I am struggling to understand why patients decide not to get the covid vaccine
BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n3152 (Published 24 December 2021) Cite this as: BMJ 2021;375:n3152
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Dear Editor
Our healthcare professionals and care home staff have done an outstanding job in supporting us through the pandemic often in the very worst of situations and it must very difficult for them to envisage any situation whereby someone might refuse the Covid vaccine. However the reality is that vaccination, like everything else in life, is not without risk. For some the balance between risk and benefit comes down heavily in favour of vaccination and that’s the end of the matter. For others (even those who start off thinking that way) the balance shifts considerably when they become one of the unfortunate few who suffer a vaccine induced injury.
The reputation of the Vaccine Damage Payment Unit in the UK currently does little to reassure people that they will be helped in the rare event that they suffer negatively through vaccination.
The poorly performing system is inefficient and enmeshed in stories of lengthy delays and a lack of empathy for disabled people and their families.
While it may be unthinkable to HCP’s etc that any practicality would take priority over health and well being, the reality is that vaccine injury seriously impacts on families and knowing that there is no readily available ‘safety net’ to provide help when things go wrong, may contribute to vaccine hesitancy and refusal.
Severe disablement brings with it many taxing challenges and burdens.
Every aspect of vaccination should carry a shared responsibility to include ensuring that the few who suffer because of it are immediately acknowledged and assisted.
The emphasis on our shared responsibility to have vaccines should equal our shared responsibility to help those who suffer because of it, both swiftly and efficiently.
In 1984 Lord Allen Of Abbeydale got it right when he said………………
“The argument was that society asked for these vaccinations to be carried out in the interests of the community and it was right that the community should shoulder responsibility when things went wrong”
Competing interests: I represented by daughter in a claim at the VDPU.
Dear Editor
We are writing about what is happening in real life as opposed to what the numbers show and beginning to understand why some people may not want to take up COVID-vaccine.
We work in a city with a multi-ethnic population and have the opportunity to talk and deal with various different facets of society. We are a strong advocate for vaccines and have been involved in campaigns and webinars in a wider society allowing us to interact with people from many different backgrounds. Our observations have shown that vaccine hesitancy predominantly exists in young, in particular ethnic, educational or social backgrounds. This is true for both healthcare professionals and the general public. A recent UK study identified sixteen key reasons for poor vaccine uptake, the most common of which was a fear of unknown side effects. Six percent would not want to take the vaccine at all, while thirteen percent of population in this study were unsure. Younger people, those with no medical issues and people from ethnic minorities were also reluctant [1]. Our observations have also been similar.
When we consult with our patients or carers, one of the routine questions is: “Have you had the COVID jab, and if not can I help?” From certain communities, we often receive an answer along the lines of, “I don’t want to talk about COVID”. There are some genuine fears.
A number of people have developed vaccine induced thrombocytopenia and many therefore are reluctant to have either further doses or even the first dose, due to fear of similar issues. This, in both authors' observation has caused the biggest scare among young people, even though the overall incidence was extremely low [2]. I think we have failed to convince people about its rarity and explain the balance of risks and benefits. I struggle to convince a number of patients who experienced unusual problems following the vaccine. Although the problems are extremely unlikely to be linked to the vaccine, it has put people off receiving further doses or alternative vaccines.
When we speak to people who are reluctant to have vaccines, first and foremost comes the lack of trust in the healthcare bodies and the science. This seems to have stemmed from previous failures with a number of medicinal agents and a fear of the unknown, particularly with mRNA vaccines.
Many are reluctant to accept the daily COVID figures from the government, claiming it is made up, while others question the reliability of the vaccine due to the speed with which it was produced, suspicious that the general public are being used as ‘guinea pigs’. This fear is further reinforced by the lack of publication of the morbidity and mortality data, and the lack of transparency from pharmaceutical companies, who many believe are making huge financial gains from the vaccine roll-out.
Conspiracy theorists are no longer a minority, with unfounded claims being shared far and wide across the population. Furthermore, a seeming reluctance from the government to accept the fact that COVID has disproportionately affected certain ethnic and social groups, has garnered major mistrust and reinforced many of these conspiracy theories [3].
We however have not seen the same level of reluctance in Caucasians. The current admission data shows disproportionately more non-Caucasians and majority of unvaccinated in our hospitals [4].
What is even more disconcerting is speaking to patients who have refused vaccines and later become severely ill with COVID infection without any regret. Vaccine reluctance has a stronghold on the thought process among many people. One may ask why there was little or no vaccine reluctance during other vaccine roll outs, such as the small pox era. One difference that cannot be underestimated is the influence of the internet and social media. In an era of information overload, people are no longer dependent on healthcare staff for health advice. The plethora of opinions and untrustworthy news and media sources has contributed to the wide spectrum of stances and reasoning amongst the general public, regarding the COVID vaccine. A survey in US has shown that 78% of adults believe at least one misinformation about COVID-19 is true. Interestingly the beliefs and vaccination status are linked to partisanship or political beliefs and news channels, Republicans and unvaccinated trust the misinformation more than Democrats and vaccinated [6].
Has Omicron changed anything? If anything, the new variant has made it difficult for us to explain to those against vaccines why vaccinated people are getting infected. Disease severity and hospitalisation is a topic that most will not reason with. The new variant and the discussions regarding a third and fourth dose have deepened mistrust, confusion and scepticism.
Many compare Europe with Africa and other underdeveloped countries and question the efficacy and validity of vaccines in Europe with third and fourth waves of infections.
There is constantly growing evidence for the current COVID wave, that vaccination give us protection and immunity. The only way to acquire herd immunity without causing a further rise in death toll is to improve vaccination uptake. We also know that three out of five intensive care beds in hospitals are occupied by unvaccinated COVID patients [4]. Should all the populations be vaccinated? Is it a moral obligation towards the society and the NHS? Should there be legislation? What about individual rights and freedoms? These are complex questions that will take time, deliberation and debate to solve.
An important lesson from this pandemic, is that health discrimination based upon race and class has been evident from the very beginning [3].We must strive to understand the perspective of the five million unvaccinated population and the challenges they may be facing. Whether that is of education, finance, living standards, health awareness and so forth, we must learn to empathise before persuading them to accept scientific recommendations [5]. It is crucial to understand these barriers to improve vaccination and healthcare interventions for future.
References
1. The UPTAKE study: a cross-sectional survey examining the insights and beliefs of the UK population on COVID-19 vaccine uptake and hesitancy. Sonika Sethi, Aditi Kumar, Anandadeep Mandal, Mohammed Shaikh, Claire A Hall, Jeremy M W Kirk, Paul Moss, Matthew J Brookes, Supratik Basu.
https://bmjopen.bmj.com/content/11/6/e048856,http://orcid.org/0000-0002-...
2. Vaccine induced immune thrombocytopenia and thrombosis: summary of NICE guidance BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2195 (Published 01 October 2021)
3. Razaq A, Harrison D, Karunanithi S. BAME COVID-19 deaths- what do we know? Rapid data & evidence review. The Centre for Evidence-Based Medicine. University of Oxford, 2020. Available: https://www.cebm.net/covid-19/bame-covid-19-deaths-what-do-we-know-rapid...
4. What to do about the UK’s unvaccinated? No 10’s Covid dilemma: growing frustration at vaccine refusers has crept into ministers’ speeches recently,Rowena Mason Deputy political editor Guardian,Tue 28 Dec 2021 16.43 GMT
5. How many people in England are unvaccinated? https://fullfact.org/health/expose-england-population-vaccinated/21 DECEMBER 2021
6. KFF COVID-19 Vaccine Monitor: Media and Misinformation Liz Hamel Follow @lizhamel on Twitter , Lunna Lopes , Ashley Kirzinger Follow @AshleyKirzinger on Twitter , Grace Sparks Follow @gracesparks on Twitter , Mellisha Stokes , and Mollyann Brodie ,Published: Nov 08, 2021 https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vacci...
Competing interests: No competing interests
Dear Editor
I agree with the anonymous author that it is disappointing to see a significant portion of population (about 10% of eligible population in UK) is refusing vaccination against Covid 19. It is more disappointing to see that some of our medical colleagues are trying to justify this.
Yes, every human being should have freedom to choose their treatment. They should have right to refuse vaccines. But their freedom/right is encroaching on other person’s freedom/right to live their life normally. Their decision to refuse vaccination is preventing us to achieve herd immunity and get a grip on the situation and helping virus to mutate. They are contributing to the ill-health/death of fellow citizens. Hospital/ITU beds are being used up by unvaccinated people with Covid preventing other people to have their life sustaining treatment and have elective procedures/surgeries to improve their quality of life. Hence it is difficult to support their freedom to refuse Covid vaccination
The rationale of absence of long-term data of Covid vaccination is also not acceptable in pandemic situation. The clinical trials and real-life data have already clearly showed that vaccination is preventing hospital admission and death without any significant adverse effects. These trials are done as rigorously as any other important clinical trial. If our medical colleagues practise evidence-based medicine and can follow MHRA and FDA recommendations for other treatments, they should also have faith in Covid vaccine trials and associated regulatory authority recommendations.
Competing interests: No competing interests
Dear Editor
One aspect not yet changed in the Green Book is at risk groups. I believe many of those described as young and fit who have occupied beds have in fact been overweight. To qualify as at risk you ned to have a BMI of >40. Very little publicity has been given to just being overweight as a risk factor.
The official view is also very controlled, with no easy to find evidence of risk to those who have had proven covid once for getting severe disease in the future or their risks of infectivity if jabbed or not.
No informed people would doubt that covid kills and also causes long covid, and that these are reduced by vaccination.
But at a public level the information flow is very much pro mRNA vaccines that we now think need 3, 4 or even more doses (based on the UK buying another 120 million doses). Outside the mainstream medical journals there is a lot of debate about unpublished or withheld evidence and secret contracts. Openness all around can only help. In Europe to get your covid pass you need to have been vaccinated or recent proven infection. For reasons one can only assume are political, in the UK we allow self taken lateral flow tests which have a vanishingly small evidence of preventing infection (based on the Liverpool mass testing programme).
Competing interests: I get paid to vaccinate people
Dear Editor,
This BMJ opinion piece is anonymous, not commissioned nor peer reviewed.
We are told that the author is a consultant anaesthetist. He or she describes being very busy and tired. Maybe that is an important part of the problem - no time to read or talk to anyone who knows about vaccines, particularly covid vaccines - or generic anti virals - or even vitamin D, a vital nutritional product.
Has the anaesthetist never heard of McCullough, Risch, Kory et al ? (1)
Why is it that many doctors in the UK do not notice when it is pointed out that there is no shortage of evidence that generic anti-viral based protocols, if commenced in the community, greatly reduce the risk of hospitalisation, and death ? (2,3.) Considering the number of people who may be dying unnecessarily, and the pressure on ICUs, these are daily disasters, encountering a lack of professional intellectual curiosity amounting to indifference, or negligence.
The anonymous anaesthetist may not be aware that UK MHRA figures for deaths and ADRs following covid vaccination are almost never mentioned in the public nor professional media, making it impossible to provide and discuss comprehensive information about risks and benefits, without which informed consent is legally invalid.
Great as those concerns about the validity of informed consent may be, there might be even greater concerns, unremarked in the public media, that disease and deaths due to covid vaccines seem to negate their alleged benefits. (4,5,)
1. US Senate Committee on Homeland Security and Governmental Affairs. Statement of Harvey A. Risch, MD, PhD, Professor of Epidemiology, Yale School of Public Health.
2. https://www.bmj.com/content/374/bmj.n2022/rr-2
3. https://www.bmj.com/content/374/bmj.n2223/rr
4. https://www.sciencedirect.com/science/article/pii/S221475002100161X
5. https://retractionwatch.com/2021/10/04/author-defends-paper-claiming-cov...
Competing interests: No competing interests
Dear Editor
Re: I am struggling to understand why patients decide not to get the covid vaccine.
I am pretty sure that the BMJ will not publish this response if I suggest that people decide not to get the covid vaccine because they are making a stupid decision (although this does not necessarily mean that they are stupid people).
I believe that the decision to be vaccinated should be seen as a moral decision.
Dietrich Bonhoeffer argued that stupidity was not an intellectual failure, but a moral failure. We fail morally when we do not protect those who are more vulnerable than ourselves. If we increase the risk of spreading a disease to the sick and vulnerable by not being vaccinated, we are in this group.
Boenhoffer also argued that it is difficult to be stupid on our own. If we are alone we have to think and use our own intellectual ability. In the twenty first century no-one is alone due that wonderful invention, the internet. We are all connected and rather than thinking for ourselves, it is far easier to go online and ingest and regurgitate someone else’s opinions (even if they are a celebrity chef or TV personality with no expertise in RNA virus infection, biostatistics or immunology).
Sadly, Bonhoeffer paid the ultimate price for his moral stance and was executed just before the end of the Second World War by the Nazis for his anti-Nazi stance and his part in the plot to kill Hitler.
Long before the pandemic took hold I used to joke to my children that if they invented a vaccination against stupidity, 10% of the population would refuse to have it. It now looks like, sadly, I might have been right.
Competing interests: No competing interests
Dear Editor
I am not being facetious when I say I hope now 'Anonymous' understands more about the reasons people decline to be vaccinated.
Sometimes the 'for the moral good of all' argument proposed so forcibly by those in authoritative positions who wish to impose what are still trials requires dissenters to stick to their guns exactly for the moral good of society when there are so many reasonable doubts included as expressed so clearly here. There is very little coercion not to be vaccinated compared with that used to coerce acceptance. The 'consent' is not as accepted generally in medicine It is, we don't know how often, against persons' genuine thoughtful differering wishes which are often based on personal research and it must be said informed by mistrust based on the scandals revealed all through the pandemic. Often enough the vaccination is accepted for social reasons and it would be an interesting study to discover how many people would have refused if the fear of exclusion and scapegoating using very powerful tools were removed.
Ramping up disapproval against those who have complex and differing reasons is creating a frightening situation for some who decline vaccination so I would ask for more empathy for people who decline. We are not all tough, individualistic, uncaring of others but in addition to what is happening in our own countries feel the fear of those all across Europe who are suffering for their decisions but are taking a moral stance based both on the science and the right to remain a social human being without harsh judgement from those making different decisions.
Competing interests: No competing interests
Dear Editor
This anonymous author is letting us know that there's a problem with understanding and imagination in relation to decisions about taking the Covid-19 vaccine.
It is frequently the case that we understand our patients (and ourselves) only in part. There are many dynamics at play within one's own mind, between people and in society at large.
That doesn't mean it's not incumbent on us to become humble and attempt to deepen our understanding of ourselves and one another in matters relating to health. However, this understanding will always be limited. Our work is about tolerating this partial understanding, without coming to premature conclusions. The freedom to choose one course of action over another is an act of self-determination. Its end result may not be pleasing or desirable according to the wishes of the treating doctor, but perhaps healthcare is not about pleasing the doctor, but about facilitating a process that allows our patients to make use of their freedom, agency and responsibility as much as possible, without prejudice.
Yours sincerely,
Competing interests: No competing interests
Dear Editor and dear Anonymous,
Thank you for giving us the opportunity to reflect on our "struggles" in understanding one another.
I probably come from the type of “population that is also socially and economically deprived with all the associated health effects” you make reference to. I however tend to see patients when they are very much awake, and certainly not awaiting surgery or intensive care. “We are tired. We are working at greater capacity than ever before and have been for nearly two years” but probably not for the same reasons. What has substantially increased mine, in general practice, has been health anxieties expressed online too, serious mental health concerns in ever younger patients, and patients’ need to spend time with their doctor like never before.
But most interestingly, just like you “I am struggling to understand” the opposite of what you don’t: why do doctors decide to get - and promote - COVID vaccines to populations who are neither at risk of hospitalisations nor deaths for this infection? You seem to suggest these vaccines protected against COVID transmission. I am afraid the map of this world seems to show an inverse relationship between vaccination prevalence and new COVID infections. Maybe “inclusion and diversity” in medicine will hopefully help you and I understand each other. This epidemic has confirmed differences in what physicians consider “safety”: for most, in developed countries, it means either “acting at all costs to prevent possible death” or “follow The Leader”; for a minority, and usually one that has lived less comfortable lives than the former, “do no harm” and questioning fear often prevail.
There is no right and wrong here: maybe just a different view of what not just medicine, but also life, is about. Should we request colonoscopies in anyone with diarrhoea since this is a “change in bowel motions”? Or should we ask a few more questions first? Interestingly, most doctors in developed countries seemed quite comfortable not offering early treatment for COVID disease to those most at risk of hospitalisations and deaths, citing “not enough evidence”, yet enthusiastically embraced phase three gene-based products they really knew very little about. Places in the world with a majority of “population that is also socially and economically deprived with all the associated health effects” used early treatments with molecules they were familiar with and seem to be presently less affected by this epidemic than we are. Maybe, fear-based medicine has shown its positive impact on longevity ... but not really on a life lived healthily. Facing a crisis with presence, patience and openness to learning is what “socially and economically deprived” populations learnt to do every day: maybe it is time we listen to them too?
Competing interests: No competing interests
Re: I am struggling to understand why patients decide not to get the covid vaccine
Dear Editor,
I am struggling to understand why the author remained anonymous? The claim that 90% of patients in ITU with COVID-19 are unvaccinated has been banded around a great deal recently but is not a fact. According to the ICNARC on Dec 17th the figure is actually less than 50%. There is little transparency in the mainstream media about what constitutes 'unvaccinated' - the working definition now being used by many is anyone who has not received a 3rd dose or booster (rather than the much maligned 'refusnik' who has yet to receive a first-dose). What the author does not acknowledge is that across vaccination status the majority of patients on ITU with COVID-19 are obese (ICNARC Dec 2021), but this receives next to no press, instead we are bombarded with adverts for sugary drinks and home delivered fast food to ease our discomfort at being told to stay home and protect the NHS.
It might surprise the author of this article to learn that most people choosing not to take the experimental inoculation for COVID-19 are in fact critical thinkers who are making empowered decisions about their health in the face of the most unprecedented campaign of coercion and mainstream media misinformation that has ever been conducted. We have seen almost no discussion of naturally acquired immunity as a long-lasting and robust defence against COVID-19. We are seeing data from across the world as to the negative efficacy of vaccines against Omicron. There is a systematic censoring of numerous high-profile doctors and scientists who are championing effective early treatments and highlighting the misleading reporting of vaccine efficacy, adverse events and deaths. Just a few days ago one of the inventors of mRNA vaccine technology Dr Robert Malone was removed from twitter and YouTube for raising legitimate scientific arguments that run counter to mainstream narratives. He remarked that we are now living through a period of 'mass formation psychosis' which seems accurate given the promotion of vaccination and boosters to the exclusion of other interventions and perspectives (particularly the successful use of repurposed off-patent drugs such as Ivermectin which have been subjected to ruthless smear campaigns by the mainstream media and big-tech). We live in a world where nuanced scientific debate has been side-lined by the all-powerful big tech algorithms. My hope is that as a medical community we can show humility and compassion once again. Let us rescue the once sacrosanct principles of free informed consent and bodily autonomy from the ashes of ever more universal vaccine mandates that have no basis in public health or ethically driven evidenced based medicine.
Competing interests: No competing interests