Two and a half years ago, Ashish Jha was the White House’s COVID-19 response coordinator, a job that meant getting as much of the country as possible on board with the federal government’s approach to public health. For much of this summer, he’s been doing the opposite of that.
As Robert F. Kennedy Jr., the secretary of the Department of Health and Human Services, dismantles nearly every core component of the country’s vaccine infrastructure—defunding vaccine research, restricting access to shots, spreading mistruths about immunizations, purging experts who might threaten his anti-vaccine agenda—“I’m spending all my energy trying to help states come up with how they’re gonna manage this situation,” Jha told me. He, like many others in public health, wants Kennedy removed, and for the government to push back against HHS’s new direction. The best way to achieve that, he said, “is for states to do a sharp break with ACIP and CDC, and basically declare CDC defunct.” In June, Kennedy dismissed the entire roster of ACIP—the CDC’s Advisory Committee on Immunization Practices, which for decades has used scientific evidence to guide the agency’s nationwide vaccine recommendations—and has since been restocking the panel with anti-vaccine researchers who lack relevant expertise. The CDC “no longer has any credibility as a public-health entity,” Jha said. “States have to do it themselves.”
And some states are. This week, Washington, Oregon, and California announced that they would form a coalition to issue their own vaccine recommendations. Hawaii joined soon after. Several states in the Northeast might do the same. Several professional medical societies, including the American Academy of Pediatrics and the American College of Obstetrics and Gynecology, have revolted against the government, and last month published immunization guidelines that diverge from the current CDC’s. These secessions—each driven by a loss of faith in the scientific soundness of the CDC’s recommendations—seem designed to destroy the agency’s credibility. “I’ve told folks, ‘In the not too distant future, you won’t be able to believe anything that’s on the CDC’s website regarding vaccines,’” Nirav D. Shah, who served as the CDC’s principal deputy director until February, told me.
Kennedy’s recent actions may just be the opening salvo. “We’re on the threshold of an even more transformative period,” Jason Schwartz, a vaccine-policy expert at Yale, told me. Kennedy has promised that, with a report assembled in a few short months, HHS will soon end the years-long debate on the drivers of autism—which Kennedy has repeatedly and baselessly linked to vaccines, despite decades of evidence debunking that claim. Kennedy is also reportedly eager to yank mRNA COVID vaccines off the market—which would remove any option to immunize children under 12, including highly medically vulnerable ones, against the coronavirus. Later this month, his handpicked ACIP could vote to restrict several more immunizations, including ones that protect babies against hepatitis B, measles, mumps, rubella, chicken pox, and RSV. (Kennedy has maintained that people who want COVID vaccines will be able to get them. When reached for comment, Emily Hilliard, HHS’s press secretary, wrote that “ACIP remains the scientific body guiding immunization recommendations in this country, and HHS will ensure policy is based on rigorous evidence and Gold Standard Science, not the failed politics of the pandemic.”)
“We’re watching a massive experiment unfold,” Bruce Gellin, who directed the National Vaccine Program Office from 2002 to 2017, told me. A united front is one of the best defenses against infectious disease: The science supporting vaccination holds true everywhere, and pathogens don’t respect state borders. “It doesn’t make any rational sense for a kid in Pennsylvania to get a different vaccine recommendation than a kid in Ohio,” Jha said. But a version of that is what the country is about to try. The federal government has functionally abdicated its role in keeping Americans safe from dangerous illness. In the vacuum it has left, states will chart their own paths, almost certainly in diverging directions. Florida this week announced that it would abandon vaccine mandates entirely. The country’s defensive shields against disease are shattering, in ways that could take decades, even generations, to mend.
In the U.S., the job of deciding which vaccines people must get has largely fallen to the states. But for decades—essentially since the 1960s, with the inception of ACIP—states have mostly chosen to hew to what the CDC says about how and when people should immunize. And in the 1990s, the nation’s medical experts, realizing the costs of divergent advice, aligned their recommendations with the CDC’s too.
After a major measles resurgence began in 1989, scientists moved to add a second dose of the MMR vaccine to bolster protection—but the American Academy of Pediatrics and the CDC’s vaccine-advisory panel disagreed on the optimal time to administer it. “It caused a lot of confusion,” Walter Orenstein, who directed the country’s National Immunization Program from 1993 to 2004, told me, as providers felt torn between following their professional society and the government. And so “every major medical organization came together to issue a single immunization schedule”—one that would harmonize with ACIP’s. Although states still make independent decisions about how to require shots in schools, the nation has long stood behind one grand, unifying theory of how its people should approach infectious disease.
That synchronization was premised on an agreement that scientific evidence, above all else, would guide vaccine recommendations. That same premise is now pushing professional societies and states to diverge from the CDC’s guidance. This week, the governors leading the West Coast contingent of defections issued a joint statement saying the CDC had “become a political tool that increasingly peddles ideology instead of science.” In a statement outlining its own vaccine recommendations, the AAP specifically called out Kennedy’s flagrant disregard for expertise, noting that AAP leaders would, in contrast to the CDC, “continue to provide recommendations for immunizations that are rooted in science.”
When I asked HHS about states’ recent departures from precedent, Andrew Nixon, the department’s director of communications, answered only about “blue states,” criticizing them for pushing “unscientific school lockdowns, toddler mask mandates, and draconian vaccine passports during the COVID era.” But HHS has also signaled its support for states that align with Kennedy’s push for less vaccination. Last month, the department sided with West Virginia’s governor in a fight with its board of education by urging the state to allow religious exemptions for school vaccine requirements; this week, HHS doubled down on that position, issuing guidance that states participating in the federal Vaccines for Children Program, which offers vaccines to kids whose families can’t otherwise afford them, “must respect state religious and conscience exemptions from vaccine mandates.”
Kennedy seems to believe that the evidence is on his side. At a congressional hearing yesterday, he repeated his past claims that mRNA vaccines are dangerous and deadly, despite overwhelming evidence showing that the shots have saved millions of lives and come with only rare risks. And he is surrounding himself with people who won’t argue otherwise. In the past seven months, he and his allies have ousted several top health officials whose read of the evidence hasn’t aligned with his—most recently, Susan Monarez, who directed the CDC until last week, when Kennedy and Trump fired her after she reportedly refused to preemptively rubber-stamp recommendations from the secretary’s bespoke ACIP. (Kennedy, in this week’s hearing, described this recounting of events as a lie.) And they have installed into positions of power at HHS several researchers—many of them lacking vaccine or infectious-disease backgrounds—with fringe vaccine views.
The government’s scientific advisers, too, are now ideological allies rather than independent experts. ACIP, which as recently as June was filled with 17 scientists whose backgrounds spanned vaccinology, pediatrics, infectious disease, public health, and more, now includes individuals who have advocated for pulling mRNA shots from the market, denounced COVID vaccines at an anti-mandate rally, and publicly argued that their child was injured by the MMR vaccine. Within scientific branches of government, the currency of checks and balances has always been data; Kennedy and his allies have forcibly dismantled those guardrails. “They’ve replaced everybody who could push back on the administration,” Fiona Havers, a former CDC official who quit the agency in June in protest of Kennedy’s anti-vaccine actions, told me. The true power of the federal government’s various health agencies, several federal health officials told me, rests with the scientific expertise of its people. But as of this year, expertise is no longer their hallmark of HHS.
Kennedy has done more than simply meddle with recommendations. Over the past century or so, the federal government has thrown its weight behind every major part of the country’s vaccination pipeline: funding vaccine research, scrutinizing and regulating shots, advising the public on how to use them, and helping monitor vaccine safety and performance. Kennedy has introduced a clog into just about every part of this system. The infrastructure that offers Americans routine protection against up to 18 different infectious diseases “took decades to build,” Havers said. “Kennedy has managed to destroy it in a very quick amount of time.”
Many of those changes are reversible, in theory. Personnel can be rehired; ACIP members’ term limits will run out; new leaders can rewrite policies. Those people and policies, though, will not be effective if the public overall has become less inclined to listen to them. Governors, physicians, and public-health experts are arguing for a calculated rift with the federal government because it’s necessary to meet the political moment, Jha told me: Restoring the CDC’s integrity requires first persuading the public to discount it. Eventually, these experts acknowledge, if they regain control of the federal health apparatus, they’ll have to ask the public to trust in those same agencies again. In the interim, they are hoping most Americans will keep looking to scientific and medical experts as a source of constancy—even as they embroil themselves in a fight with the nation’s leaders.
That gamble might not pay off. When experts moved to harmonize the country’s vaccine schedules in the 1990s, the recent outbreak had laid out the stakes and benefits of synchronization clearly. “It wound up being easy,” Orenstein told me. The differences between the AAP’s recommendations and the government’s “were fairly minor” too. This time, though, the schisms between the CDC and the states and professional societies go far beyond the timing of an additional dose of vaccine. They’re about whether scientific evidence should guide the country’s approach to immunity—and, ultimately, how much say the federal government has in how Americans protect themselves.
The likeliest catalyst for a quick realignment would be a severe uptick in disease—local epidemics, another pandemic. Even then, many of the experts I spoke with fear, the country’s vaccine infrastructure, having been razed, could not easily contain those outbreaks, and the U.S. would struggle to rebuild its health agencies to their former strength. “The more of the system is destroyed, the longer it will take to rebuild,” Gellin told me. And the more lives will be needlessly lost in the meantime.
Already, states and health-care providers are having to fight to preserve access to vaccines. Recommendations for immunization may be relatively straightforward to adjust state by state. But if the FDA alters the licensure of certain vaccines—or strips it away entirely—the shots might simply not be available, even in parts of the country where people are told to get them. The FDA has already limited approval for COVID vaccines enough that the current AAP recommendations for the shots won’t be easy to follow this fall, for instance. Some state laws also prevent pharmacists from administering vaccines that haven’t been recommended by ACIP—a snarl that’s prompted pharmacies to limit access to COVID vaccines in more than a dozen states. Insurers, too, have traditionally followed CDC recommendations when choosing what vaccines to cover. States have some leeway to change these dynamics: This week, Massachusetts became the first state in the country to require its insurance carriers to cover vaccines recommended by its Department of Public Health “and not rely solely on CDC recommendations.” Today, New York’s governor signed an executive order to allow pharmacists to prescribe and administer COVID-19 vaccines, even without ACIP’s okay. Still, the federal government’s vaccine safety net is impossible to replace. More than half of American kids are eligible for the federal $8 billion Vaccines for Children Program, which relies entirely on the guidance of ACIP to decide which immunizations to cover.
Kennedy, meanwhile, is finding other ways to crater the availability of shots. He has already canceled funding to vaccine makers, including Moderna—but policy changes, too, could deter companies from manufacturing more shots or developing new ones. The secretary also recently announced his intention to remodel the Vaccine Injury Compensation Program, put into place in the 1980s to limit pharmaceutical companies’ exposure to lawsuits over vaccines’ health effects—and, by extension, to protect the stability of the nation’s vaccine supply. Some experts worry that Kennedy could make it easier for claims to be paid out, potentially, in part, by pushing to add autism to the list of compensable health issues—an anti-vaccine concession that could rapidly overwhelm the system, and leave manufacturers more vulnerable to liability, Gellin told me. Vaccines have never been a terribly lucrative product for pharmaceutical companies; under financial and political pressure, their market could quickly collapse. “Even in good times there’s fragility in this complex system,” Anne Schuchat, who served as the principal deputy director of the CDC until 2021, told me.
The consequences of the current fracturing may not be apparent right away. Immunity takes time to erode. “If we stop vaccinating today, we would not have outbreaks tomorrow,” Orenstein said. When the fallout lands, Kennedy could be long out of the government, and limiting the damage he’s done will be someone else’s problem.