Educate then vaccinate
I remember the infectious disease lectures during medical school: slides of sad-looking children with weepy eyes and skin the colour of salmon, black-and-white photographs of men and women encased in iron lungs, tales of patients with paroxysms of coughing so severe and protracted they either vomited or passed out. These images have stayed with me, but thankfully, as a doctor who graduated in the 2000s in a developed country, they have remained just that: a shocking photo montage from an undergraduate lecture.
In my work as a GP in the inner city, I am much more likely to counsel a patient about the side effects of the measles/mumps/rubella vaccine than I am to encounter an actual case of measles. To date, I have never seen a patient with diphtheria or tetanus or rubella. But this is a relatively recent phenomenon. My father attributes his soft voice to a particularly severe attack of childhood pertussis, or whooping cough. My mother recounts her own debilitating bout of measles during her paediatric rotation to the Adelaide Children’s Hospital. But such is the efficacy of vaccines – within a generation, they can suppress microbe numbers to such low levels that people like me can remain blissfully unaware of the diseases they have prevented.
The danger, of course, is that we forget. In the absence of the disease, our fear finds new focus – in the vaccine itself. This is understandable. Human beings’ behaviour is determined not by statistics or by black-and-white photos but by what we perceive to be our greatest threat. I have no doubt, for instance, that my vigilance around giving my children the flu vaccine has its origins in two key events: an encounter with a young girl at The Royal Children’s Hospital who was paralysed after a flu-induced encephalitis, and the experience of nursing my own daughter, several years later, in a bed at the very same hospital as she battled a flu-induced bronchopneumonia.
When I heard about research conducted by the Australian National University, which found that Covid-19 vaccine hesitancy in Australia had increased from August 2020 to January 2021, I wondered if the same phenomenon was at play. In August 2020, Australia was still recovering from the peak of its second wave, daily case numbers were in the triple digits and Victorians were in a severe lockdown. By contrast, in January 2021, daily numbers of Covid-19 cases had fallen to the double digits and were stable. Apart from select areas of Sydney, most Australians were free to gather and travel. But while previous research suggests public enthusiasm for a vaccine is linked to the threat of the disease, international data does not support this theory in the case of Covid-19.
In France, for example, vaccine hesitancy increased between May and September last year, despite the country experiencing a surge in Covid-19 cases. A similar trend was observed in the United States across the duration of 2020. Potential explanations offered by researchers included concerns about the safety and efficacy of the vaccines, how quickly the vaccines were being developed and mistrust for the pharmaceutical companies and governments producing and distributing the vaccines.
I have long wished the media would devote as much attention to groundbreaking scientific discoveries as it does to sporting scandals and celebrity weddings. In 2020, to some extent, I got my wish. Barely a day went by without an update about Covid-19 vaccines. And with good reason – our lives and freedom quite literally depended on it.
At the same time, institutions, including the World Health Organization, sought to manage our expectations. In August 2020, the director-general of WHO, Tedros Adhanom Ghebreyesus, said: “There’s no silver bullet at the moment – and there might never be.” Scientists repeatedly warned us that even if an effective vaccine was developed, it could take several years to run the necessary trials, let alone manufacture and distribute on a mass scale. Across the world, people took such news with a heavy heart.
And then, in November 2020, the seemingly impossible happened. Reports emerged of Covid-19 vaccines that were more than 90 per cent effective. Some of us – relieved to finally have some good news – celebrated. Others, remembering the previous warnings, wondered if the vaccine development had been rushed. In truth, the success was a result of massive global investment and collective scientific will, the scale of which the world had never before witnessed. But these finer details didn’t always cut through to the general public. Many who were less familiar with the iterative nature of research, found the blow-by-blow coverage and evolving recommendations for vaccine scheduling and dosing not only confusing but inconsistent.
I remember learning about vaccine refusal during my general practice training. The key point I took away from the session was that conscientious objectors represent a small minority of patients. The larger group, by far, are those people who are undecided or ambivalent about vaccination. Research from ANU highlights this, with only 5.3 per cent and 7.7 per cent of participants reporting in August 2020 and January 2021 they would “definitely not” vaccinate, respectively, as compared with an undecided group of 35.3 per cent and 49.5 per cent for the same period. This larger group may well hold the key to Australia’s success in achieving that much lauded goal of “herd immunity” and, as such, they deserve our attention, not our derision.
Previous research conducted by the ANU Centre for Social Research and Methods identified females, people living in disadvantaged areas, people reporting that the risk of Covid-19 was overstated, and those with more populist and religious views, as being the groups more likely to be hesitant or resistant to Covid-19 vaccination. Some within this broad group – due to previous experiences both in their countries of origin and in Australia – may be untrusting of governments and people in positions of authority.
We will need much more than a few images of smiling politicians and chief health officers getting jabbed on national TV to rouse this hesitant group to get vaccinated.
Instead, this group will need to feel that their concerns and questions about the Covid-19 vaccine are being addressed. And their questions will need to be directed to the right people with the right expertise to answer them. In many cases, this will be the patient’s GP. But a vaccine-hesitant patient is unlikely to make – and indeed pay – for a GP appointment with the sole purpose of discussing a vaccine they are not even sure they want to get. Such discussions will have to occur in an opportunistic fashion as these patients make appointments for unrelated problems. Like most preventive health measures, it will need to be squeezed into a brief and already jam-packed consultation.
In preparation for phase 1b of the rollout, I have started raising the topic of Covid-19 vaccination with my patients. Quite a few have expressed concerns, citing the recent suspension of the AstraZeneca vaccine in Europe. This does not surprise me. What does surprise me is how quickly I am able to allay their fears with evidence-based information. Far from being defensive, they seem eager to be educated. It is in this space that I feel I can make the greatest contribution to the vaccination program as a general practitioner – in helping patients navigate their way through the ever expanding labyrinth of misinformation.
Of course, to reach those patients who won’t see a GP in the coming months, a smart and comprehensive public education campaign is needed. A campaign that uses all forms of media in multiple languages and calls on the expertise and labour of every health sector. Information and FAQs buried in a health department website won’t be enough. The education campaign will need to find and reach vaccine-hesitant patients both in real life and online, which brings us to possibly the greatest challenge of all – the need to compete with the largely unchecked and unregulated space that is social media.
Whether an individual vaccine is 80 or 90 per cent effective won’t matter if only a minority of the population is vaccinated. Huge supplies of vaccines are no good to us if they don’t end up in people’s arms. Herd immunity won’t be achieved until somewhere between 70 and 90 per cent of the population is vaccinated.
Australia has performed well in containing the spread of Covid-19, so far, but we can’t afford to fail in this final and most crucial step towards a post-Covid world. During these early days of the rollout we will see high demand for the vaccines, and the initial challenge will be ramping up services to meet this demand, but the greater challenge by far will be convincing the people who are ambivalent about the vaccine to make an appointment with their GP.
It will require a herculean effort and a huge amount of money, but it is arguably one of the most important investments we will make in the immediate future health of both the Australian people and the Australian economy.
This article was first published in the print edition of The Saturday Paper on Mar 27, 2021 as "Educate then vaccinate".
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