Vaccine, vaccine, vaccine, vacceeeeeene… 

In the spring of 2021, my favorite T-shirt to wear on the soccer sidelines sported an image of Dolly Parton singing “Vaccine, vaccine, vaccine, vacceeeeeene” to the tune of “Jolene.” Parton herself sang the rewritten lyrics repeatedly urging Tennesseans to accept the COVID-19 vaccine. It prompted countless conversations about how the vaccine was made, where people could get it, and how safe it was. As a state public health official, my colleagues and I were rejoicing at how quickly the Trump administration had indeed delivered on several vaccine options less than a year into the pandemic. As we teared up with relief in vaccinating rather than intubating nursing home patients in early 2021, we knew that what was almost too good to be true would soon become too fast to be trusted.  

Since then, vaccine hesitancy has spread from COVID-19 to even routine childhood vaccines — a shift facilitated by campaigns targeting public fears and sometimes helped along by well-intended but counter-productive moralistic public health messaging. The World Health Organization estimates that immunization saves the lives of 2.5 million people per year and saves millions of children from birth defects and lifelong disability. As health leaders collectively put energy into protecting one of the most lifesaving public health interventions the world has known, we can also look to the science on how to communicate the value of vaccines. 

Using messages that work 

One of the best public health communication responses I have been part of was the simplest. In a 2018 town hall meeting, a newly elected local Congressional representative, a physician, claimed that vaccines could cause autism. The media attention was immediate. Outraged, a few state health department employees spent hours in a flurry of scientific reviews to compile the departmental response. Our state vaccine director drafted an eloquently worded two-page press release that sealed up every crack in the legislator’s argument with well-reasoned counterarguments and countless references to undeniable scientific evidence. Just before launching that release, our Chief Medical Officer emerged from his office with an idea. Within a few hours, we had released our shortest press release ever with just a few words prominently positioned — “Vaccines Save Lives.”  

The impact was immediate. We did not restate the fallacy. We did not ridicule the speaker or engage him in back-and-forth commentary. We did not drown our audience in study after study. We were clear, concise, and as it turns out, memorable. We also lived to fight another day and simultaneously gave more senior US legislators backup for what needed to be said.  

While the public needs to hear facts stated definitively, using them strategically is important to building trust. Re-iterating “science says” doesn’t work. According to the Frameworks Institute, noting that “scientists agree” or “the data are clear,” while true, is often perceived as derogatory (i.e., if you don’t agree, you are less intelligent) and can create an argumentative back-and-forth that facilitates wedges of doubt. Likewise, re-iterating falsehoods and directly referencing polarizing figures is not as effective as framing the benefits or rewards of routine immunizations in terms of keeping kids learning in school or even decreasing ear infections and pneumonia that keep parents from missing work. 

We also need to lean into the importance of vaccination efforts for national security. The military requires vaccinations prior to any deployment to protect the soldiers who protect us. Protecting our children is also vital to national security. The threat posed by biological attacks increases with every dip in vaccination rates. Measles, for example, infects 92% of unvaccinated people exposed to a contact, resulting in serious impacts such as pneumonia, encephalitis, and death, with rates higher in the very young. A community vaccination rate of 95% is needed to prevent the spread of measles from one case. Visual models such as FRED quickly show the impact of increasing vaccination rates on disease impact in most communities in the United States. The infrastructure to keep vaccine research, distribution, safety monitoring, school age requirements, and public communication strong requires ongoing and significant funding and coordination. Lapses in that that funding will create lapses in safety and protection. 

Repeat, repeat, repeat 

The concept of illusory truth effect explains how the more a person hears something, regardless of whether it is true, they begin to believe it and then hold tightly to it. It becomes part of our brain’s adaptive response to the 35,000 decisions it is required to make every day. Even people who would know better gradually accept repeated information as an adaptive shortcut to save mental energy while making sense of the world. Public health has an opportunity to similarly bombard the public with evidence-based messages about the life-saving value of vaccines through a significant coordinated effort. We have to increase our volume and amplify each other’s messaging. Likewise, we can increase uptake of the message by varying that message to keep it from getting stale and testing it and tailoring it to our audience.  

Finding the right hands for the microphone 

By the summer of 2022, my Dolly Parton T-shirt was received with glares rather than questions on the sidelines. Perhaps not surprisingly, our administration received a letter from senior party leadership in our state General Assembly demanding that the health department not offer the newly approved COVID-19 vaccine for children ages 2-5 years old. It pulled talking points directly from misinformation in the media and from high-ranking officials in other states. I personally knew many of those who signed that document, and I knew the signees were concerned about their communities and the health of their friends and family. As a pediatrician, I was also very aware of the families in my state celebrating the arrival of vaccine for their immunocompromised kids.  

While the media again demanded a response to the memo, we at the health department had no intention of humiliating and infuriating the senders with public comments. Our objective was to maintain access to COVID-19 and every other vaccine available in the short and long term, and we had to maintain trust with the General Assembly to do that. In the end, the department facilitated behind-the-scenes communication with legislators conducted by trusted messengers, including clinicians. The pragmatic argument held the day: Nearly two-thirds of the state’s counties would not have access to the vaccine if the health departments did not administer it. And every parent of a kid with cancer or Down syndrome wanted a choice in how to protect their children. 

Public health knows the benefits of partnering with well-known community figures and building relationships with community-based organizations that have been trusted over long periods of time. Every politician has the ear of its constituents, and every government entity has grantees and advisors in every sector in the community — getting key information to them and letting them inform and share that messaging now is critical. While “organized medicine,” health care facilities, and insurers are losing trust due to high cost and cumbersome access, people’s personal relationships with their health care providers still matter. Nurses in particular are trusted. And while health care providers are improving their communication skills with families questioning vaccination, we as public policy experts are doing the same.  

Have resources handy when the need arises to dig deep 

While not leading messages with “science says” in all contexts, public health and public policy officials certainly need to stay up to date on the scientific literature and think critically to assess good and bad study design methods. Every major medical organization in the United States and abroad endorses the safety of routine vaccination, as well as the vaccine infrastructure that supports safety, efficacy, and transparency. Each of those organizations has its own collection of resources and welcomes opportunities to provide expert testimony and consultation. A few of those resources follow: 

• Healthychildren.org offers resources for parents on how vaccine myths emerged and evidence to address the most common ones 
• Vaccineinformation.org is a repository of testimonials and scientific resources for the public that accompanies its clinical companion, immunize.org, which also offers expert consultation on vaccine-related questions  
• Multiple pediatric health care and research centers have established helpful resources for public access to information  
• A recent review by the Center for American Progress notes the history of vaccination science, lives saved per vaccine, state and national policy landscape, and impact of vaccine hesitation 

As states are thinking about how best to shore up their own messaging and policy to protect families, we are going to need more than Dolly’s famous “cup of ambition.” We are going to need courage, creativity, savvy, and outright tenacity.