Eleanor R. Menzin, M.D. in The New England Journal of Medicine
“It’s your fault!” the renowned infectious disease attending told the cluster of students and residents. In the late 1990s, the varicella vaccine was relatively new, and uptake was disappointingly low. “You pediatricians,” he went on, “must correct your wording. Instead of telling parents their child is due for the MMR vaccine and then half-heartedly offering the varicella vaccine, you should include it with the same declarative certainty: ‘Your child is due for varicella and MMR vaccines.’”
Though it has been nearly 30 years, I remember that moment as one of those rare crystalline learning moments when a gifted teacher’s wisdom solidifies in a receptive student’s mind. His advice permanently changed the way I, and in turn my trainees, discuss vaccines. More important, I internalized his conviction that vaccinating patients was a fundamental responsibility of a pediatrician.
Throughout my career, I have seen new vaccines approved: pneumococcus, rotavirus, meningococcus, and human papillomavirus. In each case, I have studied the data, reviewed published recommendations, and adjusted my language to encourage vaccination. I consider the high immunization rate in my patient panel to be one of my greatest professional accomplishments — a quantitative metric of the benefit I provide.
Much of pediatrics advice is more cultural wisdom than science. Does it matter whether an infant consumes green vegetables before orange ones? Unlikely. Some of what we do (antibiotics for acute otitis media) is probably of limited benefit. There are so few things — like car seats or sleeping on the back — for which we have robust data. And the greatest of all these is vaccines.
Every so often, parents will look at me over a smiling infant and tell me they want their child to have only one or two recommended vaccines. Can I choose the most important? I tell them the question is akin to asking me to pick my favorite child — an impossible task.
I replay for them the kaleidoscope of vaccine-preventable illness I’ve seen in my training and practice: a toddler with varicella encephalitis from my medical school days, an apneic infant admitted to the hospital with pertussis during my residency, a 9-year-old with central venous thrombosis after influenza and dehydration when I was a young attending. I also recount stories of adults who live with the ongoing effects of now-avoidable diseases: a wise and beloved radiologist who hung films one-handed (faster than most people could with two) as his polio-affected arm rested by his side, or the college friend who suffered through colposcopy and cancer scares from human papillomavirus infection.
Some will ask, “Can you recommend a good pediatrician who does not believe in vaccines?” No, I say, no more than I can recommend a good physicist who does not believe in gravity.
Beneficence has been the guiding ethical principle of my life in medicine; encouraging vaccines has been my fullest expression of that value. Professionalism, I was taught, meant that religion and politics had no place in medicine. Though I understood how policy affected patients’ lives, I abided by that rule. Privately, I voted for political candidates I thought would help patients who were bogged down by poverty, seeking education, and battling addiction. Publicly, I was quiet.
But now is no time for silence. Politics now threatens to erase the gains of science, reduce access to vaccines, and undermine the vast public health benefit of the vaccines I have spent my career championing. Now is the time to lament loudly, to beat my chest, and to wail.
In this precise moment, beneficence requires more than seeing patients, doing research, or writing erudite journal articles. Today, beneficence requires physicians to step into a public role that may contradict our understanding of our job description. Regardless of our politics, if we are reticent in this moment, harm will come to the patients we seek to help.
Even if patients are skeptical of the alphabet soup of institutions designed to protect and safeguard their health, they still have confidence in the long-standing relationships with their clinicians. To deserve that trust, we are obligated to raise our collective voice in defense of science, health, and vaccines.