On December 5, I started my hospital shift learning that the ACIP (Advisory Committee on Immunization Practices) had voted against offering universal administration of hepatitis B vaccine at birth, opposing the long-standing practice endorsed by experts. After a long day of examining newborn babies and counseling families, my mind drifted back to the announcement and unearthed a memory of a boy named Sam.
Sam was born a healthy newborn to loving parents who delighted in every shriek and wide-eyed stare. At several weeks of life, his pediatrician detected an abnormality in his liver function while evaluating persistent jaundice. He was diagnosed with biliary atresia, a rare condition of obstructed bile flow.
Despite early corrective surgery, his condition progressed to severe liver failure requiring a transplant. I first met him as a resident in the pediatric ICU, where he awaited a new liver.
In that long month, I observed the emotional whiplash endured by his family. My heart soared when a possible donation surfaced and crashed when that organ was deemed unsuitable. His mother pondered how this period felt like both purgatory and advent. Symbiotic with her fear was a reverent hope, like awaiting the birth of a baby. In her waiting, she chose to hold that hope for the little life in her arms, as she once did when he was in her belly.
Sam’s liver arrived one night when I was on call. Like a battle-ready platoon, we sprang to action when he returned from the operating room, carefully monitoring the organ’s transition to life in its new body. Post-transplant care is a tenuous dance: You intervene as little as possible to promote healing yet remain vigilant for the slightest sign of trouble. It is nearly impossible to discern whether a shiver of pain, a shift in vital signs, or an abnormal lab value represents expected surgical trauma or a harbinger of complication. In this vigilance, I first learned to feel powerless to the capricious nature of disease: I had immense responsibility and yet so little control.
Learning this powerlessness is essential in pediatric training. By bearing witness to the trauma of a critically ill child, we gain respect for the ravage of disease and can truly appreciate the tools we have to prevent catastrophic outcomes, such as immunizations.
I now spend my days in a dichotomy of the newborn nursery and inpatient pediatric care. Within a single shift, I oscillate between caring for well newborns transitioning earthside and acutely decompensating children. My career has shown me how dangerous the world outside a mother’s womb can be: Diseases spread quickly and prey disproportionately on newborns. Despite advancements, physicians remain clinically impotent against many infectious processes. This is the power of immunizations: We can prevent what we cannot effectively cure. Yet that power is being systematically dismantled by a political agenda, using the bedrock of our patients’ trust as collateral.
Globally, hepatitis B remains a major cause of chronic liver disease in children. Newborns infected at delivery have more than a 90 percent chance of developing chronic disease and complications such as liver failure, liver cancer, and death. Transmission can occur vertically (from mother to child) or horizontally (from infected community members). Many infected individuals are initially unaware, as symptoms can take years to manifest. After the United States shifted from risk-based administration to universal newborn vaccination in 1991, annual infections among infants and children dropped by 99 percent.
From this data we extrapolate two truths: First, our risk assessment is often incorrect; second, our health care system does not reliably provide the universal prenatal or pediatric care necessary to support a risk-based immunization model. Our current evidence suggests that the best way to prevent this illness in anyone is to protect everyone, even infants at relatively low risk. This broad approach would be more concerning if the vaccine carried significant risk. It does not. The hepatitis B vaccine has a reassuring safety record, with only one reported allergic reaction per 2-3 million doses.
The evidence is clear: Our current practice dramatically reduced disease burden in the United States. This suggests that ACIP’s decision was not based on concern for child health outcomes; the science and safety record support our status quo. Instead, this reversal weaponizes a benign and effective intervention to cultivate fear and mistrust.
Currently, the decision to immunize a child is a shared, consensual process between parents and clinicians. Declining vaccines has always been the right of families whose beliefs conflict with immunization. But for many babies, birth in a hospital is the only time in early childhood when they will have access to a physician due to social barriers that limit engagement with the health care system. As of 2024, one in ten children lacked access to a primary care physician. Removing the safety net of offering universal immunization will disproportionately harm these patients. In terms of clinical ethics, this decision does not take away existing autonomy; it simply strips the system of equity.
As a clinician, my expertise has been hard earned by sharing the grief of families with suffering children and witnessing the success of interventions that allow them to thrive. While I have learned resilience to the impact of disease itself, I am gutted by the moral injury of politicians undermining my knowledge, efforts, and intent. Sam suffered from a condition that could not have been prevented. This will not be the case for children destined for similar outcomes because of a preventable illness contracted through systemic failure.
In my despondence, I think of Sam’s mother holding both fear and hope. While I worry for children’s health, I also remember that I am part of a fierce collective of child advocates who will lose sleep over this decision. Tomorrow, we will wake up and spread the mortar of our daily work: listening, learning, and uncompromised caring. Brick by brick, this is how we rebuild the trust required to create rightful equity for our children.
A. Lane Baldwin is a pediatric hospitalist.
