Portside

Since its inception, in 2000, Gavi, the Vaccine Alliance, which works with local governments to bring vaccines to low-income countries, has helped administer 1.9 billion vaccines and reached a billion children. Global vaccination work has nearly halved the global infant-mortality rate, saved more than a hundred and fifty million lives, prevented innumerable costly hospitalizations and long-term disabilities, and strengthened local health services in many remote places. “I can’t imagine a more successful, cost-effective public-health organization than the Gavi alliance,” Peter Hotez, a pediatrician and vaccine researcher at Texas Children’s Hospital, told me. “I mean, you had close to half a million kids dying of measles every year when Gavi was launched, and they got it down to less than fifty thousand deaths. And made similar gains with pertussis—which is whooping cough—diphtheria, tetanus, H. influenzae b meningitis, you name it.”

In the United States, we’re somewhat blinkered about what vaccination means to the other ninety-six per cent of people in the world. On Wednesday, the Secretary of Health and Human Services, Robert F. Kennedy, Jr., announced that the U.S. intends to withhold the amount that the Biden Administration had pledged to Gavi, 1.6 billion dollars. He claimed that Gavi had “ignored the science” about vaccine safety. He had already dismissed all seventeen members of the C.D.C.’s Advisory Committee on Immunization Practices, before saying that his hand-picked replacements would review the U.S. childhood-immunization schedule.

All this is to say that an enormous amount of energy has gone into grossly misleading “debates” about vaccine safety and effectiveness. The problem that led to Gavi’s formation, however, was not skepticism but scarcity. By the late nineties, relatively wealthier nations had childhood-vaccination rates of more than ninety per cent, and were seeing few cases of vaccine-preventable diseases. “But manufacturers in high-income countries were producing vaccines for high-income markets,” Violaine Mitchell, the recently retired director of global immunization efforts for the Gates Foundation, a founding partner and funder of Gavi, told me. “Low-income markets had really very little hope.”

Mitchell, who grew up in Kenya, started her career in agricultural development. While working on an animal-husbandry project in Cairo, she saw that many people had donkeys that were dying of tetanus. “I was, like, I grew up on a farm; tetanus is easy to prevent,” she said. Affordable, locally made tetanus vaccines were available in Egypt, though accessibility could still be an issue. But when she went into the households of the owners, she saw that infants were dying of neonatal tetanus, contracted from the razors that were used to cut their umbilical cords. This turned her career. She has worked with Gavi since its earliest days. “The idea behind Gavi was: Could we pool demand from developing countries so that the poorest countries in the world could then together negotiate with manufacturers?” This strategy was aimed at lowering prices and attracting more vaccine manufacturers at a time when many were closing down. Gavi wasn’t meant to cover all the costs of buying and distributing vaccines, but it would offer aid, loans, and technical advice. Gavi proposed funding the first five years of a vaccination program, and then the costs would gradually shift to the individual nations.

“It was pretty hard sledding in the beginning,” Mitchell said. Countries were hesitant to collaborate. “They were afraid there would be a loss of commitment. As one very skeptical manager told me, ‘Well, at least we’ll have five years of birth cohort protected against hepatitis-B cancers. At least we’ve done our piece.’ ” Mozambique was the first country to work with Gavi, followed by Ghana, Rwanda, and Kenya. “And then it kind of snowballed,” Mitchell said. “It was extraordinary. We went from single manufacturers to, now, fairly robust, competitive markets.” Prices have gone down, supply has increased, and countries have taken on more of the financial burden. India covers ninety-nine per cent of its vaccine costs. Nicaragua covers eighty-nine per cent. “We’ve had some close loan defaults, for sure, of countries that’ve really struggled with coups and other things,” Mitchell said. But no country has ever fully defaulted on their financing with Gavi.

When I spoke to Mitchell, she was in Nigeria on a goodbye tour, of sorts, shortly before retiring. Her colleague Greg Widmyer, who was there, too, would take over her role. Mitchell remembered visiting a vaccine clinic in Nigeria twelve years earlier. “There were no fridges, and no vaccines, and nobody had showed up,” she said. Even now, one in eight children under the age of five in Nigeria dies from vaccine-preventable diseases, but it used to be considerably worse. “Today, there were lots of mums, lots of people talking, lots of people coming for vaccination. It’s a very different world.”

Prior to the second Trump Administration, the U.S. typically contributed about thirteen per cent of Gavi’s budget. The United Kingdom, the largest sovereign donor to Gavi’s core programs, has cut its budget for overseas development by roughly half, to compensate for increases in defense spending, though it has said that aid groups such as Gavi, the Global Fund to Fight AIDS, and the WHO are among its top priorities. On Wednesday, at a meeting in Brussels, Gavi’s donors—countries, foundations, individuals—made their pledges, totalling nine billion dollars for the next five years. This amount falls short of what is needed. Mitchell says she worries that if Gavi is not fully funded, “the options and vaccines that we’ve been able to make available to children and young women all over the world will not be the same.”

The U.S. may be doing more than simply failing to aid global vaccination efforts. The domestic stoking of anti-vaccine sentiment is itself infectious—a disease-carrying rat population on the ships exporting American culture. Hotez, the vaccine researcher, used to see the American anti-vax movement as its own thing, separate from the vaccine skepticism of other countries, which is sometimes tied to a distrust of government that stems from colonial histories, civil wars, and political instability. But he now believes that the U.S. anti-vax movement, with its wellness-influencer and health-freedom themes, has become an export, threatening global vaccine goals. “You’re starting to see the same garbage that’s put out on Fox News pop up on the African continent,” he said. Latin America, which had very high vaccination rates, has also changed. Hotez said that it used to be the case that, when he would give a presentation in a Latin American country, he would start off by congratulating the pediatricians on holding the line and preventing contamination from the U.S. anti-vaccine movement. “I see that beginning to falter also,” he said. “Certainly, with Brazil, it happened with Bolsonaro.” Jair Bolsonaro, as President of Brazil, attempted to push legislation that would require a prescription for standard childhood vaccinations. He also speculated that COVID vaccines could cause AIDS. In his tenure, childhood-vaccination rates fell from eighty-five per cent to less than seventy per cent.

Here at home, if vaccination rates drop substantially, it won’t be because we can’t afford them but because people have turned against them. In that case, the country could see something that resembles the two and a half decades of Gavi run in reverse. A recent study, published in the Journal of the American Medical Association, devised forecasts for the next twenty-five years if vaccination rates decline by various rates. A ten-per-cent drop in measles vaccination, for example, would lead to some eleven million additional cases.

A number of moves—some that have already happened and some that are anticipated—could lead to vaccination rates falling by much more than ten per cent. “There are a lot of ways, without explicitly saying the C.D.C. is anti-vax now, that the apparatus of government can be used in subtle ways to reduce vaccination rates,” Jonathan Berman, the author of “Anti-vaxxers: How to Challenge a Misinformed Movement,” told me. David Geier, a prominent anti-vaxxer who was disciplined by the Maryland State Board of Physicians for practicing medicine without a license, has reportedly been appointed by Kennedy to lead a study looking for a link between autism and vaccines. This could lead to the F.D.A. revoking the authorization of proven, safe vaccines. Or the C.D.C. might continue to incrementally diminish its endorsement of COVID vaccines, as it did recently when it decided to no longer recommend them for pregnant women and healthy children. Less money could be put into the campaigns that remind people to get flu shots. The C.D.C. could stop recommending a vaccine, which could lead insurers not to cover it and people to lose confidence in it. “And I can imagine a situation where our stockpiles of polio vaccine are expiring, and the decision has to be made: do we make more?” Berman said. There is precedent here. In May, the government cancelled a seven-hundred-and-sixty-six-million-dollar contract with Moderna for late-stage work on an avian-influenza vaccine for humans, even as the disease has been turning up in dairy workers.

The replacements that have been named to the Advisory Committee on Immunization Practices include Robert W. Malone, who has promoted the use of hydroxychloroquine and ivermectin for the treatment of COVID, and James Pagano, an emergency-medicine physician who has written two novels but appears to have published virtually nothing on vaccines. The committee will soon be voting on recommendations for flu and RSV vaccines for the upcoming winter and will continue to get to vote on access to and recommendations for both new and existing vaccines.

Nathan Lo, an assistant professor of infectious diseases at Stanford University and one of the JAMA paper’s authors, told me, “A lot of the motivation for this study was making sure that evidence was available ahead of any serious considerations for reëvaluating the childhood-vaccination schedule.” The study predicts that, if routine childhood vaccinations are halved, the U.S. can expect to see more than sixty-five million cases of preventable diseases in the next twenty-five years, with four million of those being polio—cases that will likely cluster in certain parts of the country, such as areas that have higher anti-vaccine sentiment or larger populations, or that are hubs of travel. “The funny thing, or maybe the sad thing, is that when we first thought of doing this paper, we thought, Oh, this is really timely. However, it takes time to design a study, to develop models, to validate findings,” Lo said. “We generated the first set of our main results right around Christmas, and had identified a potential hot spot for measles in Texas, and I was thinking, It’s my home state, that’s interesting.” He went on, “And then, a month later, this massive outbreak started.” By early March, Texas had a hundred and fifty-nine cases of measles, more than a hundred of them in Gaines County, home to a Mennonite community with many unvaccinated children. There have since been outbreaks in dozens of states and parts of Canada and Mexico.

Ironically, it’s likely that some of the skepticism around vaccines, in the U.S. and elsewhere, comes from their efficacy, their almost magical-seeming eradication of diseases that were once familiar terrors. “Most people have never seen measles, whooping cough, or polio. The immediacy of those devastating diseases is hard for people to imagine now,” Robert Hopkins, the medical director of the National Foundation for Infectious Diseases, told me. “What I don’t want to see return is the days of my childhood, when it was not unusual to lose a friend to one of these diseases.”

Memories are short, even in countries with recent experience. Widmyer, the new director of global immunization efforts for the Gates Foundation, speaking from Nigeria, mentioned the “meningitis belt that ran right through where we are now.” A geographic swath of sub-Saharan Africa that extends from Senegal to Ethiopia used to have an outbreak every five to twelve years of a deadly meningitis that disproportionately affected children. “People operated in complete and utter fear,” Widmyer said. “They would lock down whole villages when these outbreaks came back.” Efforts coördinated in part by Gavi led to the creation of an inexpensive vaccine that has effectively eliminated a strain of meningitis. “Folks forget that a little bit,” Widmyer said. Misinformation about COVID is widespread in Nigeria, and, although vaccination rates over all are much improved, cities tend to be more vaccinated than rural areas. “What was once a supply-side problem can become a demand-side problem when diseases become less of a threat,” he said.

From an early age, Hotez was set on formulating remedies for tropical diseases, which were often neglected, because they were rare in wealthy countries. A vaccine for hookworm anemia that he started work on forty years ago was recently shown in clinical trials to provide high levels of protection. Much of his work involves investigating methods of making vaccines that are affordable in low- and middle-income countries. A team that he led with Maria Elena Bottazzi at the Texas Children’s Hospital Center for Vaccine Development produced an inexpensive, patent-free COVID vaccine that has reached a hundred million people in India and Indonesia. “Yeast is one of the most common technologies available, so when the COVID-19 sequence was made available, we were able to use that technology to make a low-cost vaccine,” Hotez said. The work was mostly funded by private donors in Texas.

Several years earlier, Hotez had received a call from the National Institutes of Health, asking him to speak with Robert F. Kennedy, Jr. “It was Tony Fauci and Francis Collins,” Hotez said. “The thinking was, You’re a vaccine scientist and you’re a pediatrician—you can explain why vaccines don’t cause autism.” Hotez and Kennedy had a series of long phone conversations and e-mail exchanges. “Those were not productive discussions, in that they did not convince Mr. Kennedy,” Hotez said. “But they helped me understand the psychology of the anti-vaccine movement, and led to my writing a book called ‘Vaccines Did Not Cause Rachel’s Autism.’ ” Rachel is one of Hotez’s four adult children.

As Hotez became a favored enemy of anti-vaccine groups, he was stalked and harassed; he even received death threats. “But I also found it fascinating,” he told me. He sees the current anti-vax movement in the U.S. as a convergence of the distinctly American libertarian right-wing with parts of the wellness and influencer industry, “which is based on buying whatever you can in bulk, which are usually low-cost antiparasitic drugs like hydroxychloroquine or ivermectin, then jacking up the price, repackaging it, and selling it with telehealth visits for thousands of dollars. That’s the CliffsNotes version.” He began to feel that countering anti-vaccine activism was maybe as important as the vaccines he was formulating.

What we think makes us healthy has at times included radium-infused water, milk transfusions, and “snake-oil” made of turpentine, red pepper, and beef fat; what we think makes us sick has included the curses of witches. Vaccine developers can profit from their products, but designing and testing a vaccine is a lot more work than selling a plant flavonol called quercetin as a treatment for COVID, and supplements are not subject to the same kind of regulatory oversight as drugs. It’s not surprising that Joseph Mercola, who made millions selling supplements, also spent millions funding the powerful anti-vaccine group the National Vaccine Information Center. The Trump meme coin was launched three days before Trump’s Inauguration; Mehmet Oz, now the administrator of the Centers for Medicare and Medicaid Services, made his name promoting “miracle” supplements for which he issued health claims that were often unsupported by scientific evidence. Showboat sales pitches and the holding of a federal office is a popular combo, and, in the realm of public health, a deadly one. 

Rivka Galchen, a staff writer at The New Yorker, has contributed fiction and nonfiction since 2008. Her books include the novel “Everyone Knows Your Mother Is a Witch.”

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