A doctor’s reflection: can responsible experts disagree in public during a pandemic?
The “united front” approach might not be as compelling to the public as some imagine.
Earlier this month, I wrote that I would not get my three-year-old vaccinated with the Pfizer Covid-19 vaccine if it received authorization until data showing it is effective—not merely safe—were available.
Shouldn’t have been a controversial statement, right? After all, we don’t knowingly give vaccines and treatments that are safe yet not effective. Placebos are also perfectly safe, but we don't give them to patients. We only offer vaccines and treatments that are known to be both safe and effective.
I also indicated, both in my writing, and in media appearances (two clips below), that we would already have vaccinated our daughter if she were five years old, because there are droves of available data for children ages 5 and up indicating that the Pfizer Covid-19 vaccine is rock solid, both on effectiveness and safety.
In case you haven’t been steeped in this debate, in late January, at the urging of the FDA, Pfizer appeared poised to apply for emergency use authorization (EUA) of its vaccine for children under age 5, even though data from December had indicated that its trial found that two 3-microgram doses of its Covid-19 vaccine had not produced a sufficient immune response in 2-4-year-olds—though it apparently had succeeded among children ages 6-24 months. Since then, Pfizer has been testing a third dose of the vaccine in both age groups. When I wrote last week, the plan then being floated was that Pfizer would request an EUA for the 2-dose series for all children ages 6 months up to 5 years, despite these setbacks; the idea was to start vaccinating this age group with 2 initial doses up front, before any data about the effectiveness of the 3rd dose became available. I disagreed with that plan, which has since been scrapped. Now Pfizer plans to proceed with its EUA request only after data on whether the 3rd dose was effective are available. That’s the right call.
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I received a huge volume of responses after my essay was published.
Many were from parents, telling me that they were grateful to have someone in the medical community explaining frankly what we know about the Pfizer vaccine for children under age 5 (i.e. that the vaccine is safe) and don’t know (i.e. what dose will provide consistent adequate protection). Many, if not most (including other physicians), agreed with my conviction that it would make sense to wait until more data have been collected and reported before proceeding with an EUA for children ages 6 months to under 5 years, especially given how low uptake has been in children ages 5-11, in whom the vaccines have already been shown to be incontrovertibly safe and effective.
Some other responses however, mostly from fellow doctors, healthcare workers, and science professionals, expressed sharp disagreement, not so much with my perspective on the vaccine (though there was some of that) as with my decision to air my views in an environment in which so many parents are already hesitant to get their children vaccinated against Covid-19. They argued, both on Twitter and in private messages and conversations, that I was sowing doubt about the vaccines at a moment when it was critical to shore up faith in them. They argued that my approach would only confuse parents, and even give fuel to those who intentionally spread misinformation about vaccines. My remarks were not inaccurate, these people said, but they were unhelpful to the important cause of getting more Americans vaccinated.
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I have taken these responses seriously and wrestled with whether I should have been more measured in my comments — or even kept silent on the issue entirely. I’m sure I will continue to reflect on these questions, but here is what I think right now.
I do wish in retrospect that I had toned down some of my language. For example, instead of saying I would “absolutely not” get my child vaccinated unless there were data that the vaccine was certain to work for her, I could have said that we “won’t proceed until” all the data we need are released. While the meanings are in essence the same, “absolutely not, unless” and “won’t proceed until” have different emotional potencies. Again, I was very clear that I was eager to get my child vaccinated as soon as a vaccine that has been shown to be both safe and effective is approved. Like many parents, I had hoped that we would already have one by this point. Once Pfizer has new data that in fact shows the 3-dose series is effective in 2 to 4-year-olds, I will be thrilled. But I wish I had not used words like “absolutely,” just to avoid the chance that my article could be misinterpreted or misused.
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As to the larger question of whether I should have kept to myself my criticism of Pfizer and the FDA’s apparent (now reversed) decision to push forward with applying for an EUA for 2 to 4-year-olds despite the trial having failed in that age group, I am not convinced I did the wrong thing. I do think that the issue is complex, however, and that reasonable people can disagree with me.
Essentially, it comes down to the question of what is the best way for experts to communicate with the public about complex scientific questions during a public health emergency. Should we acknowledge openly and frankly where the gaps in our knowledge are, describe what we know to be true and distinguish it from what we suspect to be true but are still uncertain of, and what remains totally a mystery? Can we effectively send the message that the authorized/approved vaccines are proven to be safe and effective and that everyone who is eligible should get them, while acknowledging that vaccines and treatments that are still being tested may not in fact work because of dosing challenges? If the FDA had gotten ahead of the science and authorized a 2-dose series that had not been proven to be adequately effective (nor that a 3rd dose was guaranteed to patch the hole), could responsible public health experts criticize that decision, without undermining the vaccines more broadly?
Or does public health communication need to be simple to be effective? Do we need to elide areas of uncertainty and disagreement, in order to send a consistent message to the public? Should I keep my mouth shut when I think that public health authorities—experts whom, on the whole, I respect and agree with on most things—get something wrong, in order to maintain a unified front in an environment in which science has been politicized, and elected officials daily spout false and dangerous ideas about the virus?
I think most of my colleagues—even many of the ones who were most critical of my article—would actually agree that we need to find a way to be honest with the public, even when the messages aren’t the ones we had hoped for. A little raw honesty, even the exasperation that I was expressing in my essay (have you figured out that I am extremely eager for Pfizer or Moderna to get an effective vaccine into my child?), captured an authenticity that many parents outside of the medical community appreciated, and in fact are hungry for. I know this, because I heard that from many parents, many who have already vaccinated their older kids, but were seriously confused by the now-scrapped Pfizer/FDA plan. These parents told me that my approach made them more likely to get their preschoolers vaccinated, once good data are out there.
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I think the “other side” has so effectively undermined the scientific process and demonized the scientific community, that there’s understandable anxiety about any break from the perceived party line on vaccines or any other topic. That’s unfortunate because the bad rap is largely unearned.
So, we shouldn’t let the other side's successful tactics sway us from our principles. At our best, we scientists have always been the ones to tolerate well-reasoned dissent, insisting on an open process, and having the humility to say when we do not yet have the answers. My belief is that by continuing these traditions, and in fact by leaning into them, we’ll bring more people into the fold than we’ll ever scare off.
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