The Unvaccinated Among Us

The vaccination rates for COVID-19 are plateauing; there is no concern, at least in the US, over supply, no lack of public service announcements, no financial barriers. It is time to face the reality that those eligible and not vaccinated are not taking our advice. [1] They have found their second opinion and have elected to follow another path.

When I was practicing, my ego was bruised by some not “heeding my wise words.” In some cases, upon reflection, I thought I might have communicated better, that I had failed them. In other instances, I was relieved that an “entitled” patient was now someone else’s burden; and very infrequently, though I hate to admit it and still feel a bit of shame, I experienced schadenfreude, being happy in the misery of others. 

In short, I reflected on how those second opinion rebukes affected them and me. Can we apply the same to the unvaccinated among us?

The unvaccinated and me

While we might frame this as a public health concern, deep down, I am most concerned about how the unvaccinated will impact my life and family. While it may seem selfish, I think it might be more the public health version of the “invisible hand.” The vaccines are very effective, especially against the earlier variants. There is little evidence that I am at significant risk of hospitalization and death from the current variant of concern, delta. More importantly, my close contacts are all vaccinated; my pandemic pod has expanded. The only time I face the risk of being exposed to the unvaccinated is mainly in public spaces, which are often outdoors or socially distanced. And by socially distanced, I am talking about near-normal distances – I have avoided the subway, more over concerns of crime, and am happy to take the train. In short, the unvaccinated do not adversely impact my personal space and life.

The unvaccinated will continue to become ill and hospitalized; some will die. But that doesn’t change my thinking; after all, some people continue to smoke and develop lung cancer, and I pick up their medical tab through my taxes and insurance costs; why should I be more indignant over the unvaccinated. The unvaccinated do serve as a breeding ground for new variants, more hosts, more chances to mutate. But again, those types of health choices have been with us for some time – not everyone gets a seasonal flu vaccination.

Could I, as a physician, now healthcare communicator, do a better job convincing the naysayers? That comes down to how much you trust me, just as it often was the underlying motivation for those second opinions. It reminds me of the husband caught in bed with someone other than his wife whose denial when confronted is, “Do you want to believe me, or your lying eyes.” Trust is hard-earned and easily broken. Could we, as a society, have made the vaccine more accessible? Here I am reminded of the individual who prays every day to win the lottery and, after several days, becomes embittered by a lack of response. Finally, an exasperated presence says, “I have not forsaken you, but you have to buy a ticket.” Isn’t there some minimal effort necessary on their part?

The unvaccinated

I believe these adults are putting themselves at unwarranted risk, but that is my calculation. Their fully autonomous choice; they live, become ill, or die on their terms. While I find no joy in their bad outcomes, no schadenfreude, in this case, to be honest, my feelings are somewhere between resignation and washing my hands of them. Again, I have felt this way before, so maybe I am more comfortable with their decisions. Why would I continue to be so crazed over the unvaccinated? Is it different than smoking where the linkage is clear, and we have made no effort to ban the product? [2]

Inevitably, there are downstream effects of our decisions – both to and not to vaccinate. For the unvaccinated, in addition to their personal risk, which at this point I believe they understand and fully consent to, there may be collateral damage. You can become ill and spread the disease to Mom or Grandpa, and it “takes them out.” You can become sick, recover, and have long-term consequences which impact the quality of your and your family’s life. Your body, your choice, your choice, your family. Deal with it.

Chasing after an unwilling patient was always a bad idea as a physician. You could never satisfy them because there was an element of distrust at the heart of the relationship. It might be papered over, but they never found the treatment entirely successful, or there was a moment in care that was unpleasant beyond their tolerance – just as those who do not want to be vaccinated will point to breakthrough cases or side effects. 

At this point, I believe we have done the best we can to inform and treat. I am tired of the hand-wringing in the media; we have other concerns. My priority would be to get the vaccine to those who want it rather than continue in an increasingly futile effort to change people’s minds. The unvaccinated are adults that have made an informed decision; it is long past the time when we should continue to expend our resources on changing their path. 

An important disclaimer: I and the American Council on Science and Health believe in vaccinations,

including those for COVID-19. 

[1] I am writing today to the adults. Whether to vaccinate your children involves uncertainties that vaccinating adults does not – the risk-benefit tradeoffs are different.

[2] That raises another contradiction in my thinking. I do believe that vaccination should be mandated for healthcare workers because there is, to my mind, overwhelming evidence that they can transmit the disease to their patients, and that violates healthcare’s first ethical principle of “do no harm.”