What is the war on vaccines really about? Just after the New Year, like someone racing to fulfill a resolution, Robert F. Kennedy Jr.’s MAHA alliance at the Department of Health and Human Services released a radically revised federal vaccine schedule, bypassing the usual procedures and abruptly cutting the number of diseases for which shots are recommended from 17 to 11.
The new guidelines certainly look like the frontal assault on vaccine science many Americans have been fearing for a year. But a different way to think about it is this: as another attack on the country’s threadbare social safety net by health libertarians whose strategy for making America healthy again appears straightforwardly to mean letting more of the country’s weak and vulnerable suffer and die.
On a recent episode of the podcast “Why Should I Trust You?” the new head of the federal vaccine advisory panel, the pediatric cardiologist Kirk Milhoan, said flatly that his goal was to make “individual autonomy,” rather than “public health,” the top priority of the country’s public health apparatus. As part of that mission, he questioned whether we should even be vaccinating for polio.
Kennedy and his acolytes have defended their new set of recommendations as a way of bringing America’s standards in line with those of other wealthy countries. In some narrow sense, their argument is accurate. Many countries maintain policies closer to the old American set than the new one, but generally speaking, they require fewer shots. One country in particular stands out as a natural comparison for the new American standards: Denmark.
But as many public health workers have responded, in considering why the United States and Denmark had taken such different approaches to vaccination policy, you should at least consider the fact that, well, the United States isn’t Denmark. It is much larger and more diverse, with a much more unhealthy population and more severe health disparities, too. Not to mention: The health care systems that attend to the sick in the two countries are very different, as well.
Part of the problem is that the two countries face different disease landscapes: In 2023, per capita rates of chronic hepatitis B, for instance, were more than three times as high in the United States as in Denmark. The hepatitis B vaccine is now recommended by the C.D.C. only for high-risk groups, but that points to another major difference: Because of its patchwork health system, the United States is far less effective in screening for risk than countries in which health care is universal and health surveillance is both more far-reaching and feels less obtrusive.
When people do get sick in other rich countries, it’s generally easy and affordable for them to get care. That isn’t always the case here, where more than 25 million Americans lack health insurance and, partly as a result, many maintain an erratic and distrustful relationship with health care. There are also obvious demographic, behavioral and morbidity differences, which mean that many more Americans are vulnerable to opportunistic infections than their counterparts in Denmark.
And what this implies is rather striking, and rarely discussed by those outside of public health: that among their many purposes and benefits, vaccines have served now for decades as a kind of substitute health safety net in America. They are a way of limiting the downside consequences of all of our country’s notorious shortcomings: its lack of universal or free health care, its imperfect health insurance system, its lack of robust disease surveillance and screening, its declining trust in medical institutions and practitioners, its yawning gaps of economic inequality and equally horrifying disparities in morbidity and mortality.
Elsewhere, these problems might be addressed in other ways, through various forms of redistribution, welfare policy and social spending. In the United States, it seems, the best we’ve been able to do is to protect against some of the health manifestations of those problems with a few shots. Give a pregnant mother an R.S.V. vaccine and you can worry less about whether her child will have easy access to care and treatment for respiratory infections. Give a newborn a hepatitis B shot and it matters much less whether someone in the family is an intravenous drug user who might be carrying the disease. Give a full course of M.M.R. protection and you don’t need to worry quite as much about the way measles is much more punishing for those suffering malnutrition. And if you don’t do any of these things, or you make it harder for others to — well, all those problems start to loom a bit larger.
If America were a healthier, better cared for and solidaristic place, perhaps we could get away with somewhat less aggressive vaccination, trusting that those who really needed the boost of protection could be reliably identified ahead of time and that those who fell sick later could be capably treated. As it is, mass vaccination is not just a disease prophylactic but among the simplest tools we have to limit the damage of America’s many social pathologies and inequalities. And the consequences of rolling back that safety net are likely to be profound.
How profound? Much of the answer depends on how much is actually rolled back, and — for now, at least — it seems likely that large parts of the country will stick closely to the old recommendations, state by state. This is another way in which the MAHA reign has been as much bark as bite: Many states have decoupled their own recommendations from the federal guidelines, and leading health organizations, from the American Academy of Pediatrics to the American Medical Association, are doing the same.
But almost certainly that won’t be the case everywhere, and it is probably least likely in those places that are already falling way behind in most measures of health and well-being. In some Southern states, such as Mississippi and Alabama, life expectancy is more than half a decade shorter than in Northeastern states, including Massachusetts, Connecticut and New York.
Look by county and the disparities are even starker, with life expectancy over a decade shorter in large swaths of Appalachia than in the upper Midwest. That’s about the same as the life expectancy gap between Liechtenstein and Bangladesh.
These American disparities are not merely the results of gaps in vaccine coverage. Vaccines are one way we have of addressing the underlying pathologies, social and individual, that give rise to them. Without vaccines, the diseases will be both much more ravaging and far more common. Perhaps more disconcertingly, those now in charge seem basically fine with that.
“What we’re going to have is a real-world experience of when unvaccinated people get measles,” Dr. Milhoan, the head of the vaccine advisory panel, said, sounding somewhat excited about the possibility. “What is the new incidence of hospitalization?” he asked. “What’s the incidence of death?”
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