Former health secretary tells inquiry some healthcare settings did run out - "and it was awful".

When I was taking German in college in the early years of this millennium, I once stumbled upon a word that appeared foreign even when translated into English: Diphtherie, or diphtheria. “What’s diphtheria?” I wondered, having never encountered a single soul afflicted by this disease.

Diphtheria, once known as the “strangling angel,” was a leading killer of children into the early 20th century. The bacterial infection destroys the lining of the throat, forming a layer of dead, leathery tissue that can cause death by suffocation. The disease left no corner of society untouched: Diphtheria killed Queen Victoria’s daughter, and the children of Presidents Lincoln, Garfield, and Cleveland. Parents used to speak of their first and second families, an elderly woman in Ottawa recalled, because diphtheria had swept through and all their children died.

Today, diphtheria has been so thoroughly forgotten that someone like me, born some 60 years after the invention of a diphtheria vaccine, might have no inkling of the fear it once inspired. If you have encountered diphtheria outside of the historical context, it’s likely because you have scrutinized a childhood immunization schedule: It is the “D” in the DTaP vaccine.

Vaccine breakthroughs over the past two centuries have cumulatively made the modern world a far more hospitable place to be born. For most of human history, half of all children died before reaching age 15; that number is down to just 4 percent worldwide, and far lower in developed countries, with vaccines one of the major drivers of improved life expectancy. “As a child,” the vaccine scientist Stanley Plotkin, now 92, told me, “I had several infectious diseases that almost killed me.” He ticked them off: pertussis, influenza, pneumococcal pneumonia—all of which children today are routinely vaccinated against.

But the success of vaccines has also allowed for a modern amnesia about the level of past human suffering. In a world where the ravages of polio or measles are remote, the risks of vaccines—whether imagined, or real but minute—are able to loom much larger in the minds of parents. This is the space exploited by Robert F. Kennedy Jr., one of the nation’s foremost anti-vaccine activists and now nominee for secretary of Health and Human Services. It is a stunning reversal of fortune for a man relegated to the fringes of the Democratic Party just last year. And it is also a reversal for Donald Trump, who might have flirted with anti-vaccine rhetoric in the past but also presided over a record-breaking race to create a COVID vaccine. Kennedy has promised that he would not yank vaccines off the market, but his nomination normalizes and emboldens the anti-vaccine movement. The danger now is that diseases confined to the past become diseases of the future.

Walt Orenstein trained as a pediatrician in the 1970s, when he often saw children with meningitis—a dangerous infection of membranes around the brain—that can be caused by a bacterium called Haemophilus influenzae type b or Hib. (Despite the name, it is not related to the influenza virus.) “I remember doing loads of spinal taps,” he told me, to diagnose the disease. The advent of a Hib vaccine in the 1980s virtually wiped these infections out; babies are now routinely vaccinated in the first 15 months of life. “It’s amazing there are people today calling themselves pediatricians who have never seen a case of Hib,” he says. He remembers rotavirus, too, back when it used to cause about half of all hospitalizations for diarrhea in kids under 5. “People used to say, ‘Don’t get the infant ward during diarrhea season,’” Orenstein told me. But in the 2000s, the introduction of rotavirus vaccines for babies six months and younger sharply curtailed hospitalizations.

To Orenstein, it is important that the current rotavirus vaccine has proved effective but also safe. An older rotavirus vaccine was taken off the market in 1999 when regulators learned that it gave babies an up to one-in-10,000 chance of developing a serious but usually treatable bowel obstruction called intussusception. The benefits arguably still outweighed the risks—about one in 50 babies infected with rotavirus need hospitalization—but the United States has a high bar for vaccine safety. Similarly, the U.S. switched from an oral polio vaccine containing live, weakened virus—which had a one in 2.4 million chance of causing paralysis—to a more expensive but safer shot made with inactivated viruses that cannot cause disease. No vaccine is perfect, says Gregory Poland, a vaccinologist and the president of the Atria Academy of Science & Medicine, who himself developed severe tinnitus after getting the COVID vaccine. “There will always be risks,” he told me, and he acknowledges the need to speak candidly about them. But vaccine recommendations are based on benefits that are “overwhelming” compared with their risks, he said.

The success of childhood vaccination has a perverse effect of making the benefits of these vaccines invisible. Let’s put it this way: If everyone around me is vaccinated for diphtheria but I am not, I still have virtually no chance of contracting it. There is simply no one to give it to me. This protection is also known as “herd immunity” or “community protection.” But that logic falls apart when vaccination rates slip, and the bubble of protective immunity dissolves. The impact won’t be immediate. “If we stopped vaccinating today, we wouldn’t get outbreaks tomorrow,” Orenstein said. In time, though, all-but-forgotten diseases could once again find a foothold, sickening those who chose not to be vaccinated but also those who could not be vaccinated, such as people with certain medical conditions and newborns too young for shots. In aggregate, individual decisions to refuse vaccines end up having far-reaching consequences.

Evolutionary biologists have argued that plague and pestilence rose in tandem with human civilization. Before humans built cities, back when we still lived in small bands of hunter-gatherers, a novel virus—say, from a bat—might tear through a group only to reach a dead end once everyone was immune or deceased. With no one else to infect, such a virus will burn itself out. Only when humans started clustering in large cities could certain viruses keep finding new susceptibles—babies or new migrants with no immunity, people with waning immunity—and smolder on and on and on. Infectious disease, you might then say, is a necessary condition of living in a society.

But human ingenuity has handed us a cheat code: Vaccines now allow us to enjoy the benefits of fellow humanity while preventing the constant exchange of deadly pathogens. And vaccines can, through the power of herd immunity, protect even those who are too young or too sick to be effectively vaccinated themselves. When we get vaccinated, or don’t, our decisions ricochet through the lives of others. Vaccines make us responsible for more than ourselves. And is that not what it means to live in a society?

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Robert F. Kennedy Jr., the nominee to be the next secretary of Health and Human Services, is America’s most prominent vaccine skeptic. An advocacy organization that he founded and chaired has called the nation’s declining child-immunization rates “good news,” and referred to parents’ lingering doubts about routine shots as COVID-19’s “silver lining.” Now Kennedy may soon be overseeing the cluster of federal agencies that license and recommend vaccines, as well as the multibillion-dollar program that covers the immunization of almost half the nation’s children.

Which is to say that America’s most prominent vaccine skeptic could have the power to upend, derail, or otherwise louse up a cornerstone of public health. Raising U.S. vaccination rates to where they are today took decades of investment: In 1991, for example, just 82 percent of toddlers were getting measles shots; by 2019, that number had increased to 92 percent. The first Trump administration actually presided over the historic high point for the nation’s immunization services; now the second may be focused on promoting vaccines’ alleged hidden harms. Kennedy has said that he doesn’t want to take any shots away, but even if he were to emphasize “choice,” his leadership would be a daunting test of Americans’ commitment to vaccines.

In many ways, the situation is unprecedented: No one with Kennedy’s mix of inexperience and paranoid distrust has ever held the reins at HHS. He was trained as a lawyer and has no training in biostatistics or any other research bona fides—the sorts of qualifications you’d expect from someone credibly evaluating vaccine efficacy. But the post-pandemic era has already given rise to at least one smaller-scale experiment along these lines. In Florida, vaccine policies have been overseen since 2021 by another noted skeptic of the pharmaceutical industry, State Surgeon General Joseph Ladapo. (Kennedy has likened Ladapo to Galileo—yes, the astronomer who faced down the Roman Inquisition.) Under Ladapo’s direction, the state has aggressively resisted federal guidance on COVID-19 vaccination, and its department of health has twice advised Floridians not to get mRNA-based booster shots. “These vaccines are not appropriate for use in human beings,” Ladapo declared in January. His public-health contrarianism has also started spilling over into more routine immunization practices. Last winter, during an active measles outbreak at a Florida school, Ladapo abandoned standard practice and allowed unvaccinated children to attend class. He also seemed to make a point of not recommending measles shots for any kids who might have needed them.

Jeffrey Goldhagen, a pediatrics professor at the University of Florida and the former head of the Duval County health department, believes that this vaccine skepticism has had immense costs. “The deaths and suffering of thousands and thousands of Floridians” can be linked to Ladapo’s policies, he said, particularly regarding COVID shots. But in the years since Ladapo took office, Florida did not become an instant outlier in terms of COVID vaccination numbers, nor in terms of age-adjusted rates of death from COVID. And so far at least, the state’s performance on other immunization metrics is not far off from the rest of America’s. That doesn’t mean Florida’s numbers are good: Among the state’s kindergarteners, routine-vaccination rates have dropped from 93.3 percent for the kids who entered school in the fall of 2020 to 88.1 percent in 2023, and the rate at which kids are getting nonmedical exemptions from vaccine requirements went up from 2.7 to 4.5 percent over the same period. These changes elevate the risk of further outbreaks of measles, or of other infectious diseases that could end up killing children—but they’re not unique to Ladapo’s constituents. National statistics have been moving in the same direction. (To wit: The rate of nonmedical exemptions across the U.S. has gone up by about the same proportion as Florida’s.)

All of these disturbing trends may be tied to a growing suspicion of vaccines that was brought on during COVID and fanned by right-wing influencers. Or they could be a lingering effect of the widespread lapse in health care in 2020, during which time many young children were missing doses of vaccines. (Kids who entered public school in 2023 might still be catching up.)

In any case, other vaccination rates in Florida look pretty good. Under Ladapo, the state has actually been gaining on the nation as a whole in terms of flu shots for adults and holding its own on immunization for diphtheria, tetanus, and pertussis in toddlers. Even Ladapo’s outlandish choice last winter to allow unvaccinated kids back into a school with an active measles outbreak did not lead to any further cases of disease. In short, as I noted back in February, Ladapo’s anti-vaccine activism has had few, if any, clear effects. (Ladapo did not respond when I reached out to ask why his policies might have failed to sabotage the state’s vaccination rates.)

  

If Florida’s immunization rates have been resilient, then America’s may hold up even better in the years to come. That’s because the most important vaccine policies are made at the state and local levels, Rupali Limaye, a professor and scholar of health behavior at Johns Hopkins University, told me. Each state decides whether and how to mandate vaccines to school-age children, or during a pandemic. The states and localities are then responsible for giving out (or choosing not to give out) whichever vaccines are recommended, and sometimes paid for, by the federal government.  

But the existence of vaccine-skeptical leadership in Washington, and throughout the Republican Party, could still end up putting pressure on local decision makers, she continued, and could encourage policies that support parental choice at the expense of maximizing immunization rates. As a member of the Cabinet, Kennedy would also have a platform that he’s never had before, from which he can continue to spread untruths about vaccines. “If you start to give people more of a choice, and they are exposed to disinformation and misinformation, then there is that propensity of people to make decisions that are not based on evidence,” Limaye said. (According to The New York Times, many experts say they “worry most” about this aspect of Kennedy’s leadership.)

How much will this really matter, though? The mere prominence of Kennedy’s ideas may not do much to drive down vaccination rates on its own. Noel Brewer, a behavioral scientist and public-health professor at the UNC Gillings School of Global Public Health, told me that attempts to change people’s thoughts and feelings about vaccines are often futile; research shows that talking up the value of getting shots has little impact on behavior. By the same token, one might reasonably expect that talking down the value of vaccines (as Kennedy and Ladapo are wont to do) would be wasted effort too. “It may be that having a public figure talking about this has little effect,” Brewer said.

Indeed, much has been made of Kennedy’s apparent intervention during the 2019 measles crisis in Samoa. He arrived there for a visit in the middle of that year, not long after measles immunizations had been suspended, and children’s immunization rates had plummeted. (The crisis began when two babies died from a vaccine-related medical error in 2018.) Kennedy has been linked to the deadly measles outbreak in the months that followed, but if his presence really did give succor to the local anti-vaccine movement, that movement’s broader aims were frustrated: The government declared a state of emergency that fall, and soon the measles-vaccination rate had more than doubled.

As head of HHS, though, Kennedy would have direct control over the federal programs that do the sort of work that has been necessary in Samoa, and provide access to vaccines to those who need them most. For example, he’d oversee the agencies that pay for and administer Vaccines for Children, which distributes shots to children in every state. All the experts I spoke with warned that interference with this program could have serious consequences. Other potential actions, such as demanding further safety studies of vaccines and evidence reviews, could slow down decision making and delay the introduction of new vaccines.

Kennedy would also have a chance to influence the nation’s vaccine requirements for children, as well as its safety-and-monitoring system, at the highest levels. He’d be in charge of selecting members for the Advisory Committee on Immunization Practices, which makes recommendations on vaccines that are usually adopted by the states and result in standardized insurance coverage. He’d also oversee the head of the CDC, who in turn has the authority to overrule or amend individual ACIP recommendations.

Even if he’s not inclined to squelch any determinations outright, Kennedy’s goal of giving parents latitude might play out in other ways. Brewer, who is currently a voting member of ACIP (but emphasized that he was not speaking in that capacity), said that the committee can issue several different types of rulings, some of which roughly correspond to ACIP saying that Americans should rather than may get a certain vaccine. That distinction can be very consequential, Brewer said: Shots that are made “routine” by ACIP get prioritized in doctor’s offices, for instance, while those that are subject to “shared clinical decision-making” may be held for patients who ask for them specifically. Shifting the country’s vaccination program from a should to a may regime “would destroy uptake,” Brewer told me.

Those would seem to be the stakes. The case study of vaccine-skeptical governance that we have in Florida may not look so dire—at least in the specifics. But Kennedy’s ascendancy could be something more than that: He could steer the public-health establishment off the course that it’s been on for many years, and getting back to where we are today could take more years still.