Transcription:
COVID Vaccine Hesitancy and Public Health

Welcome to the Peds Ethics podcast, where we talk to leaders in pediatric bioethics about a hot topic or a current controversy. Here’s your host, John Lantos from the Children’s Mercy Bioethics Center in Kansas City.

John Lantos (Host):  Hi everybody, welcome back. This is John Lantos with the Pediatric Ethics Podcast coming from Children’s Mercy Kansas City. We talk about ethical issues in pediatrics every week or two and bring in guests. We are thrilled today to Dr. Phoebe Danziger who is a General Pediatrician at the University of Michigan. Before that, she was a Fulbright Scholar in Stockholm, Sweden from 2007 to 2008, learned a lot about the Nordic model of medical care. She’s a creative writer, a fabulous photographer and has been writing some provocative pieces about some of the ethical issues that are arising as a result of the COVID-19 pandemic. Welcome Dr. Danziger. Thanks so much for joining us.

Phoebe Danziger, MD (Guest):  Thank you. Thanks for having me.

Host:  So, in an op-ed in the New York Times on July 9^th, you started with this provocative question. If a vaccine for Coronavirus became available tomorrow, will you take it? Why would people not take a Coronavirus vaccine?

Dr. Danziger:  As a General Pediatrician, vaccine hesitancy is something I’ve been wringing my hands about for many years. We frequently see families who are concerned about vaccines for a variety of reasons and sometimes choose not to give them to their children. We seem to be seeing some of these same concerns and questions pop up when parents are starting to think about the idea of a possible future Coronavirus vaccine. So, in sort of recent weeks to months, I’ve started to have families bring this up as a topic during visits and what I’m finding is that certainly there are some families where I would expect some hesitancy or concerns because in general, in the past, they’ve had sort of questions or concerns about other vaccines. But what’s been really interesting to me is that I’ve had a lot of families who typically don’t question the routinely recommended vaccines, have gotten their children immunized according to the recommended schedule but are having really serious concerns about the idea of a Coronavirus vaccine.

So, that’s what got me thinking about and sort of writing this article.

Host:  What sort of concerns do they raise with you?

Dr. Danziger:  I would say there’s a wide range which has also been interesting. For many families, there are questions about how we could possibly ensure the safety of a vaccine that is being developed on what seems to be an accelerated timeline. For some families, there are sort of still similar questions about the potential safety or side effects of different vaccine ingredients. So, some of the preservatives or adjuvants that we typically use in vaccines. For other families, it is more of a sort of a nebulous theoretical set of concerns which sort of span sort of a broad spectrum but ranging from so some families have sort of more fringe concerns I would say about the idea of whether there will be a microchip implanted in a Coronavirus vaccine and some folks really believe this and worry about this. for others, it’s again sort of more theoretical and just as we’ve seen sort of wearing face masks become a very political topic, so it is with vaccines. And so for some families, it does seem to be sort of concern about is there going to be a mandatory policy and just sort categorical sort of opposition and hesitancy to the idea of a vaccine regardless of what type of vaccine it is or what the data ends up looking like.

Host:  So, I know it’s got to be hard to generalize but is there one particular group of patients? Is it more well-educated, less-educated, white, black?

Dr. Danziger:  What’s been interesting in hearing from these families is that it really seems to sort of encompass a really broad demographic and families and individuals of all sorts of different backgrounds. And I think to some extent, that really parallels what we’ve seen with vaccine hesitancy in general. Where initially it did start out sort of as a phenomenon primarily that existed amongst sort of more well-educated, wealthy, Caucasian families but in the intervening years, it’s really spread to encompass a much broader demographic and there are – there certainly seem to be sort of patterns and trends with respect to what the specific concerns are or what’s sort of driving the hesitation or concerns sort of based on different demographic factors. But it does seem to be something that’s coming up for a lot of different people with different backgrounds.

Host:  And I know you’ve written about disagreements between pediatricians and parents both about vaccines and about some routine preventive treatments like vitamin K for newborns. How do you as a pediatrician, try to convince parents that medically the treatments that you think are medically beneficial, ought to be used for their child?

Dr. Danziger:  To some extent, when you’re thinking about it on sot of an individual level, and sort of direct doctor patient family interactions, it’s relatively straightforward in the sense that you want to offer evidence based sort of sound information and try to do so in a compassionate and nonjudgmental way, focusing on establishing trust with families and really trying to get a sense from them of who are they, what are their values, what are their fears, what do they want for their children. Most families want to do what’s best for their children and are motivated by good intentions in that regard. And so, trying to just have sort of honest and open and empathetic conversations about sort of what’s behind their hesitancy and going from there.

What concerns me is that while I think that’s the right approach on an individual level, I think what we’ve seen with vaccine hesitancy in general over the past few decades is that on a broader level, that doesn’t really seem to work. And certainly, I would say most pediatricians or physicians can think of examples of times where their counseling and sort of work on an individual level maybe has convinced a family to change their mind and to accept a vaccine or a particular recommendation. I’ve certainly had experiences like that, and it feels good and satisfying. And there’s again certainly lots of evidence that for many Americans, they do still turn to their physicians or healthcare providers as a source of trusted information about these things.

But again, there is a nontrivial sort of portion of the population for whom I don’t think this is necessarily true and for whom vaccines and sort of similar preventive types of interventions have become – it’s become much more of a sort of cultural issue and a political issue and a real –

Host:  With the Coronavirus vaccine, assuming it comes along pretty soon, it will be largely untested. So, are there special issues in the context of a raging pandemic that surround an untested vaccine? How do we convince people that the benefits of this outweigh the risks?

Dr. Danziger:  Yeah, I know I mean that’s a great question and it’s tough. I mean I think any individual vaccine certainly is going to need to be evaluated on the basis of its individual merits and taking a look at the data and sort of going from there. When you think about sort of vaccine policy, certainly I would say there is more broad consensus that more sort of mandatory compulsory type approaches or policies are more ethically defensible and justifiable in the setting of active outbreaks or epidemics and so, I think that certainly comes into play here. To some extent, I think it is a sort of a moral question that we’re going to have to grapple with as individuals and as a society of how do we approach the aspect of sort of unknown risks and the fact that we are not going to have years and years of safety data to point to. I think if depending on the type of vaccine that ends up becoming available, if it is something that closely parallels other vaccines that we currently have, then I think that is an easier conversation. But if we are incorporating some of the newer technologies that are being tested as well, then I think that’s more challenging.

Host:  Have you given an thought to what will happen if more than one type of vaccine is approved at the same time?

Dr. Danziger:  Yeah, I think we’re going to have to sort of take it as it comes and again, just to evaluate the individual vaccines based on their particular merits and sort of go from there. So, I think it’s hard, because a lot of this is sort of theoretical right now.

Host:  The studies are just starting. The phase three studies of vaccines and I know our hospital is participating and we got sent a link to a website to sign up if we were willing to enroll in the clinical trial. Have you gotten any such emails?

Dr. Danziger:  I just saw in the local news that one of the Michigan hospitals is participating as a site in vaccine trial. I have not yet followed the links to investigate further. But yup that certainly seems to be.

Host:  Would you sign up for a trial?

Dr. Danziger:  I absolutely would. Yes, I trust the process. I trust the science. So, I would.

Host:  And it sounds like you trust the review process then so that when a vaccine gets approved, you’d likely follow whatever recommendations are for indications and contraindications?

Dr. Danziger:  I would say most likely. I think one of the concerns that some families have been raising which I think is a really valid concern is what is the role of sort of political pressure and political influence right now with all of this from sort of vaccine development, testing, approval, all of that. So, again I think it’s a bit hard to say now because it’s theoretical but in general, yes, I think I trust the process, I trust the science. But that is a concern.

Host:  So, you’ve also been writing about other aspects of trying to flatten the curve and about how those play into trust and politics or the culture wars. What are you general thoughts about how we’re doing as a country and what we can do differently perhaps to flatten the curve or get ahead of this thing?

Dr. Danziger:  Yeah, I think there are a couple of approaches that we might want to look at. Some sort of related to vaccines and interventions and some sort of taking a more big picture view. One of the things that has been a source of frustration for me over recent years sort of watching vaccine hesitancy in general, prior to the pandemic unfold is feeling like with our current approaches, we have not been making a lot of headway and so I think it’s time to step back and try to think about it a little bit differently. And I think this is relevant before vaccine hesitancy in general, for vaccine hesitancy related to a Coronavirus vaccine and for like you were saying, a lot of the other measures that we’re trying to take that are supported by sort of public health evidence with respect to flattening the curve. I think there are so many sort of deep underlying cultural, political, economic issues that are contributing to some of these sort of downstream expressions of sort of discontent or concern with respect to individual interventions or recommendations and how people are grappling with those and I think until we really take a look at those upstream factors, which is hard to do, but until we really take a look at those and address those, I’m not sure we’re going to be able to make a lot of headway with the more downstream things.

Host:  One last topic. I know we’re covering a lot of ground here. So, thank you for doing this. But you have school aged children at home and we’re moving into August here. What is happening with the schools in your area and how are you thinking about what to do with your own kids?

Dr. Danziger:  Oh my goodness. Yup, so we have – we have four kids ranging from almost three to 11. So, spanning sort of preschool up through entering middle school. So, it’s been a real conundrum trying to think about how to handle this. The local public school district in Ann Arbor has recently announced that we will be returning all virtual for the beginning of the year and for the foreseeable future. So, that has thrown a wrench into things. So, we have right now just trying to get a sense of how can we balance working and sort of supporting our children’s education at various levels with what for the foreseeable future is going to be a fully virtual sort of remote options. So, it’s a challenge.

Host:  And that’s Ann Arbor. Is the state of Michigan also going all online? Or is it district by district?

Dr. Danziger:  It’s district by district for now. We have not heard any sort of statewide guidance yet on that. But yeah so, we are all sort of waiting to hear what other districts decide and if they are going to just going to be more firm guidance on the state level.

Host:  Any other thoughts on issues that have arisen in your general peds practice or in you family or just as a good citizen that we haven’t talked about?

Dr. Danziger:  Yeah, so going back to the vaccine issue, I think another idea that I’ve been thinking about and which I proposed in the New York Times piece is this idea of a green vaccine to some extent I think maybe it’s a little bit cynical to approach it this way but also maybe a little bit practical. And again, over the years, a lot of the concerns that I hear from families about vaccines, about vitamin K for babies, about other interventions really focuses on the ingredients and the safety of those ingredients and for a lot of families, you can talk until you are blue in the face about the data, the safety data, you can sort of go around and around with that but it does not seem to quell some family’s fears. And so I think not from a medical standpoint, not from a scientific standpoint, but from a social standpoint; I think we might need to start listening to that a little bit more and think about are there ways that we can design these interventions whether it’s a vaccine or something else, but in a way that is potentially more palatable, more acceptable to people so that they’ll be more likely to accept them.

Host:  Tell us a little bit more about what you mean by green vaccine.

Dr. Danziger:  A lot of families have concerns about the different sort of ingredients that are common in our routine childhood immunizations. So, some of the things that we use as preservatives or adjuvants to sort of boost the immune response, some of these are things like benzyl alcohol, or other sorts of ingredients that a lot of families will sort of Google these ingredients or look up information about them on social media forums and they get really scared because of what they see. There is robust safety data regarding most or all of these ingredients and in the amounts in which they are used in vaccines, we are very confident that they are safe. But this is something that just comes up again and again and again and families – some families it doesn’t matter how much sort of evidence there is, how much data there is; they just are not reassured by that.

So, I am not a virologist. I don’t develop vaccines myself but I do think there is sort of an untapped opportunity here for thinking about it in a different way and saying okay, families are concerned about these ingredients, we know they’re safe, but families are declining vaccines because of them; are there other ways that we can design these products that where they will be equally effective but parents will be more likely to accept them. So, I don’t know what the answer is but-

Host:  But I love what you put in your July 9^th New York Times Op-ed about green vaccines and I’m quoting here, “It should be made in a factory, in a city or town that can be easily identified and come with accessible information about development, testing, and monitoring rather than an inscrutable insert.” Those are the things that a lot of pediatricians I think don’t think about so much but as a matter of public policy, it may go a long way to increasing the likelihood that people will trust and use new vaccines. Thank you so much for talking with us. We’ve been talking to Phoebe Danziger, a General Pediatrician at the University of Michigan in Ann Arbor, a mother of four and a writer and photographer. Thanks so much for taking the time. This was fascinating.

Dr. Danziger:  Thank you for having me. This was a lot of fun. I appreciate it.

Host:  And this is the Pediatric Ethics Podcast, from Children’s Mercy in Kansas City. Thanks for listening.