麻豆传媒

In part 2 of this exclusive video interview, 麻豆传媒's editor-in-chief Jeremy Faust, MD, talks with Perri Klass, MD, of NYU Grossman School of Medicine in New York City, about the evolution of vaccine policies, the challenges of teaching modern medicine, and how collective action has made the world safer for children.

You can watch part 1 of this interview here.

The following is a transcript of their remarks:

Faust: In addition to being a luminous writer, you are also a pediatrician. And I want to talk about in your career the way the conversation has changed around things like vaccination, because you've seen a few different eras, I would say, even in just a couple of decades or a few decades at this.

Klass: I grew up with the idea that, as I say, my parents remembered polio. My grandparents were probably -- if you had said, 'Hey, we have a new vaccine,' they would probably have lined up before you told them what the vaccine was. They still had that very clear memory of what it was like to be as scared as they had been. So I grew up with the idea that this [vaccination] had made a tremendous difference.

We lived in India when I was a child, and I also grew up with the idea that there were parts of the world where vaccines were less available, and that was a huge injustice and children died.

In my own time practicing as a pediatrician, well, you mentioned the polio vaccine. I was in practice when we were still giving the oral polio vaccine. And when the decision was made that actually polio had become so rare in the United States at least, that we would stop giving oral polio vaccine, which is a live virus vaccine, and which causes a very few cases of vaccine-related infection because of the live virus. And we always had to ask if there was someone in the house who was immune compromised, we always had to worry about that, that we would change instead to giving the killed polio vaccine, which has no live virus in it, and which cannot cause vaccine-related infections.

So I remember that, and that in many ways felt like a victory. The number of cases is now so low that we can worry about those very few cases. I've also been in practice during the era when a lot of the vaccines that were not in that were mentioned, the vaccines that parents started vaccinating against some diseases which probably hadn't been keeping parents awake night after night, like Haemophilus influenza type B or pneumococcal disease or meningococcal disease. The families which were devastated by children who got those fierce, horrible, deadly, devastating bacterial infections.

They knew them, but they were comparatively rare. So I would say that I would date not only my own practice, but also my own parenthood to this question of, Hey, you know what? We don't have to worry about Haemophilus influenza type B anymore. And now I've become one of those kind of antiquated attendings who's saying to the residents 'Oh, you don't remember the way that when I was training, they used to talk to us about polio. You residents don't remember how scary it was. You don't remember the iron lungs, everything you started with.' Well, now I'm one of those people saying 'Oh, you don't remember Haemophilus influenza type B, epiglottitis, periorbital cellulitis, devastating, horrible infections that you will never see because now everyone's immunized.'

Faust: It sometimes feels like we are in 1930 because we're teaching the students to look for hepatosplenomegaly, which of course we don't need to diagnose. That's a stage IV cancer. We ask them to look for all these clinical signs and symptoms that we will pick up from our rapid antigen test or from the swab or from the x-ray. How do you teach medicine today in 2024 with trying to meld those two eras?

Klass: It's hard. I agree it's hard. On the one hand, I think anything, and I'm speaking as a pediatrician here, but maybe also as a non-pediatric patient. I think people still want to feel in the medical encounter that someone is looking at you carefully, touching you, thinking about you. So I think that anything that we can teach, which encouraged you in pediatrics, really look at the child, look at what the child can do, interact with the child, touch the child, put your hands on, matters. And I find, I don't know if you do, I find I want that as a patient too.

Faust: The greater point that I think is so accurate is that they want a doctor, they don't want a transcriber of medical information into the chart.

Klass: And I think also in pediatrics where a lot of what we do is still well visits, even I, as a pediatrician, I guess I found it reassuring when my children were babies to have the doctor listen and say to me 'Fine strong heart, fine clear lungs.' It's just, it's nice because one of the things that you might ask me and that I've wondered about a million times, and you've probably got an opinion about this is, so everything changed. All the mortality statistics so dramatically. I'm not sure parents got less anxious. I'm not sure that parenthood, I mean by all rights, we should be much, much less anxious than our grandparents. But I'm not sure that we are.

Faust: Well, I think that our social networks are bigger, and so we have more loose ties. So back then you might know a hundred people closely. Today there's a thousand people you follow around because of your social ties. And so that's a ten-fold bigger catchment for your own anecdotals. So it's interesting.

Klass: Interesting.

Faust: Yeah. So I think that maybe our immediate surroundings might be safer, but we still sense that there's a menacing threat out there. I think that drives a lot of concern.

And I think that that's actually maybe we will kind of tie this up and end here, is to say that when we talk to our patients about risk, we are very frequently, very subtly overplaying the individual risk. Because if everyone is vaccinated, your kid's protected. They're getting the benefit of that herd protection. And so in fact, we say, well, if your kid doesn't get vaccinated, they might get measles. But the reality is that's a conversation that we're having with a 1,000 people. And if enough of those people don't get vaccinated, then a bunch of their kids are going to get measles. And so it's a strange conversation to have because the individual risk only becomes great if that conversation goes sideways enough of the time.

Klass: Yes, that is so right. I mean, I said to you, I think this might be the greatest thing we ever did as a species. The best showcase for the ways in which smart -- and I still believe that vaccines and immunization are one of the smartest things we did. And I speak to you as somebody who, as a medical student and as a resident, could never learn immunology.

But here's this unbelievably complicated system that I can barely understand that I can never keep in my mind. And we learned how to trick it. We learned how to turn it on without you actually having to have the terrible disease, without you having to have the smallpox or the diphtheria or the polio. We've learned how to turn on your defenses and take advantage of that incredibly intricate mechanism, much too hard for us to have ever designed.

But then the question is, what else do you learn from this? And I think the other huge lesson is the one that you just referenced. You don't make the world safer for children, one child at a time. The reason the world is so much safer for children is because you've started applying things as public health interventions. You've started getting it out to all children. You took smallpox out of the equation by vaccinating everybody. You can stop using the oral polio vaccine because you vaccinated everybody. You make the world safer for children.

And I think this also honestly applies, if you think about accident prevention, you don't make your house childproof. You say you have to put childproof caps on all the medicines, and the world becomes safer. You don't say 'Hey, build this in your car and your child will be safer. You say, here's what we know keeps a baby safe in a car. Everybody has to do it.'

Faust: As I hear you say this, I think to myself that we need to reset the messaging. It's not that science is under attack, it's that the safety of our kids is under attack. And that is a message that the parents of the kids that we treat and the kids of the parents that we treat can really resonate with. And Perri Klass, I wish your book weren't so relevant right now, but I do hope that even if we're able to fight back against the tide that we're seeing, that people will read it just so we can reflect on the accomplishments that are captured in that book.

Klass: Thank you so much.

Faust: Thanks for joining us.

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