How to Win Friends and Immunize Kids

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):

  1. 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.

  1. 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.

How to Win Friends and Immunize Kids

Shots in the Dark

When it comes to a Sophie’s Choice sort of prioritizing, I tend to value national security over minor setbacks in other fields. This is not a popular sentiment in the field of public health, where evangelists are evangelists and the US government is a happy target frequently accused of, god forbid, acting on its own interests. In terms of bulk cost calculations – why spend billions on aircraft carriers when that same money could go to treating malaria? – I also think that Givewell types tend to undervalue hegemonic stability and underestimate, or have perhaps forgotten, the dangerous down stream flailings of a wounded giant. I am One of Those Democrats, and I’m not sorry for it.

But foreign aid, and particularly well-designed health assistance, is in the interest of national security. Unrest results from lack of satisfaction with the state of affairs; extreme dissent emerges in hungry, impoverished, and desperately ill populations where people have the balls to get angry (that is to say, in a less crude manner, societies where women possess limited rights – but that’s another post). And here are a few True Things:
1. Maintaining public health programs abroad is a critical part of the ability of the United States to influence policy abroad in a subtle, effective, and generous way.
2. Vaccination is unparalleled as far as things in our toolbox go. They save money – something entirely uncommon in international aid. This may sound very simple, but it’s extraordinary: a successful vaccination program allows us to prevent lengthy courses of treatment for expensive diseases in difficult-to-access areas.
3. The vaccination “scandals” in the US – such as Andrew Wakefield’s ridiculous shenanigans – have resulted in an inexplicable amount of damage. Accusations of vaccines causing autism in a nation where most people are literate, where 70% graduate from high school after completing a basic biology courses, have been crippling: as an example, one of the most conservative governors in the nation was bullied into not mandating a Gardasil vaccine. The amount of damage associated with something most people don’t understand is amplified as the education of the general population plummets. So when a rumor starts up that US vaccines are intended to render Muslim children infertile in Nigeria? People believe it, and consequently have their children die from preventable diseases.

In attempting to use DNA samples obtained from needles to confirm Osama Bin Laden’s presence in the compound, we did not give the Pakistani children in Abottabad the full 3 courses of the hepatitis B vaccine necessary to ensure functionality. Those kids are not going to have access to the full course – and if they do, why should they trust it?! Why on earth should they, when a legitimate ruse has been constructed against them in which vaccination was hardly considered a fringe benefit? I don’t see what this should have to do with the political sympathies of the children involved, or of their parents; when the United States lies abroad, when we conduct ineffective schemes in places where our word is already compromised, we make enemies. When we do a good thing poorly, we make enemies. Let’s stop doing that right now.

Shots in the Dark

Numbers, engineering, and other things people in public policy tend to dislike

Work in international development is a study in constraints.

Work in international health takes this rule and ups the ante by virtue of sheer complexity.

Here’s one example: many vaccines are temperature sensitive, and can be spoiled by fleeting exposure to heat (for instance, 80% of tetanus vials will no longer be potent after 3 hours at 65 degrees Celsius – an entirely achievable temperature in the back of a metal truck). Vaccine vial monitors have by and large minimized the issue of administering ineffective doses, but the primary problem of spoilage remains. This can happen if, say…

  • A drought in Kenya decreases output of hydroelectric dams, resulting in rolling blackouts in the relatively well-developed city of Nairobi that subsequently cut power to refrigerators.
  • Crumbling rural infrastructure and poorly-managed roads slow delivery trucks to a crawling pace, virtually negating cooling systems (if there are any).
  • A health care worker without proper training mishandles the package. This, of course, could happen anywhere, but is much easier to come across in locations with high rates of illiteracy.
  • A flimsy source of funding to a rural clinic is cut, preventing payment of any electrical bill.
  • Et cetera. And the potential impact can be just as varied: a waste of labor, time, physical resources, and money in a setting where none of those things are readily available, not to mention the potential health impact upon a population (worse if the vaccines are administered anyway and a sense of entirely unwarranted protection is developed; worse still if this a HPV vaccine distributed to potential rape victims, or whatever other awful scenario you can think up). Implementing an effective aid program requires very careful and systematic prediction of where things can go wrong, and failsafe plans for when things not-thought-of do. Similarly, post-program analysis can also benefit from more rigorous methodology, such as with use of controlled studies to evaluate the effectiveness of aid (here is a fantastic study on the effectiveness of various methods of HIV prevention among adolescent girls).

    This particular way of framing complex problems in international affairs is not only beneficial but essential to forming strong policy. A thoroughly analytic, numerically focused perspective is invaluable in constructing effective development programs: building a bridge in Nicaragua, a complex of biosand filters in El Salvador, an economic program to support schools in Pakistan. This isn’t a thought process I’ve ever had to implement in a political science or policy studies course, but instead is incredibly reminiscent of the manner in which I’ve had to approach design problems in engineering classes – and I’d like to argue that it places people with this sort of training in a key position in policy agencies. Only so much can be learned from reading case study after case study; students intending to enter high-stakes fields need more trial-and-error, more hands-on practice in program development and design. USAID doesn’t hire systems engineers, but they should if we ever intend to become serious about development.

    Numbers, engineering, and other things people in public policy tend to dislike