For those of us keeping count — unavoidable to me as an emergency physician — it is clear we are facing a fourth wave of COVID-19. Cases, hospitalizations, and even deaths are increasing nationwide, driven largely by spread among unvaccinated people. The virus we have been battling for 18 months, stronger with new variants, is finding chinks in our armor and wreaking preventable illness and suffering. On Wednesday, the city announced new restrictions to cope with the delta variant — putting much of the onus on businesses to choose between required masking or proof of vaccination, and prompting questions about enforcement in the next stage of COVID-19 life.
With so much health messaging, information, and disinformation zooming around us, I see daily how doctors fall short in the mass communications realms — and wonder how we might rethink public health messaging altogether.
Doctors’ communication modes can seem almost quaint in the world of social media, 24-hour news channels catering to specific ideologies, and general information bubbles. Moving away from the authoritative, do-as-I-say approach of previous decades, physicians now aim to engage in discussion and evidence-based recommendations with their patients. In general, we follow an informed consent model — presenting information in a meaningful way, discussing risks and benefits of treatment, offering options with explanations, and discussing suggestions and recommendations based on patient input.
The sweet spot of this approach is one-on-one conversations. In knowing their patients and building on a baseline of mutual trust, physicians know that not all people who are unvaccinated fall into the staunch anti-vax category. They have been able to meaningfully advise and reassure some of those who have valid concerns. Beyond the work of physicians, targeted community outreach has increased vaccination rates through direct communications, phone banks, and canvassing, where questions and concerns could be immediately addressed and followed with an easily accessible vaccine shot.
But even when we do change minds, other hitches in the system await. Local physicians and providers were not part of the large-scale deployment of mass vaccination through either the city’s Public Health Department or FEMA. We could strongly encourage patients to get vaccinated, but not necessarily help with appointments. I have been frustrated after spending time answering questions to persuade someone to get vaccinated, only to have to refer them to the website for appointments and see the uncertainty creep back in their faces as they navigate a system that seems impersonal and distant. Many doctors in our area felt that their hesitant patients would have been less reticent if they could have received the vaccine from their usual doctor in familiar surroundings, instead of from overwhelming mass sites.
“I’m thrilled to see business leaders embracing the idea of requiring proof of vaccination for adults throughout Philadelphia.”
And that may not be enough for the scale needed to reassure and educate those who still have not been vaccinated to protect themselves and those around them. A report published Aug. 4 by the Kaiser Foundation found that the dangers of delta are not persuading unvaccinated people to adopt more COVID-19 precautions. It reminds me of something said by my husband, who immigrated to the United States from Italy as an adult: “Doctors in the U.S. give you so much information, but don’t actually tell you what to do. Aren’t they the experts? Just make it easy for me.”
One of the pandemic lessons we may need to embrace is that some public health paternalism, through clear and unwavering messages, serves the greater good. In Europe, digital vaccine passports have been used since early summer. The personalized QR code, easily displayed from mobile phones, allows greater freedom in travel and movement with risk mitigation. In Italy, where vaccination rates had been lower than hoped by early July, and knowing most Italians vacation in August, the government implemented a rule that dining indoors, going to museums, gyms, or other similar indoor activities would only be allowed for those with a “GreenPass,” digital proof of vaccination. The following week saw a sharp surge in vaccine appointments, up to a 200% increase in some areas.
Individual choice in getting vaccinated remained, but focused restrictions followed to reduce risk of transmission while looking ahead to avoid a broad shutdown. The required tech resources and processes were also streamlined to make it easier for businesses, all sending a clear message: Vaccination is the way forward and out of this pandemic for everyone.
I am a firm believer that in medicine and public health, one size never fits all. We need the multipronged approach of empowering primary care physicians to vaccinate, continuing focused community engagement, and being ready to engage meaningfully with those who might slip through the cracks. But we must also look to the greater good and establish a common and unequivocal baseline of safety to keep individuals, communities, businesses, and our city as a whole on the path forward. I’m thrilled to see business leaders embracing the idea of requiring proof of vaccination for adults throughout Philadelphia. Our common goal is clear: We become a united front together.
Priya E. Mammen is an emergency physician and public health consultant. She is a fellow of the Lindy Institute of Urban Innovation at Drexel University and chair of the Section on Public Health and Preventive Medicine of the College of Physicians of Philadelphia. @PEMammen