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CALCULATING THE DAMAGE OF VACCINE SKEPTICISM  
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Rivka Galchen
June 27, 2025
The New Yorker
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_ It’s clear that we’re on the precipice of a surge in
preventable diseases. The domestic stoking of anti-vaccine sentiment
is itself infectious—a disease-carrying rat population on the ships
exporting American culture. _

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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.
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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
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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
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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
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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 [[link removed]],
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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_Since its founding, in 1925, The New Yorker
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