“Vaccines: Why all the Skeptics?” – with Emily Oster

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Emily, welcome back to the podcast. It is amazing to talk to you. How are you doing?

Emily: I’m good. It’s always so nice to talk to you. I’m glad we’re getting a chance to connect.

Dr. Fox: This is great. It’s like a back to back because I was on your podcast recently, which came out great, by the way. Really good stuff. Good editing.

Emily: Yeah, that was so fun.

Dr. Fox: Yeah, it was really good. And of course, all my listeners already know you and love you, so I don’t have to do much of an introduction. I’m sure I did upfront, but we’re co-authors and we’re BFFs. And you’re running the world when it comes to ParentData.

Emily: Very small, small portion.

Dr. Fox: Well, you’ve got your circle. And you’ve got some big stuff going on with ParentData and what you’re doing. So, we want to tell our listeners about that. I’m sure they’ll be very interested.

Emily: I run ParentData, which is an online platform with data-based information for pregnancy and parenting. And the two things that we are really excited about right now, which I hope will be relevant to this set of patients… So, one is that we recently relaunched our pregnancy newsletter. This is like a week by week newsletter in which you get essays and Q&As, some of which are by Dr. Nathan Fox and others are by me and others, which really intend to, kind of, walk people through their pregnancy, help them ask the right questions, help them think about the data behind what they’re hearing.

And we are also launching a new vertical on ParentData about fertility. So, moving from pregnancy and parenting, which we’ve done for a number of years, into some of the core questions that I get about trying to conceive. And in that vertical, we’re really trying to go all the way from kind of, “I’m just thinking about it. When do I have sex?” through IVF, IUI, people going through assisted fertility and trying to answer some of these very in the weeds questions I know many people have about, “What about this supplement? What about this treatment?” And I’m very excited about this, particularly this fertility part, because I feel like there is a tremendous amount of, kind of, confusing, motivated misinformation in that space. And I’m hoping that we can bring some science and real background knowledge from people who are not motivated to try to sell you something but just want to get you information. So, that’s the goal. That’s what’s going on over at ParentData.

Dr. Fox: Amazing. Well, I highly recommend ParentData to my patients, to my listeners. Yes, I do write for it, but even the parts I don’t write, I obviously still recommend. Probably more so than the stuff that I write, so go figure. And great, congratulations. That’s amazing. I’m glad that you’re expanding to that. And I do agree that the world of fertility, again, which is not my expertise, but it is definitely something that many, many people struggle with and have a lot of questions about, and confusion, and some real good data and information that’s reliable would be terrific in this space, or as you said, in this vertical. That’s a good one. I like that. A vertical.

Emily: Yeah, I’m really in business here, Nate.

Dr. Fox: Yeah, I need to get some verticals.

Emily: I’m in business. I got verticals, different horizontals and so on.

Dr. Fox: I need to find some verticals in my life. All right. So, thank you for coming on this podcast. I wanted to talk to you about vaccines, which is always definitely…right now, it’s a hot topic, obviously, because of maybe… I mean, there’s some stuff going on on Capitol Hill right now and there’s some, you know, RFKs all over it and RFK Jr. I should say is all over it. And obviously there was a lot of vaccine stuff a few years ago related to COVID. But there’s always a lot of discussion about vaccines. And who better to clear it up than the professor? There you go. So, let’s just start with just some basic background. Why is this such a controversial topic? In all of medicine, this is more controversial than anything, which is a little bonkers.

Emily: It’s a really interesting question. So, you know, vaccine skepticism has been around, kind of, as long as vaccines. So, I was once talking to a colleague in political science who was working on vaccine resistance in the, sort of, very earliest vaccines they were giving in India. And so this idea of, sort of, people being skeptical of vaccination is not new. And I think in some, kind of, vague sense, it’s not surprising because we’re doing something, putting something in your body and you don’t see what it’s doing. And if it works, then the feedback you get is not getting something as opposed to getting something, right?

So, like antibiotics, it’s clear why people like it, because if you are sick and you have a bacterial infection and we give you antibiotics, you get better. And it’s like magic. And you can see, “Wow, this definitely works.” When you give someone a measles vaccine, even if they are in a place in which there’s a lot of measles, they mostly don’t see it works except that their kid doesn’t get measles. And so I think that kind of…the preventative aspect of it makes it less visible. And therefore, I think already it’s harder for people to understand. And then there’s just a lot of… And this is the part I don’t understand really well, but I think certainly in the moment, there’s a lot of skepticism about safety and efficacy that has developed. We can, sort of, talk about how we’ve gotten to the point we are now but I think that’s, kind of, the other part of it. But in some ways, I think it begins with the fact that it’s just very difficult for people to, sort of, see this working the way you would see an antibiotic or a Band-Aid working.

Dr. Fox: Yeah, and I think also, since it’s something that, A, in order to really work well in the population and B, sort of, the way they’re rolled out is it’s not just that it’s something that you get and you don’t really see the benefit, but you’re told you have to get it and everyone has to get it, right? And then people automatically get skeptical when someone says, “Everyone has to do this.” And again, I’m not saying that’s wrong, but it’s just something that red lights go off in people’s heads when they’re told, “Yeah, the whole population has to do it.” And then they start linking it to going to school, they’re going to camp. And I think it has that potential for people to be skeptical. But again, my whole time in medicine and life, there have been some undercurrent of skepticism. But right now, it’s definitely exploded. And I think we were talking offline or by email. I think a lot of that is unfortunately been in hyperdrive because, A, just everything is in hyperdrive right now, you know, politically, but B, I think the COVID vaccine really shook a lot of people in different ways. And I think that that’s unfortunate.

Emily: Yeah. So, you know, I’ve been talking to people about vaccines. I mean, not as long as you have but for a long time and writing about it and thinking about it as a topic and research. And I would say a decade ago, I definitely heard from parents who asked me questions about vaccines. This is a common thing. And certainly there have always been hardcore vaccine skeptics. The volume of skepticism, general questions, concerns, confusion in the past, four years and in the past year, it has gone up tremendously. There’s just many more people who are not, kind of, just doing the vaccine schedule that people suggest. I guess I would trace that at least in some part to COVID, although in a way that I think is, sort of, pretty complicated and has many steps, but it’s hard to argue about the timing.

Dr. Fox: Yeah. I mean, it’s tough because on the one hand, you can look back on the COVID vaccine and say massive success for the role of vaccines.

Emily: It’s a miracle. Yes, I want to be clear. As a matter of both science and policy, the fact that we had vaccines going in people’s arms 12 months after the virus was detected and that…you know, I think it’s pretty clear it saved millions and millions of lives. I mean, that is a total miracle.

Dr. Fox: Yeah, no, it’s huge. And so you should look back and say, “Wow, we figured that out. We got it and we did this and it really worked.” And I think that that’s got, I don’t know, overshadowed. But for many people, it got overshadowed by all of the criticisms they had with the process. I think the first is they did it too fast. And it’s understandable that they expedited safety testing because there was a… As we said, unprecedented. There was a serious situation going on at the time and you had to balance, you know, are we going to take three to four years of testing for this? Are we just going to, sort of, do the best we can in six months and then roll it out? And again, there’s no perfect answer to that, but you have to balance what’s the benefit to rolling it out early versus the risks versus holding it and waiting on it for a long time. And so I, kind of, get that part, at least for the rollout.

But then I think people felt that there was overreach maybe with the vaccine about, you know, does everyone really need to get it? Do they need to get it multiple times? Does it have to be mandated? And if you don’t get it, you really have to be taken out in the public square and flogged. I mean, all these things that, sort of, happened because of maybe the mass hysteria that was happening at the same time, I think really unfortunately turned the story from a massive success into people think it was a debacle. And I don’t think it was a debacle, but I think a lot of people think that because of that. Does that make sense?

Emily: I think what’s really hard about this discussion is hindsight is 2020, right? And so if you, sort of, knew where we were going to get to now and you wanted to back up to the rollout, like, would you have done the messaging differently? If you knew everything we knew post, of course, right? There were things that people were told that the vaccine prevents transmission, right? Do you recall the phrase hot vax summer? All of a sudden, people who are in their 60w, who have been vaccinated are just going to be in a hot tub together, swinging their…whatever it was that people were planning, which was all predicated on the idea that if you’re vaccinated, not only can you not get COVID but you can’t spread COVID.

That turned out to be wrong. I don’t think that that was known at the time. And it’s not that I think that people were lied to, but it wasn’t right. And I think those, kind of, missteps or maybe getting out over the skis of what we really knew based on the science, I think that was an opportunity for lost trust, but I think it’s very hard to say like, “Well, you made a mistake there,” because you didn’t know. And so authorities were doing the things they thought were the best. And when they turned out to be wrong, then there were people waiting to take advantage of that and use it to generate further mistrust, which they then used it in other ways. So, it is an interesting question of, if you knew everything you knew now, how would you have rolled this out differently? And I think the answer is definitely would have rolled it out differently, but that was harder to see at the time.

Dr. Fox: No, I think that’s fair. When millions and millions of people have opinions and everybody did, right, some of them are going to end up being right and some of them are going to end up being wrong. And obviously I’m sure that there’s players in this that predominantly the players in it had very good intentions and try and do the right thing, and there’s probably some who are not, right, either whatever their motivations are, who knows, and it’s a mess. And that happens with these things. But again, I just think, sort of, the after effects, I do think it’s unfortunate because again, we should be looking back on that as a massive success and I don’t think people… I mean, many people do, but I don’t think everyone really sees it that way for whatever reason. And I think that that has led to this.

Emily: I agree with that. I’m curious what you think was the, sort of, turning moment because I do have a sense… And to give you a very concrete example, during the, sort of, vaccine rollout and before that, I had been spending a lot of time working with different states to talk about their school stuff but turned out some of the same people who are running school reopening were also running vaccine campaigns. And there was a really amazing guy named Clay Marsh, who was running this in in West Virginia. And his, sort of, initial rollout of the vaccine was incredibly successful.

So, he basically targeted old people. They went hard into nursing homes. They did a really successful job, sort of, early on, and they got a ton of very, very vulnerable people vaccinated at very high rates very, very quickly. And then, you know, subsequently that was a place with lower vaccination rates, but I think that there was this, sort of, very successful moment at the beginning. I feel like there was a sense in, kind of, January of 2021, February of 2021, that there was broad excitement about the vaccine. Not everybody. Not that everybody thought this was a good idea, but that there was a, kind of, buying in of this even on the right. I mean, after all, it was, sort of Trump’s Operation Warp Speed that got us the vaccine. What do you think is the moment where we, sort of, started to lose people?

Dr. Fox: Yeah. Yeah. I think it’s a great question. And I think that it was really, if I had to pin it to the biggest thing, is that once… You have this vaccine that is, again, miraculously available so soon after the virus comes out, as you said, and now appears to be exceedingly effective, right, and predominantly so safe and saving lives, and so you have all this. And I think that the next step where people said, “Okay, now not everyone should get it, but everyone has to get it. And if you don’t get it, we’re going to do A, B and C to you, right? You’re going to lose your job or you can’t do this or you can’t go out to eat or you can’t…” All those things. And again, I get it. People were thinking it’s a public health issue. What if it does spread and what if the vaccine does lower the risk? And again, I don’t think that every person who was into vaccine mandates had, you know… I disagreed with them at the time, you know, full disclosure, but I don’t think everyone who thought they were a good idea had bad intentions. I just think, you know, whatever. I just think that when you start forcing people to do things and they feel like their freedoms are being taken away from them, people really…that’s when they dig their heels in and they go like, “Uh-uh, not me.” And even if it becomes illogical at a certain point, because that is something that people take very, very seriously and very personally.

And so I think that had they been a little softer and saying, “We’re going to make it available to everybody,” or something like that, I think you would have gotten probably the same rates of take up and probably you would have saved the same amount of lives and you wouldn’t have pissed off so many people. And I think that’s really when it got ugly. You know, people started… I mean, listen, I’m in New York City, and New York was horrible with COVID and the vaccine was amazing. And then you have all these healthcare workers, myself included, right, who were called heroes, right? You walk down the street and people clap for you, and they’re giving you free stuff. And you’re unbelievable. You’re the greatest people in the world because you’re the people working in the hospital. You’re putting yourselves at risk. Half these people got COVID, right? And so now all these same people who are the heroes who got COVID and have antibodies, they’re telling them, “If you don’t get vaccinated, you’re fired.” And it’s like, “Whoa.” It was like they got turned on and so it really upset people.

A lot of people quit. A lot of people moved to different states because of it. And I just think it was the wrong move in my opinion, strategically. And I think that that’s where we really lost a lot of people. Again, that’s me. I’m a libertarian kind of guy. And so I think that that was a misstep by public health officials strategically. I think it didn’t work and I think it upset a lot of people.

Emily: Yeah. I mean, I think this, sort of, goes back to the… I think you’re right and certainly there are things that I said at the time that I was more pro-mandate, I think, than you were. And there were things I said at the time people will still bring up as they’re mad about around, sort of, how we should encourage people or force them to get vaccinated. So, I think you’re right that that hit a nerve. I would go back and this again as a question of like, what did you know at the time? Imagine that… I think there was legitimate disagreement about the impact on transmission, which subsequently we learned doesn’t particularly affect transmission. But I think reasonable people thought that the vaccine would dramatically lower transmission of the virus. And if that is true, imagine this works like the measles vaccine, right? Imagine this was like a sterilizing vaccine such that when you get it, you just can’t get… That’s it. You don’t give it to other people. You don’t get it. It’s like a sterilizing vaccine.

In that world, there is a really strong argument for mandates or at least a stronger argument to say, look, you know, there are some people who can spread this to other people and some people can’t. And we need to do that. And I think that’s the place where I think we overlap the, kind of, how are you making decisions in an atmosphere of uncertainty? And which direction do you go? I think it turned out, and this is where… There was an opportunity for those who oppose vaccines to subsequently take tremendous advantage. They were wrong about the transition effect and that meant the mandates didn’t really make that much sense. And then there’s an opportunity to say, ha, they’re wrong. They’re just trying to [crosstalk 00:18:51.669] fire you, because they hate you and I think that you’re right. That ended up being very significant. That made people mad.

Dr. Fox: I think that’s fair. And again, people are like, “Oh, they’re trying to make money.” I was like, listen, the people in the Department of Health do not have a financial stake in the vaccination, right? This is not like, you know, pharma telling you. So, I think that the whole business about money is, you know, I think it’s reasonable to question drug companies’ motives. They’re good, they’re bad, whatever it is, but this is not the people who are making the decisions. But I do think that again, and I agree that reasonable people thought a mandate was a good idea, and I think I just happen to think it wasn’t. And I think that part of it is again, when you talk about mandate, it’s also difficult to mandate something that went through expedited safety testing, right, because people are like, “All right, you’re going to mandate something that’s only been out for the public for a couple of months,” and whatever it is. And I think that that, sort of, is more pushback and it wasn’t clear what do you do with people who have antibodies, what if you could have a blood test that says I have antibodies. We knew that they were decreased risk. Or, what if people were willing to get a COVID test every day or every week when they come to work to make sure that they’re not positive? I mean, there were alternatives to mandates. And I think that, again, this is not meant to be a debate over who was right and who was wrong. This is just meant to… I think that it turned out that that upset a lot of people doing that.

Emily: That turned out to be a problem. I mean, what I think is, sort of, interesting to go into where we are to where we are now on vaccines and what I see from parents is that the hangover of this discussion has translated into other vaccines. And I think that’s the piece where it’s a kind of… I’m not sure that was predictable. I’m not sure that was super predictable, but basically, people started to distrust the COVID vaccine and then they, sort of, walk down the road to be more open to distrust of other vaccines, which do not have any of these features that you’re talking about.

The measles vaccine has been around for many decades, and is a very effective vaccine, and has been given to millions and millions and millions and millions of people. And we know a tremendous amount about its safety profile. This is not the same, even though I think the COVID vaccine is great and it has a very good safety profile. The measles vaccine is a far more effective, just a far better case for that. And the piece of it that I find most, I don’t know, upsetting is probably the reasonable word is, is the sort of way that this loss of trust has been translated to these other things where I think that it’s much less deserved.

Dr. Fox: Yeah. No, I agree. And I think that, again, before the COVID vaccine, there was always this undertone of few people would say this and that. And all the things that we’re going to talk about next about vaccines were true 5 years ago, 10 years ago, 15 years ago, in terms of the data, in terms of the safety, in terms of all these things. And we’re rehashing them because so many people are asking the questions again. And so on the one hand, that’s not good because of the distrust. I think on the other hand, it is good because you get to, sort of, re-advertise, right? There’s really not much to hide. There’s so much data about all these other vaccines. And I think it’s fair for people to ask, but I do think that if they really do a deep dive, they’re going to be more reassured than unreassured when it comes to vaccines.

Emily: So, here is where I… Let me just… So, I agree that if someone has the right training and has the right open-mindedness, that if you go into the vaccine, that’s absolutely true. Some of the, sort of, routine childhood vaccinations are some of the most highly researched, highly safety regulated, highly monitored cases of any treatment that we give anybody anywhere, right? This is just, if you know what you are looking for, if you know how to do this research, when people do this, they’ll be like, “Wow, I cannot believe how lucky we are that millions of kids are not dying from vaccine preventable illnesses. Thank God we developed these.”

However, I think that there is such an opportunity to weaponize crap research. And let me give you a very concrete example. So, all over Instagram a few weeks ago, a week ago maybe, there was a study—I use that term loosely—about autism and vaccination. And this is a paper that was published in a online journal. It’s not really a journal. It’s like a website that says it’s a journal, because you can just make up a journal, Nate. You could make up Nate’s journal of fun.

Dr. Fox: Oh, I have. No.

Emily: Yeah, it’s great. I love your journal. It’s so compelling. So, these guys, these, sort of, anti-vax activists have started a journal, publichealthjournal.com and they say it’s peer reviewed. Again, it’s not a thing you just say you’re peer reviewed. Other people who are on the website have read it. And this guy puts up this paper that says that, you know, they analyzed all this data from Florida. And they show that vaccines cause autism. And in addition to this being published in an outlet that’s obviously motivated, the paper itself doesn’t make any sense. You know, whatever data they have. The simplest thing to say is that 10% of the kids in their sample are unvaccinated according to their measure, and we know that the actual percentage is about 1%. So, most of the unvaccinated kids are vaccinated. And so this is the whole premise from there. You can’t really learn anything.

This paper is just a terrible paper. And I think, five years ago, that would never have gotten any air time of any sort. That was mentioned in the congressional hearing. RFK brought up that paper. And so now people are seeing that and they’re saying, “Oh, you know, RFK said, RFK Jr. said there’s this new paper. Let me go look into this.” And I’m not sure that everyone who is looking into this is going to understand the methodological flaws or the fact that this is in a real journal because it’s not their job. And so this is where I really worry that 0telling people, “Go do your own research,” when there’s a bunch of motivated experts who are “producing research” that is flawed. I don’t know. That makes me worried.

Dr. Fox: Yeah. I mean, well, let’s talk about that. I mean, why is there this prevalent undertone that vaccines cause autism? That’s question one. Why is that even a question out there? And number two, how do we know that’s not true, right, because that’s a big nut, right, vaccines cause autism. Everyone’s afraid of autism. Everyone gets vaccines. So, where did that come from? And why is it really not shown to be true?

Emily: Yes. I think the first, sort of, argument about… The place that this came from is about… Maybe now almost 20 years ago, there’s a guy named Andrew Wakefield in the UK who wrote a paper in The Lancet, a case study paper, which he had 12 people and kids. And he was arguing that a vaccination with the MMR vaccine had caused their autism. And he had some discussion of, sort of, case histories, basically. This person got vaccinated and then this happened. And then they had autism developed. And it turned out the paper was just fraudulent. Not just that it was wrong or had been disproven, it was like he had made up facts of the cases. He had a much larger sample of people and he only reported on 12 of them. And again, many of the facts there were not correct. It turned out he was writing this paper because he was trying to sue the vaccine manufacturer. So, he wanted there to be published research that he could get money. The paper was retracted. His license was revoked. This is a completely debunked paper, but it is still the thing that people bring up as kind of, “Well, this is the first piece of evidence that vaccines cause autism.”

Then subsequently, scientists have been like, “Okay, let’s look at this in a realistic way.” And I think the best evidence on this comes from over a million births in a European country with very good tracking. And they showed just absolutely no relationship. People have shown also in large samples, no relationship, even if you look at kids who have an autistic sibling. So, they might be at higher risk. So, there’s a bunch of very large-scale studies which show no relationship here. And then there’s this initial debunked study with made up case histories of 12 people. And somehow, despite that, still having this discussion, even though it seems really obvious that one part of the evidence is just much better than the other.

Dr. Fox: Yeah. And I think that it’s tough because once that gets said, as they say, you can’t put the toothpaste back in the tube. And so that’s out there and it’s going to be out there forever. But again, people do look at this. People care about this, right? This is not something where doctors are like, “Oh, who cares?” I mean, nobody wants to give vaccines if they cause autism. And so it’s studied constantly, and people track these all the time.

So, I would agree. I think that all of the data, good data would demonstrate that there’s no link between vaccines and autism. It’s never been seen in a quality study. And you’re talking about millions and millions and millions and millions and millions of people who’ve gotten the vaccine. So, it’s not like, you know, we haven’t had enough time to figure that out. And so it seems like that’s not it.

So, let’s say someone says, “Okay, I get it. I’ll buy that vaccines don’t cause autism. How do we know they don’t cause other problems?” So, how do we know that they’re safe in general? A, a vaccine or B, the combination of vaccines or the number of vaccines. How do we even know that or study that? Because it’s going to be different potentially with time because different vaccines get rolled out and there’s different schedules for them.

Emily: Yeah. So, when new vaccines are added, they are added after extensive trials, randomized trials. And those I think it’s worth saying that those trials are done in people who are also getting the rest of the vaccine. So, this concern people will raise, “Well, there’s so many vaccines. How do we know what happens when you give them all together?” It’s like, well, actually when they test the new vaccines, they are testing them in the context of people who are getting all the other vaccines. And so that’s part of how they’re evaluated. And we have these trials and you can see safety signals and all kinds of other stuff in the trials.

And then I think this piece is, sort of, really important. Even though we have typically, sort of, large-scale randomized trials with thousands of kids to evaluate new vaccines, there are still worries that what if there’s some really, really rare event and we don’t have enough kids in these trials to pick up an event that happens to 1 in 50,000 people, because that’s just true about trials. And so there is tremendous, sort of, post-release monitoring. The U.S. has a system called the VAERS. There’s also a separate vaccine data link system. There’s a system in Europe that tracks this. And all of these are intended for, sort of, reporting by either doctors or even individuals of any kind of thing that they think might be an adverse effect of the vaccine. And therefore you get a lot of very large-scale follow-up after vaccines are released.

And I will say there are times in which we learn something from those systems, which then causes a rollback. So, I think the obvious example was during the COVID vaccine rollout, turned out the Johnson & Johnson vaccine had some counterindications for I think women of a particular age around heart issues. That wasn’t detected in the trials because it was very rare, but it was detected once it was a rollout. And because we have these monitoring systems, there was an opportunity to just, sort of, quickly, kind of, basically tell people don’t get that vaccine if you’re in this group. So, this is a really heavily regulated and monitored space relative to most of the other medical treatments that we get, honestly.

Dr. Fox: Right. And again, it’s not just people are, sort of, skeptical who’s doing the regulation. It’s not like just one group. And it’s not the group that necessarily makes the vaccine and makes money off it. It is multiple places around the world that look at this, right? So, it would have to be everybody conspiring. You know what I mean? If you have a conspiracy theory, it’s a tough one because it would need to be literally everybody.

Emily: And, also, what is the conspiracy? I mean, this is the piece that I think people should, sort of… Sometimes there’s this tone in this like the government is trying to kill children. I don’t think that’s a reasonable belief. And I don’t think that there’s a lot of evidence that the government is interested in conspiring with pharma. Vaccines are not actually that lucrative as a, kind of… Certainly routine childhood vaccines are not typically a very lucrative part of a pharmaceutical company’s repertoire. It’s not Viagra. It’s not Ozempic, right?

Dr. Fox: Fair. And I think also, again, like what you said at the beginning, there’s nothing wrong with healthy skepticism about medicine and treatments and rollouts. Okay, fine and that’s fair. But I think it’s also important again, like you said, what’s the alternative, right? So, would you prefer that your child get measles or polio, smallpox? I mean, vaccines have been wildly effective in lowering the rates of these. And all you have to do is find one of those times where you have a place that’s not vaccinated and you see outbreaks of these diseases and it causes serious problems. I mean, kids die from these. Not all of them, obviously. Not everyone dies from the measles. But it’s not like getting a cold. And I think that people sometimes were… This kind of I think debate stems from a place of luxury that we don’t know what it’s like to live in a society where kids die left and right from these infectious diseases. And I think that that’s why we can debate about these one in a million possible side effects, because we just don’t have kids getting sick.

Emily: Yeah. And I think this is a missing piece of some of this, sort of, vaccine skeptical rhetoric. We’re talking about this like the benefits are zero. Let’s make sure that we have gotten to a zero risk because there’s no benefit of them. I think the reasonable thing to say is, you know, vaccines are not a zero. No medical treatment has no risks. And that’s why we have vaccine inserts. That’s why we talk about those risks. When you’re choosing to vaccinate your kid, they’re very small but they’re not zero because it’s a medical treatment and all medical treatments have risks but also it has benefits, which are preventing deadly diseases. And if we ignore that piece, then the conversation, kind of, makes no sense. But as you say, I think to say it comes from a place of luxury is very correct that, you know, the world in which half the population is vaccinated for measles and half isn’t, that’s the DRC. That’s a place where we’re seeing a lot of kids die of measles.

Dr. Fox: Yeah. What are the questions other than… I would imagine autism is a big one, but what are the other questions you get from your listeners, your followers, your readers about vaccines, the ones that come up like all the time?

Emily: So, I think the autism one comes up. I think, you know, many of the other concerns are, kind of, in that space. So, are there too many vaccines? What about aluminum? That comes up a lot. A, sort of, very specific thing that comes up is, you know, should I phase them out? So, is it better to phase out vaccines than not? And I think the answer is there’s really no reason to phase out vaccines. It’d be better to phase them out and get them than to not get them. And that’s an interesting messaging question, because I think doctors differ in whether they want to allow people to phase them out in the hopes that that will get people to be vaccinated more as opposed to people whose view is like, “If you say it’s okay to phase them out, it’s like you’re saying that there’s a reason to phase them out and so you should just say that.” So, that’s a complicated, sort of, psychological question.

I think an interesting piece is there are two, sort of, very specific questions that people have. One is about COVID boosters to their kids, and the other is about the hepatitis B vaccine at birth. If I had to, sort of, pick out what are the two specific vaccine questions, people want to understand why are we doing that and is that a good idea. Those are the two with the biggest sets of questions.

Dr. Fox: So, let’s talk about that. Let’s talk about COVID boosters and kids. What are you telling people?

Emily: What I’m telling people is that, you know, I think that it’s a really good idea for the elderly to get a COVID booster every year. They get a flu booster because COVID can be really serious in older people. I tell people if they want to get their kid a COVID booster, that’s totally fine and that it could, sort of, slightly lower their risk of getting COVID. I also think that I would not, from a public health standpoint, recommend that everybody do this or strongly recommend everybody do this because I don’t think that the benefits are very large to people who are not… Most of the benefits to the COVID booster are to prevent people getting seriously ill and the risk of serious COVID illness in kids and healthy adults is quite low at this point, especially given that everybody had a lot of vaccines and probably had COVID a few times. I don’t know. This is like a little bit of a… Certainly there are… I should say there are people that I talk to who give very different advice, who say everybody should get a COVID booster. This is my read of the data, but maybe you don’t agree.

Dr. Fox: No, I mean, I don’t advise people about COVID boosters for their kids because it’s not my space. It’s just I don’t know anything about it, but for example, a lot of my pregnant patients say, “Should I get a COVID booster?” And what I basically tell them is I’m fine with it. I think it’s safe. And I think again, it’ll probably lower the chance of COVID, but we’re not really seeing severe, horrible COVID, again, in otherwise young, healthy adults, even pregnant now, because they’ve all been… Like you said, everyone who’s asked me this question, I was like, “How many boosters have you gotten?” They’re like, “I got three, and I got COVID twice and maybe a third time.” And so I’m like, “All right, you’re like me,” which is like antibodies all over the place.

And so it’s not clear how helpful the vaccine is. And so I tell them, “If you want to get it, I’m totally fine with it. I don’t have an issue with the safety in pregnancy,” but I’m not twisting people’s arms is what I tell them. And they’re like, “Well, will it benefit my baby?” And I said, “Well, your baby will be born probably with some antibodies to COVID, but whether your baby needs antibodies to COVID, probably not because it’s not really a disease of newborns.” And so I say it’s sort of like dealer’s choice. I’m a little bit more, I don’t want to say forceful because I don’t really force anything, but I’m definitely more positive about the flu vaccine because we know that flu every season is different and really some pregnant women get really sick from it. And so I think it’s a good idea, as does everyone, for them to get the flu vaccine. In COVID, I’m a little more agnostic towards, but again, I don’t have any concerns with it. If people are getting it, I’m like, “Great, go for it.” But I definitely don’t push it.

Emily: Yeah, I think this is a complicated messaging about something like flu also for kids, where I think the evidence in favor of kids getting flu vaccine is much stronger. And so how do you think about the messaging if you would be happy for people to get both but you think the flu is more important? And how do you keep those lines open while prioritizing…? This is just really tricky.

Dr. Fox: Right. Yeah, and this is something… We spoke to this on your podcast. Different people are looking for different things. Some people just want the doctor to tell them what to do like, “Just tell me what to do. What am I doing with my kid here?” And fine. And if that’s what the patient wants, then tell them, “Here’s what I think.” And others really don’t want that. They want to be a part of the discussion, part of the conversation. They have strong feelings about it, and they really want to know a little more nuanced. They want you to rank the vaccines like, “All right, I’m going to give my kid one. Which one should I give them?”

Emily: And which one do you pick? Exactly.

Dr. Fox: Yeah, and that’s totally fine. And so sometimes you just have to read the room like, what are they looking for? And I think that sometimes people have a hard time with that. Doctors, I mean, some of them are very much into, “I’m just going to tell you what to do and you’re going to sit down and listen.” And the other end of the spectrum, which is, “I don’t want to tell you what to do, and I’m going to give you choices and you’re going to choose.” And I think that ultimately it has to be a little bit of both. And how much of each really depends on what the person wants. Different people want different things from their doctors, and I think we have to be flexible to help navigate that for them in the way that they want to navigate it.

Emily: Yeah, and I think from the patient standpoint, which is, sort of, more the audience that I’m talking to, it also benefits you as a patient to think about which category you’re in and to say to the doctor, “Here’s what I’m hoping to get out of this conversation, and here’s what I’m hoping to get out of your advice.” And that’s going to make it a lot easier for your doctor than to try to read the room if you just tell them, “Here’s the room that you’re in.” “Please give me the advice for this room.”

Dr. Fox: “Here’s how it goes. This is the room I occupy.” All right. And what do you tell people about the second one, the hep B vaccine at birth, I mean, in the hospital versus a few months later?

Emily: Yeah, I think one thing is some of the rhetoric people are getting about hep B is confused. And so they’re, sort of, being told you only get this through infectious drug use and risky sex and so babies don’t need it. And I think that’s actually useful to explain to people why do we give this at birth. If mom has hepatitis B, the chance of the baby having it is high and the chance of becoming a chronic carrier is really high in contrast to people who get hepatitis B later in life, where generally they just get better and they don’t carry the virus. But if you become a carrier, the risk of liver cancer is really high.

So, there is a reason from a public health standpoint that we have a policy of vaccination at birth, and there are a lot of reasons to vaccinate early because kids can get this at daycare, for example. And that would also carry a very high risk of becoming a carrier. So, I think that the benefits to vaccinating as a kid, as a small baby are very high. If mom doesn’t have hepatitis B, the benefits to vaccinating at birth are very low. So, I think for most people who know that they’re not carriers of hepatitis B, I think it’s reasonable to delay that vaccine until a first visit. And I think most doctors faced with a mom who knows they don’t have hepatitis are happy to do that delay. But I think it is important for people to understand the logic for doing this in the first place and why they probably do want to do it with the baby, even if it’s not at birth.

Dr. Fox: It’s well known that if we know the mom has hepatitis B, it’s a recommendation. You really should vaccinate the baby right away.

Emily: Very strong, yes.

Dr. Fox: That’s a strong recommendation [inaudible 00:42:00.083] this. And I think that what just happened was from a public health perspective, people said, “We’ve done this a lot. We know it’s safe. The baby’s in the hospital. What the hell? Just give it to the baby now before they go home. And that avoids one vaccine two months from now. And that way, in case someone didn’t know they had hepatitis B, you’re not going to miss.” Okay, fair. And I think that, for most people, they’re fine with it. They’re like, “Oh, whatever.” If that’s what you do, that’s what you do. And others who push back and say, “I really want to wait two months.” And again, whether there’s any benefit in waiting two months, I doubt it, but whatever. For them, they want to wait two months, pretty much to be just like, “That’s fine. As long as you don’t have hepatitis B, no problem. Your pediatrician will do it.” And it doesn’t tend to be a big thing is what I would say practically.

Emily: Yeah, I didn’t vaccinate. I will say my second kid, we were not in the hospital for long enough, basically. And they were just like, “Ah, you can leave now and we’ll do this in two months.” And that was it.

Dr. Fox: I have no recollection what we did with my kids.

Emily: Yeah, exactly. I only remember that because yeah, we were trying to get out of the hospital in 12 hours, and they were like, “Well, we could only do a few things if you want to leave.”

Dr. Fox: Got it. Awesome. All right. Emily, thank you so much for coming back.

Emily: Thank you, Nate. It’s always great to talk to you.

Dr. Fox: Always great. And I’m sure we’ll speak again in the near future.

Emily: Excellent.

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