Paul Lombardo: Reckoning with the Dark History of Eugenics

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.‌

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. Our guest today is Professor Paul Lombardo, but first we like to check in on current or hot topics in health and healthcare, and start us off. Harlan, what are you thinking?‌

Harlan Krumholz: Well, I’ve got a hot topic today, Howie, but I thought it first started because listeners might be wondering what’s the tenor in academia these days with so much going on? Of course, the whole world’s facing a lot of changes in the United States in particular with what’s going on in our government. Although our United States also is influencing other places everywhere in the world, but academia in particular.‌

We talked last week about this cutting in NIH funding that there’s also, as you discussed last week, the looming Medicaid cuts. I’m just, for people listening, want to say, gosh, the level of anxiety within academia now is off the charts, as I talk to my colleagues, and I think it’s really about the uncertainty, exactly what’s changing, how to actually address some of these things. As we talked about last week, I had written something about the cut in NIH funding for infrastructure, but we’re a privileged group. We have a lot of benefits by our position, but there’s a lot of anxiety around here these days. And also, we’re concerned there are a lot of vulnerable people, meaning that there aren’t people who are professors or tenured or who are in positions who are just wondering about what the future’s going to hold. Anyway, there’s a lot of uncertainty. I know, are you seeing that, Howie?‌

Howard Forman: A hundred percent. I mean, number one, what I noticed differently now than eight years ago is that the degree of speaking out is muted because quite frankly, there’s evidence of retribution. So people worry that they have to keep their mouths shut. And number two, as you said, it is uncertainty, but it’s not just for the Yale community, it’s the Yale-adjacent community. It’s the community health centers that are nearby. It’s the Planned Parenthood, which is just down the block from where I’m sitting right now. It’s a lot of the healthcare organizations and the scientific organizations and the community service organizations that are not certain they are going concerns right now if they lose even relatively small amounts of federal funds. So it is a tenuous time, and I am waiting and watching to see what happens. And I’m thankful that we live in a state that has a strong governor and a strong leadership that can step into some of this void to help these people.‌

Harlan Krumholz: Yeah. Anyway, just wanted to share that people might be wondering what’s going on.‌

Howard Forman: No, I appreciate that.‌

Harlan Krumholz: Like I said, I think what we feel is just what you’re saying, which is that there’s uncertainties all around us, but there’s others who are maybe experiencing even more dramatic threats and have less of a cushion, buffer with regard to what’s going on.‌

Howard Forman: So on a very different note, you had a very provocative pre-print that was led by Akiko Iwasaki, our former guest in the podcast.‌

Harlan Krumholz: Well, led by a whole team. Akiko was great. She and I were co-senior authors on this piece, and her lab was principally responsible for it. It was focusing on people who were report after vaccination, having a really disabling chronic condition and—‌

Howard Forman: Covid vaccination?‌

Harlan Krumholz: Covid vaccination. Yeah, that’s right. And how did I get into this, as a cardiologist? Well, when the pandemic began, my focus, many people in healthcare, was sort of like, how could we jump in and help? Our group got involved and we started producing scholarship around the pandemic. As things were evolving, it became clear that there were some people who were having residual effects long after the infection. And as I was meeting people who were suffering, I began to get involved and had met Akiko. And this was one of, really, marvelous collaboration. We began to develop some studies together in long Covid, and we’ve just completed a clinical trial which we’ll report out I think within a month, that is testing Paxlovid for long Covid. But we also began to meet people who were reporting very much like long Covid symptoms soon after they had been vaccinated.‌

And these people, if people with long Covid were being dismissed by the healthcare system, these people were being super-dismissed. I mean, they sort of fell into this maelstrom of people being concerned that they were anti-vax. They weren’t anti-vax. They actually took the vaccination and they weren’t political, even though other people wanted to use them politically. They were people who were just suffering. Akiko and I decided we have to follow the science. If people are suffering, we should be listening to them. We both believed deeply that the vaccinations had been very important in saving many lives. Akiko actually develops vaccines, and yet we also recognize that there’s almost no vaccine that is free from any side effect. We shouldn’t be afraid to say there can be side effects in people, Guillain-Barré Syndrome for example, neurologic problems. It happens after flu, and yet we still recommend flu shots. And there was time…some flu seasons, it’s more than others.‌

And so anyway, getting back to this pre-print, we identified a group of people who were, I call “extreme phenotypes,” people who were experiencing the most severe form of this syndrome, and we compared them to people with long Covid and to people who didn’t have the syndrome. And we were able to identify certain immunologic profiles that seemed to specific for those people with... post-vaccination.‌

Now, our numbers are small. This isn’t settled science. I think of it as a start, but it begins to provide some clues that there may be some things happening with these people’s immune system that signals that this is real. I mean, I never doubted it was real because I’ve talked to these people, they’re experiencing something, but it begins to show that there may be correlates within the immune system that are associated with this syndrome and that we need to learn much more about.‌

So this came out today. I think it’ll attract some attention, and I hope people don’t politicize it but understand it as something we need to follow. We need to follow the science, and we need to figure this out, and we need to figure out ways to mitigate the suffering and even prevent it in the future.‌

Howard Forman: Do you have any sense of the magnitude of this, like what percent of people might have had this type of syndrome?‌

Harlan Krumholz: Yeah, that’s a really good question. People ask that a lot. People want to put “rare” in front of this, a “rare syndrome.” I think it’s likely rare because although we have seen tens of thousands of people worldwide who are talking about this, it’s still a very small fraction of the people who got the vaccine. And so I think it’s uncommon, but we don’t have good numbers on it. It certainly seems like it didn’t show up in the trials, which were I think thousands of people, tens of thousands, maybe, of people who were studied in trials. But yeah, Howie, we don’t really know how common it is.‌

Howard Forman: And do you know if it’s only the mRNA vaccines and the spike protein vaccines or...‌

Harlan Krumholz: Gosh, you ask such good questions. So most of the people in our study got the mRNA vaccines, but again, this study was done in the U.S. because we had to be able to get biospecimens and send them to our lab and look at them and so forth. And the vast majority of people got mRNA vaccine. Some people got the J&J. We have a few people who got J&J vaccine, which is not an mRNA vaccine and who are also reporting the syndrome and are also in the study. But it’s hard to tell exactly.‌

Howard Forman: It’ll be great to just learn more over time, but it’s just great to see you and the group investigating this.‌

Harlan Krumholz: And a kudos to Akiko and her lab. This is really about deep immune phenotyping. That is what they do, and they do it as well as anyone in the world.‌

Howie, let’s get on to our guest. This is going to be a very interesting discussion.‌

Howard Forman: Professor Paul A. Lombardo is the Regents’ Professor and Bobby Lee Cook, professor of law at Georgia State University. Widely regarded as an expert on bioethics and the law, Professor Lombardo is the author of Three Generations, No Imbeciles, which explores the history of eugenics in the United States. From 2011 to 2016, he served as a senior advisor to the Presidential Commission for the Study of Bioethical Issues. He has also served on the Council of the American Association for the History of Medicine, and he recently completed a term on the board of directors of the American Society for Bioethics and Humanities. Professor Lombardo received his bachelor’s degree from Rockhurst College, a master’s degree from Loyola University, and both his JD and PhD from the University of Virginia.‌

So first I want to just welcome you and thank you for accepting our invitation. Neither Harlan nor I knew you before about a year ago when you published this very impactful piece in The New England Journal of Medicine about eugenics in American—more particularly the complicity of organized—medicine, if not academic medicine in the eugenics movement. And I just wonder for our listeners, this is not a topic we’ve talked about on the podcast before. If you could give a brief summary of your scholarship in this area and what that article was about.‌

Paul Lombardo: Well, I first became interested in eugenics as a graduate student when by chance I stumbled on a case that began as a seminar paper, really. And it was a case that involved a young lady who was sterilized in Charlottesville, Virginia, where I was going to school at the time, and the case went to the Supreme Court. That case was called Buck v. Bell, and the “Buck” was Carrie Buck at the time, a young teenager in Charlottesville. And “Bell” was Dr. John Bell, who was the director of a place called the Lynchburg Colony for Epileptic and Feebleminded at the time. It was a facility specifically designed to take in what today we would call children with mental disabilities. So that case was my entrée over the years. I wrote about that case a good deal, but also about other pieces of the story of eugenics in America, which is an extraordinarily broad story, covers politics and law and an awful lot of science and medicine. And so that’s really how I got involved in this and stayed involved.‌

Howard Forman: And just for our listeners, explain your interpretation of the word eugenics. I mean, I think we do use it loosely, and I don’t think we define it enough.‌

Paul Lombardo: Yeah. Eugenics, the best broad work on this recently I think is Dan Kevles still. It’s a generation old, but his book is called In the Name of Eugenics, and I think that’s a brilliant title because the word itself meant a lot of different things, and that’s one of the reasons why people say the movement was successful. I generally focus on six different kinds of laws that were passed, everything from premarital examinations, which were called the eugenics laws, the sterilization laws, the immigration restriction laws, the so-called anti-miscegenation laws preventing people of different races from being married.‌

So there’s a whole raft of laws, even prohibition, which was pushed over the finish line by eugenic arguments. So I’m interested in how these things played out on the law, but what I’ve tried to explain is that while the general idea of eugenics, which we all get from Galton, which is a system for improving society by essentially making people who are successful and prosperous have more children and people who are not successful and not prosperous, having no children, and the coercive force of the law being used to affect that by sterilizing some people or in other ways preventing them from using birth control for example. Those ideas about eugenics we all know now led us and connected us to what we know as the Holocaust. And so people are very much against that, with good reason.‌

What we don’t remember so much is that eugenics was also very attractive, so attractive that it was used as a word in advertising. For decades people sold pharmaceuticals talking about eugenical drugs because it also had the meaning of health to many people. It had the meaning of being well-born, of smiley, healthy babies, and nobody was against that and nobody’s against it now. So it’s the connection of prosperity and health and the thing that every parent and everybody else wants, which is healthy babies and babies who don’t die when they’re a year old. That’s posed against the coercive measures of law that we think about eugenics as embodying. And it’s those two things happening at the same time, playing on people’s hopes, the health part, and playing on their fears or their hatred. And that’s the sterilization, coercion, immigration restriction part. Those two things are going on at the same time. So to me, eugenics is both of those things. It’s the marriage of biostatistics coming out of Galton with rules of heredity coming out of Mendel and a whole lot of other things that get thrown into the mix.‌

Harlan Krumholz: I so enjoyed this piece, and I was looking forward to the opportunity to meet you. Just for people listening, the piece in The New England Journal of Medicine came out in March. It was called, “‘Ridding the Race of His Defective Blood’: Eugenics in the Journal, 1906–1948.” It represented the Journal being willing to take a hard look at its history and to engage someone to really put together something that ultimately was unflattering about their history but that they needed to confront. And you did this with such great style.‌

I rarely do this, but I just want to read part of it and then get your reflections on this. So what I mean is that I rarely take time to actually pull out something that one of our guests has written, but I thought this was just so important, and I’m just reading from the beginning of your piece:‌

“In 1923, Boston City Hospital chose Dr. William Mayo, already famous for the work of his Minnesota clinic, to speak at the inauguration of a new laboratory. Mayo’s thoughts on hospital administration, published in the Boston Medical and Surgical Journal (which would be renamed the New England Journal of Medicine in 1928), highlighted the common anxieties of its profession and went far beyond the anodyne comments that were usual on such occasions. Mayo amplified the phobias and fed the moral panic stemming from eugenic thought of the time, saying that municipal hospitals were swamped by the poor, as cities were besieged by criminals and the country threatened with demise by waves of defective immigrants. While Congress debated increased restriction on immigration, Mayo traced poverty to ‘constitutional inferiority and mental instability,’ declaring both ‘to a large extent hereditary.’ Mayo said one goal of public hospitals should be to ‘reduce the number of people whom it must care for at the expense of the taxpayer.’ A robust sterilization program and limits on immigration of the ‘defective’ would serve that goal. His search for ‘the final solution of the immigration problem’ rested on the assertion that poverty and disease were proof that ‘the alien is a public health problem, just as he is a social problem,’ and he saw ‘alien lawbreakers’ as the cause of rising crime.” ‌

Look, this echoes to a lot of things. It’s chilling in its description of the past. It’s also a bit chilling in some of the rhetoric that we hear of today.‌

As you look back and reflect on our profession, and there were some voices sort of against this view, but many who were for it, and it was a sort of rising tide, what lessons do you think we can learn from what happened then and how do we keep such things from happening in the future, so 50 years from now, people don’t look back and take our quotes and take our positions and show the inhumanity in them?‌

Paul Lombardo: I have to say that I think that the last thing you said is impossible. And what I mean by that is that if we’ve put pen to paper, or our words are captured some other way in 50 years, there will be plenty of things that we said that were wrong. One of the lessons of history that kind of applies to everyone is that people make mistakes. People get it wrong, experts and others. So this is a question that was asked to me many times. I used to teach medical students quite a lot and they’d always say, “What are we doing today that people are going to laugh at in 50 years?” And to me, there probably are many things. I think the better question is the one you ended with, which is, if we make mistakes, we should at least make them in good faith and consistent with the mission which we portray to the public.‌

As one of my good friends said many, many years ago, he said, “We’re doctors. We’re supposed to cure people. We’re supposed to help people. And so that’s what I need to remember,” he said, “when I’m considering whether to support certain kinds of legislation.” and so I think that the role of a healer is an important role, and to the extent that we keep that upfront and remember that the people that we’re dealing with are people, we will at least, I think, avoid the most nasty condemnations of history. We’ll be wrong in ways, but maybe we’ll be thought to be at least well-meaning in our wrongness.‌

Howard Forman: You substantially revised your book, or at least added to your book and re-edited your book recently, and it is the title, Three Generations, No Imbeciles, which refers to the Buck case. What compelled you to do that? What new knowledge did you feel you needed to impart or what changes in the environment might have led you to want to do that?‌

Paul Lombardo: Well, the book is a book about law. Of course, I’m a lawyer and I write what some people call legal history, and the law changes. Some of the states that had sterilization laws when I wrote the first edition had done away with them. There were other places, other countries and other places in the U.S., where abuses were continuing to occur and they popped up in the news and I thought it was worth bringing things up to date on that ground.‌

The biggest thing, though, was that the United States Supreme Court, in at least two different cases, started using the word eugenics in a way which I thought was just frankly false. And they were portraying both birth control, some of the justices, were portraying birth control and abortion as being part of some kind of eugenic plot that had existed for a hundred years, and that’s just false.‌

So I wrote to respond to those assertions, and I wrote by essentially trying to collect information from the time period that was at stake. And that is the period in which the birth control movement was starting in the United States, the first decade of the 20th century, up until the mid-twentieth century, and also the time in which abortion became legalized in most states in the 1970s. And that last chapter in the book essentially, I hope, sets the record straight, that the people in the eugenics movement, even the ones that we would have been most astounded at in terms of their attitudes and their callous attitudes towards people, they didn’t support abortion. So saying abortion is something that came out of eugenics is just simply inaccurate, and I wanted to address that.‌

Harlan Krumholz: I’m an editor of a medical journal, JACC, one of the leading cardiology journals, and your discussion here really gave me pause. You said, “From the first decade of the 20th century until well after World War II, the ‘new science’ of eugenics was a constant topic in the Journal.” In this case, you’re talking about the New England Journal of Medicine, the leading journal perhaps in the world, was helping to propel this. And you said, “as it was in medical journals all over the United States,” the “new way of looking at heredity promised that managing human reproduction would rid the world of social problems and improve future generations.” And one of the important parts of your writing is that this wasn’t just about, even though you just said this about health, meaning there were people with diseases or there are mutations and so forth that were being propagated, that were trying to be stopped. It was an intersection with social problems. It was seeing people, for example, responsible for crime or deceit or it was attributing certain characteristics, social characteristics, to large-scale groups and saying, we could rid ourselves of these individuals.‌

I wonder, as you think about the role of medical journals, was this exercise useful? Was the reckoning with the past something that was useful or there’s some people who could say that, “Yeah, journals like the New England Journal look back and it’s a little bit of virtue signaling.” Yeah, “we can look back,” but what does it do for a journal to be able to have this, to confront this history? And again, what can we do going forward?‌

Paul Lombardo: Well, I think it’s certainly is easy to say, that was then, this is now. And people have a tendency to do that when they talk about history. Well, we’re not the same as those people who were unenlightened years ago. I have to give the New England Journal a lot of credit because they did something very straightforwardly. They allowed a group of scholars to dig into their past. They didn’t try to control it, they just let it play out. I have been involved in something like seven or eight different state apologies for eugenics. There were 32 states that had sterilization laws and the majority of them, all but those eight, have never even admitted that those things occurred. So to me, to the first point in addressing history—‌

Harlan Krumholz: First of all, I also salute the New England Journal of Medicine for doing this, and we never would have met you if they hadn’t done this. So we appreciate that too. But just for the listeners, what are some examples of those laws? When you say they have sterilization laws, what were they enabling?‌

Paul Lombardo: Well, there were something like 60,000 plus officially, probably more, people sterilized in state institutions in more than 30 states from 1907 until at least the late 1970s.‌

Harlan Krumholz: And you mean state institutions, meaning people who... I guess what I’m saying is that these are people of a wide range of problems, health problems?‌

Paul Lombardo: Yes. In most states, they had to be in a state institution, a mental hospital, asylum, whatever it was called then. In a few states, North Carolina for example, people, the social workers who worked for the welfare department, would go out and identify people and take them in and sterilize them. So this was largely a financial issue. The argument was made that we need to sterilize people because they cost too much. Disabled people cost too much. We need to do away with them. That was a very straightforward—‌

Harlan Krumholz: And what kind of consent was associated with these laws?‌

Paul Lombardo: There were usually court orders in these cases, and so there was no need for consent. The judge ordered the operation.‌

Harlan Krumholz: People were just, against their will, were sterilized or without their consent, as you said?‌

Paul Lombardo: Yes.‌

Howard Forman: I think, I mean, just to allow our listeners to understand the story, the Carrie Buck story is just so deeply offensive, partly because Oliver Wendell Holmes uses this horrible phrase, “Three generations, all imbeciles,” and yet your research and other individuals’ research is that this was a woman who was raped by a family member and was sent off to an institution mostly to avoid shame in the family. This was not—not that it would excuse it if she were mentally disabled—but the actual story’s even worse than that.‌

Paul Lombardo: Yeah. The story is significantly worse than that because this was a case that was generated by a doctor who wanted to get immunity and a state law would give him immunity to operate on people when he wished. And so he had been sued. He didn’t like that. He had his lawyer draw up a statute that would immunize him, but also give him the power to sterilize people in his institution.‌

They picked Carrie Buck. She was a foster child in a home where she was working. Her mother was already in an institution. She had just had a baby, but she wasn’t married. So she seemed to be the perfect target for this law, which was meant really to focus in Virginia on fallen women, as they said. So Carrie Buck ends up in the institution. She’s examined, and the information that’s presented to the court is that she’s feebleminded and immoral and hereditarily so. “She’s had a baby, she wasn’t married. Her mother is the same kind of person,” they say. “We examined the baby. She’s about six months old, and it looks like there’s something peculiar about the baby too. So they’re all feebleminded. This is a perfect example of why this law was written, hereditary feeblemindedness. People like this fill the prisons and the workhouses and the other institutions, we pay for our taxes. If we sterilize her, we can stamp this out.” Case goes to the Supreme Court—‌

Harlan Krumholz: And just remind me, the year of this is?‌

Paul Lombardo: 1924 is when the law is written, and the case is first brought. In 1927 after the trial court says, yes, the law is okay, and the appellate court says the same, it goes to the United States Supreme Court, Oliver Wendell Holmes gets the opinion writing job, and he very quickly dispatches Carrie Buck by saying, “The evidence is clear that she’s part of this group of feebleminded, defective people. Three generations of imbeciles are enough,” and then she is subsequently sterilized. It turns out though that there was nothing really wrong with Carrie Buck. I met her just before she died. She was a poor woman. She worked hard all her life as she went to school and had a regular life for a very poor woman. Her daughter died at age eight. She had the measles. She got a secondary infection and died, according to the death certificate, of enteric colitis.‌

So, she was on the honor roll. I found her grades in her grade school, and she was on the honor roll. So clearly, whatever slurs they used against her were inaccurate. Carrie’s mother was ill, may have had a drug problem. It’s not clear, but she died in her 40s. And so the real dramatic takeaway from this for me is not about the doctors, it’s about the lawyers. The lawyers in this case, at the state level, were best friends. And by the best evidence I’ve been able to put together, this was a case that was fixed from the beginning. The man who was appointed to represent Carrie Buck, a man named Whitehead, essentially through the case, and was proud to report that he lost at one point, and that’s been documented. So this is a tragic case on lots of different levels. It doesn’t say nice things about doctors. It says even worse things about lawyers, and it says a great deal about how our institutions fail people like Carrie Buck.‌

Harlan Krumholz: Wow. Well, I think it just speaks to the idea that we have to speak up for what’s right, but I do think this reckoning is useful. It’s useful to have that understanding of the past and how we want to be different in the future. And I just want to thank you so much for documenting this, for coming on with us today and for sharing this with us.‌

Howard Forman: I want to just add one more point and let you just comment on it as a final thought. You recently wrote a paper, and again, I thought it was really admirable that you pursued this, pointing out that Democrats and Republicans of the time, and it’s a very different party than today, were complicit in this. I mean, I think more were Republicans than Democrats, but the point being that a lot of these laws passed or were not vetoed by members of both parties. So this was something that transcended party membership per se during that time. So a lot of this happens because people either look away or because people are just actively complicit in it. And I just wonder if today, when you look back at our political parties, if you see any reckoning there, we’re talking about a medical reckoning and we’re talking about a societal reckoning. Do you worry about anything that, I’m not talking about the moment, I’m just talking about the historic arc we’re in right now. Are there concerns that you have that may give us either hope or concern going forward?‌

Paul Lombardo: Yeah, I have many concerns. And the concerns are that the rhetoric that I hear these days is pretty much the same that I read about as a student 50 years ago. It hasn’t really changed. It comes and goes. It’s fairly high-pitched recently, but the language of talking about people who are different has not really changed. And they may be different because of their race, because of their nationality, because of their religion, because of their disability, because of their gender, you name it, “Round up the usual suspects,” as Bogart would have said. When we get anxious as a country, we tend to take it out on the same kinds of people.‌

Howard Forman: Well, I just, again, echoing what Harlan just said, can’t thank you enough to remind our listeners, I mean, the book is a couple of years out now, but it’s, Three Generations, No Imbeciles. That is a very compelling story, and you are the scholar of this topic. So thank you so much for sharing it with us.‌

Harlan Krumholz: Yeah, thank you.‌

Paul Lombardo: Thank you.‌

Harlan Krumholz: Wow, that was terrific. That was one of the best interviews we’ve had. I mean, sobering, fascinating, interesting, and a little bit of a lesson to us about how medicine can get off the tracks. But let’s get onto this segment, as you know, one of my favorite segments of your podcast.‌

Howard Forman: I appreciate that. Thanks.‌

Harlan Krumholz: The Howie Forman segment. Let’s hear it. What’s up today?‌

Howard Forman: So measles remains sort of the gold standard of infectiousness. It truly spreads like wildfire. And the reason why we see few outbreaks in most areas in the country is because we’ve actually achieved herd immunity through vaccination. Although our vaccination rates are drifting lower over time over the last several years. You need a vaccination rate of 95% or more to have herd immunity. And just to explain to our listeners again, what is herd immunity? Once you have herd immunity, you can’t sustain an outbreak. So yes, someone can bring measles into a community from the outside, and yes, it can spread to someone else who either has not been vaccinated or failed to achieve immunity through vaccination or prior infection. But then subsequent spread will extinguish on its own because it’s difficult to find more measles-naive people to infect. So that’s the definition or herd immunity. And if you can get vaccination rates in the local area above 95%, you can’t get an outbreak.‌

In the last few weeks, we’ve watched a substantial outbreak in West Texas. This appears most centered in the Mennonite community of Gaines County that has a higher-than-average exemption rate for vaccinations, religious exemptions, roughly one in five kindergartners does not get vaccinated due to religious exemption. And now we have 45 cases in this county and 58 total in Texas, as well as some additional cases in an adjoining New Mexico county. These are the reported cases, and estimates are that there are hundreds more that have not yet been found or may never be diagnosed, but are out there. Now about one in 300 to one in 500 people would be expected to die from infection, and many others will have severe illness including hospitalization, though the vast majority of people do recover without sequelae from measles.‌

In this particular outbreak, there are four people among the 58 who claim to have been vaccinated in the past. All others are thought to be unvaccinated. And this too is an important reason for mandatory vaccination programs. Not all people who are vaccinated will acquire sufficient immunity, and not all people can be vaccinated. In other words, people might be going through chemotherapy treatment; they can’t be vaccinated. The vaccine itself is 97% effective when you get both doses, 93% with one dose only. Vaccination rates vary considerably across our country, and Texas is right about the national average at about 94% while New York, Massachusetts, and Connecticut hover around 96 to 98% vaccination rates. And I’ll point out that Connecticut only recently got rid of most religious exemptions, and that is why our vaccination rate is now much higher.‌

Texas is just below herd immunity as a state, but then there are regions like Gaines County that are way below herd levels. This is all to remind you, our listeners, that your vaccination is not only protecting you but also those around you. And when sufficient people are allowed religious or other exemptions, outbreaks can occur. We’re going to continue to watch this outbreak and also applaud community public health leaders for rapidly implementing vaccine clinics, testing and getting people help when they can, but there is no cure for measles once you get it. You just have to wait it out and treat it expectantly.‌

Harlan Krumholz: Howie, this is such an important message. I have a question for you about Covid vaccine because some people listening to this have heard people talk about Covid vaccine. Are all vaccines contributing to herd immunity? Are there some vaccines that actually help reduce your risk but don’t affect transmissibility, and is the Covid vaccine one of those?‌

Howard Forman: Yeah, so there are vaccines that have close to sterilizing immunity, and that is, measles is a good example of that. Rubella is an example of that. Polio is not, by the way, not sterilizing immunity. But with Covid, what we learned is, early on, it reduces infectiousness very early on after you get your dose, but shortly after that it does very little to reduce infectiousness. So it is not sterilizing immunity. And even though you retain for several months protections from a Covid vaccine to protect you from death, hospitalization, and severe illness, you do not necessarily have a reduced infectiousness. So it’s your responsibility to continue to mask or do whatever else you can to reduce the chance of your spreading it.‌

Harlan Krumholz: What’s your view on mandating vaccinations at this point? Because this is now a contentious issue. Are there certain vaccines like measles where people’s choice not to get vaccinated may impact others that, and we’ve had this, and of course you couldn’t start school, and so then some people were homeschooling and so forth. I mean, what’s your view on this now?‌

Howard Forman: The majority of childhood vaccinations, and I won’t go through them one by one because I might get one wrong, but the majority, the ones we think about polio, measles, rubella, diphtheria, pertussis, all those, the majority of those have substantial positive externalities, meaning that my vaccination does protect other people around me. And as I mentioned, there are many reasons why someone may not get properly immunized from a vaccination, or they may not be allowed to get vaccinated because they’re getting chemotherapy or other reasons. Those are good reasons why mandatory vaccinations should be mandatory. There are substantial positive externalities. This is the way to capture that.‌

There are other vaccines like flu and Covid that are much less substantial. Flu certainly does have some positive externalities, Covid much less than that. In those situations, you’re really dealing with much more of an individual choice.‌

Harlan Krumholz: Yeah, this is sure to be something that continues to be debated. As you know, this is becoming quite a topic at federal levels. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.‌

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on LinkedIn, Threads, Twitter, or Bluesky.‌

Harlan Krumholz: And we want to hear your feedback, questions, any experiences with these topics. And if you like the podcast, please rate us and review us on your favorite app. We always read the reviews and it helps other listeners find us.‌

Howard Forman: Yep. And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/emba.‌

Harlan Krumholz: And we are so proud that Health & Veritas is produced with Yale School of Management and the Yale School of Public Health. We appreciate their support.‌

Howard Forman: Absolutely.‌

Harlan Krumholz: And thanks to our researchers, Inès Gilles and Sophia Stumpf and Tobias Liu. And to our producer, the tremendous amazing Miranda Shafer. We’re lucky to be working with all of them.‌

Howard Forman: We certainly are.‌

Harlan Krumholz: And I’m lucky to be working with you, Howie. Talk to you soon. Howie.‌

Howard Forman: Right back at you, Harlan. Talk to you soon.‌