Dear Inside Medicine Community,
As you know, my “real job” is being an ER doctor. I had a couple of early morning shifts the past few days, but kept writing Inside Medicine anyway, as I’ve been consistently doing since President Trump took office. Usually this newsletter comes out 2-3 times per week, but during the new administration’s unprecedented attack on US public health infrastructure, I’ve been writing to you all once a day or more to keep you updated—but something’s gotta give here, and I’m spending some time with my family and getting some sleep this weekend. Thank you so much for your support and understanding!
So…today’s post is not news.
Thankfully, it’s an opportunity. I’ve been meaning to share an interview I recorded with pediatrician and author Dr. Perri Klass back in January. Our conversation occurred prior to RFK Jr.’s Senate confirmation hearings to become the Secretary of the Department of Health and Human Services. Given that his nomination has now moved out of the Senate committee—meaning he is likely to be confirmed—it’s even more important to highlight what exactly is at stake here: the very health of our children and the incredible progress we have made as a society in the last century.
Please take a look and listen to this rich and informed conversation. (Closed captions (㏄) and a transcript option (📄) can be found beneath the video playback control bar).
We desperately need to hear from (and amplify) experts like Dr. Klass now more than ever, I'm sure you’ll agree.
But first…if you want to support work like this please share and support Inside Medicine. Thank you!
Nearly ten years ago, I visited Dr. Perri Klass’ office at New York University. I was in the early stages of my life as a physician-writer, and she graciously agreed to provide some mentorship. We’ve stayed in touch over the years, and I continue to admire her writing and advocacy.
In October 2020, she published a wonderful book called “A Good Time To Be Born,” about the triumph of pediatric public health in the United States during the 20th century. It is now rebranded under a new title “The Best Medicine: How Science and Public Health Gave Children a Future.”It’s a superb book (which was overshadowed by the Covid-19 pandemic) and I recommend it highly.
With some of the progress outlined in the book now under attack at the hands of anti-science rhetoric, I thought it would be a good time to discuss this book. Dr. Klass joined me for a conversation for MedPage Today and I am pleased to share it with you. The video of our conversation is above, and the transcript is below. Dr. Klass is such an engaging and informed expert and I know you will find it interesting and important.
“I think that we have collectively forgotten…what suffering these diseases meant.”
—Dr. Perri Klass.
Introduction: The State of Public Health and Vaccines, the Polio Vaccine and Forgotten Fears.
Faust: Hello, I'm Jeremy Faust, medical editor-in-chief of MedPage Today. I'm so excited to be joined today by Dr. Perri Klass. Dr. Klass is a professor of journalism and pediatrics at New York University. Her book, A Good Time to Be Born: How Science and Public Health Gave Children A Future, was published in 2020 and is now out in paperback under the new title: The Best Medicine. It's more relevant than ever and I'm so glad to have Dr. Klass with us today. Dr. Perri Klass, thank you so much for joining us.
Klass: A pleasure to be here.
Faust: Today, I opened the New York Times and I see that the nominee to run HHS is going to request that the polio vaccine be taken off the market. You're the perfect person to ask about this. What's your reaction to that?
Klass: I think that we have collectively forgotten and are in danger of really, really forgetting what suffering these diseases meant. How much pain, how much agony, how much misery, and say -- I'm a pediatrician -- even within our field, how they were dreaded not just by parents, but by pediatricians. And it's almost like, and this has to be true of anybody who's talking about taking away the vaccine. It's almost like the name of the disease has no longer resonates for people.
Faust: I don't think people know what the March of Dimes was really about. I don't think that they really know what an iron lung is. Could you just tell people about those things?
Klass: So polio was a disease that was really dreaded in the twenties, thirties, forties, fifties. I grew up with parents who had very clear memories of the summer polio epidemics. They grew up in Brooklyn, and what their memories included was not just the fear and the anxiety. But the truth that every year there were empty seats left in classrooms, that there were children who ended up -- the iron lung was what was available to help a child breathe when a child got paralytic polio and the paralysis extended to the respiratory muscles. It didn't have the technology or the ability to ventilate, so they would put the child in an iron lung, a sort of big metal cylinder, which would use positive and negative pressure to try to keep the child breathing.
But polio, that paralysis did not generally resolve. Children spent some of them years and some of them their whole lives in those iron lungs. I have heard stories in pediatric history of residents being asked to experience the iron lungs so that they would understand what was being asked of the children.
And you mentioned the March of Dimes because there was this huge campaign on the part of the public, on the part of parents, on the part of the charity. That was the March of Dimes, to raise the money for research. And it was originally done by asking people to send in dimes. And it was a huge example of the power of popular fundraising. But it was so popular because this was such a universal terror for parents of every place in the country, every social class.
The Transformation of Childhood Survival in the 20th Century
Faust: And zooming out your book, really the central thesis of the book is that sometime during the 20th century something changed or enough changed that surviving childhood became the norm. And there's a graph on page 294 of your book, which I've seen a million times, and it just shows the infant mortality rate from I think the 20th century up until recently. And you see that we started at a death rate of a hundred per thousand, 10% of infants were dying. And then of course many didn't survive childhood. Today it is 95% lower than that. How do we get there? Vaccines? What's the secret sauce?
Klass: It's a lot of things. And what I'm arguing in the book is that human beings, we get a lot of things wrong. We make a lot of messes. This might be the best thing that we ever did collectively as a species. If you go back through human history, you're probably losing 30, even 40% of the babies born alive don't make it to the fifth birthday. You're talking about infant mortality in the first year of life, but you're not talking about who gets diarrhea at the time of weaning or who dies of the complications of measles at the age of one or two. And those are ailments which were especially likely to hit you when you were one or two, or who gets diptheria or who gets polio.
So we are talking about all through human history, probably losing 30, 40% of the children born by the fifth birthday. So that means that every family, every city knew this grief. And look what we've done. I'm talking mostly about the part of it that we've seen in the last a hundred, 150 years just because it's so close.
If we go back a hundred years to the 1920s and we think about, say, my grandmothers who were pregnant with my mother and my father, one out of every 10 babies born died by the first birthday. Nevermind the two year olds and the three year olds and the four year olds. It means if you gathered a group of people around the table, even if they ranged from the poor to the rich and powerful, everyone would have lost a child, lost a sibling, seen this happen to neighbors, to friends. It was just part of being a parent. And it was obviously also part of being a pediatrician, because the polio epidemic would come or the infant diarrhea would come and there was nothing you could do.
Vaccines had a huge amount to do with this, but so did sanitation, so did public health measures, so did parent activism. There's a lot of different pieces. I don't want to think of it as one campaign, but we did it. We got to a place where if you have a child today, you can and you should be able to expect that barring terrible and unexpected and very rare tragedies, you're going to watch your child grow up.
Faust: It also changed the interaction between parents and children because, and this is something where you talk a lot about, you want to read to your children and you want to do other things that enrich them. But if you have so many kids because half will die and there's an emotional detachment, I think there's an argument to be made that it didn't just change the death rate, but it changed the kinds of lives kids have.
Klass: Well, it's a really interesting question because one of the things you have to think about when you think about this topic is how did parents live with it? And I think one of the things that's a little, that's more than a little heartrending, is actually parents love their children, they bonded with their children. They grieved and mourned for those children who died. We have so many traces in history if we start looking for them.
And yet that was part of the deal. If you were going to be a parent, and I think I quote Charles Dickens to this effect, and many other writers said, this is part of being a parent. You know that there is this grief and you have to manage it. And many of the women are grieving while they're pregnant again, and I can't always understand how some of them managed and how they survived. I think they did love their children, but I think they loved them the way that you love somebody who you know is precarious.
Faust: Right, there's a distance or there's a bargaining that happens and it's a thing that we don't associate it today with childhood, we might associate that with how we deal with the end of life for loved ones. And I see that detachment.
Modern Patient Expectations.
And this is where I want to pivot, 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 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 New York Times article that ran today 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.
Teaching Medicine in a New Era
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 four 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 tenfold 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 thousand 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.
Public Health: Making the World Safer for All Children
Klass: 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 A Good Time to be Born 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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