Pediatricians like me come to our job with the conviction that children should not die — that whatever might hurt or kill them should be prevented, whether through car seat laws, safety tops on medication bottles, pediatric cancer research or, above all, routine vaccination.
Now we’re worried that vaccination will become less routine and less available. That the health care structure that keeps children safe may be under threat. That we will watch children suffer and even die, watch families grieve — and that part of the horror will be knowing that these were preventable diseases.
The Centers for Disease Control and Prevention’s vaccine advisory group met last week — its first meeting since the health secretary, Robert F. Kennedy Jr., dismissed the panel’s 17 experts and installed eight handpicked replacements, several with histories of vaccine skepticism. There, the panel, down to seven members after one withdrew, announced a review of the entire childhood vaccine schedule.
That’s scary. The recommendations of the panel, the Advisory Committee on Immunization Practices, help determine what vaccines are provided at no cost for about half of American children through the Vaccines for Children Program and influence coverage by private insurers. If the committee turns science-based recommendations into wishy-washy talk-to-your-doctor suggestions or, worse, takes certain vaccines off the schedule, America risks unraveling the infrastructure that keeps children vaccinated and without polio, diphtheria, whooping cough, tetanus, measles, mumps, rubella, bacterial meningitis and all the other horrors.
“Every day I have at least one parent ask me, ‘Are you still going to be able to give vaccines? Can I do something now in case they’re not available later?’” said my colleague Dr. Jane Guttenberg, a pediatrician in New York City.
Can we imagine a two-tiered system in which protection is available only to those with the means to pay hundreds of dollars for a vaccination? Can we imagine not giving a vaccine that a child needs? “I’ve been thinking about that a lot,” said Dr. Sally Goza, a primary care pediatrician in suburban Georgia. “Vaccines cost us money. I can’t just give vaccines away. I wish I could.”
Nowadays, all around the world, an overwhelming majority of children live to adulthood. For much of history, almost half did not. Child mortality is still higher than it should be, and there are still harsh inequities, but this change probably ranks as humanity’s greatest achievement.
Getting here required improving nutrition; ridding drinking water of sewage; finding antibiotics to treat infections; figuring out how to resuscitate newborns and repair congenital heart defects; and so much more.
Vaccines have been absolutely a key to this; infant and child mortality started falling after smallpox became a preventable disease, thanks to the brilliant discovery at the end of the 18th century that you could turn on immunity against the most feared killer virus by tricking the immune system with a weaker, more benign virus.
Now, vaccination rates are dropping in the United States and many other countries, in part because of increased vaccine hesitancy and disinformation. Pediatricians are encountering more parents who are afraid to vaccinate their children. Dr. Goza now needs her staff to check the vaccination status every time a parent calls about a young child with a fever, since a fever in an unvaccinated infant may mean the baby is in serious danger and has to be sent to the emergency room for tests.
“I never want to see a case of polio, but I’m very fearful I will,” she said.
During my medical training in the 1980s, I worried constantly about Haemophilus influenzae Type B, or Hib, which causes devastating bacterial infections of the bloodstream (bacteremia), spinal cord (meningitis) and throat (epiglottitis). The throat infection could quickly cut off a child’s airway, requiring an emergency tracheotomy, a surgical incision into a child’s windpipe. We did blood tests and spinal taps — so many spinal taps — and we watched helplessly in the pediatric intensive care unit as children who were perfectly healthy a week earlier struggled to survive and often ended up neurologically devastated. The Hib vaccine was introduced, and in the 1990s these infections largely went away.
But unless you wipe them out, these diseases come back if you stop vaccinating. For the first 25 years of his career, Dr. Adam Ratner, a pediatric infectious disease physician in New York City, never saw a child with Hib meningitis. But this spring he was an author of a report on two cases of severe disease in unvaccinated New York infants.
Up until recently, we were clearly moving forward. We learned about certain diseases from older pediatricians who had seen them before they were preventable, but we never expected to treat them ourselves. I never saw polio during my training, but I had teachers who had managed children in iron lungs. We also didn’t see measles.
“I graduated from med school in 2002 with the full comfort that we had eliminated measles in the U.S.,” said Dr. Lara Johnson, the chief medical officer for Covenant Health Lubbock, which treated many of the children hospitalized in Texas in the recent measles outbreak. “Goodness, the world looks different today.”
When Dr. Johnson was 4, in 1980, she had Hib epiglottitis, and she still has the tracheotomy scar. By the time she trained as a pediatrician, there were no new cases, but there were still meningitis survivors, many with severe neurological problems.
We need to keep children safe. We need Medicaid. We need vaccines. We need clear recommendations. We need the Vaccines for Children Program.
Truly science-based guidance will continue to come from the American Academy of Pediatrics. Already groups are mobilizing to help families follow those recommendations, including pressing insurance companies to continue to cover essential vaccines.
Pediatricians and parents will need to keep pushing back against misinformation and against the anxieties that are being deliberately and needlessly fomented. Research suggests that sustained engagement with concerned parents can help overcome vaccine hesitancy. There are parents who devote themselves, often in memory of a dead or devastated child, to vaccine advocacy, but no one should have to go through the heartbreak they have gone through.
Dr. Tammy Camp, a professor of pediatrics at Texas Tech University Health Sciences Center, described an infant last year who developed bad whooping cough and spent time in the pediatric intensive care unit being fed through a tube into his stomach because he could not stop coughing enough to drink. Whooping cough cases have risen amid falling vaccine rates; and the baby, too young to be vaccinated, was somehow exposed. His mother and grandmother told her that they had had no idea how terrible the disease was. The grandmother showed Dr. Camp a video of the child’s tiny body racked with the characteristic and sometimes life-threatening cough. “We’ve all seen those videos,” Dr. Camp said. We used to watch them in medical school to learn about a historical disease, a disease we expected to see rarely, if at all.
Will we really tolerate turning back this clock?
Dr. Perri Klass is a professor of journalism and pediatrics at New York University and the author of “The Best Medicine: How Science and Public Health Gave Children a Future.”
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