on, my day to day experience has changed quite a bit. I’m seeing way more COVID anti-vaxxers than I anticipated. And the social media backlash against the vaccines has been remarkable - and not in a good way.

The stuff that you see on TV and on social media about the COVID vaccines feeds fear with unproven - or frankly untrue - assertions: that they reduce fertility (they don’t), that they cause the virus to mutate (uncontrolled spread perpetuates mutation), that the mRNA affects your genes (humans don’t make the enzyme that can convert RNA into DNA, which makes up your genes).

But when I speak to my patients who aren’t vaccinated, the group that’s worried about the fringe stuff is only a small minority - the rest of them have surprisingly normal concerns, gaps of information, and sometimes incorrect ideas.

In other words, the unvaccinated are like every other patient (and person) dealing with every other disease.

The unvaccinated haven’t read the clinical trials, but the vaccinated haven’t either

I’ve written before about the “doing your own research” phenomenon that more and more patients are reporting to me.

One aspect of pandemic sociology that’s been really interesting to me has been the reaction of people who got vaccinated, wear masks, and practice social distancing to those who don’t live their lives the same way.

There’s a tendency to dismiss the people who don’t want vaccines and don’t wear masks as “anti-science” or, even more negatively, as idiots who don’t know what’s good for them.

But there’s one fascinating similarity between these two groups: neither one has read any of the clinical trials before coming to a conclusion.

We all have trusted sources of information, and very few of us read the primary source data ourselves. The majority of us outsource that to someone whose opinion we trust and implicitly assume that person has looked at the data themselves.

The difference between the vaccinated and unvaccinated patients that I’ve seen hasn’t been about who “believes in science,” but rather it’s been about where their trusted sources of information come from.

My unvaccinated patients take my medical advice on other topics and adhere to their medical treatments in a manner that’s no different from my unvaccinated patients.

And so when I’m explaining my vaccine views to an unvaccinated patient, I explain that I’ve read the clinical trials and found the evidence persuasive enough to be convinced to get myself and my family vaccinated. I also reiterate that I make my recommendations based on a calculation of the risks and benefits and that no decision - even one to get vaccinated - is without risk.

The messaging from public health officials has led to some mistrust of the vaccines

Since the beginning of the pandemic, public health messaging has been a challenge.

I’ve had quite a few patients mention to me that they stopped fully trusting public health guidance on the pandemic during the social justice protests of the summer of 2020 when influential voices started to advocate gathering to protest systemic racism.

When the same public health officials and physicians who had previously been suggesting that we all stay in our homes and avoid big groups start recommending gathering together to protest something unacceptable, it can lead to a confusing message.

It also conflates what you know - that large, unmasked gatherings can become superspreader events - with what your values say - that systemic racism is unacceptable and that bringing attention to that will improve things.

That conflation of knowledge and values means that if there’s a flaw in the reasoning of one part, people who are inclined to disagree may stop trusting everything you say.

In some ways, this is similar to what I’ve observed about the reaction to the argument that we need to eat less meat because it’s bad for the planet and bad for our health. Once people start to realize that the health concerns of eating meat are based on low quality evidence, it makes them more skeptical about the evidence behind the environmental argument and a bit more skeptical of plant based diets overall.

With public health messaging, my anti-vaccination patients have taught me that conflating what you know with what your values are can make people less trusting of your knowledge if they don’t agree with your values.

Some of the worries about the vaccine are quite granular

I’ve run into patients with a handful of specific - and reasonable - concerns about getting vaccinated against COVID.

The FDA hasn’t fully approved the vaccine, so it’s still an experimental treatment.

The worry that the vaccine is still under EUA (emergency use authorization) rather than fully approved has certainly reduced the number of vaccinated people. In my view, this an instance where our policymakers aren’t understanding the gravity of the situation in a common sense way - there are high minded ideals about the process, but during a pandemic sometimes the usual bureaucratic process should be sped up.

The vaccines are amazing, the evidence behind them is quite strong, and the full approval is anticipated shortly.

Some people don’t think that they will get very sick because their underlying health is excellent and so the risks of vaccination may not outweigh the benefits for them.

A reasonable person can look at the low infection fatality rate and make the calculation the risks don’t outweigh the benefits since they aren’t likely to get very sick and that our treatments have gotten better.

While this isn’t wrong, it is naive. The more unchecked spread there is, the more likely that COVID is to mutate into a variant that either evades our vaccines completely or causes more severe disease in the unvaccinated.

Some people are afraid of needles.

Fear of needles is driving a surprisingly high amount of vaccine avoidance. Conquering fear of needles isn’t just for kids going to the pediatrician.

Some people are sick of their friends and family putting pressure on them to get vaccinated.

My patients who have chosen not to get vaccinated have been adamant that no amount of messaging from their friends and family can convince them otherwise. They’re annoyed that people won’t stop asking them about it.

In summary: the messenger matters more than the message

We all take shortcuts with information because it’s impossible to know everything. Trusted sources of information will always trump high quality sources of information.

That’s why it’s so crucial to have vaccination ambassadors, make access to vaccination easy, and to keep public health messaging tightly focused on the important things. Every person on the margin who can be persuaded that vaccination is the best thing for their health is a win for all of us.

But it’s remarkable how hard it is to reach people who are more persuaded by what they see on YouTube more than by what they hear in the doctor’s office.

One thing that I’m certain about is that putting more peer pressure on people won’t work. Vaccine mandates are a tough issue - and certainly one I’m not going to address in a newsletter that’s already getting a bit too long.

With Delta on the rise, there will continue to be ongoing discussions of booster shots for those already fully vaccinated - and it appears that these will be available to us soon - but that’s a topic for another day.

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