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Physician leader Janet Jokela discusses her article “How federal actions threaten vaccine policy and trust,” highlighting the unprecedented removal of expert members from the Advisory Committee on Immunization Practices and its replacement with individuals lacking clinical experience, some holding anti-vaccine views. Janet explains the downstream risks to immunization standards, insurance coverage, and public health, and describes swift pushback from major physician groups and ongoing legal challenges. She also examines the role of professional societies, emerging initiatives like the Vaccine Integrity Project, and the urgent need for new health communication models to rebuild trust. Janet offers actionable strategies to safeguard evidence-based policy, protect patient-physician relationships, and maintain vaccine access in the U.S.
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Transcript
Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Janet Jokela. She’s an infectious disease physician and former treasurer of the American College of Physicians. Today’s KevinMD article is “How federal actions threaten vaccine policy and trust.” Janet, welcome back to the show.
Janet Jokela: Thanks so much, Kevin. Delighted to be here.
Kevin Pho: All right, so tell us what your latest article is about.
Janet Jokela: I’ve been thinking a lot about trust, just the concept of trust, and thinking about what’s been happening on the national level. But then I was thinking, “All right, well, how does that translate back to what we see in the exam room?” And reflecting upon that, I do think things have changed in the exam room with our patients. In the past, patients would say, “Doc, what do you think I should do? If you were in my shoes, what would you do?” And, “I’m so glad you’re here. Great to see you.” All that kind of thing. Those comments imply a bond of trust between your patient and you.
But now in the exam room, things have changed a little bit. Patients might say, “Well, I don’t think I want to do that,” whatever it may be. Or, “Google says we should do this, that, or the other thing,” or even more threatening kinds of comments. You realize things in the exam room have changed, just as they have on a larger scale. So that’s kind of where my mind has been.
Kevin Pho: And of course, you’re an infectious disease physician, and that means talking about vaccines with your patients. And as we all know, the topic of vaccines is highly polarizing in public. So when you say that patients aren’t as trusting in the exam room or in the hospital where you see them, and you even use the word “threatening,” have you personally experienced or seen some of this mistrust, and what exactly does that look like?
Janet Jokela: Yeah, I think it varies from patient to patient. Some years ago, yes, I experienced that kind of mistrust and anger. That was over an opioid prescription, and that was quite unsettling to the point where, from the hospital’s point of view, I sought extra protection from the hospital’s security people for myself and the staff. But that aside, otherwise, it’s also just been more lengthy conversations. Like, “Should I really get this vaccine? Do I really need it? Why?” All those kinds of discussions. So yeah, there’s been a lot of that as well.
Kevin Pho: And why do you think over the past few years that mistrust has grown bigger?
Janet Jokela: Certainly in primary care, I think there are a few aspects to that that are important. One is the systematic, if you want to call it that, minimization of primary care relative to other specialties perhaps. Also, our time pressures are being squeezed. I think to really develop trust, you need time to develop that relationship and time to really connect with the patient and listen to them. When our time is squeezed, some of those things are, on the surface anyway, the easiest things to move on from, and that really hinders us.
The second major thing, I think, of course, is the pandemic. I can’t help but think that in many ways, all of us—patients, physicians, everybody—are all still reeling from the effects of that. And I think that’s in large part maybe where we are.
Kevin Pho: So when we talk about trust, of course, the actions by the federal government sometimes may play a role in that. In your article, you talk about the recent removal of the members of the ACIP, the Advisory Committee on Immunization Practices. So tell us more about what you wrote about that in your article.
Janet Jokela: Yeah, Kevin, when that all came down, which was back in June, I believe, it was so sad. It was just so sad. ACIP in many ways has flown under the radar for probably as long as it’s been in existence. All of us in medicine, in public health, and the public have known that the members of that committee have been thoroughly vetted in a very transparent process, and the work that they do was of the highest caliber and highest quality. These are national vaccination experts from all over the country, and you could really place your trust in them.
For a federal government official to go in and just unilaterally dismiss the committee and then replace them with individuals who have not been vetted is a problem. We don’t know what all the conflicts of interest are. We’ve heard a bit about what some of their positions are on vaccines and vaccinations. It’s just kind of like a federal-level gut punch, if you will. It’s like, “How did we get here? How did that ever happen?”
Kevin Pho: So for those who aren’t familiar with what the ACIP members do, what exactly are their roles?
Janet Jokela: Yeah, it’s a good question and it’s a really important committee. Again, I think in retrospect, many of us have just taken it for granted because it’s worked so well for decades. But in essence, they make the vaccine recommendations to the CDC for how kids should be immunized, how adults should be immunized, and all of that. They look at things like which vaccines are important, which vaccines should be given, when should they be given, what are the ramifications if a vaccine is given at this time as opposed to that time, and what is the safety of the vaccines? All the various permutations of that. You can imagine why it would be so critical to have vaccine and vaccination experts in that place and in that room making those decisions.
So that’s a lot of the work that they do. Taking it a step further, these recommendations guide U.S. policy on insurance practices. So will insurance programs, Medicaid, and all of that cover vaccinations? It’s a really important committee for the whole country and everybody’s vaccinations.
Kevin Pho: So, of course, a large portion of the electorate would read this news and then they would read the explanations by our federal officials as to why they removed these members. What kind of reasons is the public getting in terms of why these ACIP members were removed?
Janet Jokela: Kevin, it saddens me to say this, but the rationale that was given for the firing of all these ACIP members is that they wanted to restore trust in this committee and in the process. I mean, it’s just a very—and this is my opinion—a very legalistic twisting of the concept of trust. It’s exactly backward. But maybe that’s what some people do who are trying to promote a certain position or other points of view in certain places. So it was tragic. It was just tragic.
Kevin Pho: And who did they replace these members with? You earlier said that they weren’t vetted, and sometimes they may have viewpoints outside of the medical mainstream. So tell us, just in general, who did they replace these members with, these people who will be determining and making recommendations about vaccine policy going forward?
Janet Jokela: Sure. And that’s important. One of the articles that I referenced in the piece that I wrote does go into that in more detail. The article that was published in the Annals of Internal Medicine, authored by Jason Goldman and also Robert Hopkins, who’s been a longtime internal medicine doc and a national expert on vaccines and vaccinations. What they mentioned, as I recall, is a handful of people. The committee was replaced with eight people, one of whom withdrew early on, so there were only seven there in total. The lead person, the chair of the committee now, was one of the authors of the Great Barrington Declaration, which was a very controversial statement early on during the pandemic, just talking about the importance of herd immunity and all of that, but he is a non-physician. Then there’s someone else, as I recall, who has been very visibly involved in some anti-vaccine initiatives and activities and is very publicly known to hold, for lack of a better phrase, an anti-vax position. So off the top of my head, that’s who I recall. The article that I referenced goes into it in a little bit more detail.
Kevin Pho: So if we have members with contrasting views on the committee, tell us about some of the ramifications that you can imagine going forward.
Janet Jokela: I think we’ve been seeing some of that already. Even how the ACIP spent its time when it did meet. They debated the topic of thimerosal, and this was an issue that had been put to rest a number of years ago. The risk of thimerosal causing any serious consequences in kids is just not an issue; it’s a non-issue in the way that vaccines are manufactured today. So anyway, to bring that up again, to go through data, which as I understood it was questionable to begin with, and to spend time on an issue like that as opposed to time on more meaningful and pressing concerns, is an example of a really unfortunate opportunity cost. To be spending time on issues which are not critical issues versus spending time and energy on other issues which are important and do need to be considered is a problem. So that’s just one example.
Kevin Pho: So I’ve read some perspectives saying that sometimes if we suppress voices that are outside of the mainstream, that could only sow more distrust, and that was one of the reasons why we lost that trust in public health, especially during the pandemic. Even if they promote views that are outside of the mainstream and that have zero scientific credibility, what’s the best way to handle those alternative viewpoints? Because a substantial amount of the electorate believes them. And sometimes if we suppress them and don’t allow them to speak, that can only sow more distrust. So it’s a little bit of a paradox here. What are some ideas you have going forward in this environment that we’re in?
Janet Jokela: Kevin, that’s exactly where my head has been. Like, “How do we do this and how do we navigate this?” On the larger levels, the federal level, public level, and all that, I think it’s exceedingly difficult. There are some really wonderful communicators who do address this in a very respectful, empathetic way. The challenge on that level is just because there may be a loud voice about one point or another, it doesn’t mean it’s a majority voice or that even 20 percent of people agree. That may not be the case at all. The data that we do have shows that the vast majority of people in this country support vaccines and vaccinations and know how important they are.
The question is, how do we best support good scientific approaches to what we do in medicine and public health, and how do we do it in a respectful way that at the same time doesn’t give more weight or more credence to these other positions which are not grounded in what we know is correct? At the same time, you want to be respectful to those folks but not give them a major platform or not present information as being equivalent, like “It could be this or it could be that.” No, that’s not right. So it’s a very nuanced conversation that I think many people are giving a tremendous amount of thought to, to figure out how we navigate this. It’s really not easy.
Kevin Pho: So what’s the response of our professional societies like the ACP? How are they responding to some of these changes?
Janet Jokela: Yeah, that’s really important. The professional societies have become increasingly vocal, I think, about these things, certainly with the ACIP issue. ACP has been right there. They’ve been issuing statements, publishing editorials. And then really remarkably, they were one of a handful of organizations that entered as plaintiffs in a lawsuit, essentially saying, “Look, this is just wrong. It’s endangering patients.” This had to do with the new COVID-19 vaccine recommendations for pregnancy and also for healthy children. So they’ve been right there. There’s a lot of really good information, I think, published on the ACP website and elsewhere that really addresses this. IDSA has been active too, as have the pediatricians. So there have been a number of professional societies that have become increasingly vocal.
Kevin Pho: So we are seeing changes, of course, not only with the ACIP but the U.S. Preventive Services Task Force as well. And sometimes they’re being replaced with members with views that may be outside of the medical mainstream. The problem is they’re giving recommendations to federal agencies like the CDC, and the public is going to view these recommendations, which may be suspect. How do you reconcile that going forward? Do you see that we need competing recommendations with members that are more scientifically accurate? How do we sort this out going forward?
Janet Jokela: I think it’s going to be really difficult for our patients for that reason. We’ve gotten so used to, over many, many years, relying upon guidance and recommendations from the federal government on these things. Now there are individuals in place in the federal government who possess alternative viewpoints, and when that guidance and advice goes out to the public, it’s no surprise that the public would be confused. It just makes it a lot more difficult for us when we’re in the exam room with patients to try to mitigate that and combat that a little bit. That’s a challenge when there are individuals in positions of authority in the federal government saying whatever it is they may be saying, and we know that’s incorrect. We have to remain steady and, in some ways, push back against that in a way that we know is correct.
The ACP is doing that. There’s this interesting project out of the University of Minnesota, the Vaccine Integrity Project, which in a way is another group that’s nascent, it’s still new. But it may evolve into something like what you were just mentioning, an alternative—ironically, right? That should be primary—but an evidence-based and scientifically sound source of guidance on these different issues where the government is going in a different direction.
Kevin Pho: We’re talking to Janet Jokela, an infectious disease physician and former treasurer of the American College of Physicians. Today’s KevinMD article is “How federal actions threaten vaccine policy and trust.” Janet, as always, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Janet Jokela: Sure. Thank you, Kevin. I think three things come to mind. One is to remain engaged with our professional societies like the ACP. The ACP is in a great place, doing good and sound work. It’s inspiring to me and certainly to many others. Second, I think it’s important to keep our eyes on the horizon in terms of how things are evolving nationally and what’s going on. And third, the last one, I really like Paul Farmer’s advice. He’s the one who helped found Partners in Health and did some wonderful work there. His comment about trust was, “Trust is built one patient at a time.” For those of us in exam rooms and in that space, that’s all we can do. And with that approach, he built this amazing entity that continues to do good work today.
Kevin Pho: Janet, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.
Janet Jokela: Thank you so much.