As anticipated, RFK Jr. continues to be a wrecking ball on the American healthcare scene as HHS secretary. His latest move to undermine vaccines in any way possible is to reduce the number of vaccines on the routine vaccine schedule from covering 17 illnesses to covering only 11. This will have the predictable result of reducing vaccine compliance and increasing preventable disease.
How he is doing this is as important as what he is doing, so let’s take a closer look. First, the CDC recommendations are now divided into three categories – population-based, risk-based, and shared clinical decision making. The first category is what we already understand as routine vaccines to protect individuals and prevent the spread of infectious disease throughout the population. The second category, risk-based, essentially means that vaccines in this category are only recommended for people in a high risk population. The third category (which I suspect RFK would eventually want all vaccines in) means that there is no specific recommendation, just a discussion between doctors and patients.
This is partly intended to be a political shell-game – RFK can argue, as he does in the announcement, that all vaccines currently on the schedule are still on the schedule, just in different categories. So he can say he is keeping his promise that he is not taking vaccines away from Americans. But this is transparent nonsense. Removing a vaccine from the list of routinely recommended vaccines will reduce uptake, and private insurers can make it more difficult to get coverage.
Hepatitis A, Hepatitis B, rotavirus, meningiococcal disease, influenza, and COVID-19 are all moved to the “shared clinical decision making” category, which effectively removes them from the list of recommended vaccines (although technically still “on the schedule”).
How does RFK Jr. justify this change? This is where things get more interesting, and alarming. First, there did not appear to be any review process. Normally the vaccine schedule is reviewed by a panel of experts, who pour over all of the scientific research and discuss the risks vs benefits of each vaccine. The panel that does this is ACIP (Advisory Committee on Immunization Practices). We have already discussed how RFK gutted this committee, firing everyone and then hiring a panel of anti-vaccine quacks and cranks. Previously this panel decided to remove Hep B from routine recommendations. But this time RFK appears to have bypassed the panel.
Process, of course, is critical to science. Science, and any profession based on science and evidence, is all about process. In science you have to transparently show your work, as how you get to a conclusion is more important than the conclusion itself. RFK’s process appears to be – just trust me.
He does try to justify this new schedule with an incredibly weak argument, that he spends 33 pages making. His main argument is that the new schedule aligns better with – Denmark. Why Denmark? Great question. It is not because they are a good analogy for the US, or that they have a superior process of vaccine review than the US or other countries. I can only suspect that he just cherry picked a country with a vaccine schedule more to his liking as justification for his latest anti-vaccine move.
It is not hard to see, as many have, why Denmark is a horrible analogy to US health care. Denmark has a population of only 33 million, and they have universal health care with centralized tracking. So everyone is in the system and has access to routine preventive care. In such a system, something like shared decision making is much more viable. The US, by contrast, has 330 million people, with 27 million uninsured, no centralized healthcare database, and individuals frequently moving to different providers and insurance. So putting it on individuals to take the initiative to seek out a specific vaccine is likely not to work well.
Keep in mind, it only takes a drop in a few percentage points of vaccine uptake for some infectious diseases to spread much more easily. Such a drop also leaves millions of people unprotected, and is likely to result in significant morbidity and mortality. Vaccines are a preventative measure. They need to be part of routine care in order to be effective, and since every percentage point counts, they need to be as easy, cheap, and convenient to get as possible in order to maximize effectiveness. RFK’s new schedule will cause death and disease, the only question is how much.
So RFK abandoned a decades-old process of having experts make recommendations based on the current science, and substituted his own bias thinly justified with a terrible analogy to a cherry picked nation. We know from following RFKs shenanigans over decades what his biases look like.
First, he is clearly anti-vaccine, despite his coy protestations. His behavior over the last year should dispel any confusion on this point. He has done all the things we predicted he would do based on an anti-vaccine agenda.
But to dig one level deeper – part of his problem is that he confuses hazard for risk. Medicine functions optimally when it is explicitly founded on a science-based risk vs benefit analysis. For each intervention, what is the net effect on the health outcomes of the patient? What is the benefit of the intervention vs the side effects and other risks? This should make obvious sense.
Hazard is the mere potential for harm, without any consideration for the probability of harm. The analogy I favor is the notion of a shark at an aquarium in a tank. That shark is certainly a hazard, but as long as it remains in the tank and you remain outside the tank, the risk is very low.
What RFK is doing is the equivalent of not driving to the hospital to be evaluated and potentially treated for an acute life-threatening disease because you are afraid of getting into an accident on the way there. Sure, car accidents are a real hazard and can cause death and injury. But the risk of getting into an accident on one trip is very low, meanwhile the risk of not treating a serious acute illness is far greater.
RFK is worried (ostensibly) about the known and unknown hazards of vaccines, more so than is justified by the evidence. He is also less worried than he should be about the negative consequences of the diseases that these vaccines can help prevent. This is partly due to his poor understanding of medical science and clinical decision making (he is not an expert), but also due to the fact that he appears to be a full-fledged conspiracy theorist. He does not trust the system and does not trust experts. He thinks this gives him clearance to just substitute his own beliefs for the consensus of expert opinion.
This is what happens when you abandon respect for proper process, when you put incompetent ideologues in charge of science-based professional organizations, and what happens when you erode trust in expertise. This is a systemic problem in modern society that goes way beyond RFK jr and the vaccine schedule, but he is perhaps the worst manifestation of it and one likely to cause significant death and misery.
