These are the famous last words of the National Institutes of Health Director Dr. Francis Collins who recently retired after a  twelve-year tenure. To me, this is such an important acknowledgement. I hope it signals a change in direction towards greater investments in studying human behavior. Not psychiatric or mental health issues, but human choices. Several issues facing us today are related to human behavior choices. Wearing masks. Cleaning hands. Getting vaccinated. What to do with guns in homes, if they are needed at home, and how the people with guns can make choices that will not hurt themselves or others. What to do with unplanned pregnancy. How anyone can make choices (e.g., financial, physical safety, emotional safety) that will not hurt oneself or others. Whether everyone deserves access to healthcare. Risk perception is vastly different among people, which underlies the practice of safety behaviors. If the science of safety is up for voting by everyone regardless of level of training and expertise, then we do need to evaluate all the behavior choices systematically. Urgently.

About vaccine hesitance, Dr. Francis Collins said, “I never imagined a year ago, when those vaccines were just proving to be fantastically safe and effective, that we would still have 60 million people who had not taken advantage of them because of misinformation and disinformation that somehow dominated all of the ways in which people were getting their answers. And a lot of those answers were, in fact, false. And we have lost so much as a result of that.”

In my infectious diseases clinic this year, I have seen several shades of vaccine hesitancy. I have observed that what we call vaccine hesitancy is actually a constellation of different manifestations such as (disclaimer: these are my made-up terms) vaccine ignorance, vaccine fear, vaccine anger, vaccine defiance, and vaccine arrogance. The first two are relatively easier to address within the umbrella of what we call “vaccine counseling” for patients. We point them to the right sources of information, answer their questions, address their fears and most of the time, the patients accept the vaccine recommendation. One patient just needed me to hold her hand when she took the vaccine. Vaccine anger manifests as a recall of Tuskegee and all the other ways the Black community was hurt and abused in the past, and sometimes, deescalating the situation and explaining that the patient’s race was included in the trials help to some extent in acceptance of the recommendation to get vaccinated. Vaccine defiance is the manner in which some patients respond to the counseling – “no matter what you say, I am not going to change my mind, and I am not as concerned as you are about consequences for myself or others.” As for vaccine arrogance, I often find myself at a loss when I find myself in the situation. Patients who manifest this behavior in clinic are totally disrespectful of scientists, science, accusing them of all sorts of things like being hand-in-glove with pharmaceutical companies, and can come across as vaccine nihilists. Some of these patients try to make you feel guilty for asking them to get vaccinated. They induce anger at times, and the situation can deplete the wellspring of compassion inside you. Interestingly, all these patients accept the medications we offer them for various disease conditions, the reason why they are in my clinic in the first place, even though the evidence base for making some treatment recommendations is smaller than the SARS CoV2 vaccine recommendation. Each physician figures out own ways of addressing these behaviors and works to increase vaccine acceptance. There is no set formula, there is no protocol. In fact, situations like these are complex and sometimes intractable. Counseling patients to get vaccinated this year has been very similar to my previous work in improving the practice of hand hygiene and other infection prevention measures among healthcare personnel.

Dr. Collins, I would lose the word, “maybe”. I do think we underinvested in studying human behavior. We do not understand choices that people make, even if they are about their own safety or wellbeing. It is time for science to change direction.