Why would people who care about their children’s health choose to ignore the evidence-based recommendations of the government and health-care system? Photograph by BSIP / UIG / Getty

On Wednesday, the House Energy and Commerce Subcommittee on Oversight and Investigations held a timely and important hearing that had no hope of getting media attention on the same day that President Trump’s former personal lawyer Michael Cohen testified before another committee. The overlooked hearing focussed on ongoing measles outbreaks in the United States. Between January 1st and February 21st, a hundred and fifty-nine cases of measles were diagnosed in ten states—more cases than there were in all of 2017. Measles is highly contagious and potentially deadly. It’s also entirely preventable through vaccination.

Testifying at the hearing were Anthony S. Fauci, the head of the National Institute of Allergy and Infectious Diseases, and Nancy Messonnier, the director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. One after another, subcommittee members asked Messonnier and Fauci if measles was dangerous and vaccines were safe. The doctors, neither of whom is a stranger to public speaking, exchanged befuddled glances. How does one handle a question to which the answer is obvious? Time after time, Fauci and Messonnier handled the questions with grace and patience. Grace, though, is a double-edged sword: a polite, respectful response to an ignorant question inevitably affirms the impression that the question itself is valid.

Representative Jan Schakowsky, a Democrat from Illinois, asked Messonnier to answer “yes” or “no” to a question about the primary culprit behind the outbreaks: Is it “vaccine hesitancy and misinformation”? Messonnier responded with a diplomatic “Yes and no.” She explained that children who are not covered by health insurance are less likely to be vaccinated, which suggests that parents’ opposition to vaccination is not the only reason that fewer children are being vaccinated. In response to a later question from Representative Frank Pallone, a Democrat from New Jersey, Fauci was more decisive: he called disinformation “an important problem.” But he immediately cautioned against blaming parents who have bad information; the goal, he said, should be to provide them with better, evidence-based messaging.

Sitting behind Fauci was a woman who kept silently raising a book titled “How to End the Autism Epidemic.” The phrase refers to a bogus, long-ago debunked theory that preservatives that were once used in the vaccine for measles, mumps, and rubella (M.M.R.) caused autism. The British gastroenterologist who once hypothesized this link lost his medical license years ago, but books, brochures, and articles promoting his theory continue to circulate and inspire people to reject vaccination and even to protest during congressional hearings.

Vaccination is a basic political issue, because it is the subject of community agreement. When a high-enough percentage of community members are immunized, a disease can be effectively vanquished. In epidemiological terms, this is known as “herd immunity,” which cannot be maintained below a certain threshold. When enough people reject the community agreement, they endanger the rest. Willfully unvaccinated adults and children can spread diseases to those who cannot be vaccinated or haven’t been vaccinated, such as infants and people with a compromised immune system; these vulnerable populations would probably be safe in conditions of herd immunity. Vaccination and the refusal to vaccinate are political acts: individual decisions that affect others and the very ability of people to inhabit common spaces.

Both Fauci and Messonnier repeatedly mentioned insular communities as hubs of measles outbreaks: Hasidic Jews in New York State (where an outbreak in 2018 and 2019 was apparently triggered by an infected visitor from Israel) and Somali-Americans in Minnesota, where, in 2017, an infected visitor from Somalia started an outbreak; both of these communities had many unvaccinated people. But a majority of vaccine resisters in this country are non-Jewish, white, educated Americans. While all states have laws that require vaccination, most allow for religious exemptions, and seventeen states allow people to refuse to vaccinate their children for reasons of personal philosophy. In other words, the suggestion that foreigners, immigrants, or tiny, strange religious minorities are overwhelmingly to blame for the measles outbreaks is misleading, as is the suggestion that lack of access to accurate information creates the conditions for poor vaccination coverage. From all available evidence, a majority of anti-vaxxers—educated white people, such as those who send their children to Waldorf schools—have access to public-health information and to vaccination; they choose not to believe and not to participate.

Measles is a quintessential political issue of the late two-thousand-teens, one that turns on the conflict between facts and lies. There has even been some reporting that Russian trolls have been spreading anti-vax propaganda. If they are, they are tapping into existing tensions and preconceptions, just like they do when they spread electoral propaganda. On Facebook, a tiny cluster of anti-vax pages seems to have disproportionate reach. And, just as with other kinds of propaganda, the key question is what makes the soil fertile for it.

Why would people who care about their children’s health choose to ignore the solid, evidence-based recommendations of the government and the health-care system? The simple answer is because they don’t trust the government or the health-care system. Theirs is not an unreasonable position. The American health-care system is opaque and profit-driven. Working in concert with the pharmaceutical industry, it gave us the deadly opioid epidemic. It gives us the highest infant-mortality and the lowest life-expectancy rates among the world’s developed countries—as well as the highest bills.

Not only do people not trust the health-care system but the health-care system itself doesn’t trust patients. It infantilizes them and keeps them in the dark. It ignores them when they ask for help, especially if they are female or black. It doesn’t take their word for anything. Americans who receive medical care abroad may find it striking to be treated as reasonable sources of information on their own bodies. I once flew to Australia for a three-week fellowship, only to discover upon arrival that I had left prescription medicine at home. The following day, a doctor at a Melbourne clinic heard me out and, clearly satisfied that I knew what I was talking about, wrote a prescription; the visit to the doctor cost sixty dollars, and the cost of my prescription medication was ten per cent of its price in the U.S. When I wrote a Facebook post about the experience, I was bombarded with stories that were similar to mine, by Americans who were shocked to have received fast and affordable medical care in countries that aren’t the U.S.—but, above all, they were shocked to have had an interaction based on trust.

About a year later, I sought treatment for a broken jaw, from a bicycling accident, at a New York City hospital. I needed a CAT scan, and a young male intern insisted that I first take a pregnancy test. I told him that I’d had a radical hysterectomy several years earlier. I pointed out that I was fifty-one years old. I mentioned that I didn’t have sex with men. He wouldn’t budge. I don’t know what kind of concerns drove this protocol, but the protocol itself was clear: never take the patient’s word for anything.

The solution to under-vaccination lies not in getting the right kind of information and messaging to the “vaccine-hesitant” but in changing the politics of health care. Political agreement is unlikely among partners who do not trust each other, and near impossible when one side is explicitly profiting from the other. The American health-care system is ill-suited to protect public health, because a profit-driven industry cannot serve as the guardian of public good.

In the congressional hearing that everyone watched on Wednesday, Cohen implored Republican legislators to stop lying for the President as he said he had for years. They ignored him. Whether driven by perceived profit—financial or electoral—or willful belief, they would hold the line that they had adopted, facts and the public good be damned. In both hearings, one could observe the utter disintegration of politics.