Vaccines Will Have to Prove Themselves Again. The Hard Way.
We’ve already quietly begun an all-American clinical trial
The only way to prove a vaccine works is with a large clinical trial. We did those back in the 1930’s to 1960's. But Americans don’t read history, so we’ve forgotten.
So now we’re unintentionally arranging a new one. It’s big — the U.S. has about 22 million children aged 0–5. It’s not double-blind. It’s only sorta randomized. But it does feature a placebo arm: the vulnerable kids of vaccine-hesitant moms.
Over the next few years, if substantially more of them are hospitalized or die, we’ll once again have fresh data proving vaccines really do work.
I welcome this. I’m tired of arguing. Over the last few years, public-spirited doctors have written dozens of earnest essays about how they must regain the public’s trust, become better messengers, learn to persuade mothers rather than speak down to them, and so on.
I used to agree. Now I say the hell with it. The anti-vaxxers have won. Their alternative facts have out-shouted real ones. The defenders of vaccines — Tony Fauci, Paul Offit, Peter Hotez, Greg Poland, whoever — are routinely dismissed as tools of Big Pharma. Pro-vaccine journalists like me are seen as their court jesters. The Disinformation Dozen, the ivermectin quacks and the vitamin pushers are on the verge of assuming public office.
So I say let’s just wait. When children begin dying, moms will figure out who was lying.
It’ll be ugly. It won’t work out as I’d schadenfreudianly prefer, hurting only the children of anti-vaxxers. In their first two years of life, babies are heart-breakingly unprotected, too young to vaccinate or build solid immunity. We ring-fence them now by vaccinating all their older siblings, their siblings’ friends who drop by for playdates and their cousins who come for Thanksgiving.
Some pro-vaccine parents will watch helplessly as their infants suffer. The extended-family fights, the confrontations at school drop-offs will be vicious, as in “Your unvaccinated brat killed my baby, you selfish bitch.” (How do I know this? Because every time my kids got lice in kindergarten, the parents all whispered among themselves to figure out whose kid brought in the cooties — and they were harmless. Imagine how that will escalate when someone brings diphtheria to school and a child strangles, or introduces mumps and a little boy gets swollen testicles and is rendered infertile for life.)
Still, the suffering will likely be concentrated among the unvaxxed. The data trends should become obvious.
We’re laying the groundwork for the trial. Twelve years ago, about 95 percent of the country’s kindergarteners had all their shots against measles, whooping cough, rubella, mumps, polio, diphtheria and tetanus. Now it’s about 93 percent and dropping, according to the annual survey by the Centers for Disease Control and Prevention. Back then, 1.4 percent had religious or “personal philosophy” exemptions; now it’s more than double that at 3.3 percent.
But those are the national figures. Anti-vaxxers live in state-by-state pockets, as you can see in this graphic from the CDC report.
Idaho may have the honor of going first. Only about 80 percent of its kindergarteners are vaccinated — by far the lowest rate in the nation.
On the other hand, epidemics thrive in crowds and Idaho isn’t crowded. Also, they often start in destinations that draw lots of foreign tourists. The big 2014 California measles outbreak, for example, started in Disneyland. Idaho has nothing comparable.
Running one’s eye down the list of the next-most-likely states — Alaska, Utah, Oregon, Arizona, Wisconsin, Nevada, North Dakota, Oklahoma — the one that jumps out is Nevada. Las Vegas is plenty crowded and has lots of foreign visitors and workers who go back and forth to their home countries. Virologically, whatever happens in Vegas will definitely not stay in Vegas.
(Notice something odd in the data? The Trump-trophic states of the Deep South have high vaccination rates. The low ones are the states where libertarianism and “gettin’ Western with it” hold sway, plus the elitist anti-Trump Left Coast, with the exception of California. California was low until the Disneyland outbreak led it to outlaw religious and personal exemptions. Mississippi, by contrast, used to consistently have 99 percent vaccine coverage. I suspect that was a vestige of racism; before anti-vaxxing became a fad among conservatives, disease outbreaks often spread from poor black communities to white ones, so Mississippi used to grant zero non-medical exemptions.)
Another factor is at play: Vaccine resistance tends to concentrate in certain ethno-religio-philosopho-puddles that defy generalization. In the last 30 years, measles and polio outbreaks have popped up among Somalis in Minnesota, Orthodox Jews, Amish farmers, Waldorf students, and faith-healing cults.
But because of racism and other -isms, average Americans don’t identify with Somalis, Orthodox Jews, the Amish, Waldorf kids or faith-healers. So the lessons those mini-studies could have taught were ignored. In some low-vax states, however, we may have reached the tipping point where an outbreak in one sub-group can become generalized. Once it threatens all that state’s Beaver Cleavers, Opies, Bart Simpsons, Becky Thachers and Margaret Simons, average Americans may pay more attention.
In New York City, most of our children will probably be safe. The city’s health department has long resisted religious or personal philosophy exemptions, and the state outlawed them in 2019 after a major measles outbreak in Brooklyn’s Orthodox neighborhoods infected more than 600 kids and hospitalized almost 50 of them. (Maine, Connecticut and West Virginia also ban all non-medical exemptions, including religious ones.)
By the way, if you think your religious beliefs can never be questioned or restricted because the First Amendment guarantees freedom of religion, think again. Courts don’t let parents watch their children die because they have religious objections to blood transfusions. We wouldn’t let someone claiming to be an Aztec priest perform human sacrifice; we’d arrest him for murder. We don’t even permit polygamy, although it’s the norm in the Old Testament. In 1879, in Reynolds v. United States, the Mormon Church challenged Utah’s anti-bigamy law on the grounds that it violated their First Amendment freedoms. The Supreme Court unanimously ruled against them, holding that, if it permitted polygamy — which it called “odious among the northern and western nations of Europe” — it might then have to permit human sacrifice and bride burning.
(On the other hand, the 1993 Supreme Court unanimously permitted religious animal sacrifice, so practitioners of santeria and voodoo are safe. Today’s Supreme Court might okay throwing virgins into volcanoes, but I’m hoping not.)
I doubt that our all-American clinical trial will produce a runaway epidemic. Parents often re-think their opposition when they realize their children are truly at risk, and vaccines are still plentiful.
I would change that bet, however, if vaccines become scarce. Shortages could quickly develop if RFK Jr. and a Trump-dominated Congress remove the controversial protection that vaccine companies now have against liability lawsuits. The companies might simply quit the business rather than face billion-dollar legal bills. That’s what they threatened to do in the 1980’s, after the Supreme Court in 1977 lifted the ban on lawyers’ advertising and we became a hyper-litigious society. Most old vaccines are low-profit items, more of a public good than a smart business. That’s why Congress created the no-fault Vacccine Injury Compensation Program.
A sudden shortage on top of anti-vax fearmongering could be disastrous. The risk isn’t just hypothetical; in 1993, after the Soviet Union collapsed, shortages, mistrust of government and health-system breakdowns triggered a major outbreak of diphtheria— a disease the U.S.S.R. had conquered 30 years earlier. It led to 3,000 deaths among children and adults. (Diphtheria vaccine protection wanes with time and bacterial strains mutate, so even American adults who were last vaccinated in childhood are vulnerable. Are you one of them?)
I just wish we didn’t have to do this all over again. Last July, Lena H. Sun of the Washington Post did a terrific piece interviewing older Americans about their memories of having measles 60 years ago. All recalled being miserable. One was in a coma for 30 days, another had to live in a dark room to prevent eye damage. One infected his pregnant mother and feared he was why his sister was born disabled. While all survived without major damage, each had a lingering symptom — leg weakness, vision problems or an autoimmune disease — that they suspected was linked to their long-ago infections.
Yes, most kids recover. But in those days, many families (including mine) had five or six children in part because they knew some wouldn’t make it. Maybe Elon Musk, father of 12, has spares, but most American families now have only one or two children. The wailing could be awful.
Donald G. McNeil Jr.’s partially autobiographical book, The Wisdom of Plagues: Lessons From 25 Years of Covering Pandemics, will be available in paperback in January.
