The Centers for Disease Control in Atlanta was a silent partner in my primary care practice in Oakland, California. Over the years, I scurried between exam rooms focused on individual patients in three different settings: private practice, Kaiser, and a public clinic. My job always included counseling people to prevent chronic disease, but I also treated sick patients. I depended on the recommendations of public health officials because I couldn’t possibly keep up with all the aspects of public health at home and abroad. Like me, doctors around the world have turned to the CDC for advice. This is the institution the current administration seeks to dismantle.
The CDC mission, “to protect public health and safety by controlling and preventing disease, injury and disability in the U.S. and globally, focusing on health security and promoting health equity,” supported my efforts concretely. At the clinic, a large poster from the CDC described the vaccine recommendations for adults. The CDC’s regular publication, Morbidity and Mortality Weekly Report, kept me abreast of global health concerns. The advent of the AIDS and Covid-19 epidemics were announced in those pages.
It was part of the Center’s job to compile the national statistics on infectious diseases collected from state health departments around the country. When I started in practice in the 1980s, we sent the health department a small card by mail for each diagnosis we made. Later we reported online. Physicians are mandated to notify the health department of sexually transmitted infections like syphilis and gonorrhea along with many other infectious diseases, including common ones like hepatitis and rare ones like hantavirus. The states determine which diseases are notifiable, so the list varies from state to state. Without these statistics, as well as reports about antibiotic resistance, we don’t know where infections are prevalent or how to treat them.
At the website www.CDC.gov, there is a library of health care information, from country-by-country recommendations for global travelers (which I have used extensively) to pictures of poisonous snakes and descriptions of the symptoms caused by their venom (which I have never used). When faced with diagnostic dilemmas among our hospitalized patients, the infectious disease specialists sent serum from those patients to CDC laboratories for novel tests that only they performed. For all of us, the CDC was the ultimate answer to “Who you gonna call?”—always available as the consultant of last resort and the first line of defense against threats to public health.
During the pandemic, people complained that public health advice for how to cope with Covid-19 changed over time. This puzzled me, because recommended treatment is always changing in medicine, especially in a fast-moving epidemic. The same thing happened with AIDS: as we learned more, strategies changed month to month. There are always new drugs on the market, older ones are relabeled for emerging side effects, new diseases like Zika spread suddenly. Primary care doctors work hard to keep up, constantly learning. Continuing education lectures from university professors are often called things like “What’s New in Rheumatology” or “What’s New in Cardiology.” What was new in infectious disease always cited the CDC.
As we observe the vaccine wars, it’s instructive to remember that public health has never been an easy sell. Dr. Alice Hamilton, a pioneering physician in the field of occupational medicine who lived from 1869 to 1970, commented in her autobiography, Exploring the Dangerous Trades: “Perhaps it is our instinctive American lawlessness that prompts us to oppose all legal control, even when we are willing to do what the law requires.” Her work is a good place to start if you want to get a sense of the breadth of public health.
Among other things, Dr. Hamilton visited factories at the turn of the twentieth century and exposed industrial toxins. Lead workers were falling ill, but the bosses claimed that it was not from work exposure. Doctors who hospitalized patients did not write down where the men worked, so she had to connect them to the employer. “It was not an easy task I faced, tracking down actual proved cases of lead poisoning among men who came from the Serbian, Bulgarian and Polish sections of West and Northwest Chicago, and were known to the employing office only as Joe, Jim or Charlie, with no record of the street and number!” She had to find each one, or else a relative who spoke enough English to tell her where he worked.
In 1964, the Surgeon General’s Report on Smoking and Health collected the scientific evidence that smoking was harmful, but it required a decades-long campaign to convince people of the dangers. Eventually public health efforts to decrease smoking prevailed, despite the tobacco companies who opposed the anti-smoking movement and tried to cast doubt on the science behind it. In the end, they had to stop advertising cigarettes on TV and were required to put warning labels on cigarette packages; ultimately, laws were passed that prevented the selling of cigarettes to children and banned indoor smoking.
As a result of similar public-health efforts, America also legislated seat belt use and the use of infant car seats. People did not voluntarily adopt these safety measures. I remember an aunt who drove “like a bat out of hell,” according to my mother, her sister. She did not want to use the seat belt because she imagined herself trapped in a burning car. It is true that there are times that passengers in an auto accident might have survived if they had been able to get out of the car. However, studies show that most of the time people, and children in particular, sustain injuries and die because they are thrown from the car. Those who reject studies and choose to rely on their own fears to direct policy are a danger to the public.
Which leads us to Make America Healthy Again. I give the administration credit for taking action that acknowledges we cannot look to the market to promote public health, even though they would never describe their crusade against food additives in those terms. Yet at the same time the administration wants to expand production of oil, coal, and natural gas, pleading economic necessity as they shut down new wind and solar projects. This would increase the harm of fossil fuel pollution, which is still estimated to cause 350,000 premature deaths a year in the United States. The energy industry has followed the lead of the tobacco industry, spending millions of dollars to convince the public that there is still controversy about the health effects of fossil fuels. (There is none.) Congress passed the Clean Air Act in 1963, not because of concerns about possible climate change, but because people right then could not breathe. Since 1970, particulate matter emissions from motor vehicles have dropped by ninety percent, carbon monoxide emissions by eighty percent. We have forgotten this success story.
With the same historical amnesia, Americans don’t fear the adverse consequences of childhood diseases anymore. Few people in the United States have seen a case of measles, but in sub-Saharan Africa there are currently 28,000 deaths from measles every year. This past year, we’ve had about a thousand cases and three deaths in the United States so far, in communities with low vaccination rates. If my child died of a preventable disease, I would be distraught, wracked with guilt. The parents of one of the children who died have declared that they still oppose vaccination. Clearly they found it impossible to consider that they might have made a mistake.
Parents used to be terrified of polio, especially after President Roosevelt’s illness at age thirty-nine, which left him paralyzed from the waist down. Swimming pools were closed for fear of contagion. My mother made sure we received the Salk polio vaccine as soon as it was available in the 1950s. I remember the Saturday I lined up at a school—not my own but a different school—to get a shot. As a doctor, I have treated many patients who live with the sequelae of polio infection. My husband’s uncle walked with crutches all his life and developed post-polio syndrome as he aged.
My professors in medical school, who practiced before childhood vaccines existed, cared for men rendered sterile after mumps orchitis, along with babies born deaf and with heart disease from congenital rubella, or with pneumonia and encephalitis from measles. They would be astounded to hear that anyone would want to return to the days of anxiety before vaccines, where everyone knew someone who had a bad complication and mothers prayed that their children would be spared. These worries used to be behind us.
The rates of death and complications from measles, mumps, and rubella plummeted when the vaccines were introduced, initially separately, in the mid-1960s. The health benefit was clear. Now there is talk about vaccines causing autism, but the steep rise in the rates of autism started in the 1990s. Millions and millions of children around the world received the vaccines without difficulty in the last century. Even without an understanding of the many studies that do not show a link between autism and vaccines, the fact that the rise in autism rates is not related in time to the introduction of the vaccines makes the association ex-tremely unlikely.
Was there any change that did coincide with the rise in autism rates? What is discernible is a broadening of the criteria for diagnosis. Psychiatrists point to the fact that Asperger’s syndrome (a term that has fallen into disuse in favor of “a neurodiversity spectrum”) was recognized as a billable diagnosis in 1994, when it was included in the fourth edition of the Diagnostical and Statistical Manual of Mental Disorders. The diagnosis is based on behavior, and children with milder symptoms are now judged to be “on the spectrum.” Since 2001, all the states have passed laws that require insurance companies to provide treatment for autism, so the diagnosis benefits parents who otherwise could not afford therapy for symptoms. In addition, the American Academy of Pediatrics began to recommend screening toddlers for symptoms of “autism spectrum disorder” in 2007. This all resulted in increased incentives—medical, social, and financial—for arriving at an autism diagnosis.
By and large, the medical community stands behind the safety of childhood vaccines. But physicians who want to argue facts with MAHA forces encounter a Catch-22: respect for science and experience brands us as elitist and therefore untrustworthy. The original Hippocratic Oath says, “I will reverence my master who taught me the art.” The revised oath I took in 1977 says, “I will respect the hard-won scientific gains of those physicians in whose steps I walk.” Either way, we swear to uphold a tradition handed down from other doctors.
Say what you will about physicians (and I have), most of us take our oath seriously. Plenty of doctors are Republicans—sixty percent of surgeons and anesthesiologists, fifty percent of dermatologists. Primary care doctors lean Democratic, possibly because we are the ones who have long-term relationships with patients; we see them in context, beyond the sterile field. But no matter our perspective, few of us in practice are willing to ignore our scientific training. The administration has lost potential allies with its anti-science rhetoric.
What about diet and exercise? Isn’t the MAHA message helpful in that realm? Yes and no. Studies confirm that people can adopt healthier behavior if they have enough support. The support does not have to be one-on-one in-person counseling; folks also benefit from groups and phone calls. But so far tech innovations have been disappointing. Fitness trackers work best for those who are already exercising and want to document their achievements. The greatest public health benefit comes from getting couch potatoes moving, not from coaching well-heeled jocks to peak performance. Perhaps you don’t know anyone starting at zero. Doctors do.
What we don’t need is misinformation about “eating clean,” which implies that adherence to a certain expensive regimen is a guarantee against illness. Genes, environment, and above all luck count, too. We humans do not have the power to fend off disease entirely by supercharging our immune system, or drinking raw milk, or engaging in power yoga. For me it is not the specific recommended practice that rankles, but the arrogance of the conviction that our destiny is completely under our control. Robert F. Kennedy, Jr., may look like an over-tanned body builder now, but he was lucky to survive fourteen years of heroin use. My thin, active friend who died at age forty-nine from metastatic prostate cancer was very unlucky. His doctor told him that he was one of only ten patients in California that year under age fifty with such severe prostate cancer. As though that would make him feel better.
In 1992 Dr. Elizabeth Fee remarked, in an editorial in the American Journal of Public Health: “Public health as an entire field suffers in social value through being associated with the more ‘feminine’ values of sustaining and maintaining health rather than with the ‘masculine’ heroics of high technology medicine.” In fact, in the early twentieth century women who had received their medical degrees, but were then denied the internships they needed to practice medicine, ended up with careers in public health: more suitable, in the eyes of the profession. It was not an area that men considered lucrative or exciting enough to fight over, then or ever.
Still, many affluent people, as they age and face their own mortality, develop an interest in health, specifically in their own longevity. They work out and adopt a healthier diet; they rue their youthful dissolution. Their new health ideas, gathered indiscriminately, reflect their personal experience and that of their friends (a generally privileged group), not scientific research or historical perspective or proven behavioral strategies, which they don’t know. I meet these people at social events—often tech experts or lawyers, who want to convince me that they have found The Way while I have wasted my life practicing Western medicine.
Even with the best of intentions, such a lawyer would struggle to be effective or useful if suddenly appointed Secretary of Health and Human Ser-vices. Controlling and preventing disease, injury, and disability is rooted in an understanding of the circumstances of the lives of other people, including their diet, their work, their children. It is not extrapolating the preventive needs of the population from how one wealthy individual has chosen to age.
So far, as I write this, the current Secretary of Health and Human Services has laid off a fifth of the CDC work force, dismissed all the members of the Advisory Committee on Immunization Practices, and fired the Director of the CDC, who had only served for a month. These actions plunged the agency into litigation and grief, demoralizing doctors across the country, who fear that our reliable silent partner may not have the strength to support us anymore. What happens next is anyone’s guess.
Those of us with an Ivy League education learned in college that inherited wealth does not correlate with intelligence. Not content with this finding, the current administration is running its own non-randomized observational study, which tracks the behavior of assorted middle-aged white multi-
millionaires placed in government service. We have learned that their speech is unrestrained and their actions unpredictable. They do not accept counsel, and they exercise power without substance, like whirlwinds, destructive to lives and livelihoods. In medical research, studies that demonstrate harm to patients are terminated early. It seems likely this one will continue to the bitter end.
Toni Martin is a writer and physician who practiced in Oakland and Berkeley for thirty-seven years. She also served as a regional medical advisor for Social Security Disability.