What I say to persuade parents to vaccinate their kids — and what I hold back
My stories of young patients hospitalized with covid might do more harm than good
Perspective by Rachel M. Pearson
Rachel Pearson is a professor of bioethics at the University of Texas Health Science Center at San Antonio. She leads the humanities pillar at the Center for Medical Humanities and Ethics and is a pediatric hospitalist. Her memoir "No Apparent Distress: A Doctor's Coming of Age on the Front Lines of American Medicine" was published in 2017.
September 17, 2021 at 6:00 a.m. EDT
An earlier version of this article stated that “no vaccines known to man have delayed negative effects” occurring more than six weeks after vaccination. In studies of possible side effects of the Pandemrix vaccine, some subjects reported the onset of narcolepsy symptoms between six weeks and a few months after vaccination. An earlier version of the article also stated that more than 5 billion people have received a coronavirus vaccination worldwide. More than 5 billion vaccine doses have been administered globally, and more than 3.78 billion people have been vaccinated. This article has been corrected.
“Kids don’t get really sick from covid,” the father of a teenage patient tells me, “so I don’t think the vaccine is worth the risk.” My face remains composed — I hope — expressing nonjudgmental concern.
Currently, youth ages 12 and up are eligible to receive the Pfizer coronavirus vaccine, and pediatricians hope for more children to become eligible soon. By some estimates, the Food and Drug Administration could authorize Pfizer’s vaccine for emergency use in kids age 5 to 11 by the end of October. As an academic pediatrician who cares for hospitalized children, I’ve met many parents who are excited to get their kids the vaccine. Many others have questions or fears. A minority are deeply opposed to vaccination.
My colleagues and I are very worried about vaccine hesitancy. The Kaiser Family Foundation found that 40 percent of parents with kids under 12 plan to “wait and see” to vaccinate their young children, even after the shot is authorized for them. As of July 31, only 42 percent of Americans age 12 to 17 had received at least the first dose of a coronavirus vaccine. Though updated data has not officially been released, the White House announced Aug. 27 that half of American teens had gotten at least one shot. Half is still nowhere near enough to confer herd immunity against the highly contagious delta variant. Youth are suffering: The number of kids admitted to hospitals with severe covid-19 has increased by five times in the last few months. But even though children are getting sick, they are not the decision-makers when it comes to vaccination — parents are.
Parenting, in my experience, is both cognitive and visceral. I know that spitting up is not dangerous, for instance, but I leaped from my hospital bed to rescue my newborn son the first time I heard him do it. Parents’ gut responses can save kids’ lives: When we hear the particular scream that means pain, or the porcelain thump that means the toddler is trying to climb into the toilet bowl, we run before we think.
So when, as a doctor, I encounter parents who decline the coronavirus vaccine for their children, I try to remind myself that they are creatures much like me; they are trying to make rational judgments about their child’s best interests, but they’re also moved by fear, instinct and community mores. While it is tempting, in these conversations, to unload the weight of all I have seen — children stricken with severe covid, with mysterious clots and heart problems and respiratory failure — I generally hold these stories back. When parents need to feel heard and reassured, worst-case scenarios can do more harm than good.
Pediatricians have been working on vaccine hesitancy for decades, and the only method that has been shown to increase pediatric vaccine intake is the “presumptive approach.” Accordingly, I’ve trained students and resident doctors to use sentences like, “Today, we will give the measles vaccine,” instead of beginning vaccine conversations with a question like, “How do you feel about vaccines?” or “Can we talk about the measles vaccine?”
The presumptive approach leverages physician power and authority to get vaccines into kids. But we don’t know if it builds physician-parent trust in the long run. In the coronavirus era, as much as we desperately need to get vaccines into people, doctors also need to play the longer game of earning and building trust with the communities we serve. So for hesitant parents, I draw on a method developed by my colleague Luz Garcini, a psychologist with vast expertise in providing health care across lines of culture and identity. Garcini advocates taking the patient’s perspective, practicing active listening, speaking in plain language and “bridging respectfully” from vaccine myths to vaccine facts.
With the father who believes that the vaccine is riskier for kids than covid would be, I might start by acknowledging his perspective: “I have also learned that most kids with covid don’t get very sick.” Then, I continue: “But some do, and a small number even die from covid. We know that the risks from infection are worse than the risk from the vaccine — even for kids.”
Having bridged from a vaccine myth to a plain-language fact, I stop.
This takes exquisite self-control, because as a hospital pediatrician, I see only the extreme cases: They are the reality I know. And I know that some children do get very sick. In the winter, I cared for a teenager who had been flown across the state for emergency brain surgery after a stroke caused by covid-19. The surgeons sawed off a piece of her skull to relieve pressure from the bleeding, our intensive care pediatricians gradually weaned her off the ventilator, and she survived. She’d been an athlete before the stroke; afterward, she had to learn to walk again.
That teenager was unlucky. About 1 in 3,164 children infected with the coronavirus will develop MIS-C, a life-threatening inflammatory condition. 3,163 will not. Hemorrhagic strokes in teenagers with covid are known to happen, but they are so rare that we can’t accurately say how often they occur. So I keep my answer to this father factual: Myocarditis, or inflammation of the heart, is the one potentially serious side effect we’ve seen from the vaccines. It is rare: An estimated 63 in every 1 million boys between ages 12 and 17 get myocarditis after vaccination; 999,937 do not. (It is so rare in girls that we can’t yet estimate the incidence.) Most kids who do get vaccine-induced myocarditis recover quickly with an anti-inflammatory medicine like ibuprofen, and no children have died because of it.
A part of me — a part that wants my experience to be heard and trusted — wishes to trot out the stroke story. Or to talk about a covid patient who survived with a damaged heart. But I don’t. I need to build a relationship, to inspire warmth and confidence, not the adrenaline overload that comes from a scary story.
To be fair to that father’s perspective, most young American patients will not be seriously harmed by covid infection, even if they do catch it. Nationwide, only 516 children are known to have died of covid since the pandemic began. The pandemic harms most kids by a thousand losses — play, school, relationships, grandparents, financial stability, housing, supervision, calm — rather than by a catastrophic infection in their own bodies. Parents weigh those known losses against unknown threats.“This coronavirus vaccine is too new,” one says to me. “We don’t know if there are long-term effects.”
In response, I acknowledge that many parents have this concern, then add, “What we know is this: We’ve administered more than 5 billion doses of vaccineworldwide. When people do have side effects, those happen in the first days to weeks after the vaccine.” In fact, the mRNA vaccines are thrillingly safe. They contain no virus. They break down and are gone from the body within 72 hours, leaving only protective antibodies behind.
This is true of vaccines in general: Whether side effects are serious or mild, they tend to occur in the first six weeks after vaccination. I expect this data to hold for mRNA vaccines too, because the vaccine’s remnants in the human body — antibodies against the coronavirus — are most abundant shortly after vaccination. Just as with other vaccines, it stands to reason that this is when side effects would occur.
Many vaccine-preventable diseases can have serious delayed effects, however: brain scarring from measles, strokes from chickenpox, long covid. Beneath the calm and straightforward facts I communicate to parents about vaccination, my own stories roil: a child who developed a dangerous bacterial superinfection on the open skin where she had chickenpox blisters, a boy with tetanus who spasmed so hard and long that he was intubated in the ICU for months, a baby with whooping cough who stopped breathing night after night, bringing us running to her hospital room.
It is difficult to avoid blaming parents when children contract vaccine-preventable infections — we who care for the sick children sense that parents have abdicated a responsibility to protect them from known dangers. That sense of blame is coming up again with covid, as we notice that many hospitalized children live in unvaccinated households. I am ashamed of that feeling, and I work hard to ensure that it doesn’t affect my care for the child or my demeanor toward the family. But it is there.
Because my vaccine chats are focused on parents’ specific concerns, the social benefits of vaccination — protecting others and ending the pandemic — rarely come up. Parents’ identities as the guardians of their children make public-health-based arguments less convincing. The sense of collective responsibility feels less relevant when responsibility for a particular child looms so large: “I would just be kicking myself forever if she got sick from the vaccine,” another mother tells me. “I would feel so guilty.” Many parents seem to perceive possible side effects as a harm they would have done to their child — as their fault, for choosing to accept the vaccine.
Conversations like these remind me of the “trolley problem,” in which a hypothetical runaway trolley is barreling toward five people on the tracks. Someone watching the trolley — you — could push a single other bystander onto the tracks and stop the trolley, saving five lives by sacrificing one. Most people would not push the bystander, because we are not diligent utilitarians at heart. We sense that to act makes us culpable, whereas simply watching can be forgiven. Some parents would feel at fault for acting to give the vaccine. They would blame themselves less for watching their child contract an infection they could have prevented.
For American parents, the stakes seem low. A trolley barrels toward a branch point with 3,200 tracks, and their child is tied to one of them; if they have that terrible luck, their child will get MIS-C when they are infected. I offer them a chance to pull a lever that will expand the number of tracks to 32,000, and make it so the outcome of being hit by the trolley is not MIS-C but heart inflammation that will go away on its own. But the overall risk to kids is small in any case, and it is unsurprising to me when parents do not pull the lever.
When parents believe that vaccination puts children at risk, they hesitate. Even if they are the kind of people who might jump in front of a trolley themselves to save others — or who would take a vaccine to protect their communities — they won’t push their own kid onto the tracks if they believe a trolley is coming.
I understand that hesitation. I could have enrolled my baby in a coronavirus vaccine trial, as many other physician moms did. Initially, however, I chose not to. I was three months’ pregnant when the pandemic began, and Sam rode uncomplainingly through the hospital in my womb for a long time before we knew whether coronavirus infection could harm pregnant women and their babies. (It can.) Somehow I felt that Sam had already risked enough in his little lifetime by being my quiet fetal companion while I worked to help other people’s children. Joining a trial seemed supererogatory: a good thing to do, but above and beyond what was morally required.
Recently, though, I shared our information with researchers in the hopes of joining a trial. With data so far showing that the vaccines are safe and effective in all age groups — and no scientific rationale for expecting that would be different for babies — I want to get my son protected as soon as possible. He’s too young to wear a mask, and this past week, my hospital ward has seen many children severely ill with covid. I signed up out of a sense not of duty but of desperation.
At the bedside of a teenager recovering from appendicitis, a parent looks at me skeptically. I am urging her to accept the vaccine, which has been shown to be effective and safe in adolescents. “It’s just so new,” she says. “I don’t know.”
To offer a measured and effective response to the concerns of unvaccinated parents is effortful, because of the emotions that all hit me at once: my frustration, my hurt pride over how my profession is being undermined by agents of misinformation, my secondary trauma from before and during this pandemic. My occasional anger with unvaccinated adults — how I imagine my son’s life could be different, more peopled and more ample, if only they would all get the shot.
But my feelings are unhelpful, and beside the point. The point is that kind, consistent, factual communication from physicians might help lift us from this nightmare. So instead of unloading my feelings or telling the stories of worst-case scenarios, I try to offer something useful: a conversation focused on this parent’s child. This specific child. Who will probably be fine either way, but who will enjoy a near 100 percent certainty of not being hospitalized with or dying of covid if she gets the vaccine. This child’s flourishing is our shared goal, always.
I take a breath, and I begin again: “Many parents feel that this is a hard choice. Knowing the science makes it easier . . .”