Recuerda haberle gritado a su marido que estaba en la otra habitación: “¡David, tienes que leer esto! ¡No lo puedo creer!”

Nelson no tenía ninguna amiga que fuera madre y que no vacunara a sus hijos.

“Fue realmente revelador de que esto era un gran problema”, dijo.

El padre de Nelson es médico; a ella siempre la vacunaron e hizo lo mismo con sus hijos. Pero esta noticia la asustó. Sabía que los bebés eran vulnerables, ya que a recibir la mayoría de las vacunas hasta cumplir los dos meses. Y algunos niños y adultos tienen enfermedades que comprometen su sistema inmunológico, lo que significa que no pueden recibir vacunas y tienen que depender de la inmunidad del grupo. Por aquel entonces, Nelson le estaba dando vueltas al tema de la salud pública, incluso estaba considerando un cambio de carrera, de trabajar en bancos a la salud pública. Decidió que tenía que hacer algo.

“Creo firmemente que, si uno tiene la capacidad de abogar, entonces tiene que hacerlo”, comentó. “La responsabilidad es nuestra si queremos un cambio”.

Como muchas mamás, Nelson había pasado horas navegando internet. Ella sabía lo fácil que era caer por los agujeros online, en un mundo de estudios falsos e historias de miedo.

“No soporto la mala información en internet”, explicó Nelson. “Y cuando veía ese tipo de información sobre las vacunas, me apresuraba a comentar: ‘Eso no es cierto’ o ‘No, así no es como funciona’… por lo general me bloqueaban”.

Nelson fundó su propio grupo, South Caroline Parents for Vaccines (). Comenzó a publicar artículos científicos en línea. Comenzó a responder a mensajes privados de padres preocupados con preguntas específicas. También descubrió que el refuerzo positivo era importante, por eso entraba en grupos de madres con palabras de ánimo.

“Si alguien publicaba ‘Mi hijo recibió hoy sus vacunas de los dos meses'”, Nelson contó que rápidamente posteaba un comentario diciendo, “¡Bien hecho, mamá!”

Nelson, de 33 años, se inspiró en grupos de todo el país que realizan un trabajo similar. Grupos con alcance nacional como , y grupos regionales como en Washington, adoptan un enfoque similar, alentando a los padres a educarse y a compartir información con otros padres sobre las vacunas.

A nivel nacional, el 91% de los niños menores de 3 años están contra el sarampión. Pero en algunas comunidades la tasa es mucho menor. En el condado de Clark, en Washington, donde un ya llega a 62 casos, alrededor del 76% de los niños de kindergarten van a la escuela sin todas sus vacunas. Los especialistas en salud pública, preocupados por el debilitamiento de la inmunidad de los grupos, están alertando cada vez más sobre la necesidad de mejorar las tasas de vacunación.

Sin embargo, los esfuerzos para convencer a los padres sobre el valor de las vacunas a menudo fracasan. Y algunos en la decisión de no vacunar, incluso cuando se les presentan datos científicos que avalan la inmunización.

Los pediatras podrían desempeñar un papel importante, y muchos lo hacen, pero no se les compensa por tener con los padres, y a algunos de ellos les resulta una tarea frustrante. Eso ha creado una gran brecha para que surjan enfoques alternativos. Nelson pensó que sería mejor concentrarse en las mamás que todavía estaban indecisas sobre las vacunas.

“Es más fácil convencer a una mamá indecisa que a alguien que está firmemente en contra de las vacunas”, señaló Nelson. Y explicó que los padres que se oponen a la vacunación a menudo están tan convencidos de ello que no quieren participar en una discusión. “Se sienten validados por esa elección, es parte de su comunidad, es parte de su identidad”.

Lo más importante es medir los tiempos: las personas pueden necesitar información sobre las vacunas antes de convertirse en padres. Un primer embarazo, cuando los hombres y las mujeres comienzan a hacer la transición a sus funciones como padres, es cuando muchas veces surge el problema por primera vez. Nelson señala un estudio de una encuesta de los Centros para el Control y Prevención de Enfermedades (CDC) que mostró que de las mujeres embarazadas ya se habían decidido por las vacunas cuando llevaban seis meses de embarazo.

“No van a ir al pediatra todavía”, contó Nelson. “Su ginecólogo probablemente no está hablando sobre el programa de vacunas pediátricas. Entonces, ¿adónde van? Se están conectando en internet”.

Nelson trata de contrarrestar la mala información en internet con datos. Pero también entiende el valor del diálogo en persona. Organizó una clase en una biblioteca pública y anunció el evento en los foros de madres. Nelson estaba nerviosa por si se presentaba gente hostil a las vacunas.

“¿Están aquí para robarme seguidores? ¿O están aquí para aprender sobre las vacunas?”, se preguntaba Nelson. “Y decidí que, si habían venido hasta aquí, les daría la mejor información posible”.

Amy Morris estaba embarazada, pero condujo una hora y media para asistir a la clase. Morris no era la típica madre primeriza a la que Nelson intentaba llegar. Ella ya tenía tres hijos. Pero durante este embarazo, le entró un mayor nerviosismo sobre las vacunas. Había sufrido recientemente un aborto espontáneo, y le ocurrió justo en el momento en que se vacunó contra la gripe. Morris había estado leyendo artículos a favor y en contra de las vacunas en los foros de madres, y estaba empezando a tener algunas dudas. En la clase de Nelson aprendió sobre los riesgos de no vacunarse.

“Eso fue lo que me convenció”, dijo Morris.

Ahora, con su saludable hijo de 8 meses, Thorin, en el regazo, explicó que estaba contenta de haber ido, porque se sentía vulnerable.

“Siempre supe que era lo correcto”, dijo Morris. “Estaba prestándole atención a ese monstruo del miedo dándome vueltas en la cabeza”.

Nelson dijo que la comunidad antivacunas se alimenta de miedo. Y ha aprendido a hacer preguntas para ayudar a los padres a llegar a la raíz de su ansiedad.

“Creo que aprecian cuando uno se acerca a ellos con empatía y no se limita a tratar de hacerles tragar los datos a la fuerza”, indicó Nelson.

Nelson ahora está tratando de lograr que los hospitales locales integren esa charla sobre vacunas en sus clases de preparación para el parto. Está estudiando una maestría en salud pública en la Universidad de Carolina del Sur, y también trabaja con el Bradshaw Institute for Community Child Health and Advocacy. Incluso está considerando la posibilidad de presentarse a un cargo público.

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She remembers yelling to her husband in the other room, “David, you have to get in here! I can’t believe this.”

Nelson didn’t know any mom friends that didn’t vaccinate their kids.

“It was really eye-opening that this was a big problem,” she said.

Nelson’s dad is a doctor; she had her immunizations, and so did her kids. But this news scared her. She knew that infants were vulnerable — they couldn’t on most vaccines until they were 2 months old. And some kids and adults have diseases that compromise their immune systems, which means they can’t get vaccines and rely on herd immunity. Nelson was already thinking about public health a lot back then, and was even considering a career switch, from banking to public health. She decided she had to do something.

“I very much believe if you have the ability to advocate then you have to,” she said. “The onus is on us if we want change.”

Like a lot of moms, Nelson had spent hours online. She knew how easy it was to fall down internet rabbit holes, into a world of fake studies and scary stories.

“As somebody who just cannot stand wrong things being on the internet,” Nelson said, “if I saw something with vaccines, I was very quick to chime in ‘That’s not true’ or ‘No, that’s not how that works.’ … I usually got banned.”

Nelson started her own group, . She began posting scientific articles online. She started responding to private messages from concerned parents with specific questions. She also found positive reinforcement was important and would roam around the mom groups, sprinkling affirmations.

“If someone posts ‘My child got their 2 months shots today,'” Nelson said, she’d quickly post a follow-up comment, “Great job, mom!”

Nelson, 33, was inspired by peer-focused groups around the country doing similar work. Groups with national reach like , and regional groups like in Washington, take a similar approach, encouraging parents to get educated and share facts about vaccines with other parents.

Nationally, 91 percent of children under 3 years old are  for measles. But in some communities the rate is much lower. In Clark County, Wash., where a is up to 62 cases, about 76 percent of kindergartners come to school without all their vaccines. Public health specialists, concerned about weakened herd immunity, are increasingly raising the alarm about the need to improve vaccination rates.

But efforts to reach vaccine-hesitant parents often fail. And some parents in a decision not to vaccinate even when presented with the facts.

Pediatricians could play a role — and many do — but they’re not compensated to have  with parents, and some of them find it a frustrating task. That’s left a huge opening for alternative approaches. Nelson thought it would be best to zero in on moms who were still on the fence about vaccines.

“It’s easier to pull a hesitant parent over than it is somebody who is firmly anti-vax,” Nelson said. She explained that parents who oppose vaccination often feel so strongly about it that they won’t engage in a discussion. “They feel validated by that choice — it’s part of community, it’s part of their identity.”

The most important thing is timing: People may need information about vaccines before they become parents. A first pregnancy — when men and women start transitioning into their parental roles — is often when the issue first crops up. Nelson points to one survey study from the Centers for Disease Control and Prevention that showed of expectant women have made up their minds on vaccines by the time they are six months pregnant.

“They’re not going to a pediatrician [yet],” Nelson said. “Their OB-GYN is probably not speaking to the pediatric vaccine schedule. … So where are they going? They’re going online.”

Nelson tries to counter bad information online with facts. But she also understands the value of in-person dialogue. She organized a class at a public library and advertised the event on mom forums. Nelson was nervous that people hostile to vaccines might show up.

“Are they here to rip me a new one? Or are they here to learn about vaccines?” Nelson wondered. “I just decided, if they’re here, I’m going to give them good information.”

Amy Morris was pregnant, but she drove an hour and a half to attend the class. Morris wasn’t the typical first-time mom Nelson was trying to reach. She already had three kids. But during this pregnancy, she was getting increasingly nervous about vaccines. She had recently had a miscarriage, and it was right around the time she got a flu shot. Morris had been reading pro- and anti-vaccine posts in the mom forums, and was starting to have some doubts. In Nelson’s class, she learned the risks of ²Ô´Ç³ÙÌývaccinating.

“That spoke to me more than anything,” said Morris.

Now, holding her healthy 8-month-old son, Thorin, on her lap, she said she’s glad she went, because she was feeling vulnerable.

“I always knew it was the right thing to do,” Morris said. “I was listening to that fear monster in the back of my head.”

Nelson said that fear is what the anti-vaccine community feeds on. She’s learned to ask questions to help parents get at the root of their anxiety.

“I do think they appreciate it when you meet them sympathetically and you don’t just try and blast facts down their throat,” Nelson said.

Nelson is now trying to get local hospitals to integrate that vaccine talk into their birthing classes. She’s studying for a master’s degree in public health at the University of South Carolina, and also works with the Bradshaw Institute for Community Child Health and Advocacy. She’s even considering a run for public office.

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“I don’t know what I’d do without it, you know? It’s another limb. I always know where it is,” she said, laughing.

The third-year resident in obstetrics and gynecology at the Carolinas Medical Center hospital in Charlotte, N.C., works in a medical specialty dominated by women, treating women. She feels a special connection to her patients, Merriam said.

“You just, you can feel what they feel and understand why they feel certain ways. I do feel a special bond,” she said.

Nationally, 82 percent of doctors  are women. Many OB-GYN patients say they prefer female doctors. Merriam’s residency class is a bit of an anomaly — half of its members are men. Though it’s nice to work with so many women, Merriam said, she and some of her female colleagues also like the perspective that men bring to the work environment.

“No one could really pinpoint about what balance they bring, but there’s something nice about having them,” she said.

It’s important to have men in the field, she said, if only to continue to give patients options in their choice of providers. But most of her friends and other women she talks to, she said, want female doctors.

Blake Butterworth, a fourth-year obstetrics and gynecology resident at the Medical University of South Carolina in Charleston, said he doesn’t take it personally when he hears that sort of thing from a patient.

“I don’t get discouraged; I don’t get offended,” Butterworth said. “I gladly hand that patient off.”

He’s one of only two male residents in the program of 24 at MUSC and said he finds it rewarding when he can win a new patient’s confidence.

“I have patients that clearly express disdain to have to see a guy,” he said. “Then I develop rapport with her. And she says, ‘I expected you to be X, Y, Z, and you were better than that.'”

Butterworth said he chose obstetrics and gynecology because it lets him develop long-term relationships with patients — providing routine OB-GYN care and more complicated surgeries, if need be.

“Once you really get into it, and get involved in it, I don’t think that bias [that the field is best left to women] holds true,” he said.

Butterworth said he believes it is incumbent on male OB-GYNs to talk to male medical students about the benefits of having men in the field. Students need to know it’s OK to have an interest in the field, he said, and that they will find work.

In fact, says , an associate professor of obstetrics and gynecology at MUSC, it may be the opposite.

“In an effort to really diversify the applicant pool, we will apply in some cases different screening standards to decide who we are going to interview,” Savage said. “For example, we might consider an applicant with a slightly lower board score — just to enhance how many men we are interviewing and considering.”

It has been a challenge to find male OB-GYNs for the program, she said. The gender that at one time dominated the field is now at some schools considered a diversity hire. But Savage questions whether balancing the number of men and women in the specialty is as important as racial or ethnic diversity.

“The interesting thing to me is the primary motivation to [seek a diverse candidate pool] is so that patients have the opportunity to seek out physicians who might … feel like themselves,” she said. “In this particular case … all of the patients for OB-GYNs are women.”

Among practicing OB-GYNs in the U.S., a , according to the American College of Obstetricians and Gynecologists, formerly known as the American Congress of Obstetricians and Gynecologists. But ACOG predicts that 10 years from now, two-thirds of the doctors in that specialty will be female.

Still, male doctors hold many key posts in OB-GYN professional organizations.

“Leadership tends to be held by people who are older,” Savage said. “And we are still in a scenario where [more of] our older faculty tend to be men.”

´¡Ìý published last fall found that women are underrepresented in leadership roles in medical school departments of obstetrics and gynecology throughout the country. That ratio was most lopsided in men’s favor in the South.

It’s perhaps only a matter of time before that, too, changes. Savage said she recently learned that her program’s incoming class of OB-GYN residents next year will be all female.

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Take navigators. Those are specially trained people who  sign up for coverage. The federal government  by 41 percent. But that’s not an across-the-board cut.  are dealing with far deeper cuts, while others will have dollars close to what they had last year.

South Carolina and North Carolina are cases in point. South Carolina’s navigator funding is about two-thirds less than the state had last year, while most of North Carolina’s funding is intact.

The Trump administration  that it is rewarding groups that did a good job and cutting off those that didn’t. But the strategy may have the effect of hobbling navigators who have the most daunting job signing up people.

Instead, Quenga said, she will have to be strategic about where she plans to place navigators.

“It is based on those areas that are a) more densely populated and b) had a higher level of ACA enrollment for 2017,” she explained.

That means about two-thirds of the state’s counties will not have any navigators. Quenga said she is still planning to help people in those areas by using screen-sharing technology to walk people through sign-ups. People can always call the federal call center for help, but that’s not ideal, she said.

Quenga said her employees really take the time to work through complicated cases. For example, she said, “lots of people have family members sleeping on their couch. Do you count that person as a tax dependent or not?”

The answer is complicated. How much someone gets financial aid is based on his or her taxable income, which changes with the number of dependents, she said. “Choosing whether to include that person as a dependent can have big consequences in terms of your financial assistance,” she said. “The call center is not set up to run those scenarios for you.”

And with less help from the federal government, Quenga said, she feels the pressure mounting to get more people signed up for coverage during this year’s shorter enrollment period. If she does, there’s a chance her navigator group will be better funded next year.

The picture is very different in North Carolina. There, navigator groups had only about 10 percent of their federal funding cut.

Jennifer Simmons coordinates North Carolina’s largest navigator program, the and said she’s happy to report there will be someone available in each of the state’s 100 counties during the six weeks of open enrollment this year.

They’ll help people like Ilia Henderson, who is 26 and lives in Huntersville, just outside of Charlotte. She is one of those young, healthy people insurance companies want and she’s getting ready to sign up for coverage with navigator Julieanne Taylor.

Last year, Taylor helped Henderson, a massage therapist and student, sign up for a medical and dental plan within half an hour for a good price — just over $100 a month. She looks forward to working with Taylor to find a similarly good deal for 2018. Simmons said her navigators will be in libraries, public health departments and even churches around the state.

“We are remaining really laser-focused on making sure that consumers across North Carolina are able to get info they need,” she said.

“There are a lot of people that need renewal services and help in making sure that the marketplace has their updated information and that the plan that they are in is still the right plan for their family,” Simmons said. “But we are also trying to reach new people.”

Last year, North Carolina had one of the  enrollments, with more than half a million people signing up. South Carolina, with about half of North Carolina’s population, has more than 183,000 people enrolled.

Sabrina Corlette with Georgetown University’s Center on Health Insurance Reform predicts enrollment numbers will drop during this open enrollment period.

“It’s just been decision after decision,” she said, “including this navigator funding cut that will ultimately lead not to just lower enrollment in the marketplaces but sicker enrollment in the marketplaces.”

And if that happens, Corlette said, count on higher premiums with fewer people in the insurance pool.

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These days, 6-year-old Clara’s biggest struggle is holding her breath long enough to touch the bottom of the pool in her North Carolina neighborhood. But immediately after she was born in 2011, she couldn’t even breathe. She had a serious birth defect called a .

Sitting next to her mom, Chrissy Hardy, Clara reads from a book, made of construction paper, that she wrote and illustrated in crayon. “On day eight, the surgeons cut me open,” Clara reads. “Everything that was in my chest got moved back to my belly. They put a patch to fix the hole in my diaphragm.”

“We were told more than once she would not survive,” her mother adds.

But after many procedures that Hardy estimates cost more than $1 million, she finally got to cradle her baby.

“She was born two months before I turned 30,” Hardy said, “and I held her the day before my 30th birthday.”

At the time, the whole family had health insurance through Hardy’s job as a public school teacher. So their out-of-pocket medical costs were just $10,000.

Those benefits, under the Affordable Care Act, must be covered by insurers, with  on what insurers chip in to cover a particular patient’s bills. The ACA also sets an  on the amount of money a patient must contribute to help cover the bills.

Under the proposed Senate bill, if one of the ACA’s “essential benefits” — such as  — is no longer deemed essential by a state, that leaves the door open to insurers to charge more for plans that include those benefits. This could even bring back lifetime caps on how much an insurer would pay for such services for a particular patient.

Hospitalization, emergency services and prescription drugs are just some of the 10 benefits that Clara needed — and might need again.

The details of how any change in the federal health law rules would play out in various states and in each health policy are still murky; the GOP Senate bill is still in draft form, and a lot will be left up to the state. But Clara’s dad, Robert Hardy, is worried.

“I don’t really know what the limit would be, but there is probably a good chance that she’s hit it,” he said.

, a health care economist with the Brookings Institution,Ìý that if the GOP bill passes, the problem of lifetime limits on what insurers could be counted on to pay for an insured patient’s care could spread quickly from state to state, because large companies that offer health insurance could choose the list of “essential health benefits” they include in their policies from any state.

“If you are an employer with 150 employees — so you are buying large-group market coverage, and you are entirely in Pennsylvania — you can choose Mississippi’s definition of essential health benefits for the purposes of the lifetime limit provision,” Fiedler explained.

While many businesses offer insurance to keep good employees, some may cut costs by offering policies with fewer benefits. And people who buy insurance plans from the exchanges would likely be limited to what their state of residence is willing to cover, said Fiedler.

“If a benefit were no longer [an] essential health benefit, you would probably not have plans that would offer that type of coverage without an annual or lifetime limit,” he said. “People would just have no place to go.”

That means the GOP bill, the Better Care Reconciliation Act, if passed, could effectively gut protection for preexisting conditions. If a state can let an insurer opt out of offering prescription drug coverage, for example, people who require medications would probably be paying more to have them covered.

The Hardys now get their health insurance through the North Carolina exchange — they were able to get it despite Clara’s past health problems. Worries about how the cost could climb, if the GOP bill becomes law, keeps her dad up at night.

“I would like to be able to be in a situation where I knew I didn’t have to worry if I was going to have to face a decision to bet my financial security against my child’s health,” Robert Hardy said.

As Clara reads her book, she lifts her pink shirt a little, to reveal a scar that cuts diagonally across her entire stomach.

“My scar on my tummy makes me proud,” she reads. “It is a reminder that I am tough and I can do hard things.”

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