How do you protect a baby who can't get vaccinated from relatives who won't get vaccinated? Scientific arguments don't work, but proper incentives and boundaries just might. Here's what I've discovered in my first few weeks of parenthood.
A month before my son was born, I started making difficult phone calls to family and friends. “The doctor says you have to get a Tdap vaccine a couple of weeks before you can see the baby,” I told them. “If you won't get the shot, you can't visit until he receives his. Much to my surprise, these conversations went pretty well; our relatives knew what an infant with whooping cough looks like and almost everyone was happy to help prevent that outcome in our case.
But there were some holdouts, with excuses ranging from “we don't get unnecessary vaccines” to “I have X medical condition that boosts my immune system.” These weren't surprising answers; in fact, this kind of rationalization is all too common in anti-vaccine circles. According to a 2015 analysis in Expert Review of Vaccines:
... [M]any studies have shown that individuals are more averse to the risks associated with an action – getting a possibly ‘unsafe’ vaccine – than to the risks associated with inaction – taking a chance of contracting a vaccine preventable disease when there are no cases locally.
While their excuses weren't new, the realization that my family would engage in such dimwitted calculus while ignoring the potential risk to my son was unacceptable. My first thought was to cut off anyone who could be so selfish. What do you do, though, when the culprit isn't the weird uncle you only see at family reunions but someone much closer, like a parent or sibling?
That's the frustrating question I'm trying to answer even as I write this sentence. So far, I've hit on several strategies that have helped maintain the delicate balance between protecting our baby and avoiding the fallout of a family feud. [1] These aren't foolproof solutions, but looking at strategies that can combat individual cases of vaccine hesitancy might help us better tackle the problem on a broader scale.
A fight worth fighting
It's often said that vaccines work so well that we forget how important they are. This is the trap my family fell into with their rationalizations. While they may never have seen pertussis up close, it's still very prevalent. There are more than 18,000 cases of whooping cough annually in the US, and half of children one-year-old or younger who catch it require hospitalization.
The number of infections plummeted after vaccines were introduced in the middle of the last century, but there has been an unmistakable resurgence in recent years. Multiple studies have linked this unsettling trend to anti-vaccine activism. Globally, according to a 2017 study, there were an estimated “24.1 million pertussis cases and 160,700 deaths from pertussis in children younger than 5 years in 2014.”
You must be this vaccinated to hold my baby
I didn't bother citing these stats to my relatives; evidence generally doesn't convince people if they distrust the institutions that gather the evidence. But everybody responds to incentives. When more distant relatives and friends saw that we wouldn't budge on the vaccine with immediate family, it sent a signal that they weren't going to avoid their shots either. As a result, most people around our baby are now immunized. And because my wife got a Tdap booster in her third trimester, our son's infection risk is roughly 80 percent lower than it would have been.
This generally widespread compliance triggered a useful feedback loop because the holdouts saw that their stubbornness carried a real cost—namely, missing out on our baby's first days. The videos and pictures from the hospital they saw over text didn't hurt our cause either. They still wouldn't get the vaccine, but it was clear that they wanted to be part of the festivities. We had some leverage.
After consulting our pediatrician, we told the holdouts they could visit provided they weren't sick, washed their hands frequently, and wore masks whenever they held our baby. This was a compromise, but it was also an important step in the right direction for conservative boomers who heralded Donald Trump's election as the second coming of Christ. In the age of COVID, this isn't a demographic inclined to don masks.
The key to getting their cooperation, our doc said, was properly phrasing the proposal. “We'd love for you to see the baby,” I text them, “but the pediatrician says you have to take these precautions. If you're comfortable following her advice, please come visit.” This invitation had all the right nuances: it was welcoming, respectful of their autonomy, and, most importantly, clear that the baby's welfare was our primary concern. We weren't trying to win an argument.
Your own personal Dr. Fauci
Because they agreed to our compromise, the precedent has been set. They either get the recommended vaccines, or they tolerate my Tony Fauci impression at family events, where I'll enforce mask mandates and dispense hand sanitizer like a Purell salesman. One relative has already pushed back, making it clear that she won't wear a mask the next time we're all together. Instead of arguing with her, I sent back a reply I borrowed and adapted from Julia Garrett, a psychologist at Baptist Health:
This all [our pediatricians recommendations] probably seems excessive, but we're concerned about our boy and doing what we have to do to keep him healthy.
The tone of the conversation shifted at that point. She acknowledged that she takes precautions to protect her health and accepted that we were doing the same by temporarily keeping our distance. In other words, we created a situation where she volunteered to stay away. Had I told her to put a mask over her stupid pie hole or Christmas was canceled, we wouldn't have gotten the result we wanted peacefully.
Lessons learned
There are a few takeaways from my situation that apply to the vaccine debate more generally. First, taking away my relatives' Facebook accounts would have done nothing to resolve our dispute, nor would it have helped any parent in a similar position. Booting anti-vax folks off social media isn't a solution to this issue.
The counterargument is that banning anti-vaccine content from these platforms stops its spread. It's not that simple, though. Unless we totally lock down the internet (no thank you, comrade), the activists will find a way around the censors. The most effective antiseptic for anti-vaccine agitprop is good information delivered by trusted voices. [2]
Next, incentivizing my family to get their shots or mask up worked much better than demanding that they comply would have. A gentle touch is more effective than a mandate more generally, too. Of course, no antidote for vaccine hesitancy exists. There will probably always be people who, for whatever reason, view immunization with suspicion. That said, there are strategies we can use to minimize their influence. Let's give those a shot instead of wringing our hands and calling the vaccine-hesitant stupid. That may feel satisfying, but it will never solve the problem.
[1] Much of what I described above comes from Never Split The Difference, Fanatical Prospecting and Start With No. I highly recommend all three titles if you want to sharpen your persuasion skills.
[2] Scientific arguments work if you can first establish trust with your target audience. See this story for more on that.
