Yesterday, I was joined in The Doctor’s Lounge by Dr. Angela Rasmussen and first-time Inside Medicine guest, the legend himself, Dr. Demetre Daskalakis.
For those who don’t know, Dr. Daskalakis made headlines by being a hero this year—holding the line for science for as long as humanly possible at the CDC (as the agency’s lead vaccine official) before resigning this fall when he came to the inevitable conclusion that RFK Jr.’s toxic influence there meant that staying was no longer tenable. Meanwhile, we are fortunate that virologist Dr. Rasmussen has officially become a regular around here now. (Here’s a link to her highly recommended Substack, Rasmussen Retorts).
In this packed hour, we covered the latest on the Hepatitis B vaccine debacle at the CDC. Why did the acting director sign off on one of the votes from December’s CDC Advisory Committee on Immunization Practices meeting but not the other? And why is the CDC funding a randomized trial of the vaccine in infants in Guinea?
We covered that and more, including cronyism at NIH.
As always, the experts we are so lucky to have offered data-driven insights that are absolutely essential today. So please share this post!
Closed captions (㏄) for the above video and a transcript option (📄) can be found beneath the video playback control bar above. A summary with timecodes can be found below.
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Summary & Highlights from “This Week in Public Hell, December 19, 2025, with Dr. Daskalakis, Dr. Rasmussen, and Dr. Faust.”
Aided by ChatGPT.
We kick off with the premise: it’s “public hell,” and we’re naming names (0:31)
We welcome Dr. Angela Rasmussen and Dr. Demetre Daskalakis, set the tone (smart + snark), and frame Demetre’s CDC departure as a values-based exit after trying to “hold the line” inside a system that could no longer function in a way consistent with science and public service.
The CDC director signs one ACIP recommendation—and declines the other (2:32)
We lay out the new reality at CDC leadership: Jim O’Neill (non-physician, non-scientist) adopts one of RFK’s reconstituted ACIP recommendations while not adopting the second. We explain the two ACIP votes:
Hep B birth dose: shift toward “shared clinical decision-making” (i.e., making it optional) for babies born to mothers who test negative for the virus.
Serology-driven dosing: propose using antibody testing to decide whether to continue doses after the first.
We argue both are flawed, but the second is especially unmoored: there’s no validated cutoff (“meat thermometer” problem), and ACIP’s remit is vaccine recommendations tied to coverage—not ordering strategies for blood testing.
Why the serology idea is scientifically empty—and procedurally bizarre (3:57)
Demetre breaks down why the proposal collapses on contact:
The test isn’t validated for “stop early” decisions.
Testing may show something after a dose, but it doesn’t mean durable protection.
Three doses matter for long-term immunity—stopping early risks people believing they’re protected when they aren’t.
Most damning: no data were presented to support the strategy, and ACIP voted anyway.
We underscore the implications: downstream policy could normalize incomplete vaccination based on a misleading test and a made-up decision framework.
Why the Hep B birth dose matters—even when moms test negative (4:16)
Angie explains why the birth dose is critical and why “risk-based” approaches fail in the real world. Even with negative maternal testing, infants can still acquire HBV through everyday household exposures involving tiny blood contacts—cuts, diaper changes, routine play. HBV can persist on surfaces, transmission can be easy, and infection in infancy has a high risk of chronic disease.
She shares a concrete example from Alaska Native communities: rapid adoption of birth dosing helped eliminate local pediatric transmission over time—illustrating how universal strategy succeeded where “targeted” approaches didn’t.
“It sounds great… it was tried and it didn’t work.” (8:11)
We emphasize the policy lesson: the targeted strategy (vaccinate only “high risk” infants) has a track record—and it failed. Universal birth dosing is what made the problem largely go away.
We also cite a real-world narrative (raised in the discussion) that people can be “low risk” on paper and still end up infected—an argument for universal policies that don’t rely on perfect prediction or perfect implementation.
The new ACIP: fewer experts, more conflicts, and a process that looks like governance cosplay (11:44)
We zoom out: RFK Jr. fired the prior committee (despite historically low conflicts of interest) and replaced them with members who actually have more conflicts—including having made money from vaccine litigation.
We explain the key procedural point: ACIP votes are recommendations, but they only become operative when signed by the CDC Director or the HHS Secretary. That’s why it mattered that O’Neill signed off on one vote but not the other.
Why didn’t O’Neill sign the second recommendation? (12:53)
We ask the obvious question: if leadership “doesn’t care,” why stop halfway?
Demetre best read: implementation requires writing a formal supporting document (e.g., MMWR/clinical considerations). If there’s no evidence, it’s hard to write something defensible—and that likely triggered resistance behind the scenes, including legal constraints.
Angie adds that even the “voting language” process itself looked chaotic: drafts appeared mid-meeting, discussion was limited, and basic norms (including public comment expectations and stable language) seemed ignored.
The “yellow fever shot” moment that gave away the expertise gap (16:13)
Angie highlights a revealing exchange: an ACIP chair compares getting one yellow fever shot for travel to why someone can’t get one Hep B shot—confusing entirely different vaccines and immunology. We use this to illustrate that the committee often lacks baseline clinical immunology fluency, even as it makes consequential recommendations.
The entertainment problem: it looks like a real meeting—until it doesn’t (17:33)
We describe the whiplash: roll calls, motions, seconding, and “evidence” talk create an illusion of seriousness. Then the veneer drops and the proceedings resemble a clown show—both scientifically and procedurally. We argue this is dangerous precisely because it can appear legitimate to casual observers.
A related warning: delaying protection can be the whole point (18:31)
Jeremy recalls a prior ACIP exchange on RSV prevention where someone objected that prophylaxis “only works for a little while” and babies would “just get it later.” We explain the key pediatric concept: delaying first infection can convert a life-threatening early exposure into a routine illness later, when airways are larger and risk is lower. The fact that members needed that explained becomes part of our broader critique.
The “silent yes” voters worry us most (22:44)
We distinguish between outspoken bad-faith actors and the passive cohort: people who say little, then vote yes. Demetre flags the latter as especially concerning because they provide the numbers that allow weak or politicized proposals to pass with minimal accountability.
Topic shift: CDC funds a Hep B birth-dose trial in Guinea-Bissau—and we call it unethical (24:01)
We introduce the report that CDC is directing $1.6 million to a Danish research group tied to the Bandim Project in Guinea-Bissau to study the Hep B birth dose.
We argue this is alarming on two levels:
Scientific validity: the study design (as described) won’t answer the question it claims to answer.
Ethics: it exposes infants in a high-prevalence setting to foreseeable long-term harm with little chance of producing meaningful near-term knowledge.
What “nonspecific effects” are—and how they’re being used here (24:21)
Angie explains “nonspecific effects” in plain terms: vaccines trigger specific responses (antibodies/T cells) and also general innate responses (like interferon-mediated activation). Nobody disputes those general responses exist. The dispute is whether they meaningfully alter longer-term clinical outcomes unrelated to the vaccine target.
She notes that related work often uses all-cause mortality as an endpoint because Guinea-Bissau has high child/maternal mortality. But that endpoint can be profoundly misleading for Hep B birth dosing because Hep B’s worst outcomes typically manifest decades later.
Why all-cause mortality is the wrong endpoint for Hep B birth dosing (27:01)
We walk through the core methodological problem:
HBV prevalence in Guinea-Bissau is described as very high (around 20%).
Infants missing early protection may become chronically infected.
Chronic HBV often doesn’t cause death until adulthood (cirrhosis, liver failure, hepatocellular carcinoma).
A short- or medium-horizon trial measuring “death for any reason” won’t capture the very harms the birth dose is meant to prevent.
In other words: the design risks harming kids now, while measuring an outcome unlikely to reflect that harm within the study window.
We call out “hypothesis shopping”: deciding the answer first (33:38)
Angie argues the likely outcome of the trial will be used politically: “no difference in all-cause mortality” becomes a talking point to justify weakening birth-dose policy—despite the trial being structurally incapable of detecting long-latency HBV harms.
We frame it as inverted science: fit evidence to a preferred policy, rather than let evidence shape the policy.
Retaliation and cronyism: AAP loses grants while “friends” get funded (34:03)
We describe the timing as part of the story: the same day this grant is awarded, the American Academy of Pediatrics reportedly has major federal grants pulled—framed as retaliation amid litigation over vaccine schedule changes. We argue this looks like punishing institutional opposition while rewarding aligned networks.
The CDC IRB and ethics office were cut—so what reviewed this? (34:31)
Demetre adds a crucial operational bombshell: CDC’s IRB (institutional review board) and ethics office were reduced/eliminated (as described in the discussion), raising the question of how any credible ethical review occurred.
We spell out what an IRB does: it determines whether work is research vs surveillance, requires consent/oversight when appropriate, and exists specifically to prevent unethical human experimentation. Removing that infrastructure turns “trust us” into an empty promise.
How grants are supposed to work—and why this looks like a bypass (35:39)
We outline the normal process:
Typically there’s a competitive Notice of Funding Opportunity (NOFO).
“Sole source” funding is supposed to be rare and justified only when a single entity can uniquely do the work.
Even then, it should involve review and documentation.
We argue this case looks like an abuse of “sole source”—a mechanism that can be compelled by political leadership and rubber-stamped, especially when scientific and ethics review capacity has been degraded.
We bring in equipoise: why this trial fails the basic ethics test (38:41)
Jeremy introduces equipoise: you can only ethically randomize when genuine uncertainty exists about which arm is better.
We use a blunt analogy (seatbelts) to make the point: you don’t randomize people to “no seatbelts” to prove what we already know. Here, we argue:
The protective value of Hep B vaccination is already established.
The country is slated (as stated in the discussion) to make birth dosing standard in 2027—suggesting the “question” is already settled in policy direction.
If the real need is implementation resources, then doses should go to babies—not into a randomized trial designed to withhold early protection from some.
Angie reinforces the parallel: you can’t study long-latency harms with short-run all-cause mortality endpoints, just like you can’t randomize kids to smoking and expect lung cancer deaths in five years.
Forty-plus years of evidence: the vaccine worked so well the cohort aged out (42:06)
Angie returns to the Alaska example with a striking endpoint: a decades-long study ultimately ended because participants were dying of ordinary old-age causes—not hepatitis-related disease—because transmission had been essentially eliminated.
We use this to emphasize what we see as the absurdity of claiming we need a modern trial to “figure out” whether a well-established strategy works.
Profiles in Courage vs Profiles in Scourge (43:14)
We introduce a moral frame that Jeremy has been thinking about lately.
“Profiles in Courage” are people inside agencies trying to preserve scientific integrity under pressure (we place Demetre here, for as long as he lasted).
“Profiles in Scourge” are officials and leaders who actively enable destruction from within—that is, those making things worse.
We then pivot to NIH leadership coverage as an example of the latter.
Katherine Wu’s reporting on the NIH in The Atlantic: Bhattacharya absent, Memoli driving disruption (43:51)
We discuss an Atlantic piece by Katherine J. Wu describing NIH leadership dysfunction: Jay Bhattacharya doing media/podcasting while operational governance falters, and Matthew Memoli positioned as a key engine of internal demolition.
We connect this to a larger pattern we’ve been reporting: culture of fear, constrained dissent, and retaliatory firing.
“Generation Gold Standard”: half a billion dollars for an old platform—and deep hypocrisy (44:23)
We dig into the “Generation Gold Standard” investment described in the conversation:
Large-scale reallocation (described as around $500 million) away from mRNA platforms and toward an “old timey” approach framed as a gold standard.
We describe the technology as old-school inactivated whole-virus vaccine strategy—presented as innovation.
Angie adds a key scientific critique: influenza evolution is relentless; even within subtype groups, drift and new clades can undercut breadth. A “universal” flu claim built on limited breadth and old methods is unlikely to deliver what it promises, especially for an avian flu pandemic scenario.
Gain-of-function enters the chat (47:17)
Angie highlights a central contradiction: the platform’s underlying research included reconstructed 1918 influenza and recombinant/chimeric viruses with mutations associated with mammalian adaptation and increased pathogenicity in animal models—work she frames as gain-of-function in spirit and effect.
We juxtapose this with public statements from these leaders condemning gain-of-function research—arguing it’s a case study in “accusations as confessions.”
We shift from “save the agency” to “save the mission” (49:18)
Jeremy steps back: we may not be able to preserve legacy institutions in their current form when leadership is committed to dismantling them. The strategic imperative becomes protecting the scientific and public health mission—salvaging what can be saved, documenting what’s happening, and planning for what comes next.
We also emphasize that congressional oversight hasn’t meaningfully constrained cancellations or ideological reclassification of work (e.g., labeling grants as DEI for mentioning equity or gender).
Dissent and “culture of fear”: the opposite of what they claimed to want (50:32)
We argue that NIH and FDA are moving toward a punitive environment where dissent risks termination—despite these leaders claiming COVID-era policy failed because dissent was suppressed.
Angie rejects the “silenced” narrative around Bhattacharya: she describes extensive media platform access since 2020, and frames his complaint as not about being unable to speak, but about being criticized when he does.
We close on what we’re watching next: the vaccine schedule and VICP (54:10)
In the final segment, we ask what’s coming down the pipe:
Demetre flags a possible renewed push to scrap the U.S. childhood vaccine schedule and replace it with something like Denmark’s—described as paused until January. We frame it as either “testing the waters” or a “failure to launch.”
Angie flags a bigger structural threat: potential moves against the Vaccine Injury Compensation Program (VICP). She explains why VICP exists: it was designed to stabilize the vaccine market after litigation pressure (historically around DPT-era claims) threatened to drive manufacturers out.
We acknowledge VICP can be slow and may need reform, but we argue that eliminating it risks destabilizing vaccine supply and expanding litigation in ways that could reduce vaccine availability altogether.
We end with a warning scenario: if broad claims (e.g., aluminum adjuvants tied to asthma/allergies) were treated as compensable at scale, it could overwhelm the system—weaponizing the program or its removal to achieve anti-vaccine policy goals.
Sign-off: science, transparency, and refusing fake debates (57:12)
We close by reiterating what this format is for: translating institutional dysfunction and policy capture into plain language, fighting for transparency and gold-standard science, and refusing to validate manufactured controversies that exist to erode trust and protections.
If you have information about any of the unfolding stories we are following, please email me or find me on Signal at InsideMedicine.88.
