Oregon pediatrician on vaccine skepticism and his approach with parents

Oregon has one of the highest rates in the country for kindergarteners with vaccine exemptions. The state’s 7% rate is lower than only Utah’s (7.4%) and Idaho’s (9.8%). Ryan Hassan is a pediatrician in Happy Valley and also serves as the medical director for Boost Oregon, a group working to increase vaccinations overall through education. He says he’s seen coronavirus vaccine skepticism bleed into skepticism toward well-established vaccines against measles, mumps, rubella and pertussis. He says since the pandemic, an industry promoting dangerous disinformation about vaccines has itself spread like a virus. We talk with him about how he approaches conversations with parents of school-aged children, and how Boost Oregon is attempting to overcome disinformation with the truth about the medical efficacy and public health necessity of vaccinating against preventable diseases of all kinds.

Note: The following transcript was created by a computer and edited by a volunteer.

Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. Oregon has one of the highest rates in the country for kindergarteners with vaccine exemptions – It’s 7%. Only Utah and Idaho have more parents who opt their kids out of well-established vaccines that have been used to prevent various illnesses for decades. Ryan Hassan is a pediatrician in Happy Valley. He also serves as a medical director for Boost Oregon. It’s a parent group working to increase vaccinations in Oregon. He joins us now to talk about vaccine skepticism and the effects that the debate over the COVID vaccines have had. Welcome back to the show.

Ryan Hassan: Thanks for having me. Good to be here.

Miller: We’ve talked a lot over the last two years about COVID vaccines. But can you remind us first what the required vaccines for kindergartners are?

Hassan: The required vaccines for kindergartens are the same as they’ve been for the last couple of decades. COVID is not on that list. It’s things like Hepatitis B, Hemophilus Influenza B, Pneumococcus, MMR [Measles, Mumps, Rubella], Varicella [Chicken Pox], DTaP, Polio, and then as kids get older,

the DTaP boosters [Diptheria, Tetanus, Pertussis].

Miller: You just went through a long list of diseases. But can you give us the short version of how serious these are?

Hassan: So there’s, I think, a few things to understand about vaccine preventable diseases. Generally, the diseases for which we have vaccines are the ones that we’ve prioritized creating, being able to prevent, because of the significant impact they have on kids and on our society, generally. Most of the time it is because those diseases are potentially very dangerous and even fatal. But there’s some like the Rotavirus, for example, that’s not gonna kill any kid in the United States ever. But we still vaccinate against it because it’s incredibly uncomfortable. It causes a week or more of diarrhea in pretty much every single kid and can lead to hospitalization and even though it’s not gonna kill someone, it’s gonna be very uncomfortable for the whole family.

So the diseases that we vaccinate against are ones that when we do so, we can improve quality of life for kids and prevent these unnecessary illnesses. But some of them can become severe,

some of them can lead to lifelong disability or long term immunosuppression - like the measles virus attacks your immune cells directly and it causes you to have what’s called immune amnesia where you will be more susceptible to diseases you’ve already had in the past because your body forgets how to create immune response to them.

Miller: Long before COVID, Oregon had one of the highest vaccine exemption rates in the country. What are the factors that contributed to that?

Hassan: I think there’s a lot and it’s an area where there’s a lot of research, but I don’t think there’s enough. But from what I’ve seen from the research I’ve looked at and from my work in my clinic and through Boost [Oregon], there’s a lot of earned mistrust in the institutions that are behind or adjacent to vaccines. So a lot of mistrust of government caused by failures of government in the past and today, especially of the pharmaceutical industries who are very well known to be corporate-driven entities… are profit driven entities, that are “the bottom line is the bottom line” for them. And a mistrust in health care, which is also a field fraught with abuse of people [who] sought to care for particularly marginalized communities who had not been as well represented or been more susceptible or likely to be targeted by abusive practices by these industries. So I think that plays a large role.

And then the other thing that I think that I see a lot of is just active vaccine disinformation. Anti-vaccine profiteering is a very lucrative industry. And there are people who make quite a lot of money from selling the idea that vaccines are harmful, and there are alternatives to help people avoid disease that are safe. And this is an industry that is adjacent to and kind of works alongside alternative medicine - not to say that alternative medicine is bad, but it’s an area of our industry that is not as tightly regulated. So there’s more room for people to sell things that are not very well studied or that have been proven to not be helpful.

I think the third thing that is important is just human cognitive bias. The fact that as humans, we are not good at making logical decisions. And this is true of all of us, not just people who are hesitant or worried about vaccines. And unfortunately, we don’t really have a great education system that teaches us how to think critically and challenge our own ideas and to accept the fact that if we don’t think critically and look for information that contradicts our ideas, we are automatically going to be wrong about a lot of things that we think and do on a daily basis.

Miller: But hearing that list you just outlined, it strikes me that none of those are specific to Oregon. You’re talking about national realities or trends - for example, as you called it, the earned mistrust of government or pharmaceutical companies or health care. That is a nationwide phenomenon. If we just look at some of our neighbors that we’re similar to in some ways, I’m thinking about California in particular. They’re 10 times Oregon size. But in a lot of ways we have a lot in common. Their exemption rate for kindergartners is 0.2% compared to Oregon’s 7%. How do you explain that?

Hassan: Well, that’s an easy one. And that’s a really good example you brought up. That is because California, after they had a measles outbreak a few years ago - similar to the ones we’ve been having - rather than do essentially nothing with legislation, which is what we’ve done, California removed non-medical exemptions from their list of reasons why people could choose to not vaccinate. So it was a simple policy change.

People in California must be vaccinated to attend public school unless they have an actual medical contradiction from getting one.

In Oregon, that’s not a requirement. So we’re going to have a lot more kids who just go to school. So I think that is very telling in the sense that at the end of the day, parents want their kids to be getting a decent education and they’re not gonna let fears about vaccines get in the way of that in almost all cases. So I think that’s probably the single reason why, and especially with California,

there’s that huge discrepancy.

Miller: Did that lead to an increase in homeschooling in California? I mean, because there is a way for some people who choose to, to educate their kids without doing required vaccinations. I’m just wondering if that also helps explain that much lower rate? An increased number of parents were just saying, “Then we will opt out of public school.”

Hassan: Yeah. I think that’s very likely, [but] I don’t know for sure. I can say with pretty high confidence that there’s a higher proportion of children vaccinated. It’s not just that children are not going to public school anymore, but I think it’s very likely there are some kids whose parents took them out of public school and found alternatives because of that. Especially from my own experience, I can say that a lot of parents will get vaccines if it is required by the school. And I have parents who tell me that outright. They’re like, “You know, I’m not sure about these vaccines, but we’re gonna get them, we want to make sure our kids go to school, so we’re gonna get them before kindergarten.”

Miller: Can you explain how the exemption process works right now?  I mean, you outlined that there are no nonmedical exemptions in California. Oregon does have a system even though it changed about six or seven years ago. So what does it take?

Hassan: Well, there’s a couple of options to get a nonmedical exemption. One is you can get a signature from your health care provider saying we’ve had this discussion and this patient has chosen not to vaccinate. And that’s essentially it. The other, which I think is the most common, is that the parents can go online as, I think, there’s an instructional video you have to watch and then you sign a form saying you’ve watched it and then you turn that into the school.

Miller: Have you ever signed the form as a doctor saying I’ve talked to my patient or my patient’s parental guardians and they’re not going to get vaccines?

Hassan: No, as a provider, and in my clinic, we don’t sign those. And that’s mostly because we don’t recommend not vaccinating. And we don’t recommend children go to school without vaccines because then they’re increasing the risk to our other patients. I will make sure parents know how to access everything that they need, including ways to get to school without vaccination. And that is, I will point them to the Oregon website and say, “Here you go, this is how you do that.” But I don’t sign the letters.

Miller: How often do you hear concerns from the parents of your patients about the safety of vaccines for their kids?

Hassan: Probably on a daily basis. I think it’d be hard for me to go through a day in my clinical practice without having at least one, usually multiple patients, who have expressed some concern about some vaccine, which is, I think, a good thing. I mean, parents should have questions about the medical intervention that their children get and it makes sense that they will not be totally confident. They might have some questions or concerns about vaccines because we don’t really have good public education about vaccines. There’s not routine education about how vaccines work. I think most people don’t really understand how vaccines work. And I think that’s improved a little since COVID. There’s more of a sense of what happens in the body with the vaccine. But at the same time, there’s also a lot more disinformation about the particulars of that and a lot more concerns about vaccines because of COVID.

Miller: Interesting. We should turn to COVID now. You actually think that it has affected this in almost opposite ways?

Hassan: Yes. There’s definitely, I think, a little bit of a split that’s happened. A lot of people I see in my clinic have new concerns about vaccines, children’s vaccines generally, because of the pandemic and concerns that came to light for them with the COVID vaccine. [Also] the way the pandemic was handled and problems or perceived problems with the way the COVID vaccine was rolled out. And that has led them to be mistrustful of other vaccines. I may have seen a dozen or more patients who we spoke [to] about that exact issue just in the last month alone…

Miller: So you think that the debate over the COVID vaccine could lead to an increase in kindergarten vaccination opt-outs?

Hassan: I think it already has, at least in my own clinic with the patients I’ve worked with. There are patients I know who previously vaccinated their children completely and have now stopped or are having new kids and decided not to. I have parents who tell me, “You know, I actually regret vaccinating my child when they were younger and if I were to make a decision again, I would do it differently,”  which is a very hard conversation to have. And it’s very challenging for me because these are kids who are doing fine, they’re totally healthy because of course, vaccines don’t cause any long term problems. And the fact that these parents regret this choice tells me that they’re anxious about a potential problem that hasn’t happened, but that might be because of this choice that they already made. And that’s an anxiety they’re going to have to live with until they come to a place where they’re actually comfortable with the science behind vaccines and the safety of vaccine.

Miller: How do you navigate that as a doctor? I mean, I’m going back to that in my mind [to] that phrase you used earlier - the earned mistrust of government, of health care, pharmaceutical companies. Embedded in that is a knowledge that there can be reasons for reasonable people, thoughtful people, to be mistrustful of these powerful organizations. At the same time, we’re talking about misinformation in the case of these safe vaccines and you want to keep the trust of your patients and their families. You also want what’s best for them and then you can’t do it all. How do you navigate that?

Hassan: With a lot of difficulty and patience. I’ll say, I’m very grateful I get to work for Boost Oregon and for my clinic because the two jobs really help me be better at both. I get to take what I learned from patient interactions and to take that to Boost Oregon and talk about, how do we have these conversations more effectively? What are ways we can do better? And then I can take what we talked about and apply it in practice.

I think one of the big things I talk to when I train other providers with having these conversations is, start with accepting your limitations. 50% of the country gets the flu vaccine each year. There’s maybe an 80% vaccine vaccination rate, uptake rate, for the COVID vaccine. I’m not going to get those numbers to 100% just by talking to people. There’s a huge array of systemic issues and inequities and challenges and barriers that need to be dismantled and restructured for anything like that to happen. So acknowledging that what I can do is really very limited and that is just to engage people where they’re at, listen to my people, the person in front of me, and listen to their experience and understand where they’re coming from and gauge where they are in this journey of making a decision. Are they in a place where they’re ready to hear a different perspective? Are they ready to listen to what I have to say and will that be useful for them?

A lot of times people aren’t ready and I try to be completely honest and open with my patients and I make sure they all know that I recommend the vaccines recommended by the CDC and that I would get them for myself and I got them for my kid. And also that I respect their choice to make the decision for their own health. [That it] is their choice. I can’t force that upon them. And I don’t want to try to do that and that’s where we start.

From there, if they say that, “Yeah, I guess it’d be nice to talk a little more,” then I’ll have that conversation. I do try to acknowledge that there are good reasons to not trust the government. I don’t trust the government per se. It’s a giant multifaceted organization that is violating our civil liberties in many ways, constantly. I don’t trust pharmaceutical industries or any multi-million or multi-billion dollar industry. Their intention is to make a profit at any cost. And there’s not often enough regulation to make sure they’re not harming people in the process. And I don’t trust the healthcare industry, either. I have my own negative experiences in healthcare, but I do trust the people who have dedicated their lives to try to help others. People who are civil servants working in government for low salaries, people who are dedicated scientists who do the research, who try to figure out novel ways to prevent disease and keep people healthy, who have dedicated their lives to this nation, who often don’t get acknowledgement. The vaccineologists who have created vaccines and the health care providers like me, and nurses and staff and middle level providers who often get the brunt of the disrespect and the aggression and anger of people who mistrust the systems that they’re a part of. And I try to communicate that to patients.

It’s important to separate the institutions, which are of course hugely problematic and will always be problematic to some extent, from the people working in them who are really doing their best to make sure that we are creating a better and safer world for everyone. And that’s how I try to connect it for patients and say, I don’t necessarily trust healthcare, but I work in it and I try to make it better. And I know that there are people who work for these big pharmaceutical companies who made these vaccines not because they wanted to make money but because they wanted to save people’s lives.

Miller: I want to just touch briefly on one piece of disinformation that has seemed [to have] a really lasting impact. A paper linking vaccines with autism was retracted 13 years ago. Now, to what extent does that idea still come up in your office? How much do parents talk about it?

Hassan: You know, I would say it’s not as common now as it was previously. I don’t think that’s a talking point that has as much traction as it did initially, which is good because it has been thoroughly debunked. It’s absolutely not true. I can say that with more confidence than I can make probably any other claim regarding medicine. But I think the echoes of it are still around. People might not say or even think explicitly, “Well, this vaccine might cause autism,” but I think there’s a general sense of, “Well, it could cause some problem. It could cause some issue with my child’s development or growth in some way.” And I think that that is something that I think parents don’t always fully contend with exactly what they think about it. There’s not necessarily a logical sense of what might happen and how it might happen. It’s more of this very vague fear of like “I have heard and seen all of these things that make me get a sense of just feeling uncomfortable and overwhelmed and just generally uncertain and fearful.” I call it a soup of anxiety that parents are having to swim in and it’s hard to really specifically lay out your thought processes in specific ways and reasons you might feel a certain way.

Oftentimes, if I were to push and say, let’s boil this down, let’s talk about how you think this might actually negatively hurt your child. They won’t necessarily have a good answer. And I’ve done that before… “I don’t really know. I’m just scared. I just don’t know. And I’ve read things and I’m just worried about it.” And that’s what makes it hard because anti-vaccine propaganda speaks to people’s feelings, speaks to their fear and capitalizes on it. And at the end of the day, humans are emotional beings. We try to think of ourselves as rational and intelligent and logical, but none of us makes decisions logically. We think emotionally and then we try to create sometimes a logical reason after the fact. And I think being aware of that is a helpful first step to understanding that it is natural and OK to have fears about things we’re not entirely knowledgeable about. But it’s important to meet those fears head on.

Miller: Ryan Hassan, thanks very much.

Hassan: Thank you for having me.

Miller: Ryan Hassan is a pediatrician in Happy Valley and the medical director of Boost Oregon. It’s a parent group working to increase vaccinations in the state.

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