The Obvious Reason the U.S. Should Not Vaccinate Like Denmark

The Atlantic

6 days ago

For decades, countries around the world have held up the U.S.'s rigorous approach to vaccine policy as a global ideal. But in Robert F. Kennedy Jr.'s Department of Health and Human Services, many of the officials responsible for vaccine policy disagree. For the best immunization policy, they argue, the U.S. should look to Europe.
Marty Makary, the new FDA commissioner, and Vinay Prasad, the new head of the agency's center for regulating vaccines, have criticized the nation's COVID-19-vaccine policy for recommending the shots more broadly than many European countries do. Tracy Beth Høeg, a new adviser at the FDA, has frequently compared the U.S.'s childhood vaccination schedule unfavorably with the more pared-down one in Denmark, and advocated for 'stopping unnecessary vaccines.' (Prasad, citing Høeg, has made the same points.) And the new chair of the CDC's Advisory Committee on Immunization Practices, Martin Kulldorff—whom Kennedy handpicked to serve on the panel, after dismissing its entire previous roster— announced in June that ACIP would be scrutinizing the current U.S. immunization schedule because it exceeds 'what children in most other developed nations receive.'
This group has argued that the trimness of many European schedules—especially Denmark's—implies that the benefits of the U.S.'s roster of shots may not outweigh the risks, even though experts discussed and debated exactly that question when devising the guidance. But broadly speaking, the reasons behind the discrepancies they're referencing 'have nothing to do with safety,' David Salisbury, the former director of immunization of the U.K.'s Department of Health, told me. Rather, they're driven by the factors that shape any national policy: demographics, budget, the nature of local threats. Every country has a slightly different approach to vaccination because every country is different, Rebecca Grais, the executive director of the Pasteur Network and a member of the WHO's immunization-advisory group, told me.
One of the most important considerations for a country's approach to vaccines is also one of the most obvious: which diseases its people need to be protected from. The U.S., for instance, recommends the hepatitis A vaccine for babies because cases of the contagious liver disease continue to be more common here than in many other high-income countries. And conversely, this country doesn't recommend some vaccine doses that other nations do. The U.K., for example, routinely vaccinates against meningococcal disease far earlier, and with more overall shots, than the U.S. does— starting in infancy, rather than in adolescence—because meningitis rates have been higher there for years. Using that same logic, countries have also modified prior recommendations based on emerging evidence—including, for instance, swapping the oral polio vaccine for the safer inactivated polio vaccine in the year 2000.
Vaccines are expensive, and countries with publicly funded insurance consider those costs differently than the U.S. does. Under U.K. law, for instance, the National Health Service must cover any vaccine that has been officially recommended for use by its Joint Committee on Vaccination and Immunisation, or JCVI—essentially, its ACIP. So that committee weights the cost effectiveness of a vaccine more heavily and more explicitly than ACIP does, and will recommend only a product that meets a certain threshold, Mark Jit, an epidemiologist at NYU, who previously worked at the London School of Hygiene & Tropical Medicine, told me. Price also influences what vaccines are ultimately available. In 2023, JCVI recommended (as ACIP has) two options for protecting babies against RSV; unlike in the U.S., though, the NHS bought only one of them from manufacturers, presumably 'because the price they gave the government was cheaper,' Andrew Pollard, the director of the Oxford Vaccine Group, the current JCVI chair, and a former member of the World Health Organization's advisory group on immunizations, told me. (The prices that the U.K. government pays for vaccines are generally confidential.)
The nature of a country's health-care system can influence vaccine policy in other ways too. In the U.S. system of private health care, health-equity gaps are massive, and access to care is uneven, even for one person across their lifetime. Many Americans bounce from health-care provider to provider—if they are engaged with the medical system at all—and must navigate the coverage quirks of their insurer. In this environment, a more comprehensive vaccination strategy is, essentially, plugging up a very porous safety net. Broad, simple recommendations for vaccines help ensure that a minimal number of high-risk people slip through. 'We're trying to close gaps we couldn't close in any other way,' Grace Lee, a pediatrician and a former chair of ACIP, told me.
The U.S. strategy has worked reasonably well for the U.S. Universal flu-vaccine recommendations (not common in Europe) lower the burden of respiratory disease in the winter, including for health-care workers. Hepatitis B vaccines for every newborn (rather than, like in many European countries, for only high-risk ones) help ensure that infants are protected even if their mother misses an opportunity to test for the virus. More generally, broad recommendations for vaccination can also mitigate the impacts of outbreaks in a country where obesity, heart disease, and diabetes—all chronic conditions that can exacerbate a course of infectious illness—affect large swaths of the population. American vaccine experts also emphasize the importance of the community-wide benefits of shots, which can reduce transmission from children to elderly grandparents or decrease the amount of time that parents have to take off of work. Those considerations carry far more weight for many public-health experts and policy makers in a country with patchy insurance coverage and inconsistent paid sick leave.
The current leadership of HHS thinks differently: Kennedy, in particular, has emphasized individual choice about vaccines over community benefit. And some officials believe that a better childhood immunization schedule would have fewer shots on it, and more closely resemble Denmark's, notably one of the most minimalist among high-income countries. Whereas the U.S. vaccination schedule guards against 18 diseases, Denmark's targets just 10 —the ones that the nation's health authorities have deemed the most severe and life-threatening, Anders Hviid, an epidemiologist at Statens Serum Institut, in Copenhagen, told me. All vaccines in Denmark are also voluntary.
But 'I don't think it's fair to look at Denmark and say, 'Look how they're doing it, that should be a model for our country,'' Hviid told me. 'You cannot compare the Danish situation and health-care system to the situation in the U.S.'
Denmark, like the U.K., relies on publicly funded health care. The small, wealthy country also has relatively narrow gaps in socioeconomic status, and maintains extremely equitable access to care. The national attitude toward federal authorities also includes a high degree of confidence, Hviid told me. Even with fully voluntary vaccination, the country has consistently maintained high rates of vaccine uptake, comparable with rates in the U.S., where public schools require shots. And even those factors don't necessarily add up to a minimalist schedule: Other Nordic countries with similar characteristics vaccinate their children more often, against more diseases.
At least some of Kennedy's allies seem to have been influenced not just by Denmark's more limited vaccine schedule but specifically by the work of Christine Stabell Benn, a researcher at the University of Southern Denmark, who has dedicated much of her career to studying vaccine side effects. Like Kennedy and many of his allies, Benn is skeptical of the benefits of vaccination: 'It's not very clear that the more vaccines you get, the healthier you are,' she told me. Along with Kulldorff, Høeg, and National Institutes of Health Director Jay Bhattacharya, Benn served on a committee convened in 2022 by Florida Governor Ron DeSantis that cast COVID-19 vaccines as poorly vetted and risky. She and Høeg have appeared together on podcasts and co-written blogs about vaccine safety; Kulldroff also recently cited her work in an op-ed that praised one Danish approach to multidose vaccines, noting that evaluating that evidence 'may or may not lead to a change in the CDC-recommended vaccine schedule.' When justifying his cuts to Gavi —the world's largest immunization program—Kennedy referenced a controversial and widely criticized 2017 study co-authored by Benn and her husband, Peter Aaby, an anthropologist, that claimed that a diphtheria, tetanus, and pertussis vaccine was increasing mortality among children in Guinea-Bissau. (Benn wrote on LinkedIn that cutting Gavi funding 'may have major negative impact on overall child survival,' but also noted that 'it is reasonable to request that WHO and GAVI consider the best science available.')
Several of the researchers I spoke with described Benn, with varying degrees of politeness, as a contrarian who has cherry-picked evidence, relied on shaky data, and conducted biased studies. Her research scrutinizing vaccine side effects— arguing, for instance, that vaccines not made from live microbes can come with substantial detriments —has been contradicted by other studies, spanning years of research and scientific consensus. (In a 2019 TEDx talk, she acknowledged that other vaccine researchers have disagreed with her findings, and expressed frustration over her difficulties publicizing them.) When we spoke, Benn argued that the U.S. would be the ideal venue for an experiment in which different regions of the country were randomly assigned to different immunization schedules to test their relative merits—a proposal that Prasad has floated as well, and that several researchers have criticized as unethical. Benn said she would prefer to see it done in a country that would withdraw vaccines that had previously been recommended, rather than add new ones. In a later email, she defended her work and described herself as 'a strong advocate for evidence-based vaccination policies,' adding that 'it is strange if that is perceived as controversial.'
When I asked her whether anyone currently at HHS, or affiliated with it, had consulted her or her work to make vaccine decisions, she declined to answer. Kulldorff wrote in an email that 'Christine Stabell Benn is one of the world's leading vaccine scientists' but did not answer my questions about Benn's involvement in shaping his recommendations. HHS did not respond to a request for comment.
What unites Benn with Robert F. Kennedy Jr. and his top officials is that, across their statements, they suggest that the U.S. is pushing too many vaccines on its children. But the question of whether or not the U.S. may be 'overvaccinating' is the wrong one to ask, Jake Scott, an infectious-disease physician at Stanford, told me. Rather, Scott said, the more important question is: 'Given our specific disease burden and public-health goals, are we effectively protecting the most vulnerable people? Based on overwhelming evidence? The answer is yes.'
That's not to say that the U.S. schedule should never change, or that what one country learns about a vaccine should not inform another's choices. Data have accumulated —including from a large clinical trial in Costa Rica—to suggest that the HPV vaccine, for instance, may be powerful enough that only a single dose, rather than two, is necessary to confer decades of protection. (Based on that growing evidence, the prior roster of ACIP was considering recommending fewer HPV doses.) But largely, 'I'm not sure if there's a lot in the U.S. schedule to complain about,' Pollard, the JCVI chair, told me. On the contrary, other nations have taken plenty of their cues from America: The U.K., for instance, is expected to add the chickenpox shot to its list of recommended vaccines by early next year, Pollard told me, based in part on reassuring data from the U.S. that the benefits outweigh the risks. The U.S. does recommend more shots than many other countries do. But the U.S. regimen also, by definition, guards against more diseases than those of many other countries do—making it a standout course of protection, unparalleled elsewhere.