You cannot treat those who challenge you with contempt. Conversations must be navigated with respect and compassion.
Giving birth during fellowship
Halfway through infectious disease fellowship, I gave birth in the hospital in which I worked. It was complicated. I received good care, but during my stay, and for many weeks afterwards, I was startled by my vulnerability and uncertainty. I was cheerfully assured my hypervigilance and emotional lability was to be expected.
And why wouldn’t it be? My infant was horrifyingly fragile, and I was astoundingly unskilled in his care. My endocrine system was in rapid flux, I was sleep-deprived, and after relocating for medical training, I was far from most friends and family. I had many privileges, but had felt much more supported during intern year, with a cavalry of clinicians ready to help, and highly-vetted pocket reference books.
Our villages are scattered
New mothers would ideally also have a cavalry of support and high-quality reference books. But often, our villages are scattered and increasingly replaced by a disturbing substitute: Google searches and parenting forums. Anyone who has desperately searched these forums at 2 a.m. trying to decipher their newborn will have encountered an extremely high ratio of noise-to-signal, with pragmatic and scientific advice mixed with conspiracy theories, snake-oil hustlers, and an onslaught of corporate ads—and vaccine skeptics.
But that was what I had to navigate those fraught early months. Multiple times, I jolted awake in a silent dark and rushed to ensure my son was still breathing. Though I scowled at the anti-vaccination comments, confident about good science, I had become uncertain about so many things. Even things within my expertise became murky; despite a decade of training in sterile fields and normal bacterial colonization, everything appeared distressingly contaminated.
“Our fears are informed by history and economics, by social power and stigma, by myths and nightmares. And as with other strongly held beliefs, our fears are dear to us,” observed Eula Biss in her book “On Immunity: An Inoculation.” Bliss’ meditation on motherhood and the science and sociology of vaccination was a great solace during those long nights. “Risk perception may not be about quantifiable risk so much as it is about immeasurable fear.”
Writer Kaitlyn Teer described the unique vulnerability to other people’s ideas while caring for her infant amid a frightening measles epidemic. A visiting relative assailed her with anecdotes about vaccination harms. Teer, firmly committed to vaccination, wrote in her essay, “I was either too anxious, or too exhausted, to muster a counterargument.”
The internet also has a countervailing vaccination-defense mob – proponents of science, who meticulously argue why vaccines are safe, effective, and life-saving. These arguments cite scientific evidence from prestigious organizations. We know that “vaccine hesitancy” is deeply harmful, with the re-emergence of measles and the World Health Organization listing vaccine hesitancy as a threat to global health. Defending science has become more urgent in our current political climate.
The underbelly of the pro-science crusade
But there is a distressing underbelly to this crusade. Follow any number of pro-science defendants on social media and their memes, and a slippery pattern starts to emerge: the “anti-vax” interlocutor is invariably coded as a she – as a mother. And once the pattern emerges, one starts to recognize familiar, toxic tropes beneath the well-meaning jokes—mothers as dumb, foolish, and anti-progress. “The debate over vaccination tends to be described with…’troubling dualisms,’” writes Biss. “These dualisms pit science against nature, public against private, truth against imagination, self against other, thought against emotion, and man against woman.”
Perhaps targeting women reflects only the probability of the situation: leaders of the anti-vaccination movement are statistically and visibly women. Even so, the scientific curiosity should drive one to ask: what drives this disproportion?
Despite a push for better gender equity in parenting, women in heterosexual relationships still take on the great majority of care in early childhood. In the US, women make 80% of the healthcare decisions for their families. More importantly, female patients have also been deeply mistreated and mistrusted by the medical system for centuries. Our pain is so systematically ignored, and the misdiagnosis and undertreatment of women so widespread, it has a name: Yentl Syndrome, for the heroine Isaac Singer, who pretended to be male in order to be taken seriously by the medical community. “Hysteria” is no longer an ICD code (at least, not exactly), but women are often told their symptoms are psychogenic. The consequences are real, including missed acute coronary syndrome, longer delays to adequate analgesics, and the statistics of black maternal mortality, in which the deadly intersection of sexism and racism is devastating.
“Debates over vaccination, then as now, are often cast as debates over the integrity of science, though they could just as easily be understood as conversations about power,” wrote Biss. Why wouldn’t mothers mistrust healthcare and the government after such extensive mistreatment? When we approach anyone with shaming and unexamined sexism, we only exacerbate the alienation and division. No one wants to be treated with disdain. This widening rift is rich for exploitation by the unscrupulous.
So here are pragmatic suggestions for navigating anti-vaccination sentiment in a more respectful and productive way in our roles as healthcare workers.
1.) The first Oslerian rule in medicine is to listen to the patient.
Perhaps the new mother is not so much confronting you on the science of vaccination, as she is feeling under-supported and overwhelmed. Perhaps the patient who demands treatment for chronic Lyme has had years of neglected chronic pain that deserves a thorough work-up and plan for alleviation. Those who have been mistreated or stigmatized in their medical care are rightfully suspicious. It takes time to rebuild trust. Motivational interviewing is a framework for non-judgmentally assessing patients concerns and has been shown to be effective in vaccine discussions. Listening itself is therapeutic and builds the trust that is the heart of the patient-clinician relationship.
2.)Vaccine hesitancy exists on a spectrum.
Labeling everyone as “pro” or “anti” risks losing the opportunity to address many who are ambivalent about vaccines. There is a broad gradient of attitudes towards immunization, and many vaccine skeptics, rather than refusing vaccines, accept them and question their safety, or tend to select or delay vaccines. This is a group that may benefit from further education and explanation.
3.) Education is still critical. You will not convince the die-hard anti-vaccination advocate, even with (especially with) the best science. However, given that those with vaccine hesitancy are often ambivalent, it is important to educate those patients on the safety and benefits of immunization. Healthcare providers still have strong influence on the patient uptake of vaccines. Techniques include:
Emphasizing the evidence-based adverse effects of not vaccinating is more effective than attempting to debunk misinformation.
Explaining the ways in which anti-vaccination arguments cherry-pick and distort the science.
Emphasizing the scientific consensus of vaccine benefit (e.g. “90% of medical scientists agree that vaccines are safe.”)
Explaining that herd immunity increases vaccine uptake. As Biss wrote, ““However we choose to think of the social body, we are each other’s environment. Immunity is a shared space – a garden we tend together.”
As critical as it is to address patients one-on-one, policy can have a more potent and widespread impact. Advocating for stronger vaccination policy at state level, such as limiting vaccine exemption, has met with recent success. Advocacy by physicians and other healthcare workers is a key and necessary part of our patient care. This includes not only policies that promote widespread vaccination, but also policies that increase equitable access to healthcare, social services for mothers and during early childhood, and a close look at our own practices to ensure shared decision making, and that all patients are treated with respect and dignity. Implicit bias must be taken on directly. We must continue to build our trust with the public.
Biss wrote, “You cannot back down from anti-science, from truth. These must be confronted. But you cannot treat those who challenge you with contempt.” We live both in an era that is attempting to make corrections for a long history of mistreating women, that “women should be heard and believed,” but also in a time of widespread anti-science sentiment with material consequences. We must navigate this complex landscape with respect, compassion, and commitment to what is right.