Sharfstein JM. Vaccines and the Trump Administration. JAMA Health Forum. Published online February 22, 2017. doi:10.1001/jamahealthforum.2017.0011
Writing recently in the New York Times, infectious disease physician Peter Hotez warned: “It’s looking as if 2017 could become the year when the anti-vaccination movement gains ascendancy in the United States and we begin to see a reversal of several decades in steady public health gains. The first blow will be measles outbreaks in America.”
Joshua M. Sharfstein, MD
These fears have everything to do with the new administration in Washington, DC. During the campaign, Donald Trump met with discredited British physician Andrew Wakefield, who first alleged a connection between the measles, mumps, and rubella (MMR) vaccine and autism in a now-retracted Lancet article. Then, in a September 2015 primary debate, Trump himself suggested that vaccines cause autism. In January, Robert F. Kennedy, Jr, known for his engagement with vaccine conspiracies, emerged from a meeting with the President-elect to claim that he will lead a new vaccine safety commission.
Some have drawn reassurance from the fact that the Trump administration has yet to confirm that there will be such a commission. Moreover, in his confirmation hearing, Health and Human Services Secretary Tom Price, MD, stated his understanding that science does not support a connection between vaccines and autism. However, Price also declined an opportunity to recommend the current vaccine schedule, stating, “As a physician, I encourage individuals and families to consult with their physician on the most appropriate care for them and their loved ones.”
It is foreseeable that in the coming weeks, challenges to our vaccination system will come from 3 directions at once.
First, there will likely be greater attention to theories that vaccines cause harm. Whether through news made by a vaccine commission, tweets from high-ranking government officials, or claims made at an upcoming rally in Washington, DC, the effect will be the same: ideas well outside the scientific mainstream will receive far greater exposure than they deserve based on their merits.
This exposure, however, will not necessarily be very successful in changing public perception of vaccine safety. In the early 2000s, in the midst of a bout of vaccine skepticism led by former Congressman Dan Burton (R, Indiana), the Institute of Medicine issued a series of comprehensive reports that concluded that evidence favors rejection of the hypothesis that vaccines cause autism. These reports blunted national concern and were one reason why the major outbreaks that occurred in Europe around that time (and since) have not been seen in the United States. The evidence on vaccine safety has grown stronger since that time.
Recently, the American Academy of Pediatrics organized more than 350 organizations, including the American Medical Association, to write a letter to President Trump to endorse vaccination. The letter stated that “claims that vaccines are unsafe when administered according to expert recommendations have been disproven by a robust body of medical literature.” Continued leadership of organized medicine and its members should help withstand direct assaults on the scientific foundation of vaccination.
However, even if vaccine skeptics are not able to convince the public about purported risks to vaccination, they will still likely argue that vaccines should not be mandatory for school entry. This second foreseeable challenge to vaccination will be based in ideology, not science. For many years, a strain of popular thinking has resisted the idea that government should put any pressure on parents to make specific decisions about the health of their children. Secretary Price has been an active member of an organization that resists laws requiring vaccination for school entry, on the grounds that they are “equivalent to human experimentation.”
This individualistic ideology, however, does not fare well in the wake of preventable outbreaks. For example, the Disneyland outbreak at the start of 2015 led, as some anticipated, to public pressure and rapid passage of a law eliminating broad exemptions to vaccination in California. The public quickly grasps that small infants, children with cancer, and others who are immunocompromised are at risk of serious illness when coverage levels fall below those needed for community protection. Indeed, a recent survey by the Pew Charitable Trusts found that more than 4 in 5 US adults support requiring vaccination for measles, mumps, and rubella for school entry. If there is a push to roll back these laws, the continued threat of measles will be the strongest argument for maintaining high coverage rates.
A third coming challenge to vaccination targets the critical role of government agencies and scientific organizations in ensuring the safety of vaccines. The goal is to undermine trust in our nation’s system that generates and evaluates evidence. Robert F. Kennedy, Jr, for example, claimed his commission would be focused not just on vaccine safety but rather on “vaccine safety and scientific integrity,” with the second phrase needed “to make sure that we’re getting good science out of the CDC [the Centers for Disease Control and Prevention].” Kennedy recently joined with actor Robert De Niro to promote a Congressional briefing covering the topic of “ongoing inherent conflicts of interests at the CDC.”
Central to this effort is an attempt to weave specific emails, analyses, and disagreements between scientists into a larger narrative of corruption and incompetence. The weakness of this attack, however, lies in its refusal to acknowledge the big picture of vaccine oversight in our country. There are scores of scientists at the US Food and Drug Administration and the CDC who have devoted their careers to the development of safe and effective vaccine programs. There are also hundreds of scientists outside government engaged through advisory committees and the peer review process. This includes many devoted clinicians standing behind the American Academy of Pediatrics’ Red Book recommendations, and experts from across the country who participate in the Advisory Committee on Immunization Practices. This multifaceted system has identified safety signals, investigated them rapidly, and taken a broad range of actions, including removing vaccines from the market entirely.
Resisting this third challenge requires countering the false narrative that portrays a nameless, faceless, inflexible, and corrupt bureaucracy facing off against a scrappy group of advocates and parents. It is critical instead to tell the accurate story of the many devoted clinicians and scientists who follow the evidence, debate important scientific questions, take action when needed, and, who understandably, resist those who have already made up their minds that vaccines are unsafe. This is a bipartisan message, as a recent letter from Senate and House leaders illustrates.
Hotez’s warning may prove prescient. Or it may help motivate resistance to coming vaccination challenges. We will be able to tell the difference by the number of measles cases in the United States in the months and years ahead.
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Joshua M. Sharfstein, MD Joshua M. Sharfstein, MD, is Vice Dean for Public Health Practice and Community Engagement and Professor of the Practice at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. He previously served as Secretary of...