Public Health Experts Nervously Await the Next Trump Administration

Brian Lehrer: It's the Brian Lehrer show on wnyc. Good morning again everyone. Well, it's now official. President-Elect Trump announced yesterday that he is nominating Robert F. Kennedy Jr. to be the Secretary of Health and Human Services. During his campaign's final days, Trump said he would let Kennedy, ''Go wild on health.'' They're branding this as Make America Healthy Again to go with Make America Great again. Some of Kennedy's priorities are relatively standard, such as focusing on the health effects associated with ultra-processed foods. Yet others may undermine the public's health like his opposition to vaccine mandates. Not just for COVID. Here he is on MSNBC the day after Trump's victory was announced.

Robert F. Kennedy Jr: If vaccines are working for somebody, I'm not going to take them away. People ought to have a choice and that choice ought to be informed by the best information. I'm going to make sure the scientific safety studies and efficacies are out there and people can make individual assessments about whether that product is going to be good for them.

Brian Lehrer: Individual assessments, individual choice for you and by extension your kids and those who might now be unvaccinated against childhood diseases, who your vaccinated one might soon be mingling with at school. We'll get a reaction to this prospect. We'll also talk about his stance on processed foods, on fluoridation in water and as much as we can get to with Dr. Katelyn Jetelina, epidemiologist, data scientist, and author of the newsletter called Your Local Epidemiologist. An epidemiologist by the way, is somebody who studies the spread of diseases or illnesses in populations. Hi. Dr. Jetelina. Welcome back to WNYC.

Katelyn Jetelina: Yes. Thank you for having me. Excited to be here.

Brian Lehrer: You wrote that this prospect of RFK Jr. in charge of health is deeply disconcerting for you. Let me go right to a worst-case real-world effect that you wrote about that most of our listeners probably aren't aware of. You wrote that RFK's influence has already led to an outbreak of measles in Samoa that caused more than 80 deaths, mostly among children. What happened in Samoa and why do you link it to RFK Jr.

Katelyn Jetelina: Yes. The government of Samoa was shut down for a few days because of this massive outbreak of measles. Kennedy visited Samoa months before appearing alongside local anti vaccine advocates and even staff members of the US Embassy. His organization eventually sent a letter to the Samoa prime minister encouraging officials to question the MMR vaccine. He peddled very false and dangerous claims that the vaccines are linked to autism, despite the fact that there's just numerous scientific studies that have debunked this baseless claim.

Then after there was a massive measles outbreak that killed about 80 children and infected much more than that. It has a detrimental impact on that community, and that false information has continued to spread.

Brian Lehrer: MMR, measles, mumps, rubella, the vaccines for kids for those three diseases are given in combined shots. Why are they given together? This is something I've heard parents who aren't even anti vax in the slightest ask. That's a lot to give a kid all at once. Why don't they spread them out and do you know what would be smaller doses, I guess, because they'd be given individually? Do you know the answer to that?

Katelyn Jetelina: Well, a lot of it is convenience. I'm a parent of a four and five year old. I actually don't want to be going to the doctor's office more than I have to and even more so don't want to be pricking my child who does not like the feeling of getting shots. A lot of it is convenience and there actually ends up being less antigens given if we start combining these vaccine formulas and it's been incredibly effective and it's still very safe. We have decades of studies showing the efficacy as well as the safety of all three of these in a combined vaccine.

Brian Lehrer: I think we owe it to the public, to the listeners, to give some of that science if we know it, since this is going to be an actual public policy debate apparently. With Kennedy as Health and Human Services Secretary if he's confirmed, it's going to matter as to what people actually are allowed to do or prohibited from doing so. Do you know any of the studies? Is it possible to say in a simple way for the radio if you've looked into it as an epidemiologist this closely? What is the rate of any serious side effects from those vaccines in young kids versus the rates of death or serious illness from measles, mumps or rubella, which whooping cough, I believe. What the risk benefit analysis actually is statistically?

Katelyn Jetelina: Yes, we could go through every vaccine if we want, but for measles, for example, say that there's 10,000 people that get measles, about 2,000 of those children will be hospitalized, 1,000 will get ear infections with potential a permanent hearing loss, and there will be about 10 cases of kids with encephalitis or brain damage. There's going to be 10 to 30 child deaths. That's if 10,000 people get measles. If we compare this to 10,000 people getting the MMR vaccine, there's going to be about 3 fever related seizures-- oops, sorry about that, and less than one allergic reaction.

All of this comes down to do the benefits outweigh the risks? What we continue to see time and time again is that the benefits of a vaccine continue to greatly outweigh the risks of an infection. There's just no question about that, especially with these routine vaccinations that have been on the market for decades.

Brian Lehrer: I said rubella is whooping cough. That's wrong. Pertussis is whooping cough. That's another vaccine. Rubella is German measles. We played the clip in the intro of RFK last week saying he won't take away anyone's vaccines. On the surface, that can sound benign being pro choice on your health sounds like a liberal thing. What does it actually mean in this case?

Katelyn Jetelina: Yes. There's a couple ways to look at this. One, I actually believe him that he's not going to take away vaccines. In fact, about 90% of the US population really strongly supports vaccinations. The biggest question though, and that's underlying the surface, is that I think we're going to see the support for vaccine mandates be dramatically shifted in the coming years. Vaccine mandates for kindergartners, for example, date back to the 1800s when the smallpox vaccine was introduced. There's overwhelming evidence that mandates increase vaccine coverage and reduce the incidence of diseases.

However, what is shifting that I'm starting to watch, is that how some people weigh the scientific evidence with their values. The role of individualism versus collective good is shifting. The reason this is a problem, for example, infectious diseases, is that infectious diseases violate the assumption of independence. What you do directly impacts the person next to you, or what one state does directly impacts the states around them because diseases don't see borders.

The whole purpose of vaccines is really a community level response. If that starts chipping away, we're going to see more and more pockets of unvaccinated people, and some of those had the choice not to get vaccinated. A lot of people don't have the choice to get vaccinated. For example, those under 12 months old are not eligible to get the MMR vaccine. They will get measles And it'll be dramatic and even possibly deadly.

Brian Lehrer: Listeners, all our lines are full from people who called in even before I gave out the phone number. This is one of those segments. If you want to text, that doesn't fill up. 212-433-WNYC or once we get to phone calls when we get through a few people and those lines open up. 212-433-WNYC. 433-9692 on the nomination and the public health implications of the nomination of RFK Jr to be Health and Human Services Secretary with Dr. Katelyn Jetelina, who writes a newsletter, Your Local Epidemiologist. Just to stay on childhood vaccinations for another minute or two, what is the state of childhood vaccination mandates today? Is it school district by school district or state by state? Can RFK Jr even tell a local school district or a state that they're not allowed to mandate an MMR vaccine or a smallpox vaccine or a polio vaccine or anything else?

Katelyn Jetelina: Not directly. Vaccine policy in the United States is actually primarily governed by individual states rather than the federal government. Each state has the authority to create its laws and regulations, for example, around school attendance or employment requirements for health care workers. Given the really strong historical bipartisan support of vaccines, there's been very little state level policy variability. Right now all 50 states still require certain school entry vaccines. What we are seeing a difference is, is the rise of vaccine exemptions.

More and more people are getting non-medical exemptions, for example, for personal reasons or religious reasons. That doesn't mean he can't have an indirect impact on vaccine policy at the state level. There's a lot of ways he could do this. Slowing down studies, the review process over at the FDA, removing emergency authorization, for example, if we get another pandemic, determining vaccine policy at the CDC and then other indirect levers.

For example, even Trump has suggested using the Department of Education to withhold funds from schools with vaccine mandates. All of this can happen, but I do want to be clear that one of my biggest concerns as an indirect lever is not necessarily through policy at all, but continuing to sow doubt and confusion about vaccines from one of the most powerful offices in the world. That could have a profound impact on Americans' ability to make evidence based decisions.

Brian Lehrer: Has Kennedy, just to be clear, stated how far he would roll back childhood vaccination mandates for schools or use those indirect pressure levers, the measles, mumps, rubella vaccine tends to be the most controversial one, despite the clear evidence from everything I've read and everything that you were just describing that it's safe and effective. Would he make polio vaccines voluntary? Pneumonia, whooping cough, diphtheria, hep B, all of them.

Katelyn Jetelina: I think this is what is driving a lot of anxiety in the public health world right now, is the unknown future of this field, including policies like routine vaccinations. I will say though that removing vaccines already on the market, this is possible. We've done it in the past. We did this with the Johnson and Johnson COVID vaccine after we started seeing blood clots among women, but only with really strong evidence that this vaccine is causing more harm than good.

Removing vaccines for other reasons would be incredibly hard to accomplish and it would honestly probably land at the Supreme Court and it'd be a very weak case. There is a possibility of removing it from the market, but I think again, it's more of these indirect levers that can have equally damaging impact.

Brian Lehrer: Let's take a call. Here is Monique in Tarrytown. You're on WNYC. Hi, Monique.

Monique: Hi. I was just calling to see what impact did the COVID vaccine as opposed to, let's say, have on parent understanding of the difference between immunity and immune response and the flu shot is elective and the effectiveness of the COVID vaccine was not as strong. I was wondering, has there been a greater confusion on how important it is to have vaccines against measles and rubella? That's my question.

Brian Lehrer: Yes, that's a fair question because I think a lot of people were disappointed in the COVID vaccine, Dr. Jetelina, in that they expected that like it wiped out polio in the United States when that vaccine came in, that after they got vaccinated against COVID, that they would never get COVID, but there were plenty of cases, still are plenty of cases of people who are vaccinated against COVID. What I think the data shows is that it's very effective in preventing hospitalization level cases and deaths.

A lot of people thought that they weren't going to get COVID because they had the vaccine and it's not a one to one like it is with some of these other vaccines. I wonder if that's coloring perception of, say, the childhood vaccination debate.

Katelyn Jetelina: Monique, that's a fantastic question. It absolutely had an impact. We're starting to see studies around parents who had really legitimate questions about the COVID vaccine and now having other really good questions about other routine vaccines. I think it is a combination of general amnesia. A lot of us, including myself, don't really know what it's like to hold a child with measles or what a child paralyzed from polio looks like. I think the other thing is that there's absolutely bad actors adding to this noise, and people have legitimate questions they can't find answers to. It has created this perfect storm that COVID really catalyzed.

You're right. How well vaccines work is very dependent on the actual virus as well as how much of that virus is around. One of the reasons measles vaccines work so well is, yes, they're very safe and effective vaccines, but it's also not circulating in our communities and we're just not getting exposed at the levels we are seeing with COVID 19. There's a lot of nuances here, but I absolutely agree that COVID catalyzed this perfect storm, and a lot of these questions about routine vaccinations are now mainstream that were previously seen on the fringes.

Brian Lehrer: How about the fluoridation issue? This is not something people think about very much. Again, I don't know if it's end the mandate, if there is a mandate, or prohibit states and local water systems from fluoridating the water. He may be against big pharma, but it seems like he's in bed with big cavities. From what I heard on a New York Times audio piece, the science is that, yes, if there are large concentrations of fluoride in water, it can have detrimental health effects, but that's not what we have in this country. I wonder if that's how you would put it yourself or if you would enter that in any other way.

Katelyn Jetelina: Yes, that's right. We've been putting fluoride in our water supply since 1945, and currently actually not 100% of Americans receive fluorinated water. It's about 75% of Americans do. The value of fluoride isn't controversial, but what is up in question is whether fluoride is good, whether it should be added to our public water supply. Fluoridation in water is one of the top 10 public health achievements over the past century. What we see is when we start taking fluoride out of water and we study what happens to children's cavities, it increases about twofold.

We see a causal evidence of fluoride in water being very beneficial to children. You're right. The dose makes the poison. The U.S. Public Health Service recommends fluoride concentration of about 0.7 parts per million in drinking water. This level is carefully chosen to prevent cavities. Higher levels of fluoride are dangerous, but you have to start adding this up. You would have to drink, I think it's about five cups of direct fluoride to have toxicity levels that start impacting our skeletal bones. That is just not something we do or is in our water.

The other thing that I think is being very lost in this national conversation about fluoridation is the importance of equity. One of the reasons why fluoride is so important in our water supply is because a lot of lower income families still struggle to find dentists who take insurance or even have insurance. Because the public water system equally fluoridates water, the impact of these disparities and access to dental health care kind of go away because they're preventing cavities. This is the crux of public health is we have these population interventions that are invisible.

We don't necessarily see them, but are actually doing a lot of good. If we start chipping away at that, it starts increasing those inequities and can have detrimental effects to our children.

Brian Lehrer: I want to acknowledge that we're getting several phone calls and texts from people unconvinced about the lack of relationship between the MMR vaccine and autism in children. We have a parent. We're not going to have time for everything, so I'm going to summarize that we have a parent on the line who says they have an autistic child and they believe that it was from the vaccine. We have somebody on the line who says just that he works with disturbed children. We didn't used to have these rates. I think he means autistic children.

Here's a text, it says, ''Obviously, the vaccine is effective and safe. I think the argument on the other side is the side effect as autism, given the increasing number of autistic children and any studies refuting that.'' It ends with that question. The text isn't perfectly written, but the idea is, so what is causing the increase in children diagnosed with autism? Is there an alternative theory that lets people dismiss the MMR one?

Katelyn Jetelina: Yes. I think it's-- I don't discount people's confusion around the correlation between MMR vaccine and autism, because there isn't one. There was this 1998 study that was published that has now been retracted due to very serious methodological flaws. One of the big question is what we always ask in public health is correlation doesn't mean causation, and so yes, we're seeing a rise in autism, but we're also seeing a rise in publications, for example.

That doesn't mean that the MMR vaccine causes a rise of publications in scientific literature. I think it's a really important question of what is causing the true rise in prevalence in autism spectrum disorder. There's a few hypotheses. One is just improved awareness. Two is expanded diagnostic criteria. Over time, the definition of autism has broadened. There is diagnostic substitution. In some cases, conditions previously classified differently are now recognized as autism, and there's access to services.

Just increased availability of development screenings and specialized services that can be contributed to earlier, more frequent diagnoses. I think we all need to be careful, especially going into the next four years where we're going to hear a lot of falsehoods, misconceptions and confusion and anxiety to really think about correlation versus causation and trying to provide accurate communication about them from a place of empathy.

Brian Lehrer: By the way, I was surprised to see this from the New York Post editorial board given their usual politics. They put out an editorial yesterday after Kennedy was nominated to be secretary of HHS. It says, ''The overriding rule of medicine is first do no harm. We're certain installing Robert F. Kennedy Jr. To head HHS breaks this rule.'' Then they go on to say they sat down with him in May 2023 and that they appreciate that he's an independent thinker who ''sees through a lot of bull. When it came to that topic, his views were a head scratching spaghetti of what we can only call warped conspiracy theories and not just on vaccines.''

Interesting coming from the New York Post. Let me close with this with you. Is it possible that he might do some good with respect to one of the other big reasons or one of the big reasons that there is more childhood health problems or there are more childhood health problems and even adult health problems, and that is ultra processed foods. I wonder if RFK Jr. Is going to wind up running afoul of Trump, if Trump is influenced by the processed food industry. Here is RFK on MSNBC earlier this month responding to a question about clearing out the top level federal service members at the FDA. Here's what he said.

Robert F. Kennedy Jr: In some categories of work, there are entire departments like the nutrition departments at FDA that have to go, that are not doing their job. They're not protecting our kids. Why do we have Fruit Loops in this country that have 18 or 19 ingredients and you go to Canada and it's got 2 or 3.

Brian Lehrer: Do you happen to know? I don't know if it's in your portfolio as an epidemiologist, if it's true that Froot Loops have so many more ingredients in this country compared to in Canada, and if there's anything you would anticipate from RFK Jr. in terms of regulations promulgated by the federal government to crack down on ultra processed foods?

Katelyn Jetelina: I want us to start out saying I think the fast food industry is as bad as, for example, Big Tobacco. They have huge lobbying groups making a ton of money in spite of the damage they created. It'll be interesting to see if and how, like you mentioned, he can or if accomplishes movement towards a more nutrient dense diet among Americans. I think one thing we can all agree on is that America has room for improvement. We live the shortest lives, have the most avoidable deaths, have worse health care access. I think the first step is accurately identifying--

Brian Lehrer: [crosstalk] Compared to other wealthy countries, you're saying compared to.

Katelyn Jetelina: Yes, sorry, compared to other wealthy countries. The first step is accurately identifying what is causing us to be unhealthy and fix that. There's a lot of nuance needing to be around around ultra processed foods. They are not inherently bad, but they are linked to lower diet quality, eating more calories and higher gain of weight. A nuanced approach also includes showing that there's a balance between reality of also personal family finances as well. It's a really complicated topic. It'll be interesting to see how he approaches it.

Brian Lehrer: Dr. Ketelyn Jetelina writes the newsletter Your Local Epidemiologist. Thank you for being ours today.

Katelyn Jetelina: Thank you for having me.

 

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