Vaccine "Skepticism"

I am a vaccine skeptic.

Now before anyone blows a gasket or has an intracranial hemorrhage, let me explain. A skeptic is simply a person who does not accept things without evidence. Let me give you an example.

In the spring of 2020, I thought it was unlikely that we would get an effective vaccine for COVID-19. We did not have vaccines for other novel coronaviruses (SARS and MERS) so I assumed that we would not get an effective one for COVID (in retrospect, those other novel coronavirus outbreaks were more easily contained so we never really got to the point of vaccine development).

When the early data came out on the mRNA COVID vaccines, I was pleasantly surprised. And the more data we got, the more I became convinced of their efficacy. I was thankful to get my first dose right at the end of 2020 and have had multiple doses since then. After the vaccine was out, data continued to be collected from many different places and types of sources and it became clear that the vaccine significantly decreased the risk of serious disease and death. Other data came out showing that the adenovirus vector vaccines (not the mRNA vaccines) had a rare but serious clotting side effect (thrombotic thrombocytopenic purpura) so they were withdrawn from use. The mRNA viruses were found to have a potential side effect of myocarditis, though this happened less often with the vaccine than with COVID infection and tended to be much less serious if it was a result of the vaccine.

The vaccines aren’t 100% effective or 100% safe. Nothing is. If we required that level of certainty, no one would get out of bed in the morning. We need to know if the benefits outweigh the potential risks. For at least the first couple of years of COVID, the answer was that for the vast majority of people, the benefit of COVID vaccines definitely outweighed the risk. Or to put it another way, the risk from not getting the vaccine was higher than the risk from getting it.

Through the years I have applied that same approach to other vaccines, particularly the ones we give in our practice. At one point years ago, I compiled a notebook of vaccine safety studies for parents who expressed concerns about side effects and declined vaccines for their children. I assumed if folks had access to accurate information, they would act in ways consistent with the evidence.

But no one looked at my notebook of studies. It took me years and years and many frustrating conversations to conclude that some self-identified “skeptics” are not actually interested in evidence. That is, they are not really skeptics.

In the old days if we wanted to read a study, we would need to go to the medical library, look it up and find the volume of The New England Journal of Medicine or The Journal of Pediatrics or whatever other journal the study was in and sit in a cubby in the library to read it or pay to photocopy it to take it with us. Now all of that is readily accessible to anyone who wants it, yet we have folks (including policymakers) confidently making statements that are patently false and easily disproven.

If someone says “There are no studies comparing vaccines to placebo,” you can simply do a PubMed search (https://pubmed.ncbi.nlm.nih.gov/) and find 547 pages of results on the topic. Same for someone who says that the MMR vaccine has not been tested for safety (104 pages of results). A person who makes statements like that is not a “vaccine skeptic.” They are the opposite of a skeptic, a person who makes claims without regards to the evidence.

I have largely given up on trying to convince people to vaccinate. You can’t use evidence to convince someone who is not interested in evidence. I have spent far too much time and energy in the past trying to convince folks who confidently repeat demonstrably false talking points. I make my recommendations and explain why I am recommending what I do. And I am quite happy to answer questions and address any concerns. But if they persist in making claims not based on the evidence, I no longer try to persuade them because experience tells me it won’t work anyway. It feels like failure to not be able to provide the best evidence-based care to patients, but I can’t be responsible for the decisions of others.

When our children are young, we try to teach them. “You need to wear your coat. It is cold outside.” Sometimes they listen but sometimes you just need to let them go without a coat and get cold and let them learn the hard way. I think that is kind of where we are in the United States now with medical disinformation. We have to live with the consequences of our own collective choices. Hopefully it won’t take us too long to learn our lessons and the harm will not be too extensive, especially for those too young to make their own medical decisions. But I think the effects will outlast my time in practice.

And the people convincing folks not to vaccinate will not be there to help the baby who is blue and gasping for air from a Pertussis infection or the child in the ICU with measles encephalitis.

Changes

Sometimes something sparks a memory and I am reminded how much has changed since I started in practice.

For example, consider an 18 month old who comes into the office with a fever of 104 and lethargy. She has some mild cold symptoms. She acts really sleepy and doesn’t react much when I examine her (it’s her nap time but mother also says she has been sleeping more than usual today). Her ears and throat look normal, her lungs are clear, she has no rash, and everything else looks and sounds normal other than just looking sick.

Here is my possible thought process in the late 20^th century:

• There is a good chance this is influenza but I don’t have any way to be sure
• Could be an early pneumococcal pneumonia (physical exam findings often do not show up right away so having clear lungs on exam does not necessarily exclude pneumonia)
• Could be another invasive bacterial infection such as a blood stream infection or meningitis which can not be ruled out on exam, especially in a young child
• Could be a kidney infection (a toddler is not going to complain of painful urination and you can’t really judge frequent urination in a child in a diaper)

What I might have done:

• Get some bloodwork to check for an elevated white blood cell count (particularly a type of white blood cells called bands) which could be a sign of a serious bacterial infection
• Get a chest X-ray to see if there is a pneumonia that I could not hear on exam
• Catheterize her to get a urine sample to check for signs of infection (she’s too young to pee in a cup and a bagged urine specimen is not reliable to rule out infection)
• If all other testing is unrevealing, potentially do a spinal tap to rule out meningitis
• Possibly admit her to the hospital for observation or for presumptive treatment of one of the above until further results are available.
• If I send the patient home, lie awake at night worrying that I may have missed something

Same patient in 2026:

• Since we now have the ability to test for influenza in the office, swab her nose
• If positive, discuss the expected course of the illness and symptomatic care and consider treating with Tamiflu.
• Discuss worrisome signs that would indicate a need to be rechecked.
• If negative for flu and other viruses that we can test for easily, maybe get a urine sample (but would probably wait to see if things resolve over a couple days before doing so because catheterizing an 18 month old is no fun for anyone involved)
• The other worrisome scenarios are vanishingly rare in a fully-vaccinated toddler in 2026 so can probably sit tight for now and treat symptoms unless she gets worse or something new develops.

In this scenario, I prefer 2026 and the patients and parents do as well.

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