Taylor wore her embroidered sorority sweatshirt and a mask below her nose when she came to see me. She was 19 and had just finished her freshman year at the local university. Her story was cliché, as well: cough, runny nose, and sore throat “that wouldn’t go away.” She’d been sick for 8 days and she’d come in to get antibiotics. This isn’t a story about antibiotic stewardship, though.

“Have you been tested or vaccinated for COVID?” I asked her after forcing myself to sit mute and listen for the 90 seconds I know I’m supposed to give every patient.

She stared at me scornfully and paused as our initial cordial rapport vaporized.

“No.”

From the combination of her expression and the tone of that single word, I could tell how the rest of the interaction would go. As I began to explain that COVID was (currently) the most likely cause for her symptoms, I was interrupted with predictable rhetoric. I can’t recall Taylor’s exact argument, but it had all the conspiracy catchphrases: hoax, microchips, and “guinea pigs.”

I’d wager that we all have had many similar encounters recently with the half-masked and unvaxxed. Given the vaccine’s effectiveness in preventing symptomatic infection and the current surfeit of available vaccines in the U.S., the majority of patient’s arriving with COVID symptoms nowadays are willfully unvaccinated. While a rare few may have come to this position based on a careful review of the available data weighed against their personal risk profile, most have not. Most have chosen not to receive the vaccine based on a variety of beliefs, generally with strong political overtones. The skepticism and distrust abound as they describe notions of nefarious plots involving government─pharma collusion.

I cannot deny that these patients are exceptionally frustrating to care for on many levels. Their convictions in these alternate beliefs commonly lead to conflictual interactions. On a practical level, it’s hard to deliver safe care as they try to steer clinical conversations into discussions about political ideology at every turn. Most significantly, though, the refusal of eligible patients to get vaccinated is undeniably drawing out the pandemic and putting vaccine-ineligible individuals (eg, children) at risk.

At first glance, this seems highly reprehensible. And if this behavior were willful, then it would be. However, we must remember that in the worldview held by most of the COVID antivaxxers the threat of the virus is overblown and the vaccine is the real danger. It is reminiscent of Hanlon’s Razor: “Sufficiently advanced ignorance is indistinguishable from malice.” This seems true. It is highly unlikely that the roughly 45% of Americans electing to forego vaccination are making this choice to terrorize our nation’s children.

So, if we cannot blame the antivaxxers for their intentions, we can at least find them at fault for their ignorance, right? While I confess that in my more exhausted moments I do just that, I don’t think it’s entirely fair. The vast majority of “information” consumed, not only related to the pandemic but on any given topic, is now delivered through social media or other platforms using similar user retention tactics.

Facebook, Instagram, YouTube and other ad-supported, public internet-based forums have created sophisticated algorithms to keep users engaged with their devices. This insidious phenomenon is articulated in detail in the 2020 documentary, The Social Dilemma. Because we humans prefer to hear the opinions of those who we agree with, these platforms’ artificial intelligence (AI) engines quickly learn our beliefs through our preferences and what keeps our attention. Our feeds become echo chambers, preferentially exposing us to “news” and opinions which corroborate our existing worldview. The result: we all end up being fed a different version of reality. And with these viewpoints being repeated to us ad nauseum, our beliefs become reinforced exponentially. It’s like adding rebar to concrete.

So, while it would have been convenient to blame Taylor, not only for her own current misfortune (her COVID test was positive), but also for our nation’s ongoing collective misfortune, it misses the mark. It’s like blaming an addict for their substance use or an obese person for their weight. Certainly, there’s some personal responsibility, but there were larger and more villainous forces at play leading to her current state of suffering.

 Now, unlike overweight and addicted patients, the antivaxxers personal choice has a more palpable and direct impact on their communities at large, regardless of their individual culpability for that choice. This is why mandatory vaccination for eligible citizens is not only appropriate, but necessary. This may be the land of the free, yet we require seatbelts and heavily restrict indoor smoking. Similarly, vaccination is undeniably a matter of not only individual wellbeing, but most importantly from a policy standpoint, public safety. Recognizing this, President Emanuel Macron of France, in a compelling address, recently outlined his rationale for compelling French citizens to be vaccinated. As the U.S. remains far and away the world leader in COVID-19 infections, American leadership would be wise to follow suit.

Without such a mandate and with the rise of the Delta variant, I fear that the pandemic will smolder for many months to come. In the meantime, for our own sanity and burnout prevention, when seeing an infected and unvaccinated patient it would behoove us to realize that they’re suffering on several levels. Most obviously, they’re afflicted with unmitigated COVID itself. However, they’re simultaneously facing intense cognitive dissonance as their personal reality and the false narrative they’ve been fed and subscribed to are now undeniably at odds. And people aren’t the best versions of themselves when they’re going through that. So, try to show them some grace. This isn’t malice, just ignorance. Ignorance resulting from a broken and pervasive system perpetuating unfettered propagation of misinformation. Our patients aren’t the con artists who’ve come up with the conspiracy theories, they are the ones who’ve fallen victim to it.

Victimized or not, until some version of a vaccine mandate arrives, we still must encourage these patients to get vaccinated (if they’re fortunate enough to recover). By virtue of showing up in our UC, they’ve put at least a modicum of trust in us. Counseling them about vaccination is not only the right thing to do because we are all officers of public health, but given the echo chamber effect of fake news and science, we are often the sole counterpoint and voice of reason they’re exposed to. And direct advice from healthcare providers is often more impactful than we realize, especially if we can muster sharing it from a place of concern and compassion. After all, the unvaccinated are indeed the ones suffering the worst of the pandemic now.

The Unvaccinated Aren’t the Enemy

Joshua Russell, MD, MSc, FAAEM, FACEP

Quality and Provider Education, Legacy - GoHealth Urgent Care, is affiliated with the University of Chicago Medical Center in Vancouver, WA, and is Editor-in-Chief of JUCM.
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