For months, President Donald Trump’s Administration has launched a full-scale attack, led by his Secretary of Health and Human Services, Robert F. Kennedy, Jr., on America’s public-health system. In the past week, however, the efforts escalated: Kennedy, who rose to fame in part owing to his conspiracy theories about vaccinations, pushed to fire Susan Monarez, the director of the Centers for Disease Control and Prevention, which is part of H.H.S. This came after Monarez refused to follow the lead of Kennedy’s advisers, who have tried to restrict vaccine access. (Trump has now named a Kennedy deputy, Jim O’Neill, as her replacement; Monarez’s lawyer claims that her firing was “legally deficient.”) The Trump Administration has already tried to limit access to COVID vaccines; earlier this month, the F.D.A. approved updated COVID vaccines but limited access to them to people sixty-five and older, and those with certain preëxisting conditions that put them at risk of severe illness. In mid-September, a C.D.C. advisory committee will meet and is expected to make a recommendation on who should be able to get the shots.

I spoke about the crisis at the C.D.C. with Paul Offit, the director of the Vaccine Education Center at Children’s Hospital of Philadelphia, and a professor of pediatrics at the Perelman School of Medicine, at the University of Pennsylvania. During our conversation, which has been edited for length and clarity, we discussed the extent to which the federal government can deter or restrict vaccine access, what Kennedy is really trying to accomplish, and why making it more difficult for pharmacies to inoculate patients may change public health in America.

How important are C.D.C. recommendations to vaccine uptake? How centralized a process is this?

Everyone who is involved in administering vaccines looks to the C.D.C. for their recommendations. So the Food and Drug Administration (F.D.A.) is a licensing body. It says a company can sell their vaccine, but it’s the C.D.C., specifically the Advisory Committee on Immunization Practices (A.C.I.P.), that gives specific recommendations. They say, O.K., now that it’s licensed, you can administer this vaccine to these people at these time intervals. And they have always been the central source, so they’re critical. They are the group that people look to for advice.

And so, when you say “people,” you’re talking about doctors, pharmacies, insurance companies, everyone, essentially.

Yes. I think parents look to their doctors for advice, but I think the doctors and the pharmacists and others are looking to the A.C.I.P. for advice.

I imagine there will be a lot of doctors, a majority of doctors in the United States, who are going to end up disagreeing with the Trump Administration’s guidance about vaccines. What, then, do doctors have the ability or inability to do, based on what the C.D.C. does?

So, for example, the C.D.C.—prior to Kennedy becoming the Secretary of H.H.S.—had recommended that young children receive a vaccine based on data that were presented in April of this year showing that thousands of children were being hospitalized, that one in five of those children hospitalized were being sent to the intensive-care unit, that a hundred and fifty-two children had died, that virtually none who died were vaccinated, and that half who died were previously healthy. Most of those children were less than four years old, and many were less than six months of age. So therefore there was a clear, firm recommendation by the C.D.C. to vaccinate young children. Then, at the end of May, Robert F. Kennedy, Jr., stood and said H.H.S. is no longer recommending the COVID vaccine for healthy young children and for pregnant women, even though children under six months of age could only be protected by vaccinating their mother [during pregnancy].

That threw a wrench into the system, and here’s how it played out. The American Academy of Pediatrics is going to publish a clear recommendation in its journal saying that all children six months and older who have not been vaccinated should be; and that children less than two years of age should clearly be vaccinated because of the data showing that COVID can be a serious and occasionally fatal infection in that age group. Then the American College of Obstetricians and Gynecologists stood up in the defense of pregnant women and said that pregnant women should receive a vaccine.

The only vaccine available for children less than five is Moderna’s vaccine. And that is licensed only for children in a high-risk category. So now you’re stuck. You’re wondering, Is insurance going to cover this? Is insurance going to cover a young child, a healthy child getting a vaccine? Are physicians going to feel comfortable, in terms of liability, giving that? And, for the most part, physicians are covered by the National Childhood Vaccine Injury Act, so, more important, are pharmacists going to feel comfortable? And, even though that act does not include COVID vaccines, another act does. I talked to two lawyers and my understanding is that it doesn’t cover pharmacists, so they are being left in the lurch. It’s all confusing, and I think that’s the point. I think Kennedy’s point is to make it confusing.

Why is Moderna the only one making a vaccine for kids, and why did they only recommend it for kids who are not healthy?

Moderna and Pfizer initially had a vaccine approved under an emergency-use authorization (E.U.A.), and then Moderna advanced that from the emergency-use authorization to a licensed product. But that licensure through the F.D.A. unfortunately only included children who were at high risk, because what the Trump F.D.A. did was they basically usurped the role of the C.D.C. The job of the F.D.A. is to say, O.K., if this vaccine is safe and effective, then it’s licensed and the company can sell it. Then it’s up to the C.D.C. to say, O.K., looking at the epidemiological data that we have, it looks like all children older than six months benefit. But the F.D.A. preëmpted that, and basically they took over the role of the C.D.C. Project 2025 wants to eliminate C.D.C. as a recommending body. And one way to do this is what the F.D.A. just did, which is to limit the vaccines to just those children who are at high risk. Pfizer’s vaccine was approved through an emergency-use authorization for children less than five years old, but they just didn’t advance the license quickly enough. And so Kennedy saw an opportunity and basically said, We’re not going to approve anything through E.U.A. anymore. And that eliminated Pfizer’s vaccine for children.

I have read that some countries in Europe have a more relaxed attitude to children’s vaccinations than we did before Trump. Is that accurate? And do you think that there’s anything to be said for that?

The goal of the vaccine is to keep people out of the hospital, keep them out of the intensive-care unit, keep them out of the morgue. You’re not going to be protected against mild to moderate disease for long after either a natural infection or a vaccination. Four to six months later, your antibody response will fade; you’re still going to be protected against severe disease for a fairly long time, but you’ll still be at risk for mild to moderate disease. So then the question becomes who’s getting hospitalized? Who’s dying? That’s who you’re trying to protect. It really falls into four groups: people who are pregnant, people who are over seventy-five, people who are immunocompromised, and people who have high-risk medical conditions like chronic lung or heart disease. The logical response is to say, O.K., let’s just target those groups. Let’s give the vaccine every year to those groups, the groups most likely to be hospitalized or suffer serious illness.

We didn’t. We just kept saying everybody over six months of age should get a yearly vaccine—and I think that was wrong. Very early on, actually, I started to say that we should target the groups who are being hospitalized. That’s the goal of the vaccine. I was getting a lot of criticism for saying that we should just target the high-risk groups. I suddenly had gotten off the bus, and I think, in the public-health world, you’re either on the bus or off the bus. Someone I talked to in that world said that would be seen as a nuanced recommendation, which is going to be seen as a garbled recommendation. And the best way to get everybody vaccinated who should be vaccinated is to make a universal recommendation. I guess it’s a testable hypothesis, but I don’t agree with that. And so it was always seen as a messaging issue. And the A.C.I.P., in April of this year, started to discuss whether they should just target high-risk groups. But then those people got fired and replaced by this group with members who are science-averse and anti-vaccine.

So then, just to clarify, what exactly is your recommendation regarding kids?

Of course we should vaccinate children who haven’t been vaccinated. I think we should not have that relaxed attitude. If you can prevent something that causes serious, and occasionally fatal, infections safely, then do it. So I disagree with those countries that have a relaxed attitude about childhood vaccines. I think we should continue with what we had, which is to vaccinate young children who haven’t been vaccinated or naturally infected.

This is the difference between a yearly vaccine and a primary vaccine. I think everybody who has never been vaccinated and has never been naturally infected should get a primary vaccine. Most of this country has either been vaccinated or naturally infected or both. So now we’re talking about, for the most part, a yearly vaccine. And I think that should target high-risk groups,

And then the high-risk groups are what you were talking about in terms of getting the yearly shots?

Yes, exactly right.

The New York Times and others have reported that in many states CVS and Walgreens are going to be limiting COVID vaccines to those with prescriptions, or stop offering them completely. Can you discuss why?

This would be disastrous. COVID is going to [go the way of] respiratory diseases, like influenza, that individually cause hundreds of thousands of hospitalizations and tens of thousands of deaths every year. COVID will become flu. We will see it every year. There are four older strains of human coronavirus that circulate in this country that account for maybe ten to fifteen per cent of the hospitalizations at our hospital. They have likely circulated among humans for centuries. The other two were more recent. Assume this virus is going to be with us for decades, if not centuries—so we’re going to be dealing with it, and the question is how best to deal with it.

When the vaccine first came out, in December of 2020, we had a problem. We wanted to try and vaccinate the population. And, although there really wasn’t an infrastructure for mass-vaccinating adults, that’s where pharmacies came in. Most adults get their vaccines from the pharmacist, whether it’s the flu vaccine or the COVID vaccine. I think that, by making it unclear whether pharmacists have liability protection for, say, a healthy thirty-five-year-old who wants to get a vaccine, [that practice will] decrease. And, because of that uncertainty, these pharmacists at CVS and Walgreens who were giving the vaccine are in a conundrum about how to handle all this. And that’s Robert F. Kennedy, Jr.,’s goal—to make things confusing, which will therefore lessen vaccine uptake.

So it seems like there are two separate issues. The first is just liability protection. If something goes wrong with the vaccine, which happens in a tiny, tiny number of cases, then people are worried about getting sued, right?

Yes. The label says you can only give it to a high-risk person. So someone who has a high-risk medical condition or is elderly or whatever falls into one of those categories. A person who is, say, thirty-five, who’s scared of getting long COVID, who works in a nursing home, around a vulnerable population of people, or who has an elderly person at home—all perfectly reasonable reasons to get a vaccine—they may not be able to get a vaccine. The pharmacist may feel, I can’t give this person a vaccine. So it’s pregnant people now who have gone to the pharmacist and tried to get a vaccine, but they haven’t been able to get one, even though they are a high-risk group. This was the way adults get vaccinated. Many adults don’t go to a doctor. When they do go to a doctor, usually they don’t get vaccines. It was the pharmacist who was giving them vaccines.

But it seems like there’s another issue, which is that CVS is now saying they’re not able to offer COVID vaccines in some states, even to people who meet the newly restrictive criteria. It seems like some states have a law that they have to follow guidelines.

Interestingly, the A.C.I.P. really hasn’t weighed in on this yet. The F.D.A. has. It’s a licensed vaccine for people in high-risk groups who are under sixty-five. And the A.C.I.P. typically weighs in much earlier in approving the vaccine. [In years past, the committee’s advisory meeting was held earlier in the summer.] But we still don’t know what they are going to do yet. Maybe that’s what they’re going to be saying in September.

Well, right. I think that’s the issue for these pharmacies. They’re waiting until A.C.I.P. weighs in.

And will they weigh in? This Retsef Levi, who is now the head of the COVID working group [at the C.D.C.], is virulently anti-vaccine, certainly anti-COVID-vaccine. So what will the A.C.I.P. say? We’ll see.

This all makes me think about how public-health groups and states are going to have to think about public health differently, at least for the next three and a half years. How do you think about that question?

I think that’s the most important point, right? Because, historically, they look to the A.C.I.P. for what they can and can’t give. And now we basically don’t have a real A.C.I.P. anymore. We have this group of voting members, many of whom have an anti-vaccine bent—can you trust them? No. I think medical and scientific groups don’t trust the A.C.I.P. anymore. Frankly, they don’t trust the C.D.C. anymore. So now what do you do legislatively? Do you change the laws and say, We’ll go with what the American Academy of Pediatrics says or what American College of Obstetricians and Gynecologists says? That’s a matter of changing the law. It’s hard. This is never the way we’ve done it before. We haven’t looked to these professional societies to legally [determine] what to do.

Forgive me if this is a stupid question, but what about doctors’ offices giving patients the vaccine themselves? How plausible is that?

For adults, that’s hard. Historically, that’s been hard. Most adults, including me, get their vaccines from the pharmacist because it’s so much easier. You just walk in. It’s much harder in the doctor’s office because you have to make an appointment. Can you get an appointment? Will the doctor have the vaccine in stock?

But nothing would actually stop that.

That is right. But that certainly didn’t work, say, in 2021. The reason we were able to vaccinate seventy per cent of the U.S. adults between December of 2020 and July of 2021 was because of pharmacists.

Is there anything you think pharmacies can or should be doing here that they’re not doing? Every article I read about this says they’re in a tough bind. Are there different steps they could be taking?

I’m not sure what they can do other than try and work with their local legislatures to see whether or not they can pin recommendations to professional societies. But that’s not something that’s going to happen quickly. And COVID is not going anywhere. We’re going to have COVID every year, and every year three and a half to four million children are born, who, by six months of age, will be fully susceptible to this virus. And there are a lot of adults who are having trouble getting this vaccine in their pharmacies. I do think it would be great if this hole could be made up for by the physician, but I just don’t see that.

Everybody who’s at high risk does need to be vaccinated every year to keep them out of the hospital. Last year, according to C.D.C., some forty-seven thousand deaths were attributed to COVID. Hundreds of thousands of people were hospitalized from COVID. This is preventable. Same thing with flu. During the 2024-25 flu season, we had two hundred and sixty-seven children die from flu, which is the biggest number for flu deaths in this country since the 2009-10 flu season, when there was a swine-flu pandemic. It’s because they’re not getting vaccinated. And I think under these now more restrictive and confusing rules, fewer people will get vaccinated and more people will suffer.

You mean vaccinated for all things, or are you talking about COVID?

I mean vaccinated for all things. If you talk to people on the ground regarding measles, for example. If you look on the C.D.C.’s website, you’ll see fourteen hundred cases of measles this year. One person from the Texas Department of State Health Services said to me that this is a vast underestimate for what’s really happening. And so, because the C.D.C. has been shredded under this Administration, because it doesn’t have its surveillance capacity, because it can’t now fund the immunization clinics that it used to, not only are we going to be left unimmunized across the board; we’re also not going to know exactly what’s going on out there.

It seems like what you’re saying, though, in the bigger picture, is that they want to legally restrict who can get the COVID vaccine. And then once they’ve restricted it legally to that smaller group, then they want to make access even for that smaller group harder, even though, ostensibly, they’re arguing that these groups should have access to it?

I agree. What’s happened is that the anti-vaccine activists have been shouting from the sideline for decades. Now they’re making public policy. In summary, we’re screwed. ♦