Suggestions for a Practical Way of Responding to RFK, Jr: Reflections from an Infectious Disease Doctor

An anonymous academic infectious diseases physician advises the media & his colleagues

This is the second post from an anonymous east coast ID doctor. A prior post explained Why no one was going into Infectious disease.

Why No one Wants to Match into Infectious Diseases

This post makes the case that infectious disease doctors are not responding correctly to RFK Jr. Although he is an ID doctor and I am an oncologist, you will see that we think similarly about evidence because these principles are universal, and sadly poorly taught in medicine.

Finally, if you support what I am doing in this Substack, including bringing in guest voices, please subscribe

-Vinay Prasad MD MPH

I am an academic infectious diseases physician at a prominent medical center in the United States. Although I also have concerns and disagreements, the vast majority of my colleagues are incorrect in their analysis of why RFK, Jr. has risen to prominence and how to address public health issues going forward. Unfortunately, because of the extremely partisan and left-leaning climate in which I work (academic infectious diseases), I need to write this article anonymously. In a prior essay, I explained why.

Here are practical suggestions for my infectious disease and public health colleagues as we navigate medical policy challenges going forward.

1. Don't impugn RFK's motives. I disagree with RFK, Jr. on many things, and I think he is badly misguided on certain topics. However, I believe he does sincerely care about public health, children, the American people, and so on. Calling him a monster or tyrant or whatever else is not accurate and won't be effective.

2. Don't call RFK a quack. Again, I disagree with RFK on many things. But he made it through law school and successfully advocated for several changes related to the environment because of his concerns about toxins and pollution. In fact, he was so important in the environmental field that President Obama, a beloved figure among my colleagues, considered appointing him to be the EPA Administrator. Would President Obama have considered a "quack"?

Finally, just criticizing RFK's intelligence is unlikely to convince anyone who might be swayed by his rhetoric. It is ad hominem.

3. Acknowledge where RFK, Jr. has some legitimate points. I believe RFK is wrong about certain routine childhood vaccines. However, he has several important points that are worth evaluating. These include:

- The US being the only country in the world other than New Zealand which allows pharmaceutical companies to directly advertise to consumers.

- Pharmaceutical companies providing much of the funding for the FDA. It is an insane system we have in which pharmaceutical companies partially fund the drug-approval process in the United States. This is literally the opposite of what drug regulation is supposed to look like.

- Addressing the chronic disease epidemic in the United States. Saying we don't have a chronic disease epidemic is burying our heads in the sand. People have enough basic intelligence to know that the U.S. has many health problems. We can disagree about what is causing the chronic disease epidemic, but not even acknowledging the problem is foolish.

- Addressing the obesity epidemic in the United States. We have a massive obesity problem in the United States. RFK, Jr. wants to address that. That is not a bad thing. Again, I think he is off-base here. As Dr. Prasad once tweeted, I also believe it is highly unlikely that making the Froot Loops sold in the United States match the Froot Loops sold in Europe is going to change anything.

The obesity problem in the United States is related to excessive caloric intake relative to expenditure. There is no getting around this basic law of thermodynamics. We can have whatever debates we want to have about why people are taking in more calories than they are able to burn off (and whether certain ingredients in foods are addictive). But the point is that RFK, Jr's desire to help Americans become less obese is, I believe, sincere.

4. Acknowledge past public health mistakes. It is now well-described that the public does not trust the scientific establishment and does not trust doctors.

The only way we can regain the trust of the public is to acknowledge mistakes that have been made. This is not dissimilar from the U.S. government ultimately accepting responsibility for the unethical Tuskegee experiments related to the natural history of syphilis, which were conducted by the U.S. Public Health Service from the early 1930s until the early 1970s.

Many recent public health errors occurred during the Covid pandemic. They include the following:

- Overhyping Paxlovid for treatment of acute Covid-19 in people who have previously been vaccinated and are not at high risk for bad outcomes from Covid

- Keeping public schools closed much longer than our European counterparts who were operating at the same time with access to the same information and data in real time

- Instituting draconian hospital visitation policies despite a lack of evidence that such policies made any difference with regard to nosocomial transmission of Covid

- Prematurely stating that initial Covid vaccination will prevent someone from ever developing the infection. This assertion was made confidently and repeatedly by many scientific leaders in the United States. When millions of people developed Covid after having been vaccinated, they were understandably mistrustful of everything they were hearing coming from the scientific establishment thereafter. We don't call this "misinformation," but that is what it was.

5. Stop lumping all vaccines together. Instead, emphasize what is critical, and acknowledge where there is uncertainty.

Vaccines are a medical product, just like any other medical product. They have risks and benefits. In some cases (such as with the polio vaccine), the benefits vastly outweigh any potential risks. In other cases (such as with the Covid vaccine for a healthy 15-year-old), the risk/benefit assessment is much less clear.

Lumping the two situations listed above together is (1) not correct and (2) unlikely to succeed if our goal as infectious disease physicians is to prevent a resurgence of deadly childhood diseases from the past.

Here is the list of routine childhood vaccines which I believe should continue to be strongly recommended for essentially all children (with the exception of the MMR live-virus vaccine for kids with true immunocompromising conditions):

- Hepatitis B

- DTaP (diphtheria, tetanus, and acellular pertussis)

- Haemophilus influenzae type b (Hib)

- Pneumococcus

- Inactivated polio vaccine

- MMR (measles, mumps, and rubella)

- HPV (human papillomavirus)

You'll notice in the list above that I have not included several routinely prescribed here in the United States. Heresy! How could I possibly do that as a card-carrying infectious disease physician? The reason is that the rest of the world does not necessarily do things exactly like the United States.

Let me show you 2 examples of how European countries recommend vaccines for common conditions, influenza and varicella (the virus that typically causes chickenpox in kids).

You have to be willing to start by acknowledging where there is uncertainty. Do the European countries that don't routinely recommend the influenza vaccine or the chickenpox vaccine hate their children or their population? Do they want them to get sick? Are they simply crazy?

The answer to these questions is, of course they don't want those things, and they are not crazy. They are not routinely recommending these particular vaccinations because they don't believe the risk/benefit ratio is in favor of doing so, not because they are "anti-science" or "anti-vax."

Conversely, some European countries (such as Italy, Portugal, and Spain) routinely recommend the serogroup B meningococcal vaccine to their children prior to adolescence. The United States does not recommend this currently to all children (we start at age 11-12), despite the fact that currently rates of meningococcal disease in the US are highest in children <1 year of age. Does it make the US and the CDC "anti-vax" that we are doing something different than certain European countries? Of course not. Our risk/benefit calculation is simply different.

We should focus on encouraging routine pediatric vaccination for the absolutely most critical infectious disease conditions with the highest morbidity and mortality that we have successfully controlled. I am not an ethicist, so I will leave questions about mandates to others. We can also offer the whole menu of vaccines as we'd like, but berating parents about the Covid vaccine for their healthy 13-year-old equally as much as focusing on polio vaccination for babies is misguided and most importantly, unhelpful and unlikely to succeed.

In addition, not all vaccines are given to all people all the time everywhere. Here’s a good example: we do not routinely give the BCG vaccine (for tuberculosis) in the United States because TB is not widespread here. BCG vaccine is given in other countries to infants. Again, this does not make the United States "anti-vax." It is simply another illustration of the basic point that each vaccine should be considered independently for its public health benefit in a particular geographical and epidemiologic context.

The take-home point is that vaccines have indeed been a miracle for controlling the spread of certain deadly infectious diseases in the history of humanity, but not all vaccines are the same. The risk/benefit ratio of each one should be individually calculated, and only those meeting the highest bar of benefit should be recommended as a matter of routine medical care for otherwise healthy people.

6. You must be willing to answer people's questions about vaccines, not just dismiss them as "kooks" or "conspiracy theorists."

It is easy for my infectious disease colleagues to overlook the fact and forget that the original "anti-vax" movement started in more educated, upper middle class groups who often identified as liberal on the traditional political spectrum. Only over the past decade or more has "anti-vax" become coded as "right-wing."

This is not just a theoretical political science point to misdirect readers. Here is a full transcript of MSNBC host Joe Scarborough’s interview with RFK, Jr. from June 2005. In this interview, Scarborough “platforms” RFK so that the latter could discuss his concerns regarding vaccines, thimerosal, and autism. The left currently hates RFK, Jr., but they used to admire at least some of what he was doing.

Given the new era we are in, dismissing anything that anyone brings up as "anti-vax" won't work. We must meet the population where they are, which currently is distrustful of science and the medical establishment. If we just hate them, we aren't going to get anywhere. Instead, we need to acknowledge where we are today and slowly earn back the public's trust. Mandates, edicts, and rules are equally unlikely to succeed. It is just going to harden everyone in their current positions.

For example, if patients or parents ask questions about "the DTP vaccine in Africa" because they've heard some of RFK, Jr's points about this, the right answer is that certain problems were previously identified with this vaccine, so the United States (in 1997) and the rest of the world switched to the DTaP vaccine, which is the acellular form of the pertussis vaccine (and safer).

Here is CDC’s own wording on the subject: “Local reactions such as redness, swelling, and pain at the injection site occurred following up to 50% of doses of whole-cell DTP vaccines. Fever and other mild systemic events were also common. Concerns about safety led to the development of more purified (acellular) pertussis vaccines, which are associated with a lower frequency of adverse reactions. No DTP vaccines are currently licensed in the United States.”

Another example of switching vaccine types to minimize occurrence of adverse events is when the United States changed to using the inactivated polio vaccine in the year 2000 instead of using the attenuated live-virus oral polio vaccine. The oral polio vaccine was beneficial when cases of paralytic polio were rampant in society, but it is also true that it can cause vaccine-derived polio disease in a small number of people because of low-level replication and spread among some persons in areas where vaccine coverage is suboptimal. This does not happen with the inactivated (not live) injectable form of the vaccine, which is why we switched to it. These are the types of conversations we have to be willing to have and to explain to patients and the public.

Here's another interesting anecdote that this entire vaccine debate reminded me of. When I was a resident many years ago, a physician colleague of mine, a non-infectious disease person, told me that he and his spouse had just had a baby. He said the following to me: "My spouse and I are both doctors. Neither of us has hepatitis B. I am sure we didn't get it while she was pregnant. I'm not anti-vax, but why did they give my kid a hep B vaccine right after birth? What are they trying to prevent on the second day of life?" This physician colleague was not being "anti-vax." He was simply asking a rational question that people are entitled to ask. We had a good conversation about the topic, and I forgot about it after that. But the recent firestorm reminded me that even medical professionals sometimes have reasonable questions about what we are doing and recommending.

Finally, here are the CDC's own words: "Vaccines are safe and effective. However, they are neither perfectly safe nor perfectly effective. Consequently, some persons who receive vaccines will be injured as a result, and some persons who receive vaccines will not be protected. Most adverse events associated with vaccines are minor and involve local soreness or redness at the injection site or perhaps fever for a day or so. Rarely, however, vaccine[s] can cause more serious adverse events. Whether an adverse event that occurs after vaccination was caused by the vaccine or was merely temporally related and caused by some totally...independent factor is often difficult to ascertain."

I encourage everyone to read this full CDC chapter here: https://www.cdc.gov/vaccines/imz-managers/guides-pubs/downloads/vacc_mandates_chptr13.pdf

In summary, as infectious disease practitioners, we must be willing to acknowledge uncertainty where it exists. We must acknowledge prior mistakes that were made. We must equally continue to emphasize and advocate for the most critical elements of public health as it relates to infectious diseases. This is the only recipe for regaining the public's trust and trying to improve public health in totality as much as possible.