Crisis Negotiation as a Vocation
How a pediatrician in South Kazakhstan has been convincing parents to accept vaccinations for a quarter of a century
“There are pretty many rejections this year, there has never been anything like this,” says Kanymkul Alzhanova, deputy chief doctor for maternal and child health at Shymkent Polyclinic No. 11. The doctor, who has been responsible for the immuno-prevention for the past 24 years, bitterly watched what was unfolding at the beginning of the school year. Parents, fearing that first-graders would be vaccinated against COVID-19 without their consent, massively turned down routine revaccination against tuberculosis.
Kazakhstan is an epidemiologically unfavorable country for tuberculosis. Almost two-thirds of patients are carriers of the drug-resistant form of the disease. Due to refusals, BCG Revaccination in Shymkent lasted for two months, and all kinds of methods were used: parents’ meetings with medical workers, individual talks in policlinics, and invitations to observe the vaccination process directly.
“I tried to meet with all the parents as much as possible,”
She is a well-known doctor in the city, though she tries not to brag about it. 25 years ago, when she started as a young pediatrician in a polyclinic, she was assigned to a sparsely populated urban area. While the authorities were building it up, Kanymkul Amangeldievna managed to work with children in almost all districts of Shymkent. Today, this circumstance plays an important role, the doctor believes. The face of a familiar doctor calms anxious parents. “Magic” works even during Zoom Meetings. The results are striking: she usually manages to convince more than half of the ten people who refuse vaccinations.
In her conversations with parents, both current and future, the deputy chief physician is accustomed to appealing to her unique experience with vaccine-preventable infections. “There used to be no thermo bags for every doctor, so we used to put dry ice and polio vaccine in an ordinary thermos and go door-to-door and give it for children up to 4 years old,” Kanymkul Amangeldiyevna tells about the peculiarities of immunization in the mid-90s.
Personal experience fits perfectly into the historical context: Kazakhstan was certified as a polio-free country in 2002 with the help of Shymkent doctors.
But before disarming with rational arguments, the heroine prefers to reassure anxious visitors. “Across the line, I tend to have these aggressive parents very often. We have the most hectic job with pregnant women. I try to speak their language softly, and then I speak my own language...” - the doctor says. She is not accustomed to raising her voice, but over the years learned to manage the tone and intonation so as to make the desired impression. As the number of rejections increased, communication skills became as essential in her work as immunoprevention itself.
At the beginning of November, Kanymkul Amangeldievna gladly took the opportunity to polish her skills by participating in a five-day workshop on vaccinology, hosted by the UNICEF and the Association of Family Physicians of Kazakhstan (AFPK). The workshop was part of the UNICEF Program to Strengthen Kazakhstan’s Immunization System funded by the U.S. Agency for International Development (USAID). The participants tackled false medical exemptions as one of the major reasons for the decrease in vaccination rates and interpersonal communication skills with parents. The 32-year veteran was very interested in the interpersonal communication sessions. Participants, under the careful guidance of the trainers, simulated, time after time, the most ambiguous situations from medical practice - for example, refusal to vaccinate for religious reasons. The role-playing convinced her that psychologists and social workers in health care facilities should study the basics of immunization more actively in order to sound as convincing as the doctors.
Kanymkul Amangeldievna was eager to share her new knowledge with her colleagues: general practitioners, pediatricians, and highly specialized doctors. She immediately sent the most interesting information via voice messages in chat rooms, and after the program was over, she organized her own miniseminar on vaccinology. It was at this meeting that the staff at the Shymkent Outpatient Clinic, for example, learned that there is a “live” flu vaccine and that intracranial pressure disorder or perinatal encephalopathy are not contraindications to vaccinations.
True and false medical exemptions in children were one of the most important topics at this seminar. Domestic neurologists often identify various abnormalities in children, and pediatricians and therapists give a medical exemption from preventive vaccinations on this basis. Kanymkul Amangeldievna admits that as she grew older, she began to follow the advice of her colleagues and not insist on vaccinations.
Earlier, while working as a district doctor, she often made decisions in favour of vaccination after collecting the medical history.
The training reminded her of these moments, and the specialist once again assured herself of her knowledge and competence. Besides, Kanymkul Amangeldievna’s experience in dealing with a measles outbreak in 2018-2019 is under her belt. A 23-year-old boy who arrived for service in a city military unit from the capital turned out to be infected, and soon the infection spread beyond the garrison. Alzhanova’s subordinates traveled in teams for emergency immunizations, and more than a thousand people were then vaccinated against measles.
“There was fear inside, of course, but it was our sacred duty. We were especially concerned about young children, so we brought in all the doctors and nurses at that time. Everyone was sent out on door-to-door rounds* to identify children with fever in the early stages and isolate them on the same day,”
The outbreak was contained then, but the situation is hardly getting any better: Every year in Kazakhstan, 5,000 to 8,000 parents refuse to vaccinate their children, threatening a new surge of the disease within five years.
Kanymkul Amangeldiyevna is certain that negative publications and posts about vaccination in social media and mass media strongly fuel parental skepticism. “We persuade, speak on television, translate into Kazakh and explain in our own words,” the doctor notes with satisfaction the efforts of her team, adding that she herself is engaged in education literally “at every step”. Now “the team is working in full swing again” - the vaccination of teenagers against coronavirus has started in the country, and Alzhanova has already had several schoolchildren immunized under her watch.
When she is asked if she likes her job, she answers, almost without hesitation: "I like it. But I get very tired. Emotionally tired”. After a minute her voice has no sign of fatigue: “I feel sick just from being old, but when I go to work, I have energy, I am surprised myself!”. It soon becomes clear that whatever working schedule Kanymkul Amangeldievna has, its harmonious order is invariably disturbed by colleagues who come for consultations “with the baby, with pregnant women, and with nursing mothers.” “I never turn down a consultation. I have to, but what can I do? It’s my profession. That’s how I have to help,” summarizes the doctor.
*Door-to-door rounds are an anti-epidemic measure consisting of visits by medical workers to households in order to actively identify patients with infectious diseases.