When our newest daughter was born at home this summer, my midwife provided us with the names of numerous audiologists in the area to conduct a newborn hearing screening. At several prenatal appointments, she warned that we should get the test done quickly because if we didn’t, the state of Maryland would “stalk” us.

Boy, was she right.

As instructed, we had our daughter’s hearing checked within her first month of life. But for some reason, the results didn’t make it back to the state or our pediatrician, and so, despite our best efforts, we experienced the full “stalking” effect from the state.

It started with a call from our pediatrician, a gentle reminder from the nurse on staff to get the test completed in a timely manner. I offered to send in the results — our daughter had passed the test days earlier — but they (incorrectly) assumed they were on the way to the doctor. Then another call, this time from the state. Then another call, again from the pediatrician. And then a letter from the state. There were so many points of contact within her first seven weeks of life, I honestly can’t keep them all straight. Finally, I emailed both the state and the pediatrician the proof that my daughter had passed. They prefer to receive it from the audiologist directly, but it seems the proof I sent in finally did the trick: We haven’t heard about the hearing test since.

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But the experience got me thinking: How is it that the full force of the state government and my pediatrician can be zeroed in on this relatively minor test, and why can’t the same effort be extended to other medical care that I can refuse during my kids’ first weeks, months and years of life that could result in death if I opt out of it? The worst outcome of refusing a newborn hearing screening is extra time before we would have a diagnosis of hearing loss, which could lead to developmental delays. But refusing other medical interventions, namely vaccination, could have far worse ramifications.

As a conservative, I’m usually loath to insert the full force of the state into the often-nuanced decisions parents make. But what if health departments across the country used the way Maryland came after us for the newborn hearing screening test as a model and developed similar tracking, education and reminders for parents who fall behind on vaccination schedules? The power of the state coordinated with a pediatrician wouldn’t force parents to vaccinate, but their combined efforts could convince and cajole many of the “low-hanging fruit” — parents who aren’t hardcore anti-vaccine, but instead are vaccine-hesitant or maybe just too busy to get to the doctor for a wellness check, when shots are traditionally given.

The reminders did two things in my case: They put a fire under my behind, and they made me a bit nervous. At my next wellness check with my infant after I sent in the test results, I verified that they had been received and asked my doctor if I would be getting a knock on my door about the test if not. Even though I knew the law didn’t require me to screen my daughter’s hearing, that didn’t mean I felt totally comfortable ignoring the requests, either.

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According to Dorit Reiss, a professor at the University of California’s Hastings College of Law with expertise in how states enforce vaccination policies, official nudging is a possible solution, though it’s not without stumbling blocks. There is no national database for whether kids have been vaccinated; each state is in the process of developing or modernizing its own. The statewide databases are opt-out, and unfortunately, many anti-vaccine parents do just that. But Reiss suggested that health officials could flag families who decline the hepatitis B vaccine in the hospital for their newborns and contact them later with information about the safety and importance of vaccination. If a family says no to that first vaccine in the hospital, they are at greater risk of denying or delaying future vaccines as well.

At a clinic for low-income patients in the Washington area, I recently spied a whiteboard with information for clinicians about the patients who come to their offices, and on it was a fair amount of information about why these patients don’t vaccinate. The factors included fear of vaccines or needles, concern about the cost of vaccines, misunderstandings about when they can get a shot, and a lack of community and familial support to encourage vaccines and get to the clinic. Most providers are on their own trying to persuade patients to overcome these fears and apprehensions.

“Provider factors” were also listed on the whiteboard at the clinic. There, time was the biggest constraint: “Overbooked providers rushing with patients forget to order the vaccines,” and providers lack time to talk patients into vaccinations.

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When most Americans think about parents who haven’t vaccinated their kids, individuals like Jenny McCarthy come to mind. But among those who don’t vaccinate, there are varying degrees of commitment to the decision. Inoculating the “low-hanging fruit” could bring us much closer to the rates we need to achieve herd immunity. In a 2014 study testing the efficacy of different vaccine messaging, parents of infants were more willing to vaccinate depending on the emphasis of the messaging they were exposed to. According to that research, messaging can have an effect on some families who have eschewed vaccinating.

The anti-vaccine movement is gaining steam and has been recognized by the World Health Organization as one of the top 10 threats to global health in 2019. The work of educating and reminding parents of the importance of vaccines shouldn’t be left to overextended pediatricians alone. We are facing a public health crisis, and public health officials should respond accordingly. If parents’ decision to neglect a hearing test for their infant is worthy of a call and a letter from the state and a pediatrician, surely their decision to refuse lifesaving vaccines should also qualify.

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