Covid Vaccination: the Last Mile

by Danielle Ofri
KevinMD

At this point in the COVID vaccination campaign, nearly all American adults who want the vaccine have gotten it, (and are gratefully snapping up their boosters!) Those who decline vaccination are largely impervious to public service announcements, community pressure, and case counts turbocharged by the Omicron variant.

Public health experts emphasize that primary care doctors and nurses are the key to this last mile of the vaccination effort. This is an exhausting mandate on a workforce already stretched so thin as to enter into the realm of magical thinking. (It’s estimated that just addressing the currently recommended preventative care would consume 131 percent of a physician’s workday, which must somehow also incorporate all of our patients’ chronic diseases as well as their acute complaints.)  Nevertheless, we take seriously the charge of helping our hesitant patients get their COVID vaccine.

Some of my patients have been understandably confused by the onslaught of information that changes by the week. Others seem to be waiting to hear the definitive recommendation from their doctor instead of the mayor or their employer.

But there’s a resolute core of patients who don’t even want to talk about it.

There are certainly plenty of medical interventions I recommend that swathes of my patients vociferously do not desire—insulin, colonoscopies, statins. We debate these issues, sometimes tussle over them, but there’s always an interchange. Many will ultimately decline, but at least we hear each other out.

The COVID vaccine engenders a unique obstinacy that seems to blot out conversation. We doctors and nurses are exhorted to listen to our hesitant patients and hear their concerns, but this is difficult to do when patients don’t even want to talk.

These aren’t hard-core conspiracy theorists hoarding equine ivermectin. They’re not ranting about medical tyranny. But when I try to tease out the intricacies of their distrust of the COVID vaccine, the conversation sputters out. “I’m just not taking it,” they’ll say. “I don’t trust it.”

Psychoanalyst Erik Erikson described trust as the very first challenge that humans navigate after birth. We spend our lives calibrating who and what to trust. I’m fully aware of the historical mistrust of the medical establishment that informs some of my patients, but the selectivity toward the COVID vaccine suggests that this is not the full explanation.

Even when patients say, “I just want to wait,” this often doesn’t explicate as much as it seems. Almost none can identify a benchmark or timeframe that would reassure them. There’s only a vague, unsettled feeling that they have difficulty articulating.

I’m reminded of our run-in, a decade ago, with H1N1 influenza, the regrettably titled swine flu. At first, my patients were clamoring for the vaccine, annoyed at the medical profession for not curing the situation more promptly. By the time the vaccine rolled out—an impressive five months later—most of my patients didn’t want it. H1N1 cases were folded into regular flu in the minds of most people, and the situation felt less urgent, even though cases were still about the same.  Emotional epidemiology of disease is as critical as clinical epidemiology, if not more so.

What feels different this time around is the sense of deliberate manipulation and disinformation. During H1N1 there wasn’t much in the way of elected leaders actively undermining public health recommendations, to say nothing of dabblings from the Russians. Although there was state-by-state variation in H1N1 deaths, these largely tracked the migration patterns of the disease from Mexico. By contrast, recent COVID deaths have tracked fairly closely to states that have resisted vaccination and mask-wearing. Tragically, some 90,000 deaths during the delta surge were deemed to have been preventable.

The blanket—and largely uncommunicative—mistrust some of my patients express toward the COVID vaccine gives me pause precisely because it feels far less organic than the concerns patients typically express about other medical interventions.

Patients, of course, have the right to question treatments. Frankly, they should have a high index of suspicion for anything they subject their body to, whether it’s an antibiotic, an herbal supplement, or a bag of Doritos. We in the medical profession should be able to explain that honest science will always contain ambiguities and evolving data.

The politicians who mine COVID confusion for brief sugar-highs in the polls—while death rates for unvaccinated people are twelve times higher than for vaccinated—will someday live with profound regret. For now though, the medical community is stuck with what they have wrought.

This last mile of the COVID pandemic—Omicron or not—is a painstaking one-on-one endeavor. As is most of primary care. Sadly, we now have to deal with political epidemiology as much as emotional and clinical epidemiology.

We’ll sit with each of our patients, listening as much as possible, attempting to understand and address their concerns. With some, the bloc of silence may be impenetrable. This is heartbreaking, especially for those of us who’ve penned more condolence cards this past year than we have in a lifetime of clinical practice. But such is the reality of our society’s self-inflicted wounds.