Repairing our broken relationship with the vaccine hesitant

Compassion

Vaccination rates are generally high among health care workers, although they vary among professions. In the United States, 96% of physicians were fully vaccinated in September 2021, although this compared poorly with fewer than 50% of nurses and 26% of home health aides.⁷ While training and experience vary widely among individuals, this suggests that health care workers are not equally vulnerable to the misinformation propagated in mainstream and social media. At one extreme, an elite academic few may be able to appraise primary data critically as it is produced; at the other extreme, some training programs provide little formal training in reading literature, interpreting statistics, and balancing risk. Given the constraints of a lack of time, a lack of peer support, and limited knowledge and skills in research,⁸ some in the latter group may be as vulnerable to misinformation as anyone in the general public. With few exceptions, being apprised of the rapidly evolving state of medical knowledge is not simply a matter of setting aside the time to catch up. It requires a critical skill that may have been neither taught nor learned.

Both health care professionals and the general public rely on numerous competing sources for their vaccine knowledge. The quality of this information is highly variable. At the highest tier, primary data published in peer-reviewed journals is often of high quality, but it is inaccessible to all but a tiny academic elite and it is produced in a quantity that would be overwhelming to consume. Secondary literature (in the form of evidence summaries, meta-analyses, and systematic reviews) has the benefit of integrating multiple primary sources to draw broader conclusions, but it carries the substantial weakness of introducing additional bias in their interpretation. Reviewing either type of literature requires specific literacy in which even physicians and academic nurses may have limited training outside of their professional programs.⁹ Meanwhile, those outside these privileged groups are left combing through a patchwork of competing sources ranging from mainstream media to social media and personal experience.

Mainstream media outlets draw on the secondary sources described above, but they also cherry-pick liberally from primary sources, unvetted preprints, and gray literature. This can create distortions, exaggerations, and click-driven narratives that may mislead while still containing elements of truth. Social media algorithms further fine-tune these distortions, feeding consumers ever more polarizing versions of online content that their moral lens may already be biased toward and creating echo chambers in which alternative perspectives are rarely heard. With platforms such as Facebook more aggressively censoring English-language conspiracy peddlers than those in other languages,¹⁰ misinformation disproportionately reaches the minority and immigrant communities who compose a substantial proportion of long-term care workers, and this feeds existing scepticism that may have both recent and deeper historical origins.^11,12 Alternatively, some encounter the “intelligent misinformers”: seductive content creators such as Bret Weinstein, Robert Malone, and others whose training, eloquence, and argumentation lend them a superficial air of credibility. With limited medical literacy (or with limited time at their disposal while balancing front-line clinical activities and family obligations), many health care professionals have little ability to defend against this battery of poor-quality information.

How should we respond to well-meaning Canadians who navigate this tempest and emerge with vaccine hesitancy? With open dialogue. The important irony is that antivaxxers can be highly informed, well educated, and confident in their grasp of a wealth of deeply flawed information. While it is reasonable to challenge the quality of their source material, casting such a person as lazy or stupid will produce only greater resistance and division. Sceptics take pride in their fluency in a complex belief system produced by equally complex environmental factors—which must be compassionately understood and acknowledged before any progress can be made.

Empathy

Other health care professionals might view themselves as exceptions to the rule of multiple-dose vaccination and, in some cases, they have a reasonable point. Given their front-line exposure over the past 2 years in emergency departments, hospital wards, and intensive care units, nearly 95,000 Canadian health care workers had already had COVID-19 by June 2021,¹³ representing approximately 10% of the health care work force. While they would likely benefit from a single vaccine dose, their acquired immunity makes it challenging to argue that their presence imminently endangers patients.¹⁴ Suggesting otherwise is likely to fuel resentment and mistrust. Likewise, despite the demonstrated safety of the vaccines in pregnant people,¹⁵ the prospect of vaccination during pregnancy causes instinctive, understandable concern among this population. Finally, personal experience forms an important anecdotal driver of attitudes toward medicine, including vaccines: the idiosyncratic adverse event that a family member or friend swears to can have as much of an emotional impact on opinions, fears, and attitudes as more objective, rigorously produced, and randomized and controlled data. Addressing these pragmatic concerns with anything short of profound empathy is unkind.

Humility

The health care community needs to acknowledge with humility its own role in sowing confusion around vaccines. The common antivaxxer trope that the vaccines simply do not work was magnified by an earlier narrative suggesting that vaccines prevent serious disease but not necessarily infection, as well as widely circulated data suggesting that the vaccinated remain as infectious as the unvaccinated.¹⁶ Neither claim is true. Likewise, the loaded term breakthrough case incorrectly implies failure when a vaccinated patient contracts a mildly symptomatic infection, rather than the success that it is. Finally, political and pharmaceutical pronouncements of boosters and vaccine mandates before their formal Food and Drug Administration or Centers for Disease Control and Prevention approval¹⁷ have further diminished public trust that regulatory bodies have not been compromised. Addressing these missteps requires consistent messaging: namely, that vaccines prevent a great deal of infection, serious disease, and death.

A final note: We do vaccines no favours by dismissing their critics. As is the case with any biologically active agent, vaccines are not without side effects and risks; in the case of the messenger RNA vaccines (ie, Moderna, Pfizer), this means rare myocarditis events in young males,¹⁸ and in the case of those vaccines using an adenovirus vector (ie, AstraZeneca, Johnson & Johnson), this means occasional episodes of vaccine-induced thrombotic thrombocytopenia.¹⁹ Without an atmosphere of open dialogue, adverse events may be hidden or minimized owing to legitimate fears of being branded an antivaxxer, and doctors may become more reluctant to take adverse events seriously. Vaccines are safe, but not because they are inherently different from any other potentially dangerous medicine. They are safe because of experience, scientific scepticism, and constant vigilance, each of which plays a critical role in our robust system of vaccine monitoring and safety.

Our own responsibility is to respond to vaccine-hesitant individuals with profound compassion, patience, and respect. Where coercion unfortunately becomes necessary, our empathy develops an even greater importance. Understanding and discussing both reasonable and unreasonable arguments for scepticism—even when our policies may not yield—is essential for building trust among the public and among our fellow health care professionals.