COVID Vaccine Hesitancy and Public Health

Program announcer

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

Dr. John Lantos

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 have Dr. Phoebe Danziger, who's 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.

Dr. Phoebe Danziger

Thank you. Thanks for having me.

Dr. John Lantos

So in an op-ed in the New York Times on July 9th, 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. Phoebe Danziger

As a general pediatrician, vaccine hesitancy is something I've been... ringing my hands about for many years. You know, we frequently see families who are, you know, concerned about vaccines for a variety of reasons and, you know, sometimes choose not to give them to their children. We seem to be seeing some of these same concerns and questions pop up when, you know, parents are starting to think about the idea of a possible future coronavirus vaccine. So in, you know, sort of recent weeks to months, you families bring this up as a topic during visits and you know what i'm finding is that um you know certainly there are some families where you know i would expect some hesitancy or concerns because you know 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 you know typically don't question the the routinely recommended vaccines gotten their children immunized, you know, according to the recommended schedule, but are having really, you know, serious concerns about the idea of a coronavirus vaccine. So that's what got me thinking about sort of writing this article.

Dr. John Lantos

What sort of concerns do they raise with you?

Dr. Phoebe 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 still similar questions about the potential safety or side effects of different vaccine ingredients. You know, so some of the preservatives are adjuvants that we typically use in vaccines. For other families, it is more of a sort of nebulous theoretical set of concerns, which sort of span sort of a broad spectrum, but, you know, ranging from

Dr. Phoebe Danziger

So, you know, some families have sort of more fringe concerns, I would say, about, you know, with the idea of whether there will be a microchip implanted in a coronavirus vaccine. You know, and some folks really believe this and worry about this. You know, for others, it's, you know, again, sort of more theoretical. And, you know, just as we've seen sort of, you know, wearing face masks become a very political topic, you know, so it is with vaccines. And so for some families... There does seem to be sort of concern about is there going to be a mandatory policy and just sort of categorical sort of opposition and hesitancy to, you know, the idea of a vaccine regardless of what type of vaccine it is or what the data ends up looking like.

Dr. John Lantos

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. Phoebe Danziger

What's been interesting in hearing from these families is that it really seems to sort of encompass a really... broad demographic and, you know, families and, you know, individuals of all sorts of different backgrounds. And I think to some extent, you know, that really parallels what we've seen with vaccine hesitancy in general, where, you know, initially it did start out, you know, sort of as a phenomenon primarily that existed amongst sort of, you know, more well-educated, wealthy Caucasian families. But, you know, in the intervening years, it's really spread to encompass. It's a much broader demographic and 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.

Dr. John Lantos

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. Phoebe Danziger

To some extent, when you're thinking about it on sort of an individual level and sort of direct doctor, patient, family interaction.

Dr. Phoebe Danziger

You know, it's relatively straightforward in the sense that, you know, you want to offer, you know, evidence-based sort of sound information and, you know, try to do so in a compassionate and non-judgmental way, you know, focusing on, you know, establishing trust with families and, you know, really trying to, you know, get a sense from them of, you know, who are they? What are their values? What are their fears? what do they want for their children? You know, most families want to do what's best for their children and are motivated by, you know, good intentions in that regard. And so trying to just have, you know, sort of honest and open and empathetic conversations, you know, about sort of what's behind their hesitancy and going from there. What concerns me is that while, you know, 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 particular recommendation. You know, I've certainly had, you know, experiences like that, and it feels good and satisfying. You know, there's certainly, you know, lots of evidence that for many Americans, you know, they do still turn to, you know, their physicians or health care providers as a source of trusted information about these things. But again, there is a, you know, non-trivial sort of portion of the population for whom I don't think this is necessarily true. And, you know, for whom vaccines and sort of similar... preventive types of interventions you know have become you know it's become much more of a sort of cultural issue and a political issue and a real

Dr. John Lantos

um with the coronavirus vaccine assuming it's comes along pretty soon it will be largely untested so are there special issues in the context of a raging pandemic that's around an untested vaccine how do we convince people that the benefits of this outweigh the risks?

Dr. Phoebe Danziger

Yeah, no, I mean, it'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. You know, when you think about sort of vaccine policy, you know, 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 gonna have to grapple with as individuals and as a society of how do we approach the aspect of sort of unknown risk and the fact that we're 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.

Dr. John Lantos

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

Dr. Phoebe Danziger

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

Dr. John Lantos

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. Phoebe Danziger

I just saw in the local news that one of the Michigan hospitals is participating as a site in a vaccine trial. I have not yet followed the links to investigate further, but yeah, that certainly seems to me.

Dr. John Lantos

Would you sign up for a trial?

Dr. Phoebe Danziger

I absolutely would. Yes, I trust the process. I trust the science. So I would.

Dr. John Lantos

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. Phoebe Danziger

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

Dr. John Lantos

So you've also been writing about other aspects of trying to flatten the curve and about how those play into trust in politics or the culture wars. What are your 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. Phoebe Danziger

Yeah, you know, I think there are a couple approaches that we might want to look at, you know, some sort of related to, you know, vaccines and interventions and some sort of taking a more big picture view. You know, 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 for 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 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 downstream expressions

Dr. Phoebe Danziger

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.

Dr. John Lantos

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. Phoebe Danziger

Oh my goodness. Yep. So 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, yeah, right now, just trying to get a sense of how can we balance working and, you know, sort of supporting our children's education at various levels, you know, with, you know, what for the foreseeable future is going to be a fully virtual. sort of remote option. So it's a challenge.

Dr. John Lantos

And that's Ann Arbor. Is the state of Michigan also going all online or is it district by district?

Dr. Phoebe Danziger

It's district by district for now. We have not heard any sort of statewide guidance yet on that, but... So we're all sort of waiting to hear what other districts decide and if there's going to be more firm guidance on the state level.

Dr. John Lantos

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

Dr. Phoebe Danziger

Yeah, so going back to

Dr. Phoebe Danziger

the vaccine issues, 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 And for a lot of families, you know, you can talk until you're blue in the face about the data, the, you know, the safety data, you know, the, you know, you can sort of go around and around with that, but it does not seem to quell, you know, some families fears. And so I think, you know, not from a medical standpoint, not from a scientific. standpoint, but from a social standpoint, you know, I think we might need to start listening to that a little bit more and, you know, think about are there ways that we can, you know, design these interventions, whether it's a vaccine, you know, 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.

Dr. John Lantos

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

Dr. Phoebe Danziger

You know, a lot of families have concerns about the different sort of ingredients that are common in our routine childhood immunization. So some of the things that we use as preservatives or adjuvants. to sort of, you know, boost the immune response. You know, some of these are things like benzyl alcohol or, you know, other sorts of ingredients that, you know, a lot of families will sort of Google these ingredients or, you know, look up information about them on, you know, social media forums and they get really scared because of what they see. You know, there is robust safety data regarding, you know, most or all of these, you know, ingredients and in the amounts, you know, in which they are used in vaccines, you know, we are very confident that they are safe. But, you know, this is something that just comes up again and again and again. And families, you know, some families, it doesn't matter how much sort of evidence there is, how much data there is, they just are not reassured by it. that. So, you know, I am not a virologist, I don't, you know, develop vaccines myself. But, you know, I do think there is sort of an untapped opportunity here for thinking about, you know, thinking about it in a different way and saying, okay, families are concerned about these ingredients, you know, we know they're safe, but, you know, families are declining vaccines because of them. Are there other ways that we can design these products that, you know, where they will be equally effective, but parents will be, you know, more more likely to accept them. So I don't know what the answer is.

Dr. John Lantos

But I love what you put in your July 9th 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 a new vaccine. 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. Phoebe Danziger

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

Dr. John Lantos

And this is the Pediatric Ethics Podcast from Children's Mercy in Kansas City. Thanks for listening.