At the time of writing, there is a new stand-off between the Centers for Disease Control and Prevention and the Trump administration appointees in the Department of Health and Human Services. This is expressed in attempts at engineering the dismissal of key personnel, resignations of others, open letters from the biomedical and public health community, and demands for the impeachment of the secretary of the department for apparently refusing to “follow the science.” This is not a particularly edifying spectacle and one which may yet do more damage to public trust in science and medicine.
What has provoked this? The Food and Drug Administration has revised its guidance on who should be eligible for COVID-19 vaccination over this fall and winter. This changes it from a near-universal recommendation to one that is restricted to specific risk groups: adults over the age of 65 and those under the age of 65 who are immunosuppressed or have an underlying health condition that increases their vulnerability. In doing so, the US government is adopting a position that is essentially the same as that taken by most European countries. In the UK, the recommendation is now for residents in a care home for older adults; all adults over the age of 75; and persons over the age of 6 months who are immunosuppressed. In France, the eligible groups are those over the age of 80; residents in care homes; anyone who is immunosuppressed or has mental health problems, dementia or Down’s syndrome; and those individually considered at high risk by their physicians. Sweden advises vaccination for those over 75; those over 18 who are immunosuppressed or have specific underlying conditions; those, including children under 18, who have been individually assessed by their physician as being at risk from severe infection.
Those of us who do not reside in the US are used to US exceptionalism. However, this is clearly an instance where the US has been an outlier and is moving closer to an emerging international consensus. It is absurd to suggest that the scientists and public health leaders of major European countries are not equally capable of examining the same data and making a good faith assessment of the risk/benefit/cost of Covid vaccines. RFK Jr may be a difficult person to work with, and have some ideas that might politely be described as eccentric, but this change does not seem to justify the vitriol that has been poured upon it.
The ferocity of the response may, however, illustrate two interesting things about the US biomedical and public health elites.
The first is their promotion of a risk culture in the US that sees any price, social, cultural or economic, as worth paying for the elimination of a possibility of illness or death. Francis Collins admitted as much in 2023 when he conceded that the “public health mindset” was indifferent to the costs of pandemic management. It attached infinite value to saving a life and zero value to the collateral impact on economy and society, let alone other health conditions. If something can be done, then it must be done. We may contrast that with the UK approach. A national vaccination program for varicella (chicken pox) will begin in January 2026, although the vaccine has been licensed for sale since 2002. It was licensed and recommended in the US in 1995. The UK policy community were simply not convinced that the risk/benefit/cost was justifiable, particularly as there were concerns about its impact on rates of herpes zoster (shingles) in adults. The evidence was re-evaluated in 2023 and the recommendation changed. The programme is expected to reduce a small number of deaths (8-12 per year) in children and the incidence of an unpleasant childhood illness. Both of these were previously regarded as acceptable within a wider view of the potential impact of a vaccination programme.
This is not to say that one country is right and the other is wrong. The two countries have simply come to different conclusions, from the same evidence, about what risks are acceptable and how this translates into action. This is underlined by the rush of US specialty societies to contradict the FDA guidance by issuing their own recommendations to continue indefinitely more or less universal vaccination for COVID-19. We may, of course, also recognize the considerable material interests at stake in the US.
The possibility of reaching different policy conclusions from the same evidence base also raises questions about the claim that politicians should always “follow the science.” As Stephen Macedo and Frances Lee point out, in their important recent book, In Covid’s Wake: How Politics Failed Us, “following the science” also means following the values implicit in the scientist’s presentation of the science. It raises fundamental questions about the relationship between expertise and democratic government. The US biomedical and public elite are outraged because the Trump administration’s appointees have not accepted their policy conclusions. The current stand-off is a demand that democracy should defer to expertise. IT has many of the characteristics of a hissy fit or a toddler’s tantrum. A little reflection should suggest that this is not a good look.
Democracy should certainly be informed by expert knowledge but democratic governments are entitled to take their own view on the policies that might follow. Benjamin Disraeli, a 19th century UK conservative politician, once commented, after a major extension in the franchise, that political elites must now educate their masters. Disraeli showed a degree of humility in leadership that seems to be absent among the CDC and their defenders. It may not be a fashionable view in the US but, if scientific elites do not like the policy consequences of democracy, the proper response is not to copy Trumpism from a different direction but to acknowledge their own failure. If only one-third of US adults accept the theory of evolution in its Darwinian form, what does this say about the relationship between science and society?
Biomedical and public health élites are not a fourth branch of government under the US Constitution. It is time that some of them remembered that.