Making diphtheria great again? Why SA's public health experts are worried about RFK Jr
In June he accused Gavi, the international vaccine alliance, of distributing a version of DTP — the combined diphtheria, tetanus and pertussis (whooping cough) vaccine — that does more harm than good, and halting all US funding to the group.
Public health experts say what could be more dangerous than the funding cuts is the misinformation campaign he's driving, which is fuelling a growing lack of trust in vaccines with global repercussions, including right here in South Africa.
They used to call it the strangling angel.
The grey membrane would take the form of wings at the back of the child's throat, spreading quickly, thickening up like leather. As the diphtheria moved through the body, a toxin would be released, potent enough to stop the heart and paralyse the nervous system. Some of the children who caught it would die within days, their narrow airways blocked by the winged formation.
Before vaccines were widely available, diphtheria was a leading global killer. But after the World Health Organisation (WHO) rolled out standard immunisation campaigns in 1974, new cases of diphtheria were reduced by more than 90%. Today, most people would be hard-pressed to tell you what diphtheria is, never mind what it does to the body of a small child.
But one three-minute video released on social media at the end of June may change all that.
That's when US health czar Robert F Kennedy Jr accused Gavi, the international vaccine alliance, of distributing a version of what's known as DTP – the combined diphtheria, tetanus and pertussis (whooping cough) vaccine – that does more harm than good. Kennedy, known as RFK Jr, also halted all US funding to the group until it embraces what he defines as proper science.
RFK Jr's vaccine stance is completely at odds with the global public health community and years of science, ignoring years of research that have found vaccines are safe and effective and which have saved an estimated 154 million lives – mostly under the age of 5 – over the past 50 years.
It's the latest in a long and storied history of RFK Jr's anti-vaccination attacks. It's also the latest round of brutal losses for the global public health community, which has already been battered by US government funding cuts and reduced support from other major donors.
South Africa has also been hit by debilitating US funding cuts, but we won't lose out on vaccines. The government pays for ours – as a middle-income country we are a contributor to the fund, pledging $20 million in Gavi support over 20 years to ensure that lower-income countries can vaccinate their populations.
But, says Heidi Larson, the director of the Vaccine Confidence Project, the main problem is not a lack of vaccines. It's the growing lack of trust in them.
'Events in the US absolutely have global repercussions,' she says. 'They embolden others, especially those still undecided about vaccination, and that's where the danger lies.'
The trouble with RFK
To support his attack on Gavi and DTP, RFK Jr points to a small 2017 study he's cited before, an analysis from Guinea-Bissau that uses vaccine data from the 1980s. Experts say he has misinterpreted the study, and with his high profile and large social media following, is spreading misinformation about a well-established combination vaccine, shown to be safe with either form of the vaccine.
'He cherry-picks a poorly conducted study and ignores mountains of evidence to the contrary,' says Salim Abdool Karim, a leading epidemiologist and director of the Centre for the Aids Programme of Research in South Africa, Caprisa.
A recent study in The Lancet estimated that, over the past 50 years, DTP vaccines have saved over 40-million lives.
READ | 'Contribute to community immunity': Noted sceptic RFK Jr expresses measles vaccination support
South Africa, like many higher-income countries, uses a newer version of the vaccine than Gavi, called DTaP. It causes fewer mild side effects like fever or soreness, but it also requires more booster jabs. Gavi supports an older version. Called DTwP, it tends to cause mild, short-lived side effects but it offers longer-lasting protection, which is crucial in lower-income countries where the healthcare system is under strain and booster shots may be harder to deliver.
Recent diphtheria outbreaks show how quickly things can go wrong when vaccination rates slow down.
The WHO found that the Covid-19 pandemic disrupted vaccination campaigns, including DTP, causing an immunity gap. In South Africa, at least 60 confirmed cases of respiratory diphtheria, the most serious and life-threatening form of the disease, were recorded between January 2024 and June this year.
Because it is such a rare and deadly disease that spreads easily through coughing and sneezing, even one case is a cause for concern.
Deepfakes and institutionalised disinformation
As RFK Jr took to social media to spread more disinformation about vaccines, a video of an AI-generated Abdool Karim surfaced.
The video was a deepfake (a manipulated image created to misrepresent someone or something) and hijacked Abdool Karim's credibility and likeness to falsely warn viewers that those vaccinated against Covid-19 vaccines may be facing deadly danger.
In reality, Abdool Karim has been a vocal advocate for vaccines, including during the Covid pandemic, when he chaired the ministerial advisory committee which guided the government on Covid vaccines.
In a lecture in May honouring his impact in public health, Abdool Karim spoke about 'institutionalised disinformation', where the very institutions once trusted to uphold science are now the ones spreading doubt. He draws a straight line between former president Thabo Mbeki's Aids denialism which led to the deaths of over 330 000 South Africans and the coming fallout of RFK Jr's dangerous misinformation campaign. He warned that when political leaders question well-established science or spread doubt, the erosion of trust in science weakens our ability to respond to pandemics effectively.
'Where the state now becomes the source of the disinformation, you lose your bearings as to where to get the truth,' Abdool Karim said. 'That's why the right information about vaccines is as important as the vaccines themselves'.
MMR, autism and RFK
In the US, measles vaccination rates have been slipping steadily for years, largely because of the anti-vax movement that was turbo-charged by RFK Jr during the Covid-19 pandemic.
He has claimed countless times that the vaccine against MMR – measles, mumps and rubella, three highly contagious childhood illnesses caused by viruses and which spread through coughs and sneezes – is the cause of autism, pointing to a retracted study that has been refuted by reams of research.
This week, the US Centres for Disease Control and Prevention reported around 1 300 confirmed measles cases across 35 states, including New York, California, Florida and Texas – 25 years after being declared eliminated in the US.
'The chaos that is going on in the US… has a knock-on effect all across the world. It's critical for us to be proactive, rather than wait until the damage is done,' says Edina Amponsah-Dacosta, a virologist with the University of Cape Town-based Vaccines for Africa Initiative.
For Amponsah-Dacosta, the current measles flare-up in Gauteng is a stark warning. The health department has flagged a dangerous immunity gap after Covid, reporting that immunisation coverage for the second dose of the measles vaccine is below 75% in Johannesburg and Tshwane, which she says aligns with global patterns of under-vaccination seen after the pandemic disrupted routine vaccination.
READ | US Senate votes in Trump's controversial pick Robert F Kennedy Jr as secretary of health
Because measles is one of the world's most contagious diseases experts like Michelle Groome, an infectious disease epidemiologist with Wits University's Vaccines & Infectious Disease Analytics, say at least 90% of the population should be vaccinated. She explains that outbreaks of highly contagious diseases happen when pockets of unvaccinated people come into contact with someone who is infected, triggering a rapid spread.
When people think about measles, they often just consider the rash, she says. But measles affects many organs and the impact of the disease on the body can linger.
'It actually causes disease through all your systems, and so it can affect the brain. Some of the consequences can be delayed even many, many years, so that if you have measles now, you may develop problems much later.'
HPV wiped out cervical cancer
Just like some diseases take years to show problems, it can take years to see a vaccine's benefits.
An infection with certain forms of the human papillomavirus (HPV) can cause genital warts, and certain cancers, most commonly cervical cancer. Cervical cancer is the leading cause of cancer related deaths in Africa.
Cervical cancer is the leading cause of cancer related deaths in South Africa too.
In those not vaccinated, it can take up to 20 years for the cancer to emerge. That means the most dramatic effects – fewer women getting cancer and fewer dying from it – will only emerge a generation later. HPV is an extremely common sexually transmitted infection, and most sexually active people will be infected at some point in their lives, which is why Gavi makes an investment in the HPV vaccine.
READ | JFK's legacy lives on in his grandson, Jack Schlossberg – but he's carving his own path
RFK Jr has also featured the HPV vaccine in his misinformation parade, falsely claiming that the HPV vaccine caused cervical cancer, the very thing it protects against.
Australia, the first country to implement widespread HPV vaccination, is already seeing that long-term payoff. A modelling study shows that cervical cancer may be virtually eliminated there by 2028. The United Kingdom introduced HPV vaccines in 2008 – today the country has almost eliminated cervical cancer in young women who were vaccinated as adolescents.
While South Africa's school-based HPV vaccination was introduced in 2014, HPV continues to be the leading cause of cancer deaths among women here, largely because HPV vaccination began later than in wealthier nations and because access to cancer screening and treatment remains patchy.
Vaccine economics
Despite the cost of vaccines, they save money for governments because there's so much less illness and disability. A large 73-country study estimates that childhood vaccinations given over a decade (2001-2020) had a broader social and economic value of $820 billion.
'There are not that many things that are as amazing as vaccines for child health – a miracle intervention,' says Susan Cleary, the director of the school of public health at the University of Cape Town.
Her research group recently published an impact study in PLOS ONE which shows how Covid-19 vaccines helped to drastically reduce hospital admissions in South Africa; a follow-up study, which will be published soon, shows these vaccines didn't just save lives, they saved taxpayers money too.
But the knock-on effects of vaccination also help in the long term. By preventing diseases, vaccinations help to ensure people won't become ill in the first place.
'It's not just about saving lives, it's also about safeguarding livelihoods,' says Amponsah-Dacosta. 'They can go on to study just as well as anybody else in school… and their parents can contribute to the economy instead of spending money looking for treatments.'
Immunising against misinformation
Despite overwhelming evidence that vaccines are safe and effective, analysis by Larson's Global Listening Project shows rising global vaccine hesitancy. It's about a breakdown in trust in health authorities and a complex information environment.
Even more confusing for the public, says Larson, is that that fringe has now gone mainstream in the US. For example, in June, RFK Jr also dismissed all 17 members of the US Centres for Disease Control's vaccine advisory panel. He replaced them with just eight new members, some of whom are openly sceptical of vaccines.
'Vaccines have become kind of a victim of their own success,' says Amponsah-Dacosta. Because of vaccines diseases like smallpox have been eradicated while deaths and disabilities from polio, tetanus, rubella have disappeared from view, lulling people into thinking vaccines aren't needed.
'Eventually, people get to hear misinformation, so the best practice is to provide people with sound information. This way, once they're faced with myths… they are already immunised against misinformation and can make the right decision.'
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