This November, the Pan American Health Organisation will review whether the United States has lost its measles elimination status — a designation held since 2000.

As of April 23, 1,792 confirmed cases have been reported across the US. Utah is the latest epicentre: nearly 600 cases since last summer. At one to three deaths per thousand cases, the arithmetic is clear: deaths are coming.

Last year’s measles outbreak was the worst since 1992: 2,288 cases, three deaths.

A six-year-old unvaccinated girl died of measles pneumonia in Lubbock, Texas, in February 2025 — the first measles death in the US in a decade. A second unvaccinated 8-year-old girl died in the same city weeks later.

A simulation model in JAMA projects an 83 per cent probability that measles will become endemic again in the US within 21 years at current vaccination rates. Under a 50 per cent decline in childhood vaccination, the model projects up to 159,200 deaths over 25 years from measles and other vaccine-preventable diseases. Measles alone would account for 51.2 million projected cases.

Among kindergartners in the 2023-24 school year, coverage fell below 93 per cent — compared with 95 per cent in 2019-20 — while non-medical exemptions were roughly three per cent. In total, approximately 280,000 kindergartners — 7.3 per cent — lacked documentation of full MMR vaccination, leaving them potentially susceptible to measles.

A 2026 county-level analysis found exemptions increased more than fivefold since 2010-11, jumping sharply after the pandemic. A 2024 Centres for Disease Control and Prevention report found 91 per cent of measles patients were unvaccinated or had unknown vaccination status.

The pandemic cut off children from vaccination schedules at critical windows. But it also accelerated a more corrosive collapse of institutional trust. In my practice, I see parents who read the studies, identify methodological limitations and remain unconvinced. This is not ignorance. It is a trust failure so complete that no evidence can ever be sufficient.

That trust has continued to erode. Health and Human Services Secretary Robert F. Kennedy Jr fired all 17 members of an influential immunisation advisory panel and replaced them with vaccine-sceptical appointees. The CDC reduced the childhood vaccine schedule from 17 diseases to 11. The American Academy of Paediatrics broke with the CDC’s schedule for the first time, publishing its own guidance endorsed by 12 major medical organisations.

Against this backdrop, clinicians are doing the work anyway. Michael Rosenbaum, a paediatrician colleague, estimates an 80 to 90 per cent success rate in persuading patients to get essential vaccines — often over multiple visits with hesitant families through motivational interviewing. The AAP recommends this practice, and a 2022 study found it cut vaccination refusals from 31.5 to 17.6 per 100 patients in the US.

Rosenbaum begins with an open question: “Tell me more about what concerns you.”

He affirms the family’s values before pivoting to the reflection almost every parent accepts: the main focus of your decision is what is best for the baby after weighing the benefits and risks of vaccinating. Then there’s the final summary: “How do you think we can do that?”

When they question pertussis vaccination, he describes the potential apnea of whooping cough in infancy. When they question vaccinations for Haemophilus influenzae type B, he tells them what meningitis wards looked like before 1985.

“Hib was the leading cause of bacterial meningitis in children when I was a resident. It was horrible.”

He names his uncle who had polio and was debilitated for his entire life. He says: “The risks of this vaccine are minimal and the benefits potentially priceless.” He refers back to a tragic case of measles encephalitis he saw as an intern when necessary.

Some children can’t be vaccinated because they are immunocompromised and can’t receive live vaccines or because they had a concerning but not debilitating reaction to a vaccine. Their safety depends upon their peers. Some parents remain resistant to some or all vaccines for religious reasons or because they attribute an illness they had (such as cancer) or their child had (such as encephalitis) to vaccines.

In Utah, state lawmakers introduced exemption-expansion legislation during the middle of the measles outbreak. A paediatric infectious disease physician reached for the right analogy: “It’s kind of like if you were a firefighter trying to put out a house fire,” he said. “And somebody is standing on the hose.”

Florida announced plans last year to end vaccine mandates for hepatitis B, chickenpox and bacterial meningitis, with seven additional diseases to follow.

There are positive signs. In congressional testimony last week, Kennedy repeatedly backed away from his criticism of the measles, mumps and rubella vaccine. He told the Senate Finance Committee: “We have advised every child to get the MMR. That’s what we do.”

President Donald Trump has nominated Erica Schwartz, a physician who has supported childhood vaccination, to lead the CDC.

Routine immunisation has averted 154 million deaths since 1974, nearly all among young children. Sustaining that requires trustworthy, consistent and transparent institutions. We know that eliminating non-medical exemptions works. We know motivational interviewing works.

We know the diseases vaccines prevent because clinicians were trained in an era when those diseases still filled paediatric wards. The diseases eliminated by vaccination did not disappear because people stopped fearing them. They disappeared because institutions, clinicians and communities sustained the effort to keep them gone.

• Jonathan Slater is a clinical professor of psychiatry at Columbia University Irving Medical Centre