The ongoing measles outbreak in Southern California has summoned spectres of the scenes that originally motivated me to work on immunization access in the Middle East. Parents so eager to vaccinate their children that the phone would ring off the hook during stock-outs, forcing clinics to reallocate nurses to issue updates. Girls who use their hijabs to cover the trademark swelling of mumps, so they wouldn’t be removed from school. Typhoid breaking out days before a war did the same, forcing thousands into shelters crowded beyond belief with no hygienic systems to speak of.
I wish every teethy news cycle sprung up smack before a long run. My modus operandi in response to implacable rejection of basic facts is to fume – which, while generally useless, makes for good fuel. I’m presently a global health policy student, where this sort of emotional response to public welfare issues is not at all unusual.
Convincing people opposed to vaccination to inoculate their children is nigh-impossible. Evidence presented by people with 12 years of advanced scientific and medical training does not change minds. All the snarky, cathartic Amazon reviews in the world will not change minds. Banning unvaccinated children from schools does not change minds – and for what? To be homeschooled by scientifically illiterate parents, and continue the cycle? Coercion, in fact, births strategic evasion: doctors in California have allegedly begun falsifying immunization records. Hoping that the selectively unvaccinated end up with the more evolutionarily disadvantageous side effects of mumps and breed themselves out of existence is, likewise, an exercise in dangerous futility.
It’s important to remember that failing to change minds about the safety of routine immunization means more than just the failure to win an argument. The negative externalities presented by the selectively unvaccinated directly risk the lives and well-being of the unwillingly immunocompromised. If you think these people are idiots in the first place, you know this. I’m not telling you anything new. But these are the real consequences of backing people into a corner, righteousness be damned.
Doctors, public health officials, and general believers in the power of modern medicine and (yes, okay, including me) need to get their Dale Carnegie on. What we are doing is not working. Allow me to cite some depression-era words of wisdom:
“It is hard to change minds under the best of circumstances; do not handicap yourself by telling people they are wrong.”
“We are incredibly heedless in the formation of your beliefs, but find ourselves filled with an illicit passion for them whenever anyone proposes to rob us of their companionship.”
Amid the volatility and mocking disbelief, there are two instances of success I think we can learn from that illustrate these principles (these articles are both very good, and I encourage anyone interested to read them in full):
- Dr. Mohammed Pate tackled polio in Northern Nigeria – a hotbed for infectious disease that makes Disneyland look like, well, Disneyland – by treating the reluctant with unparalleled empathy and patience. Here’s an excerpt from The Art of Eradicating Polio:
For at least a half an hour, the man listened as the boy vented. The vaccinators had been rude, the boy said, insulting his mother as they tried to force their way in.
I would be angry, too, if someone insulted my mother, Muhammad replied.
Why do they bring only polio vaccine when we get no help with all our other problems? And are you going to force us to take it? the boy asked querulously. No, it is your decision. I will not force you, the man assured him. But I hope that you will change your mind. Then he patiently explained that the vaccine is safe—he had vaccinated his own kids—and it would protect them from devastating paralysis. And also, that the world has a once-in-a-lifetime chance to eradicate polio—and the boy, and Nigeria, should not stand in its way.
Then the boy’s older brother, who had been listening from behind the curtain, emerged with one more question: Will you be responsible if the children are harmed? Yes, the man promised, and the brother brought the kids out to receive the polio drops. The crowd that had gathered burst into applause.
- While all but a few hundred members of the U.S. public were entirely uninvolved, the U.S. policy response to Ebola confronted a similar form of irrational fear. Dr. Ron Klain, short-term Ebola czar, had this to say in a Politico profile:
“…you have to take the public’s fears seriously, and respect those fears. I don’t think it was a surprise that the country was very concerned about Ebola in the fall. It was a new thing to encounter in America, a frightening disease. Our approach has been to try to deal with those fears, both by putting the right policies in place and communicating with people in an honest and transparent way.”
Ron Klain also brings up the important topic of exposure bias. Once the public saw that Craig Spencer, the infected doctor in New York, did not magically infect his fellow bowlers and subway-commuters (and, grumblegrumble, once election fear-mongering died down), public hysteria passed. With vaccination, this works in reverse: as preventable infectious diseases become increasingly rare, memory of the real danger they present fades. Here, at least, the Disneyland cases have served some purpose, persuading reluctant vaccinators and prompting grassroots movements for policy change in schools.
As for top-down action, I struggle to form ideas for concrete policy interventions, generally beset with unbridled frustration at the knowledge that most tools in my toolbox don’t fit the need. But building broader coalitions in support of vaccination programs is absolutely necessary. It’s a wonder to me, frankly, that fiscal conservatives don’t cheer mandatory vaccination in droves. Disease eradication eliminates all future costs associated with vaccinating, treating, and monitoring; disease elimination from a country or region dramatically reduces them. Forever. For-ev-er. You do see a bit of this thinking occasionally surface: Rick Perry, bless his heart, issued a promptly-overturned executive order mandating HPV vaccination for sixth grade girls in 2007. Working across the aisle and encouraging politicians of all stripes to find their district-friendly argument for vaccination could soften the ivory tower.
Respecting fears is hard when you know they are ridiculous. But the outrage cycle is not just ineffectual – it’s dangerous. It’s time to swallow the vitriol and focus on developing new strategies that will produce results.