A dangerous idea is on the table: ending universal hepatitis B birth-dose vaccination in the United States. For many years, the Centers for Disease Control and Prevention has recommended that every baby born in this country receive the vaccine, preventing infections and deaths from a disease that causes liver cancer and deadly cirrhosis. (Most other higher-income countries have the same recommendation.) Abandoning this protection would condemn thousands of children every year to lifelong infection. One in four babies infected at birth eventually die from this preventable infection.
Consideration about whether to repeal the universal protection against hepatitis B was on the agenda for discussion by the Advisory Committee on Immunization Practices (ACIP) in its September meeting until a last-minute postponement — reportedly because one member wanted to change the childhood vaccination schedule by delaying vaccination even more drastically. This is just the latest example of a troubling trend: Retreat from proven, lifesaving interventions not because they failed, but because they succeed.
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After 10 years of writing, my book, “The Formula for Better Health: How to Save Millions of Lives – Including Your Own,” is being published today. I think it’s a new way of understanding and stopping many threats to our health.
The formula has three parts: See what’s invisible, believe change is possible, and create solutions that work at scale.
1. See the invisible — and make it visible
The first component of the formula is to see not only the threats to our health but also the reasons we so often fail to act on them or reverse course on effective interventions such as universal hepatitis B birth dose vaccination. One of these reasons is the prevention paradox: Small reductions in individual risk, applied broadly across a population, yield large benefits — even though most people don’t feel or even notice a change.
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The prevention paradox explains why successful health interventions become vulnerable to attack. Universal hepatitis B vaccination exemplifies this: Each baby receives small individual protection, but vaccinating all babies prevents thousands of infections annually.
This creates political vulnerability. When individual benefits appear small, even substantial population gains are hard to notice. The enormous collective benefit — 9,000 prevented cases annually — becomes invisible because individual risk and benefit seem minimal.
The greatest health threats and pathways to success are often invisible. We can’t see the 9,000 annual hepatitis B infections that universal vaccination prevents, the lives saved by air pollution reduction, or the IQ points gained from lead removal. All three of these successes are examples of the prevention paradox: small individual benefits but enormous societal benefits.
When industries such as the tobacco companies try to hide health harms, the best way to counter this blindness is to make visible the economic interests that try to hide harms and block action, and show what’s working and what’s failing. That means establishing effective coalitions, including businesses that benefit from healthier workers, families that avoid disease costs, healthcare payors that prevent expensive complications.
2. Believe in the possibility of change
Health problems that seem immutable often aren’t. Smoking rates seemed permanently fixed until they dropped by more than half. Doctors, nurses, and, most of all, community advocates changed the reality and the social norm by increasing cigarette cost through taxation, limiting availability, and decreasing the acceptability of smoking. Multidrug-resistant tuberculosis appeared unconquerable in New York City and across the United States until focused intervention cut cases by more than 90% nationally. Heart disease seemed inevitable until decades of progress prevented 20 million deaths. Making further phased progress can cultivate optimism — not only has there been progress, but more progress is possible.
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3. Create simple solutions at scale
Effective interventions succeed through simplicity. Universal vaccination works because it’s operationally straightforward: one intervention applied consistently. Simple approaches achieve scale while complex alternatives often fail. Complex targeted approaches sound smarter but have multiple failure points, including missed tests, missed follow-up visits, and unpredictable and variable transmission patterns. The hepatitis B experience proves this: targeted strategies consistently failed because real-world implementation breaks down.
Of course, implementing these three approaches requires buy-in at the highest levels of government — and right now, that’s lacking. But states, communities, health care systems, and individuals can use the formula to protect and improve their own health.
The Robert F. Kennedy-aligned, reconstituted ACIP recently changed Covid-19 vaccination recommendations to “shared clinical decision-making” for all populations — including high-risk groups: seniors and immunocompromised individuals, for whom vaccines have clear, substantial benefits reducing severe illness and death.
Shared clinical decision-making suggests that there’s no clear benefit to vaccination — something that is simply untrue, particularly for seniors and other vulnerable populations. This shift from clear recommendations to neutral guidance is an abdication of governmental responsibility to provide fact-based recommendations to doctors and the public, and, if it reduces vaccination rates in vulnerable populations, could cost thousands of lives.
But those of us outside of government can see and even help stop these failures.
When officials propose replacing universal interventions with “targeted” approaches, we need to insist on seeing real-world implementation data. With hepatitis B vaccination, for example, the targeted approach has been tried and has failed repeatedly. When there are proposals to retreat from clear recommendations for high-risk populations, we need to recognize this as abandonment of evidence-based practice.
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“The Formula” provides tools to counter these dangerous trends: Make visible invisible threats, including health risks, trends, toxins, program performance, and the technical pathway to progress. Demonstrate that progress is possible by highlighting past victories and making steady progress on current problems. Defend simple, proven solutions against complex alternatives that sound sophisticated but fail in practice.
Most importantly, recognize that we’re not powerless observers of policy failures. Armed with understanding of how and why decisions go wrong, we can see through misleading arguments, advocate for evidence-based policies, and build coalitions to support interventions that protect our health and the health of our children, families, and communities. The ability to see, believe, and create better health outcomes is a framework anyone can use to protect health and to recognize and stop dangerous threats to societal and personal health.