American Scientist

Virologist Peter Hotez is internationally recognized as a pediatrician-scientist in vaccine development and neglected tropical diseases. As codirector of the Texas Children’s Hospital Center for Vaccine Development and professor and dean at the Baylor College of Medicine, he also regularly consults on the coronavirus pandemic—how to quantify it and ways to mitigate its spread, including the development of vaccines. As the parent of an adult daughter with autism, Hotez knows well the extent to which the anti-vaccine movement presents challenges to public health. American Scientist’s Robert Frederick spoke with Hotez about the anti-vaccine movement and other challenges to vaccine development, including poverty, war and conflict, urbanization, and climate change.

You use the term vaccine science diplomacy to refer to the joint development of vaccines and related technologies, in which scientists in affected countries work collaboratively with their counterparts around the world. To what extent is that joint effort helping to overcome the challenges to vaccine development?

This concept was pioneered by Albert Sabin, who discovered the oral polio vaccines. His oral polio strains were not made into the vaccine in the United States but as a back-channel collaboration with the Soviets at the height of the Cold War. In the years right after the Sputnik launch—some of the worst times in the U.S./U.S.S.R. Cold War—the two countries put aside their ideologies: Sabin’s virus strains were made into a vaccine, tested in more than 10 million Soviet schoolchildren, and proven to be safe and effective, ultimately leading to licensure of the vaccine.

We’ve been looking at that model to say, “Could we do this with countries we don’t always agree with ideologically?” Science diplomacy is a fantastic diplomatic tool that I think is underused by the U.S. government.

The other component to your question involves some of the 21st-century forces that are driving down vaccination-coverage rates. Until a few years ago, we vaccine scientists were being very self-congratulatory because we had made great advances in vaccinating the world’s children—nearly eradicating polio and even bringing down measles rates, which is tough because it’s so highly contagious. Through Gavi, the Vaccine Alliance, we were supported by the Bill & Melinda Gates Foundation and donor countries and had made great progress with vaccinations worldwide. But now we’re starting to see those gains unravel a bit because of both social and physical determinants that we didn’t really consider before.

War and political collapse, for instance, is interrupting health systems and driving down vaccine coverage. We’re seeing that play out in the Arabian Peninsula, Syria, Iraq, Yemen, Venezuela, and the eastern Democratic Republic of Congo, which just experienced Ebola. More kids are dying of measles and cholera than from Ebola in Congo. How we’re going to overcome these 21st-century forces is a huge issue. Of course, we also have the problem of anti-science sentiments.

When joint development of vaccine work is not possible, perhaps because the vaccine already exists, how do you engender trust?

We’re seeing this scenario play out now, especially in the United States and in Europe, where people are increasingly becoming distrustful of vaccines or erroneously believing vaccines are unsafe or even cause autism or other conditions. This shift is not happening by accident. It’s happening because of a deliberate misinformation campaign led by an anti-vaccine lobby. More than 480 fake anti-vaccine misinformation websites exist, so parents who try to download health care information about vaccines will likely get garbage. This problem is amplified on social media. Amazon is the biggest single promoter of fake anti-vaccine books. It’s this media blitz that parents are seeing, and there’s not really a countervailing force providing accurate information about vaccines and explaining why it’s critical that you vaccinate your child.

This situation has been brewing for about two decades. It started in the late 1990s, but now it’s blown up into a whole media empire and political machine—and it’s affecting public health. Measles has returned to the United States two decades after it was eliminated. We now have a generation of teenagers being denied cancer prevention through the HPV [human papillomavirus] vaccination, so we’re condemning a generation of women to a greater possibility of cervical cancer. Many Americans are not getting their flu vaccine. All this is to benefit the fake anti-vaccine empire.

What were the forces that prompted this anti-science movement?

Throughout much of American history there have been fits and starts of anti-vaccine activities, but you can trace the modern movement by doing a National Library of Medicine search on vaccines and medicine. It started in 1998 with the publication of a fake paper by Andrew Wakefield and his colleagues claiming that the MMR [measles, mumps, and rubella] vaccine, especially the measles component, leads to autism, or what they then called pervasive developmental disorder.

Ultimately an investigative journalist for The Sunday Times, Brian Deer, uncovered quite an elaborate fraud scheme, and Wakefield’s paper was retracted—but not until 12 years later. We went from 1998 to 2010 with this buzz around thinking that vaccines may cause autism. It gained critical mass—to use the nuclear energy analogy—all amplified on social media and on e-commerce sites. It’s widespread misinformation, and of course there’s the political arm as well.

So for neglected tropical diseases, how would you spread limited resources?

An entomologist or a public health researcher might argue, “Let’s go after disease vectors to eradicate diseases.” That’s worked in the past, including in the United States with malaria and yellow fever. Public health folks would also consider improved sanitation. And then you can avoid, in some sense, these 21st-century human causes of challenges: war, political collapse, and anti-science bias. So why also vaccines in addition to these other efforts with disease vectors?

“We’re so fixed on vaccines as a one-stop shop for everything. Unfortunately the level of protection of these vaccines is not such that we can do that.”

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We somehow have to move past the idea that a single intervention will solve these disease problems. Remember especially that some parasitic and viral infections have evolved with humans over millions of years. The idea that you can use a single approach to get rid of these diseases isn’t likely.

Look at HIV/AIDS: Just because we have antiretroviral drugs doesn’t mean that we shouldn’t use condoms or other prevention measures; similarly, even though we have condoms and other prevention measures, we still build new antiviral drugs and now we’re building a vaccine. It’s the same with neglected tropical diseases. With malaria, for instance, just because we’re trying to build a vaccine doesn’t mean that we’re going to stop using bed nets, antimalarial drugs, and other prevention measures.

This concept is not easy to sell. We’re somehow in this false situation where we think you get only a single “shot on goal” against a disease because in the past we thought of vaccines as a unidimensional approach to solving a problem: measles, we’ll use a measles vaccine; polio, a polio vaccine. In the case of malaria or other diseases such as schistosomiasis and Chagas disease, the vaccine will be used as a parallel technology, a complementary technology. That hasn’t been an easy sell to the policy makers.

We’re so fixed on vaccines as a one-stop shop for everything. Unfortunately the level of protection of these vaccines is not such that we can do that. So vaccines are not going to replace existing technologies. But now we have the additional problem of the anti-science lobby and the anti-vaccine movement not only working to discredit existing childhood vaccinations for measles and whooping cough and so on, but also trying to actively block the introduction of new vaccines. They have gone after the HPV vaccine in a big way.

This opposition is going to be a new battlefront in the introduction of new vaccines, with the anti-vaccine lobby targeting these interventions. One thing I like to say is, This situation is also our fault as scientists: We’re so inward-looking, so focused on our grants and our papers and writing and speaking for one another, that we’ve lost our ability or even our interest in engaging the public. So we need to figure out how to shape a new generation of scientists who want to be out there, who want to be recognizable, and who want to be able to explain science to audiences. I’m starting to see among young people, who have an amazing commitment to public service, that they want to do it. We just don’t have it in the DNA of our profession right now. We don’t teach science communication or public engagement in PhD training and postdoctoral training. We have to fix that, because otherwise anti-science movements will continue their ascendancy.

Is that why you became the founding editor-in-chief for the Public Library of Science’s Neglected Tropical Diseases (PLOS NTD) journal?

That’s absolutely right. We created that journal when we realized that nobody cared about the diseases I’d spent my life working on. We realized that we had to up our game in terms of public engagement and advocacy. At the turn of the 21st century, with the [United Nations] Millennium Development Goals, the goal listed for infectious disease was to combat AIDS, malaria, and other diseases. Everything I had devoted my life to was called “other diseases.” That was going to go nowhere, right?

We spent a lot of time with colleagues such as David Molyneux in Liverpool and Alan Fenwick in London to rebrand these illnesses as neglected tropical diseases (NTDs) so people would care about them and talk about this package of interventions. We started PLOS NTD with a $1 million grant from the Gates Foundation. That’s been a game changer.

Now a billion people annually receive treatment for these diseases, and we’re developing new vaccines. It’s an example of how every now and then as a working scientist you have to take that risk to step outside the lab and get people to care about what you’re doing. And now we’re seeing this play out with neglected diseases of the poor in the United States.

The other thing I did with PLOS was to write a book called Forgotten People, Forgotten Diseases, which my kids like to call “Dad’s forgotten book on forgotten people with forgotten diseases.” But now it’s in its second edition. For the second book we wrote about the hidden, neglected tropical diseases among the poor in the United States. We estimate 12 million Americans living in extreme poverty have a neglected tropical disease, such as Chagas disease, hookworm, toxocariasis, dengue, and others. That again required me to step outside of the laboratory. Interestingly, we’ve not done nearly as well on that issue. It’s been easier to get people to care about neglected diseases of the poor in Africa, Asia, and Latin America than to care about those here in the United States. I’m still trying to figure out why.

A podcast interview with the researcher: