I’ve spent a lot of time in children’s hospitals. I trained as a pediatric resident in New York City at the turn of the millennium and was a pediatric infectious-diseases fellow in Philadelphia after that. Twenty-five years later, I still love the challenge of a difficult diagnosis, the chance to help a family through a hard time, a moment of connection with a frightened kid. Children’s hospitals are places that no family wants to end up, but they’re also places of immense hope.
I was a tiny part of a long, steady progression in the profession of pediatrics. Thanks to an upward curve of knowledge and skill, we could do more to help sick children than the generation of pediatricians before us, and my colleagues and I would inevitably be surpassed by the generation that followed.
Childhood acute lymphoblastic leukemia had been a terminal diagnosis a couple of decades before. We expected kids with A.L.L. to make it through the new chemo regimens, to survive. It didn’t always work out that way, and the outer limits of what pediatrics can do at any point are measured in tragedies. The magic was there, though. Younger and younger preemies survived; kids got a new heart or liver.
And Hib! Hib (Haemophilus influenzae type B) was the scourge of pediatricians a generation before mine, a deadly bacterial infection that preyed on young infants until a vaccine came on the scene, in the late 1980s. During my years of training, I didn’t see a single case.
This is how it should be. Most of life doesn’t necessarily feel like a march of progress, but in the unique eco-system of a children’s hospital in a wealthy nation, the past few decades sure felt like we were moving forward.
Until it didn’t.
In the autumn of 2018, an unvaccinated traveler returned to the U.S. with an unexpected viral souvenir. But instead of it ending up as a one-off case of measles, or a handful of cases, an outbreak took off in New York City. By the time the health department stopped counting, the total number of infections was nearly 650, mostly affecting kids. About 50 were hospitalized. Twenty required intensive care. We were lucky that no one died.
Before that outbreak, measles was one of those things I had filed in my brain under “solved problems.” It is the most contagious virus known to science—putting flu, polio, the coronavirus, Ebola, and anything else you can think of to shame. But we had tamed it.
Using mucus from the nose of a schoolchild in the mid-1950s, John Enders, a veteran of the fight against polio, figured out how to grow measles in a dish and forced it to adapt to all sorts of unfamiliar conditions (kidney cells, chicken embryos, and the like). In the process, it lost its ability to cause disease. That same weakened virus, the Edmonston strain, is the heart of the vaccine that we still use—the one that controlled the disease’s spread and eliminated it from the U.S. about a quarter-century ago.
The number of people killed by measles before there was a vaccine is uncountable. In Mesoamerica in the 1500s, measles and smallpox together wiped out more than 90 percent of the population. In Fiji in the 1800s, when British colonialism brought measles to the islands, a quarter of the population died. When Jacob Riis visited the tenements of New York City in the 1880s, he described measles as killing children “right and left.”
More than 60 years after its introduction, the measles vaccine remains safe, and it continues to work. The 10 million measles cases and 100,000 deaths that we still see globally each year are by choice, as was the 2018–19 outbreak in New York City. We have the tools that we need to eradicate measles, as we did smallpox and rinderpest, the cattle-plague virus that happens to be measles’ closest relative.
Because it is so contagious, we need more than 95 percent of people vaccinated to prevent measles from spreading in a population. In New York City, about 98 percent of kindergartners were up to date with their measles vaccines in 2019, but in the neighborhood that was the epicenter of the outbreak, that figure was less than 80 percent. Targeted anti-vaccine messaging based on junk science had appeared in the years leading up to the measles outbreak. Family by family, the wall of community immunity eroded.
The same thing happened in Samoa, where measles killed more than 80 people, nearly all of whom were children. Anti-vaccine activists, including R.F.K. Jr., had pounced on a local tragedy, stoked fear among parents, and set the population up for an explosive outbreak.
So far this year, we have seen measles cases in Texas, Rhode Island, Georgia—and it’s only March. The resurgence is predictable. Kindergarten vaccination rates are down to about 93 percent and falling. These figures augur a coming disaster. Measles is first because it is so contagious, but higher rates of other vaccine-preventable diseases—whooping cough, diphtheria, and even polio—may not be far behind.
Oh, and Hib? The scourge of pediatricians past? I’ve seen three horrific cases in the past few years.
Our kids haven’t been shielded because they live in a rich country or because their parents eat organic produce or use essential oils. They’ve been protected over decades because we have been lucky enough to be able to vaccinate them and the people around them. As anti-science ascends in Washington and vaccination rates fall, I fear that current pediatric residents will remember their early careers as the time that they saw progress slip away.
Adam Ratner is a pediatric infectious-diseases physician in New York City
