How Fragile Is Our Vaccine Infrastructure?

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Anti-vaccine sentiment is, more or less, as old as vaccines. When Cotton Mather promoted inoculations against smallpox in the 1720s, someone threw a firebomb through his window with a message attached: “Mather, you dog, Damn you, I’ll inoculate you with this.” Back then, the idea of purposely injecting God’s perfect creatures with disease seemed like heresy, and the research, anyway, was sketchy. In the centuries since, the science around vaccines has gotten more solid, and government accountability stronger. In 2021, when some people who had received the Janssen COVID-19 vaccine developed blood clots, the government discovered the issue quickly and took action. These days, vaccines are as safe and effective as ever. So why is the anti-vax movement at the height of its power and influence?

Robert F. Kennedy Jr., the nominee to be the next secretary of the Department of Health and Human Services, is “the king of the anti-vaxxers,” says senior editor Daniel Engber. (RFK Jr. doesn’t like the term anti-vaxxer, but it fits. He’s said, “There’s no vaccine that is, you know, safe and effective.”) Dave Weldon, nominated to head the Centers for Disease Control and Prevention, has accused that agency of ignoring evidence of links between vaccines and autism—“evidence” that has been solidly debunked. In this episode of Radio Atlantic, we discuss this disorienting moment, when anti-vaccine conspiracy theorists may soon be in charge of the agencies that fund, recommend, and research vaccines, with Engber and Arthur Allen, author of Vaccine: The Controversial Story of Medicine’s Greatest Lifesaver. What levers could the anti-vaxxers in charge pull to disrupt vaccine distribution? How could they affect vaccine recommendations and research? What happens if there is an outbreak? And how fragile is the nation’s vaccine infrastructure?

The following is a transcript of the episode:

Hanna Rosin: For all the parents listening, I bet you remember this moment: You have this tiny, new creature in your life. You feel vulnerable. The new baby seems extra vulnerable. And one of the first things you have to do to this tiny creature is let the doctor inject into her small amounts of disease.

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Rosin: But you almost certainly have to do it for a kid to go to school, which makes vaccines a very real way that people feel the presence of the state in their lives. And so vaccines turn out to be a very excellent way to examine this moment we’ve landed in, where people who deeply mistrust the government are suddenly in charge of critical parts of it.

I’m Hanna Rosin. This is Radio Atlantic. And today, we’re going to talk about vaccines— more specifically, the anti-vaxxers who Trump has nominated to run our health institutions and how they might change our world. One critical dividing line between the two parties right now—maybe the critical dividing line—is trust in expertise, in authority, in institutions.

And this showdown, which in the coming administration will play out over lots of arenas—the military, education, intelligence—it’s been brewing in the vaccine world for years, maybe centuries.

Let’s start in the modern world with Trump’s nominees—who they are, what they believe, and what they might do. To help me with that, we have Atlantic science writer and editor Daniel Engber. Dan, welcome to the show.

Daniel Engber: Thanks, Hanna.

Rosin: So when Trump announced RFK as his pick to be the next secretary of Health and Human Services, what was your reaction?

Engber: I thought, I can’t believe this is really happening.

Rosin: Uh-huh.

Engber: So I remember Trump had a meeting with RFK in early 2017. And RFK—do you remember? He came out of Trump Tower, and he was like, I’m going to be the head of a new vaccine-safety commission.

And I and many other science journalists immediately got to work thinking about, What will we do if that happens? And then it didn’t happen. Trump was just sort of toying with him as he toyed with Mitt Romney and many others. So in the back of my head, I kind of thought, Well, maybe that’s going to happen again.

But it’s different this time.

Rosin: Yeah. And it’s not just RFK, right?

Engber: No. I mean, so RFK has been tapped for Health and Human Services, but then there’s a whole host of kind of contrarian characters in public health who are similarly being put up for important positions.

Engber: What all of these people seem to have in common, with the exception of Weldon, maybe, is they were critics of the COVID response. But other than that, I mean, there are clear differences among these people too. Some of them are, you know, very conventional thinkers on the value of vaccination. Others are really on the kind of anti-vaccine end of the spectrum.

Rosin: Okay, so let’s talk about this broad category of anti-vaxxers, or vaccine skeptics, or vaccine doubters. Who are they, and what do we know about what they believe?

Engber: Well, I think RFK is kind of like the king of the anti-vaxxers.

Engber: I mean, he describes himself as not being anti-vaccine. I don’t think there’s anyone who describes themselves as being anti-vaccine. So, you know, perhaps we should retire that term, or maybe we should use it despite these people’s protestations.

But in any case, he’s very worried about the conflicts of interest behind the decisions that are made to approve and distribute vaccines, and particularly concerned about safety issues with certain vaccines. The measles, mumps, and rubella vaccine, in particular—he’s spread a lot of doubt about that and a potential link to autism, which has been demonstrated not to be a real connection. And also, he has a lot of concerns about mercury in vaccines. And he stepped away from it recently to run for president, but he was in charge of Children’s Health Defense, which described doubts about vaccines arising during the pandemic as the pandemic’s “silver lining” and as good news that vaccination rates were dropping for the nation’s children.

So I would say this is a radical organization on vaccine issues. So that’s RFK. And then Dave Weldon, the former member of Congress from Florida who has now been nominated to run Centers for Disease Control and Prevention—he has a long history of also being wary of vaccination, believing in the link between the MMR vaccine and autism.

He invited Andrew Wakefield, who’s best known for producing a study of the MMR vaccine and its alleged link to autism that has since been debunked. So Weldon invited Wakefield to come to Congress. You know, this is a couple of decades ago. But still, that’s the track record we have for Weldon, who has not really done a lot in public life recently.

Rosin: Now, Weldon said in an interview that, like you said, he would not describe himself as anti-vaccine—his own children are vaccinated—and that he administers vaccines in his own clinic. So help me understand how to categorize these guys. I mean, we’ve got RFK and Dave Weldon, who are specifically associated with skepticism about vaccines.

How would you, as a science journalist, characterize their skepticism? How should we understand it?

Engber: Okay, well, I mean, fully out of the mainstream is how I would describe it, just in the sense that what we’re talking about here, really, is rejecting standard public-health advice, and standard public-health advice is very mainstream. So more than 90 percent of the nation’s children are getting this sort of standard set of immunizations.

They’re required for entry into school at kindergarten. This is, like, not particularly a controversial issue for most Americans. It’s even an understatement. For almost all Americans, right? So more than 90 percent of kids are getting these shots, and the people who don’t—it often has as much to do with access or various other reasons that have nothing to do with, like, an ideological opposition or a dispositional skepticism of vaccines.

So I would say this is a fringe belief.

Rosin: So we have people who you describe as having a fringe belief in charge of varying health organizations. What does that mean? What can they do?

Engber: Well, it is unclear, right? In simple terms, the vaccine mandates for children, let’s say, to get into public school: That’s handled at the state level. There’s nothing RFK could do—or any of the people that he appoints under him—to change the requirements for kindergartners in California or New York or Florida. That’s going to be handled locally. So that’s just one thing that’s off the table.

However, as secretary of HHS, Kennedy would have control over the recommendations made by the CDC. And, of course, Dave Weldon also would be in that line of decision making. So at the CDC, there’s a committee that comes together and decides which vaccines are going to be recommended for which age groups, and they decide sort of the nature of the recommendation. I mean, there’s sort of these technical distinctions here—but is it a strong recommendation? Is it a recommendation that the vaccine be discussed between the patient and their health-care provider? That sort of thing.

Now, once those recommendations are made, insurance companies tend to pay for the vaccines, and state public-health officials tend to mandate them. So everyone takes their cues from CDC on this—not always always. But, you know, generally, this is how it works.

So what happens if people with fringe beliefs are in control of this committee? If that committee starts making recommendations, let’s say—I don’t think this is going to happen, but—against recommending the MMR shot for children, what would happen at the state level? Who knows. That would be, I think, uncharted territory. But again, the actual decision would be made—the policy decision would be made—at the local level.

Rosin: So right now the state of affairs is that there is this fairly standard and commonly accepted list of vaccines that are approved year by year by the CDC, and then that translates down to insurance companies and schools, and it’s basically a kind of routine process now? Like, it doesn’t have that many hitches—even though there is some number of people who opt out of getting vaccines for their kids, mostly it’s just gone through as a standard part of American childhood? Like, Check, check, check. Get these vaccines.

Engber: Yeah, and sometimes, you know, the vaccine schedule will change; the standard set will change. And when there are new vaccines in the mix—the HPV vaccine, for example, or the COVID vaccine and COVID boosters of recent years—then, you know, there’s real discussion. Well, this booster, should it be recommended for people of all ages or only older people?Should there be, you know, different guidance for young men, let’s say, given that there’s some evidence of some adverse heart-related effects for young men who take the mRNA vaccines? So then there’s no, you know, business as usual. There’s discussion and debate, and decisions are made, right?

There’s another part of it, which I should mention also, which is: The federal government administers something called the Vaccines for Children Program, which provides something like half of the immunizations for children in the country. That’s a multibillion-dollar program. That’s just another place where if you had vaccine skeptics in control, who knows what might happen?

Rosin: Just so I understand, you know—let’s say there’s a group of people who only can get their vaccines through a public clinic—this is federally funded.

Engber: Exactly.

Rosin: Like, federally funded vaccines, so if people can’t afford vaccines or don’t have insurance, their children can still get vaccinated and go to school.

Engber: Yeah, vaccination rates for children have increased pretty dramatically since the early ’90s, and that’s largely due to this program. And the issue, again: It’s not like there were lots of vaccine-skeptical parents in the early ’90s who have now been converted to the “proper” way of thinking, in quotes.

No, it’s just that there were a lot of children who didn’t have access to vaccines, and now they do because of the Vaccines for Children Program.

Rosin: Okay, I have to say: What you just described seems like a tremendous amount of influence—or potential influence—over routine vaccinations.

Engber: Yeah. I mean, like I said, it’s kind of uncharted territory. It’s hard to know how these things will play out, right? You know, at the level of the CDC recommendations, if there was just a dramatic shift in what was being recommended, how would the system respond?

I just—it’s really hard to imagine, right? Because I think you would still have most doctors in the country believing that these vaccines were extremely important for their patients. You would still have most parents believing that. I mean, the large majority of parents strongly endorse the value of vaccines, and many, many local health officials.

So I don’t know. I mean, it’s hard to say. I do think, too, about what’s going on in Florida as maybe a case study. So, you know, Ron DeSantis, when he was challenging Trump for the nomination, seemed to have made a decision to run as the vaccine-skeptical candidate. Trump’s history here is a little weird, right?

He took credit, reasonably, for Operation Warp Speed, which developed the COVID vaccine really quickly.

Rosin: Seemed proud of it, in fact.

Engber: Was proud of it, endorsed it initially—and then, kind of following his constituents, drifted a little bit in the other direction over time, and then came out against vaccine mandates in schools, and then, you know, seems to have an ambivalent attitude towards the COVID vaccine, let’s say.

But DeSantis, I think, saw this as an opening and said, Okay, I’m gonna really lean into this. There are a lot of, you know, Republican voters for whom this is an important issue. So DeSantis himself had been, you know, very excited about the COVID vaccine initially and then kind of turned against it.

And he brought in a guy named Joseph Ladapo to head the Florida Health Department in the end of 2021. And Ladapo has been, among other things, quite an aggressive opponent of COVID vaccination—not just of vaccine mandates; that’s kind of the standard position. Ladapo has been warning people in Florida that the COVID mRNA vaccines are potentially unsafe and that no one should get them, ever. At first, he was like, Well, you know, they’re dangerous for young people. And most recently, he’s just said, mRNA vaccines are potentially dangerous, period.

For a statewide official to be so aggressive about recommending against the use of a CDC-recommended vaccine, that’s very unusual.

Rosin: So what happened?

Engber: So he’s been in charge since late 2021. Now, I should say that a lot of the action on COVID vaccination was over by then, right? So the people who were going to get vaccinated, many of them had already been vaccinated, and then COVID booster uptake has been low everywhere.

But what I thought was quite interesting is: When I started looking at the stats for Florida, it was really hard to find, like, a Ladapo effect. Again, this would be an effect of having the person in charge of your statewide public-health department recommending against vaccination. Like, you might think, coming to this fresh, that, Well, that person is going to have so much power and control. Their word is going to be so influential. So you would expect, you know, vaccination rates—COVID vaccination rates—in Florida to fall off a cliff.

They didn’t. And age-adjusted COVID mortality rates did not increase under Ladapo. It was just kind of hard to find evidence for that Ladapo effect that I was looking for, which I, again, was sort of imagining as: This is what happens when you put someone who’s suspicious of vaccines in charge.

Rosin: Right. So what do you conclude from that? That it’s just a political position but doesn’t necessarily have much influence, either on the medical establishment, people’s personal decisions, doctors’ offices, parents—anything like that?

Engber: Yeah, I mean, it just sort of supports my general belief that there’s a lot of inertia in the system, and, you know, people are going to behave the way they’re going to behave, by and large. It’s not as easy to push parents, as a giant group of people in the United States, to suddenly stop vaccinating their kids.

So that’s kind of my baseline expectation, is that it is hard to budge this system. But again, I’ve never in my life seen people like RFK and Dave Weldon standing, you know, on the bridge, right? So this is just something that we haven’t seen before. So it’s not really analogous to Ladapo in Florida, who’s just one state surgeon general saying, Don’t get your COVID booster.

You know, a worst-case scenario is there is some dramatic shift in policy at the CDC. There could be dramatic shifts at the FDA, which approves new vaccines. You know, they could choose not to approve them, or there could be new safety requirements for vaccines, which just slow things down.

I mean, that’s another bad scenario that, you know—it’s not like vaccines are banned or taken away, but just the release of new vaccines is slowed dramatically. I mean, we could have another pandemic in the next few years: H5N1 bird flu, right? And so if we have RFK and Dave Weldon in charge, like, how fast is the next Operation Warp Speed? That’s very unclear to me, and that strikes me as a potential terrible scenario.

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Engber: What RFK could do—what someone in a position of power could do—is just create obstacles, right? If the big, dramatic success of national vaccination over the past 30 years has been providing access to children who didn’t have that access before—if that’s what brought the measles vaccination rate up from 80-something percent to 90 percent—then just undo that, right? Like, just create obstacles for people to get the vaccines they want. Just take away the whole choice architecture that leads people to get vaccinated if they don’t have strong opinions on it one way or another. Take away the clinics that provide the shots, right?

That’s how you would lower the rates if you really—if that was your only goal.

Rosin: Yeah. And just to be clear, no one said they’re going to do that. You’re just giving them free advice here.

Engber: Yeah. (Laughs.)

Rosin: Okay. All right. Excellent. Well, we’ll stay on top of this subject since we’ve never seen a thing like this before. Dan, thank you so much for joining me.

Engber: Thank you.

[Music]

Rosin: Next: how we got to this moment of mistrust and the winding path of vaccine acceptance in the U.S.

Rosin: That’s after the break.

[Break]

Rosin: We’re back from break. I’m joined by health journalist Arthur Allen, who wrote the book Vaccine. Arthur, welcome to the show.

Allen: Thanks for having me, Hanna.

Rosin: So we are about to see vaccine skeptics have power in a way they never have before, which must be strange for you, who’s been tracking them for a long time, to see people who are mistrustful of big government suddenly running the government. I mean, it’s a very weird moment.

Allen: It certainly is. I mean, when I wrote my book, and it came out in 2007, it was like there were two journalists interested in vaccines in any way.

And, you know, the idea of the skeptics were just totally fringe. I mean, that’s what everyone thought. And now here they are inside the castle.

Rosin: I know. It’s so strange. So let’s reel back, since you’re a rare person who knows this movement really well. What are the roots of the skepticism? Like, where does it start?

Allen: Well, there are a lot of strands to skepticism about vaccines. The basic thing is that vaccines are given to healthy people, often to kids, and the whole idea of them is a little bit frightening. And when they succeed, nothing happens. And so, you know, there’s very little kind of rah-rah for vaccines, like, in the vox pop, because most people alive today haven’t seen the worst of what they do.

So I mean, that’s an important condition because what happens is that, you know, there are people who just think that putting something in your body like this to prevent a disease goes against God or isn’t natural or is, you know, a pharmaceutical plot. I mean, there’s many different strands, and they all kind of tend to come together —and have, at the moment.

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Allen: But if you go back far enough—I mean, the first inoculation in North America was in the 1720s. And it was considered—you know, they were trying to vaccinate against smallpox, and it was a dangerous procedure, but it was actually beneficial, and it was widely adopted for the next 80 years.

But at that time, you know, it was considered ungodly, like, you know—not that people would take the craziest medicines. This has always been true that people will take any kind of crazy medication to treat an illness, but the idea that you would prevent something, in the first instance, was considered sort of to go against religion.

And there were also people who argued, and eventually successfully, that, you know, vaccination was a gift from God.

Rosin: But initially, it was a sense you were, like, injecting disease or sin or something like that into a pure body?

Allen: Right, and especially with a baby. You know, like you were injecting this sinful material into a baby.

Rosin: Yeah. Okay. So time went on. After the 18th century, there were several vaccines that came about. In the early parts of vaccine history, were there times when skeptics had a point? Like, they were right to be suspicious of the pushing of certain vaccines?

Allen: Well, actually, you know, a contaminated smallpox vaccine is why we have an FDA. I mean, around 1902, there was this terrible outbreak of tetanus, and it killed a number of kids in Camden, New Jersey, and in a bunch of other places, there were also deaths. And it was smallpox vaccine that hadn’t been properly made and was contaminated.

And so there were frequent reports, if you look in the literature from these days—like, I extensively looked through everything in Pennsylvania, like, the first 10 years of the century—and swollen arms were really common, you know, bad infections, you know. There weren’t any antibiotics, so if you had a bad infection, there wasn’t much you could do about it.

And the public-health people in those days—it was like a new tool that they had, and they were pretty brutal at times. I mean, there were forced vaccinations, where they would chase down workers, and they would, you know, pull them out of, like, drain pipes to vaccinate them, and this kind of thing.

And the vaccines were not entirely safe, and they were very varied. Some were; some weren’t. And so, like I said, that was one of the things that led to the creation of the FDA.

So that’s smallpox. And then, you know, you have—time marches on, and medicine starts to have some legitimacy. And then after World War II, you know, it really has legitimacy because you’ve got antibiotics. You’ve got a bunch of—you know, viruses were kind of discovered and worked on by the military during World War II.

And the flu vaccine was developed. It wasn’t very good, but a ton of other things were developed. And all this research was done into viruses, and it led to the polio vaccine.

Allen: And so the polio vaccine came—you know, there was a trial involving, like, I think, a million and a half kids. So here’s an unlicensed vaccine. You know, three million parents are happy to have their kids vaccinated with this thing. And luckily, it worked. And, you know, 1955—that was this huge moment of celebration, and church bells rang, and this kind of thing.

Allen: And it was at a time of great confidence in the system, you know, and in the government: We’d just won in World War II.

So that’s a period, and then we have [the] measles vaccine [that] came in the early ’60s, and other vaccines came along. But there was, sort of as a footnote to the polio vaccine campaign, several bad batches of vaccine made by Cutter Laboratories, and some also by Wyeth, that gave kids polio because it was an inactivated polio vaccine that hadn’t been properly inactivated.

So that was a little bit—that caused them to pause the vaccination campaign, but it really was like a blip. And to me, that’s a very significant moment, because that was possibly one of the worst vaccine accidents in sort of the modern era. But it really didn’t do much to stop public confidence in vaccination.

Really, the first blow to vaccination in a way that had ripples on a national level was the swine-flu affair of 1976, which was: A soldier at Fort Dix, New Jersey, died of the flu. It was a new strain of flu. And the CDC, the public-health authorities, thought, Uh-oh. This is, like, the new pandemic coming down the line.

Allen: They convinced Gerald Ford, and there was a mass-vaccination program.

Allen: And it turned out to be, like, a nothingburger of a flu pandemic. There were some side effects from that vaccine—not really that many, but some causing some paralysis.

Allen: So that was kind of a big fall-on-your-face moment for public health.

And then following that, there were starting to be lawsuits over the whooping cough vaccine. The whooping cough vaccine—the whole-cell pertussis vaccine—had been around since the ’30s, but there had been reports, sort of all along, that it was a very reactive vaccine.

And if you talk to the vaccine experts, reactive doesn’t mean the same as dangerous. But for a parent whose kid gets the vaccine, and they have a 103-degree fever or, you know, they have seizures, which can be benign—but, like, are terrifying—you know, it was a nasty piece of work. It was also very effective.

But there were a number of cases of lawsuits starting in the early ’80s, and it was starting to really catch on as a legal issue, like, you know, asbestos or something.

Allen: And this was, you know, a crisis for the vaccination program because a bunch of vaccine makers were getting out of the business. They were, like, frightened of the liability issue. They weren’t making a lot of money on these vaccines anyway. I mean, the pertussis vaccine at the time probably cost, like, 15 cents a dose or something.

Allen: So in sort of more contemporary times, that was the first big, like, vaccine-skepticism moment.

Rosin: So to summarize, basically over the decades, there were problems that came up with vaccines.

Allen: Right.

Rosin: Some of them were somewhat serious. Most of them, it sounds—but they were minor. Like, in the scheme of the ways that vaccines generally protected people, there were nonetheless some minor issues with vaccines until the ’70s, when those issues, for whatever reason, captured the public imagination.

Allen: That’s right, and also, it’s important to point along that during the period when vaccines are causing this or that sort of minor issue, there’s a parallel universe in which vaccines are, like, causing everything. And so—

Rosin: What do you mean?

Allen: Like, blamed for, like, causing kids to be autistic; causing, you know, rock and roll; causing, you know, headbanging; causing, you know, crime. I mean, the pertussis vaccine was blamed for, like, everything. I mean, the anti-vaccine movement really kind of had a moment of incredible growth during all of that.

And then in the ’90s, the sort of mainstay of the anti-vaccine movement, you know, really was created during the whole controversy over autism, because autism has increased over the past three, four, five decades, and no one is that sure what the cause is. And people were pointing fingers at vaccines. And a paper was published to that effect in 1998 and then refuted repeatedly. But it continues to live on, that idea.

Rosin: So at this moment, how safe would you say vaccines are, compared to their long history of safety?

Allen: I mean, I think they’re as safe as they’ve ever been. I mean, they’re tested through a number of procedures that look for really big danger signals. And then as soon as they go on the market, the CDC has a system for looking for danger signals that I think is probably better than anything they have for drugs.

I mean, it’s pretty good. It’s not like it’s a perfect system, but I personally would sort of have confidence that it would find anything fairly obvious or significant.

Rosin: So given that vaccines are relatively safe now—that there’s a system in place for monitoring their safety after they come out—how do you explain why the vaccine-skeptic movement at this moment, when vaccines are at their safest, would get so much momentum?

Allen: I mean, I think there’s a lot of money behind them. There’s a hard core of people who are skeptical of vaccines, and any new technology, in particular, they’re, like, immediately distrustful of. I mean, you just saw all the crazy stuff that went out there—you know, that Bill Gates was putting microchips in the vaccines. So I think there’s just an inherent mistrust.

And then the COVID experience, you know, that got so polarized—and arguably, public health went a little bit overboard in, you know, how long schools were kept closed in some places. Or, you know, closing beaches—that wasn’t really necessary.

So I think the turn against vaccines became part of the whole, like, mistrust of the government, which was very polarized. I mean, it was like, you know, for a lot of people, Tony Fauci was a hero, and it seemed like he was kind of a hero for everybody for a while. And then he became this demon who they want to throw in jail, to this day.

What’s kind of ironic is that, you know, vaccine safety and vaccine skepticism really don’t track together. Vaccine skepticism has to do with confidence in the government. Vaccine safety, you know, is a progressive thing that, in general, has gotten better over time.

Rosin: So was COVID a moment when what was once a relatively fringe theory gained more mainstream acceptance? Like, it just got folded into a resistance to lockdowns?

Allen: Yeah, I think so. I mean, it’s kind of interesting: In 2014, there was a measles outbreak at Disneyland.

Allen: This led to a decision by the very Democratic legislature in California to tighten requirements on school vaccination.

Allen: Up to then, in California, you could get an exemption for your kid from vaccination on fairly flimsy grounds—religious or philosophical—and they got rid of that. And there was a huge backlash against that. There were movements all over the country to tighten rules. And that really, like, gave a shot in the arm, so to speak, to the anti-vaccine movement.

And so that movement was there. And then the pandemic sort of joined them with all these, like, Moms for Liberty, and all these other sort of anti-government groups and anti-public-health people.

But the anti-vaccine core was quite strong before the pandemic.

Rosin: So now that some people who are sympathetic to the movement are in power, what are the kinds of things you think they could do?

Allen: Well, I think the thing that people don’t realize about the vaccine sort of enterprise is: It’s actually pretty fragile.

I mean, drug companies come in and out of the vaccine business readily. Like, the industry’s interest in vaccines is not that big. I mean, some of them make money now. The Shingrix makes money. The pneumococcus vaccine, which a lot of older people get, makes money. The rest of them, you know, I’m sure—I don’t know, they probably break even on some of them or maybe make a small profit—but they’re not, like, blockbuster drugs.

Rosin: When you say it’s fragile, you’re saying any amount of cultural pressure, political pressure could easily deter. There’s no great incentive on the part of the pharmaceutical manufacturers to continue to innovate and create vaccines.

Allen: That’s right. And the Advisory Committee on Immunization Practices that’s at the CDC, when they make a recommendation for a vaccine, that automatically makes it available to poor kids through the Vaccines for Children [Program].

So Trump, or RFK, can take over the advisory committee and stack it with his people, who could get rid of it altogether. It expires during Trump’s term unless it gets renewed.

Rosin: So for you, who’s tracked this for a while, what’s the worst-case scenario?

Allen: Well, there have been 16 measles outbreaks in the country this year. Whooping cough is on the upswing; that’s partly because it’s cyclical and because our current vaccine doesn’t completely prevent infections, sort of like the COVID vaccine doesn’t. Pertussis, I mean—it can be a very nasty disease, but it’s usually not fatal unless you’re a baby.

And so there could be low levels—but growing levels—of these diseases that just, you know, kind of happen, and nobody really does anything about it. And it’ll lead to chaos in emergency rooms. It’ll lead to, you know, more strains on the health-care system, and it’ll lead to deaths and misery, you know, for kids.

What worries me is, like, in a way, you almost think, Oh gee, if, like, five kids died of measles, would that turn things around? But it’s almost more worrisome to think, Well, there could be five deaths of kids, and it won’t turn things around.

Rosin: So it sounds—from what you’re saying, it seems like skepticism of government health agencies runs in waves. Like, there are periods when there’s high trust in public health. Right now, we’re in a period of pretty low trust, post-COVID. When is public trust high? Like, what is something that could turn this moment we’re in now from extreme skepticism of government health agencies back into trust?

Allen: Well, I think, unfortunately, it would have to be some kind of a disaster that public health comes in and resolves. And it could be, you know, a terrible measles outbreak or epidemic, or whooping cough epidemic that kills a bunch of babies.

I mean, based on the historical example, that’s when public health is really popular. And look at polio. I mean, that was, like, probably the high moment for public health, you know, in the last 150 years. And that was this disease that everybody was afraid of. They came in with a vaccine, and they, you know, wiped it out.

Rosin: Right. So it’s essentially what you’re saying: It would have to be a tragedy.

Allen: Yeah. Yeah.

Rosin: Okay. Well, we won’t look forward to that. But thank you. Thank you for explaining this all to us, and thank you for coming on the show.

Allen: Well, thank you so much for having me.

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Rosin: That was Arthur Allen, author of Vaccine. He’s also a writer for the KFF Health News.

This episode of Radio Atlantic was produced by Kevin Townsend. It was edited by Claudine Ebeid and fact-checked by Sara Krolewski. It was engineered by Rob Smierciak. Claudine Ebeid is the executive producer of Atlantic audio, and Andrea Valdez is our managing editor. I’m Hanna Rosin. Thank you for listening.