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Emergency physician Drew Remignanti discusses his article “A world without vaccines: What history teaches us about public health.” In this conversation, Drew reflects on historical lessons from smallpox, polio, and measles to reveal what life looked like before modern immunization. He explores the dangers of misinformation, the importance of science-based health care guidance, and the global success stories that vaccination campaigns have produced. Drew also explains how confirmation bias and the spread of anti-vaccine sentiment threaten progress toward disease eradication. Listeners will gain insight into how to evaluate evidence critically, advocate for public health, and understand the human cost of vaccine hesitancy.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Drew Remignanti. He’s an emergency physician. Today’s KevinMD article is “A world without vaccines: What history teaches us about public health.” Drew, welcome back to the show.

Drew Remignanti: Thanks a lot for having me, Kevin. I appreciate it.

Kevin Pho: All right, so tell us what inspired you to write about this article, and then tell us about the article itself.

Drew Remignanti: Well, I wrote the article because I had a couple of unique experiences. I was in my fourth year of medical school when the World Health Organization made the announcement that the smallpox virus had been eliminated from the face of the planet. My reaction was, “Wait, what? Eliminated? Gone?” We learned about smallpox in medical school, but we never saw any cases because it was effectively eliminated from the United States. I think 1949 was the last case in the U.S.

So it was a historical disease, but we knew it was prevalent throughout the world. That just stunned me, the idea that they had eliminated a disease from existence.

A little bit later in life, after I graduated in 1980, in the early nineties during my emergency medicine career, I ran into a young woman who worked for a physician who worked for the Centers for Disease Control. She told me about the fact that they now had a program in place to try to eliminate polio in the same way that smallpox had been. I thought, “Wow, I’d like to be part of that.”

Because of such a historical success, the elimination of smallpox, I realized I had a chance to be part of this now in relationship to polio. That’s what got me interested in vaccination and infectious disease elimination by way of vaccination.

Kevin Pho: So you’re an emergency physician. Tell us about your experience with vaccines, how you got involved with vaccines, and give some context, certainly about how your experience contributed to the eradication of some of these diseases.

Drew Remignanti: What we saw on a more day-to-day basis in the emergency department, when we saw young children with fever, we always worried if this could be an episode of meningitis. The HIB meningitis, Haemophilus influenzae type B meningitis, was a very common form of meningitis then, and that’s been nearly eliminated by the Haemophilus influenzae type B vaccine success.

The thing that really appealed to me about vaccine-preventable diseases was that you can get perfect equity. When smallpox was eliminated from the face of the planet, everybody’s risk for smallpox suddenly became zero. If you could have an intervention early in life to make somebody no longer susceptible to infectious disease, and if you could do that throughout the world, that had great appeal to me.

Kevin Pho: Now you’ve also had experience volunteering with the CDC and World Health Organization as well, right?

Drew Remignanti: Polio transmission was eliminated in the United States in 1970, I think. People who are unvaccinated or not completely vaccinated against polio could become infected if it was reintroduced, as we’re experiencing right now with measles in the U.S.

But to have the opportunity to eliminate, if you really want to eradicate or eliminate, if you want to bring the risks down to zero, you have to eliminate the virus from the face of the planet, as was successfully done with smallpox. We were on the verge of achieving that with polio.

Kevin Pho: One of the things I learned when I became involved with the CDC-WHO program to eradicate smallpox. Tell us a little bit more about those experiences. What did you do during those stints with the CDC and WHO?

Drew Remignanti: Well, I found out through the CDC that you could volunteer with the international effort to eliminate polio. In the summer of 2000, I went to Pakistan as part of the program there because at that point there were fewer and fewer countries in which polio existed. It’s now down to just Pakistan and Afghanistan.

There are some sociopolitical reasons why that’s true. The Muslim clerics were telling people in those countries that the polio eradication effort was an effort to create sterility among their young women so that they could not have babies and Muslims could no longer reproduce. It was a farfetched theory that vaccinating a child against polio as an infant would prevent her from being able to achieve motherhood later in life.

But people believe things if it’s floated as a possibility. They don’t have the education and knowledge to refute that, or people who can help them to refute that. They get scared. Which is what’s going on in the U.S. now. People are afraid of the MMR vaccine, at the potential risk of autism, which has been disproved again and again.

Kevin Pho: What are your thoughts about what you’re seeing now in the United States? I think I just read an article that the outbreak of measles in the United States has just been growing. It goes without saying that the administration has been sowing distrust in vaccines. As you’re seeing what’s going on now, and you put that in context with your prior vaccine experience, what’s going through your mind as you’re reading the headlines today?

Drew Remignanti: It’s ironic because we’re a highly educated population compared to the South Asia population in Afghanistan and Pakistan. Most people go to school and get educated. We have access to good information. We are trained to become critical thinkers to some degree, but it shows how susceptible even an educated population like the U.S. is to people who want to undermine confidence in health care.

Unfortunately, this seems to be one of the goals of our Health and Human Services secretary. Even our current presidential administration seems to want to undermine expertise.

Kevin Pho: What are some of the reasons behind that? Why do you think that, as you said, a society as educated as we are here in the United States, why are we so susceptible to misinformation and narratives against science and vaccines?

Drew Remignanti: Well, I think it’s inevitable when there’s uncertainty, and science is based on the idea of trying to reduce the degree of uncertainty. But we face that every day in medicine. Practicing medicine, somebody comes in with a set of symptoms, you’re uncertain whether it represents something serious or something minor, and then you do the testing to put yourself in one direction or the other.

Most people who are ill as patients have not gone through a rigorous training process to weigh evidence, pros and cons. They rely on what they hear through the media. Unfortunately, they often will allow their choices that should be scientifically based to be influenced by sociopolitical considerations: “Do I like that person? Do I like their political beliefs? Do I like that social group?”

It’s unfortunate, but that’s what we’re prone to as human beings.

Kevin Pho: Now, do you see any historical parallels to what we’re seeing now when it comes to that distrust in public health? Has this happened before in history?

Drew Remignanti: Well, I think it’s not all that different from what we saw going on in Pakistan and Afghanistan, which is you had people in power, the Muslim clerics, saying to people, “Look, this is an underhanded Western effort to cause infertility in our young women, and we should avoid it for that reason.”

I frankly can’t wrap my brain around why educated people like our president and our Secretary of Health and Human Services. I don’t really know what they get out of it personally except for self-aggrandizement.

Kevin Pho: In terms of what’s happening in Afghanistan and Pakistan because of that distrust in vaccines, you said there have been outbreaks of conditions that have been eradicated in other parts of the world, right?

Drew Remignanti: These are the two countries in the world that if we succeeded in eradicating polio from Afghanistan and Pakistan, we would have worldwide polio elimination or eradication, and we could stop immunizing against polio, just like we’ve stopped immunizing against smallpox.

We could do the same thing for measles if we committed ourselves to it, as this current outbreak is showing us. There are pockets of unimmunized children. You let the measles virus loose in the U.S., as it happened most recently. It began in West Texas and spread to, I think, 41 out of the 50 states that have had measles outbreaks. I just heard this morning on the news that there’s an outbreak going on in New York City.

If there’s a susceptible population of children who are unimmunized to measles, measles will find them and will cause serious illness and potentially even death.

Kevin Pho: Now you’re an emergency physician and an author, and I’m sure that you talk to a lot of people both in the clinical setting and outside. Have you had personal experience with people who have been suspicious of vaccines in public health? If so, how do you normally respond, persuade, or interact with people who have that inherent distrust of the health care system?

Drew Remignanti: Well, typically that doesn’t come up in regard to immunizations in the emergency department. When I see people in the emergency department, most often they’re there because they want a vaccine. They stepped on a nail and want to get a tetanus vaccine. They had a bad exposure and want to get a rabies immunization. It’s a different patient population we see in the emergency department.

I would advise those people who have become skeptical about the utility of vaccines to have that conversation and relationship with a physician they trust, ideally, the pediatrician for your children.

I think that’s the only way we’re going to get beyond this: to have that degree of trust in your pediatrician to guide you to make wise, science-based decisions regarding how to immunize your children, how and when to do that.

Kevin Pho: Let’s talk about trust in our health care system. I think during the pandemic, we’ve lost a lot of trust in our public health system, right? How do we get that trust back from a population and society level when it seems we’ve lost so much of it, especially during the pandemic these last few years? How do we get that trust back?

Drew Remignanti: That’s a huge barrier. I think the only way it can be done is on a one-on-one basis. If you happen to have a pediatrician who’s anti-vaccine, you need to say to that person, “Why are you so anti-vaccine when the bulk of your trained colleagues are pro-vaccine?” It has to be done on a one-on-one basis. It can’t be done on a political basis, wanting to be consistent with your political party.

Kevin Pho: What do you see as a path going forward? Again, drawing from historical parallels, what’s happening in Pakistan and Afghanistan? Has there been any movement in terms of gaining the population’s trust for the polio vaccine? What are some historical paths forward?

Drew Remignanti: I don’t know that there is a complete parallel. I did meet people when I became involved with the polio eradication effort. I met some people who were involved with the smallpox eradication effort. Some of them were still around, and they said they sometimes met great resistance in the same way.

People would hide their smallpox-infective relatives from the investigators and the vaccinators. It’s ignorant fear. Fear is usually based in incomplete information. When you get as complete a set of information as you can about something, you can reduce your fear.

That’s what we should be expecting from our government and from our Health and Human Services secretary, who currently is all over the map. In terms of the measles example, he has said things that just aren’t internally consistent. Our HHS secretary has said that when he was faced with this decision as a parent, he got all of his children vaccinated, but now, for some reason, he’s claiming he regrets that he had that done.

He has said that the solution to the current measles outbreak is to get vaccinated. Then, on the other side of his mouth, he says there are no vaccines that are safe and effective. When you get that kind of contradictory information coming from the same individual, and you’re not getting a chance to ask him in person, you need to set aside that source of information as not internally consistent.

You need to get a more internally consistent set of answers. We’re lucky in this country. We can access individual physicians without restriction for the most part, which they can’t do in Pakistan and Afghanistan.

Kevin Pho: I think one of the issues is that a lot of society simply don’t know what it’s like when there were smallpox, polio, or measles outbreaks because they have mostly been eradicated. People generally don’t know what it’s like to have a smallpox outbreak, for instance. From your experience and what you learned, what was it like before smallpox was eradicated, before polio was mostly eradicated? What was it like before vaccines?

Drew Remignanti: That’s the main thing that motivated me to write the article we’re referring to. I included some images that are eye-opening: rooms full of iron lungs with children who were afflicted, who could no longer breathe on their own, and that startling image of the two boys side by side, one who has diffuse smallpox and one who was vaccinated and has no smallpox.

I saw polio cases when I was in Pakistan. Even since I graduated medical school in 1980, we weren’t seeing routine transmission of polio in the U.S., and hopefully, we will never see that again.

We certainly weren’t seeing routine transmission of smallpox because it was eradicated. We weren’t even seeing routine transmission of measles, but now, practicing physicians need to know how to recognize measles. You probably never saw a case of measles, I’m guessing. Did you?

Kevin Pho: I haven’t, no. How about yourself in the emergency department? Have you ever seen a case of measles or smallpox or anything like that?

Drew Remignanti: No. In Pakistan, I did see a couple of kids who were recovering from measles at a refugee camp along the Afghanistan border. That was my only exposure.

But the numbers speak for themselves: the number of cases and deaths from preventable diseases like measles, polio, and certainly smallpox.

The people who are anti-vax or vaccine skeptics, I wish they could be put on the spot and asked, “Well, how do you explain this? How do you explain the disappearance of smallpox if there are no vaccines that are safe and effective? How do you explain the precipitous drop in measles cases and polio cases and the fact that we are on the verge of eradicating polio from the planet if vaccines are not effective?”

Kevin Pho: Is that how you would engage vaccine skeptics if you were to have a conversation with them? Would you ask them those specific questions?

Drew Remignanti: Yes, I would ask them to take a look at the data that I put in my article and ask, “Well, how do you explain that?” One of the explanations that people have come up with is, “That was just improvements in hygiene and development in the country. As we got to be a richer, more hygienic country, we were able to prevent disease spread on that basis.”

What’s interesting is that when polio first became an epidemic disease, it became an epidemic disease in the most highly developed countries in the world. At that time, the Scandinavian countries were where the first polio outbreaks came. It was felt that was due to the fact that they had progressed hygienically to the point where they had clean water supplies.

The way the poliovirus acts is that if you’re exposed to it as a young infant and you still have maternal antibodies from birth, you’re not going to get the disease. But when you have such good hygiene that you’re not exposed to circulating poliovirus in your water supply, as was true in the Scandinavian countries, you don’t get exposed to the virus until later in life when your maternal antibodies have disappeared. Now you’re susceptible to the poliovirus infection.

Improved hygiene actually caused the initial polio epidemic outbreaks. The hygiene hypothesis that infectious diseases are disappearing because we are just getting more hygienic doesn’t hold water if you look at it in a hard science fashion.

Kevin Pho: We’re talking to Drew Remignanti. He’s an emergency physician. Today’s KevinMD article is “A world without vaccines: What history teaches us about public health.” Drew, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Drew Remignanti: Again, the title of my book is The Healing Connection: A Partnership for Your Health. I think the best thing we can do for ourselves, health-wise, is to choose a primary care physician who we can put our trust in. You cannot, unless you want to go to medical school and become fully educated as a physician yourself, have that full knowledge.

Even myself, as a fully trained, experienced physician, when I have problems, as I have had personal health problems that are gastrointestinal or whatever, I go to see a specialist who knows even more than I do. When it comes to our health, you need to see somebody who knows more than you do.

Ideally, someone who’s trained in modern, science-based health care. Form a trusting partnership with that person and move forward. It doesn’t mean you can’t question what they tell you, but you need to have a source of information that’s free of political bias.

Kevin Pho: Drew, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Drew Remignanti: Kevin, thanks so much for having me on again. I really appreciate it. I hope people do seek out a primary care relationship for themselves and their children.