Bias Against the Willfully Unvaccinated
Authors: Amira Mohamed
Journal: Annals of Internal Medicine (2022)

On Being a DoctorJuly 2022Bias Against the Willfully UnvaccinatedFREEAmira Mohamed, MDAmira Mohamed, MDMontefiore Medical Center, Bronx, New YorkAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-0476 Audio Reading - "Bias Against the Willfully Unvaccinated" Audio. Michael A. Lacombe, MD, Annals Associate Editor, reads "Bias Against the Willfully Unvaccinated" by Amira Mohamed, MD Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail When I started working as a critical care physician at an academic medical center, I never imagined I would be intubating over 20 patients a day. However, this was the case in New York City in April 2020. Mobile morgue trucks were parked outside every hospital in the city, and patients in our ICU were dying in numbers I had never seen before. I went from being a junior attending who hesitated with every small decision to an ICU attending who could make up her mind in minutes, including when I decided to intubate one of my coworkers.Then there was hope: vaccines that could decrease the chance of patients getting sick and ending up in our ICU. I remember a few of my colleagues crying the day the vaccine approval was announced; perhaps they were reminded of our coworkers who we could not save. We were optimistic that we would be able to protect ourselves and that going to work would no longer mean endangering our families.By the next wave of COVID-19, I realized it was not that simple. The vaccine was not a way out of this pandemic unless everybody actually received it. The patients being admitted to the hospital during this wave were almost all unvaccinated despite the widespread availability of the vaccines. I started getting called for intubations again, and this time I found myself getting angry. This time, it felt as if these patients had been given a choice and had chosen to risk their lives instead of getting vaccinated. This time, it felt as if their choice, their ignorance, were also putting my life and the lives of my family at risk. This time, it felt like I was being asked and expected to risk spreading the virus to my immunocompromised patients simply because other patients had refused the vaccine."Isn't it the same as taking care of a smoker?" my husband's friend once asked me. I argued then that it was not because a smoker could not get my infant sick and that intubating a smoker would not risk my mother's life. I saw other health care providers struggling the same way I did, some even going as far as calling for the refusal of treatment for the unvaccinated.Every time I got a new consult for the ICU, I would routinely check their vaccination status. Whenever I saw the red unvaccinated mark, I felt my disappointment growing. I started asking every patient the same question every time: Why did you not get the vaccine? There was no answer that would have satisfied me, but I continued to ask the question anyway. I was getting more frustrated as I tried to put myself in my patients' shoes, but I struggled to understand them.This sentiment was changed by an elderly African American woman who was hypoxic and required intubation. She started crying as soon as I questioned her about the vaccine and asked me whether it was too late to get it. She had heard of it but thought it was harmful because a distant friend had received it and died shortly afterward.For the first time in a long time, I found myself disheartened by the response. Here she was, fighting for her life, when only a few weeks ago she had refused the vaccine that would have saved her. I looked at her and saw remorse and desperation as she tried to convince me that the vaccine had killed her friend as if my believing it would make it true. For the first time, I no longer felt anger; I felt empathy. I empathized with the patients who I thought I resented. I felt bad for them as I imagined them in the ICU, regretful with no other option but to have faith in the doctors and health care workers that they did not trust.That day, I cried with my patient as she asked me what her chances were. I did not have to answer because I knew she could see it on my face. Like many of the unvaccinated patients who made it to the ICU, she was going to die. I knew she was oblivious of the fact that she had most likely infected at least five more people with her carelessness, but there was no reason to tell her that now. I held her hand as she made a video call to her family for the last time, and I promised them I would do my best to save her. My encounter with that patient helped me realize that my unconscious vaccine bias may not have affected my clinical work, but it robbed me of my compassion—and, as a doctor, compassion is vital. I wondered whether my insensitivity had contributed to the cycle of physician distrust and lack of medical care that these patients continued to suffer.My anger turned to guilt as I wished I had met them before they made it to the hospital. I started holding patients' hands again, crying with families, and mourning losses in a way I had not done in a long time.I continued to ask about vaccination status, but this time it came from a place of genuine curiosity and not hostility. I started to pay closer attention to the answers, which were vastly different but all desperate cries for help. Unlike what I expected or what I saw on the news, the unvaccinated were from all sorts of backgrounds and beliefs and most of my patients were members of systematically marginalized groups who understandably had little trust in the system.As I continued to talk to unvaccinated patients, they would often reference the Tuskegee study to justify their skepticism. In fact, I found myself discussing Tuskegee more than the vaccine trials. This happened so frequently that I had to go back and reeducate myself on it. It was surprising to see that an experiment that ended in 1972 was still affecting people to this day."But you were not an African American man in the 1960s and 70s," my father had told me when I asked him about it. It was confusing to see that my father, a professor of immunology and molecular biology and a man I considered my role model, sympathized with such an ignorant viewpoint. Then again, he explained, the CDC was the same health agency that experimented on 400 African Americans with syphilis without their consent or knowledge merely 50 years ago.I thought about my perspective and began to wonder whether my patients' vaccination status had also affected my decision making and created a subconscious bias that I had never considered. Was I perpetuating another layer, a new layer of prejudice that this already disenfranchised patient population would have to overcome? I felt guilty for dismissing years of oppression and valid distrust of the health care system as ignorance.Would they have listened if I, a Black female doctor, had told them about the vaccine? Instead of feeling angry at them for not getting it, should I be angry at myself for not doing more to educate them and regain their trust? For not joining the efforts in churches, barbershops, and even grocery stores to educate systematically marginalized groups? If they constantly saw well-known singers and athletes who were skeptical of the vaccine, why would they receive it?As my perspective shifted, I started to empathize with my patients again. My renewed sense of compassion changed my approach to family discussions in the ICU. I no longer dismissed their concerns about the vaccines; in fact, I acknowledged them and told them how they were once my concerns as well. I told them how long I spent reading about the vaccines, how I had convinced my own parents to receive them, and how I cannot wait until my infant son would be able to do so. I made sure to use interpreter phones when needed to ensure that nothing was lost in translation.It was never one conversation that convinced them; it was a daily discussion with new points that would come up every time, but I felt content knowing that I was doing my part. I made it my mission to reconnect with the mostly systematically marginalized patient population I encountered and explain the efficacy of the vaccine and its ability to prevent severe infection.Having had the opportunity to observe my colleagues, I have come to realize that, like racism, this bias against the unvaccinated will slowly become part of a larger systemic problem. There is no question in my mind that patients are victims of a broken system and that, if they knew they would end up in the ICU, they would take every step necessary to avoid it. Comments0 CommentsSign In to Submit A Comment Carlos Julio AponteJulio Aponte MD, life coach9 May 2022 Regained Empathy Vey nice article; I started by understanding that my indifference and sometimes hostilty was robbing me of my empathy and now I understand that not being judjmental, I can be more open to help the marginalized and teach them better. Thanks Basem William, MD, MRCP(UK), FACPOhioHealth9 May 2022 Staff Hematologist The distrust among the African American community is understandable, and very much rightly should trigger empathy, given the sad history of what they have endured in the past. However, most of those who refused the vaccine where not African Americans but of European descent and identify themselves as "conservative" whatever than means! They reject the vaccine from a firm conviction in being "exceptional" and would not have anything forced upon them! It is really hard to empathize with hubris unfortunately! Author, Article, and Disclosure InformationAuthors: Amira Mohamed, MDAffiliations: Montefiore Medical Center, Bronx, New YorkCorresponding Author: Amira Mohamed, MD, 111 East 210th Street, Bronx, NY 10467; e-mail, [email protected]com.This article was published at Annals.org on 10 May 2022. PreviousarticleNextarticle Advertisement Audio Reading - "Bias Against the Willfully Unvaccinated" Audio. Michael A. Lacombe, MD, Annals Associate Editor, reads "Bias Against the Willfully Unvaccinated" by Amira Mohamed, MD Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ FiguresReferencesRelatedDetails Metrics July 2022Volume 175, Issue 7Page: 1049-1050 ePublished: 10 May 2022 Issue Published: July 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. 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