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WHAT TO DO WITH THE VACCINE REFUSERS?



This month at our office we have been bandying about the thought of taking a stronger stance against parents who refuse to vaccinate their children.  In a recent article in the Daily Beast entitled “Pediatrician:  Vaccinate Your Kids-Or Get Out of My Office” Dr. Russell Sanders takes the hard line 1.  He points out the tremendous health benefits that vaccines have engendered, the overwhelming evidence to support their safety, and the irrationality of declining one of the most beneficial medical treatments available.  He focuses on the issue of trust:  ..“for immunizations to be as malign as their detractors claim, my colleagues and I would have to be staggeringly incompetent, negligent or malicious to keep administering them” ...“as a parent myself I wouldn’t trust my children’s care to someone I secretly thought was a fool or a monster”.  He concludes by emphasizing that if parents can’t trust his medical advice on vaccines, then they will not trust him on harder issues, and that the anti-vaccination stance undermines the doctor patient relationship to the point where it should not continue.  
Dr. Sanders makes some very compelling points, and expresses the angst that all pediatricians ( maybe excepting Dr. Sears) feel when confronted with this issue.  It would be simple, and on one level, supremely satisfying to just send these difficult families packing, and pour our efforts instead into the families that trust us.  Who doesn’t want to be appreciated for their work?  How often does a problem come around where one can simply sent it away? Unfortunately, like most things in life, it’s not that simple.  
Suppose you decide to discharge everyone who won’t vaccinate from your practice.  How do you determine who they are?  Some people want to to do an “alternate schedule” (thanks again, Dr. Sears) and come in every few weeks for once vaccine at a time.  Would you let them stay and boot the only the 100% refusers?  Many people do all the vaccines but refuse the flu shot.  (“It gave me the flu”).  I don’t think any reasonable doctor would even consider pointing out the exit door to those folks.  What about the parent that doesn’t  vaccinate from neglect?  How does it help their children to lose their doctor when their own parents neglect them?  How about those who are truly mentally ill and paranoid.  Do their children benefit from a hard line stance by the pediatrician?  
I have friends who are into alternative medicine and “don’t believe in” vaccines (I have never been able to figure that one out).  A friend suffered greatly with painful gout for months, and swore by the alternative therapies he was taking.  (Isn’t it just amazing that such therapies are so often considered effective by the users, even when they are not working?)  He finally tried colchicine, which really helped, and his comment was “well, there is always conventional medicine as a last resort”.  ( The irony of the fact that colchicine is an extract from the autumn crocus and is probably one of the most ancient herbal remedies may have been lost on this sufferer)  My point is, people will use allopathic medicine “as a last resort” if they need to.
There will always be people who refuse to do what doctors tell them, and their distrust is not completely unreasonable.  The history of medicine is fraught with therapies that turned out to be harmful: blood letting, leaches, thalidomide, DES, unethical syphillis studies, and so forth.  It is unrealistic to say that everything modern medicine recommends is correct and never wrong.  The story of smallpox is a great example of how, in pursuit of an admirable goal, some distrust of the medical system was sown.  The elimination of smallpox was one of the best public health accomplishments of the 20th century.  Complete eradication of this virus was not accomplished completely by armies of volunteers lining up with bared arms.  During the final days of the battle to eradicate smallpox, enclaves of vulnerable peoples who had refused vaccination were ferreted out and vaccinated under coercion, at gunpoint if necessary.  (Now that’s hardline, Dr. Sanders!)
Another reason we can’t just excommunicate patients is that medicine is also a business, and the current trend we are moving towards is a model of customer service.  Increasingly our evaluations and reimbursements will be based on one thing:  the patient satisfaction survey.  In the patient-as-customer model, the customer is always right, and the “experience” they have in the office is the measure of our success.  Rare would be the private practice that could afford to turn away insured customers and risk the consequences of  bad surveys.  ( I don’t have to trust my doctor, but he sure as heck better trust me!)  Kicking out the non-vaccinators sounds good, but really it’s akin to going on a hunger strike to protest some injustice.  It hurts us much more that it would the wayward patients.
In summary, some one needs to take a hard line on vaccination, but it can’t be the physician. Maybe it is human nature not to take a threat seriously once it disappears from your backyard, but sometimes human nature gets us into trouble that we could avoid. The anti-vaccine craziness out there is going to result in children dying from preventable diseases,  and only the legislature can act to prevent this.  Pediatricians and primary care doctors can’t be the ones to take the hard line--all that does is drive families out of  good medical care.  Something needs to drive the herds back into our offices, eager and ready for their shots.   The recent California legislation authored by Richard Pan M.D. that requires non vaccinators to see a medical practitioner, discuss that decision and get a signature on a form is a step in the right direction.  Schools barring all unvaccinated children would be another strong step.   We need to apply the principles understood by our colleagues in the behavioral sciences --some carrot, some stick, --to influence families to make the right choice and protect their children.










1.http://www.thedailybeast.com/articles/2014/01/30/the-real-reason-pediatricians-want-you-to-vaccinate-your-kids.html







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