“We are … locking people out who have not got vaccinated to protect themselves and protect everybody else.”

THOSE were the words of Victorian Premier Dan Andrews as he recently announced the joyous news of Melbourne’s release after 262 days of strict stay-at-home orders.

While Premiers are announcing different road maps out of lockdown when 80% of their state populations (aged over 16 years) are fully vaccinated, many of our patients remain potential victims of the predicted “COVID-19 pandemic of the unvaccinated”.

Despite ongoing treatment for his cancer throughout 2021, my GP husband and I felt compelled to return to general practice to vaccinate isolated rural communities in central Victoria because of long-standing health workforce shortages. It’s time for health practitioners like us, who have collectively rolled up our sleeves to provide over 19 million vaccine doses in small Medicare-funded primary care clinics across the country, to share some observations about why some Australians remain unvaccinated and to share effective ways to respond to them in practice.

Vaccine access has been limited in some regions

Despite our best efforts to collaborate, the local state-funded hospital failed to cooperate with the general practices in our region, which resulted in a duplication of surge vaccination clinics on the same weekends and a waste of precious resources and vaccines when supply was short.

Government websites only provided booking information about far away vaccine clinics with no reference to local providers in general practices and pharmacies.

Vaccine supply and eligibility only opened up in rural areas like ours as recently as September 2021. Even so, it was not easy for many people, especially those with disabilities or limited English language skills, to make vaccine appointments, as online booking systems did not function with poor internet and local health service telephones were often blocked due to high demand.

Vaccine hesitancy requires empathy

We underestimated how many patients hated having needles. Needle phobia has been exacerbated by frequent media images of people “getting jabbed” and the roaming “jabber bus”. At our clinics, it was not uncommon for grown men to well up with tears while recounting their memories of waiting in vaccination queues as children.

There was a high level of distrust of the frequently changing “best medical advice” espoused by politicians, because it often varied from state to state. A lot of effort was required to counter the mountain of bizarre vaccine misinformation spread widely via social media, including by politicians. Many of our patients were concerned about the lack of research on long term side effects of the vaccines. One 14-year-old patient defiantly told me the vaccine would result in her future baby having a “deer head”, but happily returned for her second vaccine after the facts were carefully explained.

Beneath the high levels of patient angst and uncharacteristic anger in our consulting and waiting rooms were deep fears that lockdowns and the possibility of mandatory vaccination were an assault on their human rights.

However, they often readily accepted vaccination when we adopted a straightforward, harm-minimisation approach, rather than an authoritarian stance. It also helped to be transparent with patients who had antivaccination sentiments about all the advantages and disadvantages of vaccination with statements such as this:

“It is your choice. I am not forcing you to have the vaccine. But while you are here, would you like me to give you some facts?

“The vaccines have now been provided to billions of people worldwide and they are safe and effective. We know what the side effects are. We also know how to treat the extremely rare side effects including thrombosis after AstraZeneca or myocarditis after Pfizer or Moderna vaccines. All these side effects are far greater if you get the virus than after you receive the vaccine.”

And for patients who continued to refuse the vaccine:

“If you choose not to get the vaccine, it is important you know what to do when you get the virus. It’s true many people only have mild symptoms. Call the testing clinic before you present. Otherwise, stay home in isolation, away from your family and your community. Please make early arrangements for your children to be cared for by a family member, relative or friend while you are unwell.

“Do not visit any health service unless you call first. Your GP may be able to help you via telehealth consultations only. There are very few visiting nurses to help you if you become ill at home. If you experience any deterioration in your condition, including shortness of breath, call 000 early because there is a limited number of ambulances. You are likely to experience a prolonged wait. Inform the ambulance you have COVID 19, as special arrangements will be made to transfer you to a major hospital with special COVID-19 facilities including ventilation equipment.

“Please talk to your relatives, friends or neighbours now about arrangements to support your family before this occurs.”

We attribute the 95% first dose vaccination rate in our local postcodes to this caring, non-judgmental approach. After fully informing vaccine hesitant patients about ways to manage COVID-19 infection, most responded: “Just give me the vaccine”.

There is so much more we can all do to protect our communities

As many areas of Australia have never had a case of COVID-19, most people have not been confronted personally with the risks of acute suffering, long symptoms, or the lonely death associated with COVID-19, but they soon may be.

When the Delta variant spreads in our beautiful region as our population increases with the easing of metropolitan restrictions, local people will be competing with tourists for the three urgent care cubicles at the local hospital for both COVID-19 and non-COVID-19 conditions. They will also be faced with the stark reality that people, including sick children, requiring transfer out of our isolated region to a major hospital via ambulance will be alone.

Now that our local community (over the age of 16 years) is over 80% double dose vaccinated, my husband and I, like many health workers who have health risks of their own, are torn about leaving due to concerns about personal safety. In doing so, and with the deepest admiration and respect, we are acutely aware that in the next few months, our colleagues at the front line will courageously continue to treat the predicted surge in COVID-19 infections in a public hospital system already in crisis. The ongoing uncertainty surrounding the access of health workers to a booster vaccination is another major concern.

In this perfect storm, it is challenging to remain empathetic towards unvaccinated patients. But unless we do so, we risk inadvertently shaming them, potentially resulting in more preventable patient deaths at home because of attitudinal barriers deterring access to health care.

More research is required on why people continue to be unwilling or uncertain about the COVID-19 vaccines in Australia (here, here, here, here and here). In our clinical experience, having talked to many patients in one small rural GP clinic, the most effective way to increase vaccination rates further is to treat everyone, including patients and colleagues, with understanding and compassion. What is your experience?

Clinical Professor Leanne Rowe AM has served as a rural general practitioner for over 25 years and is author of the book Every Doctor: healthier doctors = healthier patients www.everydoctor.org and a website on medical writing www.medicineisbeautiful.com

 

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


Poll

Health care workers who refuse COVID vaccination should be stood down from frontline work
  • Strongly agree (61%, 296 Votes)
  • Strongly disagree (21%, 102 Votes)
  • Agree (11%, 54 Votes)
  • Disagree (5%, 25 Votes)
  • Neutral (1%, 6 Votes)

Total Voters: 483

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26 thoughts on “Before you judge unvaccinated patients, read this

  1. Andrew Cz says:

    Sadly public health can’t seem to embrace rapid testing.
    If the “point” of vaccination is to protect the vulnerable then surely rapid testing everyone engaging with the vulnerable is the best approach given that everyone vaccinated or not can still spread covid?
    It seems insane that a TGA approved test us illegal in my state because public health officials “have said so”
    Instead all elective patients must obtain a negative PCR 72 hours prior to attending…how can what is a cheaper real time test for a virus that could sideline your entire operating theatre / ED capacity not bring utilised?
    If you mandate anything, mandate this Instead of banning it…oh if it accuracy that is the quibble the tendency to false positive is the inaccuracy you want

  2. Anonymous says:

    It’s easy to blame the unvaccinated for potentially overloading the medical system etc.
    The real questions the Politicians don’t want us to ask is why did they cut back funding to Hospitals and medical research in the days preceding COVID.
    Whilst continuing to waste Public funds on far less important things.
    If that money had been better spent then perhaps we would have been in a far better place to cope with current events.
    I am unvaccinated and intend to stay that way.
    I have worked hard all my life and paid taxes etc yet found myself called a diseased rat by a pro vaxer who is in receipt of unemployment benefits that my taxes pay for.
    The truth is that when this is all over there will be some big questions asked about the way things were handled by many and they would want to have some good answers.

  3. Debbie says:

    This article is an improvement on some of what I’ve been reading from the medical profession lately however it feels a little patronising in it’s call for caring, non judgemental, empathic care for the unvaccinated (isn’t this what ALL patients should be offered?), it is also the same kind of alarmist elements although in a less obvious way about what happens if you get Covid.

    Acknowledging that most people have few symptoms is important. Making sure people know about delayed ambulances and the need for someone to take care of their families is alarmism and its the same manipulation that many who remain unvaccinated are reactive to. A friend with Covid was asked whether she wanted a DNR order and whether she wanted to be ventilated. She hadn’t had even as much as a sniffle but this terrified her. She asked if everyone got asked the same question and was directly told that they really only ask unvaccinated people because it seems they may not want to be cared for if they get sick!

    As a well informed, choosing not to be vaccinated at this time mental health professional, I have witnessed extreme trauma in people who have been forced to vaccinate or they couldn’t put food on the table, and those who had decided not to and now face extremes of discrimination and segregation.

    Being forced to cut face to face contact with my own clients (due to mandates even on my private practice) who continue to be in desperate need due to ongoing issues has done nothing to care for my health or their welfare. Over the last 18 months I have been one of a very few number of practitioners in my regional area who never stopped seeing clients face to face and many burst into tears when told they could come and see me because they were so in need of the connection.

    I didn’t have a particular view on vaccination early on and it was only when I began to see the more alarmist language and censorship of information that I had questions. My lack of trust in government has grown exponentially since then and now even my fully vaxxed husband no longer suggests I should just get vaxxed, but is asking the same questions about what is actually going on.

    Having spent my life serving my community, continuing to see clients during times when nobody else would, being a model citizen in every area of life, I am now forced to stop the majority of my work, cannot enter most retail stores, and am spoken about by politicians and the media as though I am a walking infection to be avoided.

    On top of that, in a number of medical forums I see medical practitioners demeaning and using foul language to describe unvaxxed and vowing not to provide service to them. I’ve had attempts in those forums to discredit and demean me and I’ve called people on their bullying. I seriously question their ethics and I know they are not behaving professionally.

    I am very resilient. I see what is happening and I can logically analyse it. I also now spend a good portion of my time in fear for my own future and my own right to even basic healthcare not even related to Covid. My own mental health is suffering and the fallout for many people in our communities is becoming so huge. With more and more health professionals seemingly wanting to discard the ‘non-compliant’ or strike more fear into them, I can’t see this getting better very soon.

  4. Anonymous says:

    The most worrying issue is the regulation and control between the Doctor- patient relationship where the Doctor does not have discretion to determine an individual risk assessment in order to provide an exemption. If that is the way medicine is heading were most medical decisions are mandated by guidelines which prohibit independent critical thinking and case by case decisions are not allowed then why do we need doctors? we may as well have robots or . clones built into drug dispensing machines.

  5. Belinda Cochrane says:

    As a Respiratory Physician involved in front line care of hospitalised patients with COVID-19, alongside my long term outpatients, many of whom have been frightened to venture outside their homes, let alone attend for vaccination (sometimes to their detriment), I have a respectful appreciation of your approach Dr Rowe and fully intend to incorporate some of your strategies. Thank you for sharing.
    It is not only the elderly who succumb to COVID-19 or who survive to live on with crippling respiratory failure. The delta variant is different. In Sydney’s most recent outbreak, surprisingly few elderly patients required hospital admission for any reason. We saw mainly people younger than 60 years admitted to hospital, particularly those from non-English-speaking backgrounds, or living in crowded households and with metabolic syndrome diseases, such as obesity, diabetes and heart disease. I can speak for my own hospital, which is one of two hospitals accepting COVID-19 admissions within my local health district. From conversations with the network of hospitals caring for patients with COVID-19, I understand that their experience has been similar.
    I’m not in favour of mandatory vaccination but I do strongly encourage my friends, family and patients to get vaccinated, partly because of what I have seen.

  6. Anonymous says:

    I agree with Max’s last comments. From very early days it has been clear that this is a virus with a low mortality rate in healthy people below the age of 70. This isn’t Ebola, it isn’t even the Spanish flu, it is an infection that poses minimal risk to most, and a higher risk to some, though it should be noted even 70-80% of the frail and multimorbid elderly that contract COVID19 will survive.

    A sensible proportionate response to this would be to encourage vaccination, simple hygiene measures and the like, Not mandatory vaccination. Not mandatory lockdown and border closures. Not mandatory anything unless you believe health totalitarianism is desirable.

    If like me you’re a doctor working in a hospital, think of how many stupid things you have to do each day because someone in power focussing on their narrow scope of righteousness has realised it’s far simpler to mandate you do those things than deal with the disagreements and the questions about why. The response to COVID has been disproportionately excessive to the risk, and I’m disappointed that our profession has been the chief cheerleader of this excess.

  7. Max says:

    Having been taken to task by both Rural GP and Sue Ieraci, let me (not) briefly respond:
    Leanne asked the question: I provided a series of answers that would plausibly be given. I may not agree with all of them – I am, after all, vaccinated – but I am clearly animated by a number of the issues.
    It is obviously desirable for health care workers to be vaccinated. It is not obvious that this should be mandatory. If 4000 are to be lost from the workforce in a single state at a time when the hospital system is apparently to be stretched to the limit, it might be prudent to decide which is the riskier path: the loss of all those workers, or adherence to a totemic mandate which in itself fails to address the actual problem of a potentially infected worker coming to work.
    The unvaccinated are mostly a risk to themselves. Vaccinated workers also carry and transmit the virus; CDC data shows viral load is the same (shedding period is shorter); data also shows vaccinated workers are less likely to be symptomatic when infected than unvaccinated workers and are therefore more likely than unvaccinated to present to work when infected. Therefore, if patients are to be protected from the virus, test all workers daily for the virus rather than mandating vaccination.
    What kind of tin ear does it take to ignore the significant minority of voices opposed to mandatory vaccination? These voices may resist this vaccination because of concerns about their own health. Instead of ‘embracing engagement of the patient in making decisions about their own healthcare’ (where did I read that 3 decades ago?) we now resort to old-style medical paternalism and simply dismiss their fears as ignorant and unfounded and an internet-fuelled conspiracy theory. (And Rural GP, please do not conflate the roles of GP with public health medicos: the GP is responsible for the singular patient sitting right in front of them at that moment and to no-one else. The advice given should reflect that. That’s certainly what the lawyers and MDO’s expect.)
    It is such conflation that leads clinician doctors to fudge what they say to patients: if not for them trying to play public health docs, ‘the vaccines are safe’ (yes Sue, billions of doses given world-wide) would then be replaced with: ‘we believe the vaccines are safe although they do have a number of documented but rare side effects; we have no idea of the long term consequences of these vaccines because they have not be studied for any length of time, but they seem very effective in preventing severe disease in the short term and we have no reason to suspect that there will be any long-term sequelae from what we know so far’. That is the actual statement of fact, if it is facts in which we wish to deal.
    There is no legal ability to require an individual to place what they believe to be their life and or well-being at risk for the general good of the community except through conscription, as much as we might ‘respect’ their preparedness to do so. Conscription has faced enormous resistance when ever it has been enacted in this country. It is a federal edict and cannot be raised by the states. Curiously, some people do not find issues of involuntary treatment (yes Sue, as outlined in the Nuremberg Laws) ‘absurd’.
    Where Sue sees hyperbole, I see principles. I admit that is seems deeply unfashionable these days to have those. But expediency with principles seems fine until they ditch some of your own favourites – asylum seekers come to mind – and while our pet topic of healthcare seemingly allows us to bend the public to our will, one suspects in the future we will regret our naivete and our complicity.
    The world has been convulsed by the response to this virus. That the response mirrored the example set by Communist China ‘because we could get away with it’ does not mean that was the right response. COVID is just one of myriad things out there all trying to kill you: one of them will eventually succeed. Along the way, tyrannical edicts from newly puffed-up autocrats might still need to be resisted.

  8. Sue Ieraci says:

    I also see many problems with Max’s response.

    He speaks of “guarantees” of serious illness. There are few guarantees in life. Cigarette smoking does not guarantee lung cancer. Medicine involves risk-benefit balances.

    The requirement to be vaccinated for health work is a protection for the worker as well as their patients. It is part of work health and safety, just like PPE. This is not about human rights – it’s about responsibility. Nobody will be forcibly held down and vaccinated against their will. The comparison with Nuremberg is absurd.

    Descriptions of these vaccines as safe has nothing to do with fear and all to do with evidence. Billions of doses have now been given world-wide.

    Vaccine-induced myocarditis has been both rare and self-limiting – as opposed to infection-induced complications.

    Then the long rant about lock-downs, over-reach and democracy itself.

    Long on hyperbole, short on facts.

  9. Rural GP says:

    Thankyou for this article
    I have considered Maxs’ Statement and I feel it cannot be left unchallenged.
    I see the response lies in the way the questions are posed
    The first problem I have is seeing the health worker as N=1. You are not getting vaccinated just for yourself, it is for your patients. Its being responsible for more than yourself, it is caring for the vulnerable.
    “Because preventive medicine – – should be essentially free of risk.” Sounds great, but in the real world, it is not. It is defined and studied and honestly explained. And we respect those prepared to take on side effects for the greater good.
    “Because looking at the data and predicting probability of a side effect and risk-vs-benefit is fine until it is your neighbor’s previously fit n=1 teenage son who faces a life-shattering long-term cardiomyopathy from vaccine-induced myocarditis.” Here is the nub of the problem: as a health care provider you have to be able see more than the patient in front of you. You cannot make public health decisions if you are not able to see the big picture, with the same compassion your show to neighbors teenager.
    And that is why we need coercion. Because our patients and some Health care workers may not be able to see the whole picture. Our rights were not stolen, we traded them for the our freedom.
    Unless you take on public health, rather then N=1, you may be actually harmful. ( meant with respect)

  10. Max says:

    Your article is written with real empathy Leanne, but you ask in the piece and in your comment why, for example, 4000 QLD health workers will leave their jobs rather than get vaccinated.
    Because whilst they accept that the virus is real, they are not guaranteed to be exposed (any more than they are exposed to influenza every year) and if exposed, are not guaranteed to face serious illness.
    Because they recognise when a fundamental human right is being trashed: ‘my body, my choice’ is a principle, reinforced by the Nuremberg Laws, which vaccine mandates directly violate.
    Because their ‘choice’ is in fact no choice at all but bald-faced coercion.
    Because health officers too scared of increasing vaccine hesitancy hide or dismiss discussion of the real side effect potential of these vaccines with casual blandishments to the effect that they are ‘safe’.
    Because these vaccines are so safe that a blanket indemnity has been allowed to mega-multinational companies to encourage earlier roll out.
    Because preventive medicine – designed to prevent something that is not guaranteed to happen – should be essentially free of risk.
    Because looking at the data and predicting probability of a side effect and risk-vs-benefit is fine until it is your neighbour’s previously fit n=1 teenage son who faces a life-shattering long-term cardiomyopathy from vaccine-induced myocarditis.
    Because governments recognise that their lockdowns are now being analysed and being seen to be excessive, and not perhaps even justified on health grounds. Because governments stole freedoms that were not theirs to take, and now in great magnanimity want to ease those freedoms back. Vaccine targets are not only a coercive measure but are also a political fix in order for the populace not to reflect and wonder ‘what was all that for?’ when they are coming out of lockdown with case numbers vastly higher than when they went in.
    Because despite being vaccinated, and recognising the value in trying to achieve herd immunity, the present crop of vaccines with their rapidly-waning immunity look like providing nothing of the sort even in the medium term, and better vaccines will inevitably be in the pipeline.
    Because contrary to the apparent views of some medical people (clearly not you Leanne) there is more to life than healthcare, and it becomes necessary at some point to take a stand against a despicable over-reach in a country that likes to imagine itself a democracy.
    And I am vaccinated.

  11. Leanne Rowe says:

    Unfortunately vaccine inequity exists in Australia as well as internationally:
    *lack of access to vaccine appointments in rural Australia
    *lower access to education and evidence based information about vaccines in some under vaccinated communities
    *lower vaccination rates in indigenous people, people with disabilities, those from linguistically diverse backgrounds, people with mental illness and those who are homeless.

    We should not be complacent when over 95% of our total population are vaccinated – this still means 1 in 20 eligible people unvaccinated – many of them vulnerable to COVID-19.

    And on another note, concern today about hundreds of health workers in regional Qld and SA leaving the health system due to mandatory vaccination. Have we asked them why?

    We still have a long way to go to protect our communities.

  12. Dianne McNamara says:

    When there are very contagious viruses or other infections procurations should be in place for the protection of those who are unable to take advantage of the of the Protections.

    Total isolation is very lonely

  13. A/Professor Vicki Kotsirilos AM says:

    Thank you Professor Rowe. A great article and wonderful tips to help empower our patients and understand the value of vaccination!
    When we engage and treat our patients gently with respect, compassion, understanding and empathy, we gain their trust. This they truly value. Patients also appreciate being well-informed of the benefits and risks associated with any treatments.
    Equally, it is also important we continue to treat patients fairly with respect, compassion and understanding when they choose not to vaccinate.

  14. Dr Liam Tjia says:

    Agree++ Dr Sharman.

    Very informative, perceptive and kind piece from Dr Rowe – more of these please insight!

  15. Dr Sarah says:

    A great article, maybe I might be brave enough to try this on vaccine refusing relatives!
    Anonymous represents the success of whoever out there is trying hard to destroy faith in governments and medical institutions (I seriously think this is more than just a few people with unusual ideas). A couple of years ago the idea of now refusing ALL medical care if you got Covid would have only been seen in those with an actual psychosis, now it doesn’t seem all that odd unfortunately (or saying “if I go to hospital I’ll be denied the only things that work!!”)

  16. Cate Swannell says:

    EDITOR’s note: It will be on Facebook tonight. Thanks for the feedback Brian!

  17. Brian Donnelley says:

    Professor Rowe, this article shows the art of medicine. It is very wise and should be widely spread and read … dare I say it, shared on Facebook?

  18. Anonymous says:

    ANONYMOUS the reason your choice is not respected is that you harm people in the community who are immunocompromised and vulnerable to COVID. You actually don’t understand the choice you have made.

  19. Andrew Nielsen says:

    That approach was so much more than merely being kind an empathic.

    The most important function of the frontal lobe is that it enables people to picture potential futures (especially social ones) see which one elicits the most favourable emotional state, and plan how to achieve that emotional state.

    The intervention had the patient picture their unvaccinated future. The intervention didn’t ask them to imagine getting covid, but had them getting covid as a *premise* of the situation they were instructed in: social isolation, infecting others, shortness of breath, competing for scarce ambulances, being admitted to hospital. By making having COVID the premise of the scenario, they bypassed resistance to warnings.

    AND the scenario was not given as a warning about what could happen but as helpful instructions about what to do if they did get covid. By doing that, they bypassed the idea of being warned or told to do with their life in general. Being told what to do in the event of a medical emergency is less irksome than being told what to do to prevent illness, I believe.

    The equivalent for smoking would be to encourage people to see their GP the moment they start coughing up blood.

    The intervention was a whole new angle to my understanding of what motivational interviewing is.

    GENIUS.

  20. Douglas jones says:

    Outstanding article – informed, informative and empathetic. An absolute credit to the medical profession and the author

  21. Anonymous says:

    I do not understand why a person who refuses to vaccinate should be dealt with empathy. It is his or her personal choice whether to inject something in their body they dont like, or not. Consent for vaccine is a joke when you are
    mandating the vaccine. For doctors, pushing people to have the vaccine is against tthe hippocratic oath they take.
    It is arrogance not to respect freedom of choice and to underestimate intellect of other people.

  22. Rahul Barmanray says:

    What a great example of an empathic approach to an emotionally-laden issue. It takes more time to be sure but if that’s the cost of excellent healthcare then it’s arguably a price we should be willing to pay.

  23. Saul Geffen says:

    Anonymous
    I don’t respect your choices

  24. Anonymous says:

    As an unvaccinated person, I understand the choice I have made. i do not require empathy or any other concern. All I want is that everyone respects my personal decision. I have been made to feel a pariah and an outcast. But I respect your choices, why not give me the same respect. I have already told my family that if I get ill with anything, including covid, under no circumstances are they to call an ambulance or convey me to hospital. It just doesn’t feel that it wouklkd be worth it.

  25. Scott Parkes says:

    Thank you Professor Rowe. An approach that is kind, and informative rather than coercive. A great contribution at these difficult times.
    My very best wishes to you, Scott

  26. antje vogelsang sharman says:

    I just love this article – while I am sick , tired and exhausted of having to balance my patients thoughts and fears for so many months now ,there is really no point in antagonising anyone any further. Most people will come around if we are just patient enough and kind enough. I always wondered how people will feel if they are made to feel they are the bad guys – just confirms their fears, ramps up their anxiety and pushes them in a corner. thanks for this article and reminder – makes me more patient for the next consults 🙂

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