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Emily Silverman: This is The Nocturnists: Conversations. I'm Emily Silverman. Today, I'm joined by Perri Klass, pediatrician, professor, and author of The Best Medicine: How Science and Public Health Gave Children a Future. Perri's work braids medicine, history, and storytelling to show how, within just a few generations, parents went from expecting to lose children to expecting them to grow up. In our conversation, we talk about Perri's journey as a physician writer, and what reporting taught her about science, communication, the lost world of routine, childhood death, and the cultural shift that followed.

How sanitation, pasteurization, rehydration therapy, antibiotics, and vaccines drove child mortality down dramatically in the last 100 years. Vaccine skepticism today and how clinicians can listen and advocate, and the rise of the well-child and parenting and vice culture. This is a rich conversation, and probably could have gone on for two hours longer than it did, because there was so much to cover. I hope you enjoy it as much as I did. Before you dive in, take a listen to Perri reading from her book, The Best Medicine.

Perri Klass: Our grandparents and great grandparents and all the parents before, throughout history, expected that children would die. It was a known and predictable risk that went along with being a parent. Now we expect children not to die. We are the luckiest parents in history. We who are part of this wave over the past 75 years or so, because we are the first parents ever who have been able to enter into parenthood in the hopeful expectation of seeing all our children survive and thrive. We are also the luckiest children in history, born into an era when we could expect to grow up, along with all our sisters and brothers.

Driving down child mortality in the late 19th and early 20th centuries was in no way a single project, but it can be seen as a unified human accomplishment, maybe even our greatest human accomplishment, at least for pediatricians and parents. Children used to die regularly and unsurprisingly. Babies died at birth or soon after because they were premature or just weak, because they were born with congenital anomalies, because they got infections. Older infants and one-year-olds died of summer diarrhea, often caused by microbes in the water or in the cow's milk they had started drinking after they had been weaned.

Three-year-olds, four-year-olds, and five, six, seven, and eight-year-olds died of scarlet fever, diphtheria, pneumonia, and measles of skin infections that turned into sepsis or influenza that turned into pneumonia. As recently as the late 19th and early 20th centuries, almost every family in every ethnic group and every country, rich or poor, was touched in some way by the death of children. Childhood death was always there in the shadows at the edge of the family landscape, in prayers and religious ceremonies, in the memorial portraits hanging on the wall, in popular sentimental poems and stories and dramas and paintings, because they figured so consistently in childhood and family life.

Child deaths also figured in the art and literature as songs and stories of childhood and family life from a century ago, as they had all through human history. "I am a lover of babies, and yet I can't seems to have them," wrote Mrs. WD from Brooklyn in 1917. "I am married 11 years, last July, and would have six children, and am about to become a mother again, which I almost fear. I have now but two out of six, one boy, nine years, and one six years." Two of them had apparently died some years ago. She didn't say how, but then, within a year, she had two babies and ended up losing both of them. "I gave birth to a beautiful, fat boy, and it lived," but three days, the doctor told her the baby had a leaking heart.

Three months later, she was pregnant again. This son lived to be a year old, and then she awoke one morning and found him dead alongside of me. Now pregnant again, she worried constantly both about the terrible, long labor she was likely to endure and about what would become of the baby. "I try and live a good, honest life, and my home is my heaven, and babies are my idols. I love them, but I am afraid something will happen to this one again." Mrs. WD was not living in the Middle Ages or even in the Victorian era. She was living in 1917 when my grandmother lived, and in New York City, where my grandmother lived, 10 years before my own parents were born.

In fact, Molly Ladd-Taylor, the historian who compiled the collection of mothers' letters to the children's bureau in Washington, was inspired by finding her own grandmother's letters in the file. Some of the letters came from women in rural areas, beyond easy reach of medical expertise during childbirth, but others like Mrs. WD lived in big cities where they were receiving full medical attention and their letters are notable for a mix of tragic acceptance and a hope for better answers as they searched for government advice or medical wisdom that might change the story going forward. At that time, in 1917, when Mrs. WD wrote her letter, nearly a quarter of the children born alive in the United States died before their fifth birthdays.

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Emily Silverman: I am sitting here with Perri Klass. Perri, thank you so much for coming on the show, and thank you for that fantastic reading.

Perri Klass: So glad to be here.

Emily Silverman: I loved your book, The Best Medicine. As a new parent and as a parent of two children under the age of five, it really helped me reconnect with this moment in history and feel gratitude for the time and place in which I am born. I want to talk all about the book. Before we do, if you don't mind, I'd love to talk a little bit about you, because you have a huge body of work. You're a pediatrician, you're a writer. You've written books, you've written essays, many, many, many essays. I was wondering if, to begin, you could talk to us about your journey as a physician writer. What got you into writing, and how your writing has evolved over the years.

Perri Klass: Sure, I grew up writing stories. I come from a family of writers. My mother was a writer and a passionate teacher of writing. My father was an academic and writer. My siblings are writers, my uncle, and there are a lot of writers in my family. I think I grew up with the idea that to live a full and happy life in the world, you need to be writing things down. I might compare it to growing up in a family of musicians.

I am completely tone deaf and absolutely not a musician, but if you grew up in a family of musicians, it's not that they would necessarily expect you to make your living this way, but I assume they would think that a child growing up and able to appreciate the beauties and wonders of the world would need to understand music and play an instrument. I think my mother felt that way about writing, that it was certainly not a way to make a living. Her other lesson would have been, "Of course, a writer needs a day job." I think that she felt very strongly with her students, with her children, that writing was very, very important and that telling stories really mattered. I was writing stories my whole life.

I was a biology major in college, but pretty much everything I took that was not a science course was a writing course. I took as many as I could. I loved them. I think that when I went to medical school, the huge mistake I made, or the big thing that I didn't realize, was that there was a connection. I think I thought, "I'm going to be a doctor," because I was very interested in medicine, but then I thought, as I might have thought about, again, playing the piano, "But I sure hope that I have enough time to keep writing," but they're separate.

When I started medical school, I had already amassed a huge collection of rejection slips, because this was in the old days when you would send out a paper manuscript in a self-addressed stamped envelope and then wait for it to come back with a printed rejection slip, which usually said, "Thank you for letting us see the enclosed material. We regret that it does not suit our needs at present." If you were lucky, someone would have written sorry on it in pen with an exclamation point. If you were really lucky, really, really lucky, and this only happened, rarely, an editor would have bothered to write, "Really like this story. It doesn't quite work for us, but I'd love to see something else."

Anyway, I had hundreds of those rejection slips. Then the fall that I started medical school, an editor bought a short story. It was one of those people who had responded, and I had written back and said, "Here's another story." Then when you reject that one, "Here's another story." She bought a short story that I'd written at Mademoiselle magazine. It was unbelievably exciting to have her publish it. Then the magazine was interested in doing a special issue, this is 1982, on being a woman in the first year of medical school, law school, and business school. There were not as many as there are now, but there were more than there had been, and they wanted to take account of that.

The editor who had bought my short story apparently said, "Oh, I know someone who's a woman in the first year of medical school." They asked me if I would write about being a woman in the first year of medical school. I had never published non-fiction. I'd never thought of writing autobiographically, but I guess I sort of thought, "Well, how hard could it be? Here I am." That was the first time that it actually occurred to me, first of all, that these stories might be interesting to anyone else. I've now, of course, been doing it for a very long time.

That was 1982. I've thought a lot about the connections, and I've realized that writing about it in various ways has enriched, enhanced, affected my clinical practice as a pediatrician, but also the way that I think about medicine, the way I think about colleagues. I think a lot about when something happens that really sticks with me, "Is this something which I'm actually want to sit down and write a reported piece or an essay about, or is this something which I hope someday I can use it in fiction?" They've become extremely interconnected, and I'm grateful for that, but it was not originally my idea.

Emily Silverman: You've written many, many columns and essays for The New York Times. I'm just on your New York Times page right now, scrolling down. Your most recent one was March 28th of 2025, so very recent. Then I scroll down, and it keeps going and it keeps going, and it gets all the way to the bottom. I think the earliest one I see here is May of 2006

Perri Klass: Goes back much further than that.

Emily Silverman: Does it go back much further than that? Maybe there's more pages here. Tell us about what is it like to be writing about medicine for The New York Times, to have a column, to have that platform, and how you think about that

Perri Klass: Well, so this was my first year of medical school, that I wrote about way back then. It was interesting and exciting, and it was a great learning experience, because I had no idea what I was doing. I offended some people that I didn't mean to offend. I think I did it very clumsily. In the fall of my second year, I was pregnant, and I found myself sitting in reproductive pathophysiology while pregnant, which, I'm sure you can understand, is an interesting experience, learning every possible pathological-- everything that could go wrong.

Emily Silverman: Oh, yes.

Perri Klass: At the same time, I was taking a exceptionally groovy birthing class for expectant mothers. It occurred to me that there was no overlap, that none of what we covered in reproductive pathophysiology for medical students was being covered in the birthing class, and vice versa. I wrote a old-fashioned paper query letter to The New York Times Magazine, saying, "I think it's kind of interesting." They actually wrote back and said, "Sure, read an article about this." My first venture into doing this was my idea, and it was extremely personal.

I then went on to write what was called the Hers column. They were very personal essays about being a medical student and changed my life in terms of exposure, in terms of people hearing my voice. As you well know, I started doing this as a second and third year medical student, which is not a moment when you feel you have a very loud, clear voice, or even necessarily like you deserve one. I started publishing those columns when I was doing my very first rotation, which was internal medicine, and I always felt like the least knowledgeable person in the room.

My motto would probably have been, "If something's wrong, please don't ask me. Ask the intern, ask the fourth year medical student, ask the sub intern, ask the resident, ask the attending, ask anyone but me." To try to figure out what my voice was good for, what stories I actually had to tell was certainly an interesting contrast. When I actually got the chance to write the column years later in The Times and write about issues and parents, that was actually something else, which I loved. That was a chance to learn how to report. Those were no longer autobiographical.

That was a chance to figure out, "Okay, what does this study mean to parents who are reading this column? Let me call and talk to the people who did the study and ask them to say what they think it does and doesn't show. Then let me call a few other people who didn't do the study and ask them to come in on it. Then let me call someone who practices this kind of medicine and say, "Well, is this going to change what you say to people? That was incredibly interesting, and it felt useful, and taught me a tremendous amount about what are the things that are really, really, really hard to get across to the public.

Because we lived in an era, by the time I was writing the column, that people could respond, also taught me what was coming across, what was not coming across, and also about what makes people mad. Both the experience of reporting and calling people up and say, "What is it like to have this be your everyday conversation with children, conversation with parents? What do you do that helps, but also what keeps you up at night? How does this study change things?"

I think that because I was a practicing pediatrician, a lot of people were probably willing to trust me, willing to believe that I was not on a mission to make them look bad or make medicine look bad or make pediatrics look bad. Willing to talk about some of the things that they felt more ambivalent about, or some of the areas where there is one absolutely right answer, and this is what I want everyone to know. I think people trusted me to get the science right, but also trusted me to be able to write about gray zones in a way that did them justice. I tried to.

Emily Silverman: Let's talk about your most recent book, The Best Medicine: How Science and Public Health Gave Children a Future. Tell me about taking on this topic and the process of putting this together.

Perri Klass: Well, one of the things I found about medical training and pediatric training was it changed me as a reader. If I read a book, a 19th-century novel, in which there was a child who got sick or died, I was always curious, "Can I recognize what the child is sick with?" That satisfying feeling of, "Well, now we would know what to do about that. We could cure that fictional character." That's an old interest, and I would note it down and think about it. What makes Beth sick in Little Women? It's actually interesting because all the details are there.

You can figure it out, but unless you read it with the awareness that after scarlet fever, you can develop heart disease, so that years later, you're weaker, waste away, and die, it's not necessarily spelled out for you. Then I teach at NYU. In addition to teaching in the medical school, I also teach undergraduates, and I've been co-teaching a course on children in childhood now for a decade. When you talk about the history of childhood, very often, almost parenthetically, it will say, of course, at the time, a third of all children died by the fifth birthday, almost like you might as well know that, but not like it would change everything.

From the point of view of a pediatrician, a 21st-century pediatrician, children are not supposed to die. I got stuck on it. What was it like to be a parent if a third of all children died? What was it like to be anyone providing medical care? It seemed to me that it must change everything, the practice of being a parent, when you're feeling [unintelligible 00:22:47] and looking and saying, "Oh yes, I think your throat is red." That must have been different when diphtheria and scarlet fever were in the differential and neither was remotely treatable or preventable. It must have at least crossed your mind.

I mean, I have three children. I understand that even in this day and age, there are times when you wake up at night and think, "Maybe I should call my pediatrician. Am I practicing medicine on my own children? If so, am I being too anxious or too casual? You spend your life thinking that. My children, probably like yours, they make various jokes about what it's like to have a pediatrician as parent. You do spend a certain amount of time either thinking, "Oh boy, I shouldn't have just taken that for granted," or saying to the pediatrician, "You're absolutely sure it's not this very unlikely, very obscure thing."

Emily Silverman: You do such a great job in the opening chapters of the book painting that picture, looking to history, literature, and poetry to try to understand the psyche of the parent at that time when they were having more babies, and some of them wouldn't make it past their first birthday or past their fifth birthday. How did people think about this and talk about this?

It seems to me, from some of the examples that you gave, that it was just accepted as normal. It was God's decision. There's even the example with Abraham Lincoln, when he loses his son, he lapses into this state of melancholy. His wife, in particular, is beside herself with grief, to the point that people were looking at her and thinking, "This lady is a little over the top. Children die." Bring us into that time. What was it like in the culture?

Perri Klass: Well, historians sometimes talk about a lost world and about the ways in which you can try to understand the past, but you don't feel the same emotions any more than you hear the same sounds or smell the same smells. I'm no historian, so I apologize if that's-- I like the idea of a lost world, because I don't think I understand, either as a parent or as a pediatrician. That was one of the reasons I wrote the book. I think I'm looking at those parents, and probably they're as recent as my own grandparents, my parents' parents. I'm looking at them across a gulf that I can't quite bridge because I don't know how to say this, but it was normal in a world in which you're losing one in three.

It has to be a kind of normal. One of the things that people sometimes say is, "Well, maybe they didn't get attached in the same way." It's clear if you read what they wrote, even the little excerpt I read to you from the introduction. Of course, they got attached. You get attached to a child when you take care of a child, but they had to be attached with the awareness that children were, many of them, inevitably not going to make it. I don't know. Did religion help? Obviously, religion helped a lot of people. The idea that this was a decision made higher up, or that God gathers back the most beloved, most angelic children, or that the children are with us still as angels.

All of that helped, but you have to remember that the flip side of that, and you see that with Mrs. Lincoln, is that if you're told that it is God's will that your baby died, and you still grieve, in some way, you're not being sufficiently pious. The real lesson is that you should rejoice. A lot of that recurs, even, certainly, into the 19th century, a kind of religious, sometimes sentimental idea that, "Do not grieve. Your child has gone to a better place." I think, for some parents, that's very helpful, but for some parents, it's really hard. Mary Todd Lincoln is a really interesting example. She lived a tremendously tragic life. They had four sons. One dies, probably of diphtheria, before they get to the White House.

Their two little boys in the White House, very much covered in the newspapers. The newspapers have always loved White House children. They get typhoid because it's wartime, and the non-existent Washington sewer system is completely overwhelmed by soldiers in camps, and so they're both quite sick, and one of them dies. The president, Abraham Lincoln, is bereft, and he goes through a period of what is then called melancholia, which is something he's prone to. She is beyond that, and she doesn't follow the conventions of mourning. She gives away all of the toys and clothing belonging to the little boy who died. She can't stand to go into the room again.

She doesn't do the cherishing his relics in a drawer, which is the expected thing. Her grief is wild, and the report is that, at least at that time, her husband tells her if she cannot stop grieving so excessively, that she will need to be institutionalized. Of course, the third of her four sons also dies before her as an adolescent. This is after her husband is assassinated, sitting next to her. Then the third of the four dies of possibly some combination of tuberculosis, pneumonia, pleurisy. I think it's very hard for us here in our century to say what would be excessive grief in that setting. What would be excessive mourning?

Again, I think the fact that you knew other people who had gone through it, that it was so common that you would not feel that you had been marked out by some rare and terrible tragedy, was very comforting, I think, for many people. Children who were gone were discussed. You don't nowadays. If you're going around the room at the parents' night at the daycare center, it's not so easy to say, "We have four children, but only three are living."

If you do, it's kind of a conversation stopper. One of the reasons I wanted to write about this is nowadays we would probably see this as the central tragedy of a family's life. That whatever this rare, terrible disease or this accident or this terrible story, it would be the defining event, but that can't be if 3 out of every 10 children aren't going to make it, because it's too common.

Emily Silverman: You spend a lot of time in the book talking about individual diseases, and I want to hit some of them. You talk about cholera, scarlet fever, TB, and measles. Before we get into some of those, when do you see the culture really shifting away from this idea that it's normal that all your kids aren't going to make it, toward this idea that child death or infant death is not normal? When did that idea start to pick up steam in the culture?

Perri Klass: It happens in the middle, or just before the middle of the 20th century, I think. Everything that you would expect about it happens first in the wealthiest countries, where there's the best access to sanitation, clean water, and where the medical care is the best you can provide. I think you could probably see a lot of change by the period after the Second World War, when we're starting to talk baby boom, when you've got a new reliance on science and expertise, but also when science produces the polio vaccine. You're saying, "Here was something that was really scary that killed a lot of Kids, and we've solved it."

I think it's already happening before the Second World War, but the Second World War marks also penicillin. You've got pasteurized milk and you've got clean water. I would also go further back than that. Right around the beginning of the 20th century is when you actually see organizations to combat, specifically, infant mortality, being formed in many different countries, in Europe, in Asia, in the United States. For those societies to form means you have to have decided that even infant mortality is not inevitable, which is not a foregone conclusion. There are people out there who are worried that saving all of these "weak babies" is going to damage our stock.

Now, that doesn't mean the one-year-olds so much. There are certainly people out there who are concerned that, especially if you're looking at "weak newborns," preemies, putting babies in incubators, that you're keeping alive the babies who were not really meant to survive. That's a conversation. Those societies do form, and they get a great deal of traction right in the first years of the 20th century,

Emily Silverman: That slides very easily into conversations about eugenics and racism.

Perri Klass: It absolutely does. The movement to bring down infant mortality at its very beginning, at least in this country, but also in others, is not untouched by those arguments. Usually, what they're doing is arguing the opposite, to give them credit. Usually, what they're saying is "weak babies" can turn out just fine. There's certainly some members of the societies to bring down infant mortality, who are also worried about the question of whether there are not usually racial groups, but medical categories of people who should not be reproducing.

One of the people very involved in the early days of the American society to bring down infant mortality, I bet you wouldn't guess this, is particularly obsessed with "epileptics." He feels that part of the medical mission is that people with epilepsy must be discouraged from reproducing, or perhaps not even allowed to reproduce. I think there's sort of a medical orientation, which sometimes plays out in some of the very bad stories that we know from the days of eugenics about the "feeble-minded," but it's also sometimes very specifically medical about certain heritable conditions, and in particular, epilepsy.

Emily Silverman: So specific, epilepsy. Why epilepsy and why not congenital heart disease? It's a very strange choice.

Perri Klass: I think it's a very strange choice. The way it's written about is with such passion, probably because epilepsy is a condition in which, actually, people do live to grow up

and they're perfectly capable of reproducing. I guess they felt that it was clearly established as heritable, and of course, they didn't have treatments. It seems to us very strange that the reaction to the medical helplessness, there's something we wish we could treat but we can't, is to say, "Well, in that case, let's not let them reproduce." Again, this wasn't universal. I offer it as an example of this thinking of we have to save the babies, but there are certain babies who should not be being born.

Emily Silverman: This comes up when you have 24-weekers, the ethics of the palliative care and end-of-life conversations. As an internal medicine doctor, I think of that more in the setting of the elderly and people at the end of their life who are much older. It's a whole different conversation, and just has such a different flavor when you're talking about 24-weekers in the ICU and things like that,

Perri Klass: I guess so. Although you asked me, "How did parents live with this?" I don't know. I've never had to live with it as a parent, but I wonder, when I think about the way you love people at the end of life, you can deeply and profoundly love someone, but know that that person is delicate or precarious or vulnerable, and that's the best I can do by thinking about what it would be like to bond with your newborn in an era in which you had odds like one in three.

We've all had the experience of dearly loving someone, but knowing that that person may not be here in a few months or in a year. We mostly have it with the people you take care of, not with the people I take care of. It's not like we would say, "Okay, when people reach a certain point, we stop loving them, or we stop wanting to see them."

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Emily Silverman: Okay, let's talk about some diseases. There's a lot of different ways into this conversation. You do such, I don't say wonderful, because these diseases aren't wonderful, but such interesting portraits of, for example, diarrhea, which is not a very glamorous topic, but it's something that used to kill babies all of the time. I'm talking about the summer diarrhea, the cholera, the way that rehydration, but also sanitation and pasteurization, and breastfeeding played into fixing that.

You also talk about diseases like diphtheria, which were quite lethal. Then you start getting into other diseases like measles and varicella, which can be lethal, measles, for example. There's a subset of kids who die from horrific, horrific complications, but there's also a lot of kids who do all right. In fact, you talk in the book about how measles, in a way, in the culture, was seen as a normal part of childhood, and people used to have measles parties and things like this.

I'm just wondering how you think about these different diseases and the lethality of the diseases, and how that influences the way those diseases are perceived in the culture. Of course, measles today is a very hot topic, since some people are more afraid of autism than they are of measles, and that fuels this whole anti-vax autism link, which has been disproven. How do you think about this menu of diseases, the way that we've tackled them, and then the way that the culture perceives that story?

Perri Klass: Well, diphtheria, like polio, was always a disease that people were terrified of. It was a disease that 100 years ago or so, you could be quarantined. They would hang a sign on your house. It was a disease that nobody took casually. For me, at one end of the spectrum, diphtheria is a disease that I have never worried about as a pediatrician or as a parent. Even in my most paranoid moments, I never wanted to say to my pediatrician, "Are we sure this isn't diphtheria?"

[laughter]

Even in my most paranoid moments as a pediatric resident in the emergency room in the 1980s. What kept me up at night, and what you've not seen, is Haemophilus influenzae type b and strep pneumoniae, and Neisseria meningitidis. We lay awake at night, if we got to sleep, worrying that we had missed one of the rare but really dangerous bacterial infections, all of which we now immunize against. Parents mostly didn't lie awake thinking, "I hope it's not Haemophilus influenzae type b, because that's so terrible that they were rare. Anyway,

I never worried about diphtheria. Diphtheria is a terrible disease. It can start with a sore throat, but the bacteria produce a toxin, and the toxin kills cells, and you end up with a lot of necrotic cells in your throat, and they form what's called a pseudo membrane. They form a thick plug that can obscure the airway. If you're a child, the smaller your airway, the more dangerous. It was a tremendous killer of children and her reputation for sweeping through families. It's not at all unusual to find a story about all four of the children in one family getting sick, and two or even three of them dying.

It was a bad, bad disease, and there wasn't much that anybody could do up until the first decades of the 20th century. Rich, poor, didn't matter. I think it's interesting that it just disappears, that it's now a historical curiosity, at least in most of the world. It's one of the very first triumphs of the new 19th-century science of bacteriology, that in the 1880s, they figure out what the bacterium is that causes diphtheria.

They figure out that it works with a toxin, and if you put the toxin into animals, they make antibodies to it. They do this with horses, which have a lot of serum, so you can make an antiserum, which actually won't make you immune for life, because you have to make your own antibodies to do that. It's not vaccination, but they make this almost miraculous stuff, which, if you get it during diphtheria, doesn't cure everybody, but it significantly improves your chances of fighting off the disease and recovering. It's kind of a miracle.

Emily Silverman: There's this little side story in the book about a diphtheria outbreak, I think, in Alaska, and there was a team of people using sled dogs to transport the antitoxin across the ice to cure-- Can you just spend one minute on that, because I never heard that before? It was a great story,

Perri Klass: Sure. Well, it's the most famous story about how we defeat the diphtheria. One of the reasons it's so famous is that there is a much-beloved statue in Central Park in New York of Balto, one of the heroic sled dogs. What happens is that it's the 1920s, it's Nome, Alaska, and the port has iced in for the winter. The only doctor there has ordered diphtheria antiserum, but it hasn't arrived. When children start dying of diphtheria, which is particularly lethal in the indigenous population, they don't have any antiserum, and they end up teams of sled dogs and their mushers carry it more than 600 miles over what we would now call the Iditarod Trail.

It's the route where they run the race every year, and they have to keep pausing to warm it, because if it freezes, it will lose its potency. This is being followed on news reels and in the headlines. People are watching the hero dogs and their mushers who get the antiserum to Nome. It's also true that the public health department of the city of New York has a stable in Midtown of a couple of horses where they're making antitoxin for the children of New York City. Again, the horses have names and their characters. The other thing that happens is that the same scientists figure out how to mix toxin and antitoxin. They figure out a way to immunize kids.

Polio vaccine, it's the 1950s, but in the 1920s, they're already in the public schools in New York and in many other states, immunizing children against diphtheria, and it starts to disappear. Now, of course, it's one of the diseases we immunize against, starting at two months, and it just goes away.

Emily Silverman: That's amazing.

Peri Klass: Gone. There were words, if you look at the places where they test the antiserum in--

Emily Silverman: I just got a shiver down my spine as you said that. Sorry, it's just so incredible. Anyway, go on,

Perri Klass: No, there are wards when they're testing this in the 1880s, 1890s, in Paris. You've got hundreds of children on the ward who are all choking to death. You make the disease go away, so that it becomes kind of historical curiosity. What I started out by saying is everybody was always scared of diphtheria. What I was trying to talk about in the book is what about when once you've done away with the diphtheria, when you've done away with the polio, done away with the tetanus, you start seeing some of the rare conditions. You also start worrying about the relatively rare complications of the really common diseases.

People are not terrified of measles, people are not terrified of chicken pox, certainly, people are not terrified of rubella. Of course, it turns out that if you immunize everybody against rubella, you prevent congenital rubella, and that makes a huge difference in terms of especially disability and children being born with a whole range of terrible problems. What about measles? Measles is a great example, because, as you know, measles is probably the most contagious virus we know.

If you were born 1957 or before, I think we can assume almost certainly, that everybody was exposed, and everybody who was exposed got it, and so on and so on. People weren't terrified of it. Children were dying of measles. Soldiers in the Civil War died of measles in huge numbers because it's more dangerous when you're an adolescent or an adult, very dangerous if you're a pregnant woman. Most people had had measles, and sufficiently rare that most people didn't necessarily know someone who had died or had terrible complications of measles.

Emily Silverman: What are the numbers, just for the audience, roughly, breaking down like what percentage of people is measles?

Perri Klass: It's a complicated question, because it depends a little bit on your nutritional status. I'm going to look it up and give you the best numbers that I can. I think we're talking 1 in 1,000 for the acute encephalitis, the inflammation of the brain, which is dangerous, which can kill you, and even if it doesn't kill you, can leave you very, very badly disabled. Everybody knew there was a link between measles and blindness. I think we're talking 1 in 1,000. Again, not vanishingly rare. If everybody gets the disease, a certain number of children are going to die.

Emily Silverman: Those numbers add up.

Perri Klass: Those numbers will definitely add up. For the people who do not get the complications, and their siblings do not get the complications, they will remember this as-- That measles is a miserable illness. Those children are really unhappy, febrile, uncomfortable, it's miserable, rash, but most people do not know someone who died unless they do. Otherwise, it's not remembered that way. Then similarly, with chicken pox, a disease that you know, I was born too late to have had measles, but I did have chicken pox.

Emily Silverman: I did also have chicken pox. I'm not that young. [laughs]

Perri Klass: I have three children. The older two had chicken pox. The third one was born after the vaccine, and he didn't have it.

Emily Silverman: It has a lower complication rate than measles. Far lower.

Perri Klass: Yes, but one of the really bad things about chicken pox is if you happen to be a kid with leukemia or a kid with a weakened immune system, it's devastating. Part of the argument for wiping it out and immunizing everybody was to try to protect the children who may be harder to immunize because they don't have good immune systems, but who are especially at risk. I think one of the things I wanted to say in the book was, in a certain sense, it was a privilege that we got to worry about diseases like measles and chicken pox, or, later on, Haemophilus influenzae or pneumococcal sepsis.

Anybody who did pediatrics in my generation, this is the 1980s, in a children's hospital, we saw heartbreaking, terrifying, miserable stories. Our ICU regularly had children with Haemophilus influenzae, type b sepsis. These were healthy, normal children last week, and now here they were. We were hoping they would live, but even if they lived, they were often totally devastated. We did so many spinal taps. Oh my gosh, we did so many spinal taps, trying not to miss the baby with bacterial meningitis.

There was good research, there was good epidemiology, we learned more about it, but we also started immunizing against the bad players, even though they weren't the players who kept parents up at night. I don't know if you remember this, but there used to be, regularly, every year, local news stories about some local kid in some local college who got meningococcal meningitis.

Emily Silverman: Yes, I remember there used to be outbreaks. It was scary. When I was in college. I think it was still happening. I remember having the fleeting thought of, "I hope that doesn't happen here at my college."

Perri Klass: Every time that happened, people were completely terrified, because it would be dramatized on the news, and you would hear about it, and people would be banging down the doors. "Is there a way I can keep my child safe?" That goes back to what we were talking about originally, but we as parents don't live with the idea that maybe that runny nose or that sore throat or that mild fever is the start of this, this, this or this. We just don't. It's our great, great privilege as parents, my great privilege as a pediatrician. We probably worry more about car seats and adolescents driving, and with good reason.

Emily Silverman: How do you think about this current moment where we are starting to see measles again? There is a lot of skepticism of vaccines. Some of that has to do with people's opinions about vaccines and disease, but some of it, I sense, is a symptom of just a larger distrust of institutions that's pervasive. It has to do with government. It has to do with media, like it almost doesn't have that much to do only with science. It's part of a bigger problem. I'm just wondering how you think about that today, how you talk about it, how you talk to people about it, patients about it, families about it.

Perri Klass: Well, I mean, first of all, it is beyond heartbreaking that children are dying of measles in this country. Heartbreaking, they're dying of it anywhere, because it's completely preventable, but that we have gone from being a country which had not eliminated measles, but we had eliminated endemic measles, and that just means nobody lost a child to measles. Nobody was sitting by a bedside watching a child with measles encephalopathy; it was gone.

That there are children who are at risk and have died in this country seems beyond a tragedy. It's completely unnecessary, and it's every bit as sad as it sounds. I think everyone I know in pediatrics is both grief-stricken and outraged, because it does not need to happen. It's a safe and well-understood vaccine, and it works. The question of why there's as much distrust as there is. I think one of the things you have to remember is people love their children, and they get scared.

There has been a pervasive and concerted, and in many cases, very effectively targeted campaign to scare them with misinformation and disinformation. If you tell people over and over again that something is potentially dangerous to their children, even if you're lying, it begins to echo in their heads. People love their children. In terms of being able to talk to parents about it, I think what we're learning over and over is first, you have to listen. You have to listen to what people are thinking, why they're scared, where they're getting their information, but then you really do have to push back.

Pediatricians, we have a reputation for being pretty sweet and nice, but I think this is a situation where sometimes you have to go over it again and again. Sometimes you have to scare people because you're not saying to them, "Well, there are a lot of different ways to do this, and they're all good." You're not saying that at all. You're saying, "You will be taking a terrible risk.

If something goes wrong, it will be because you made this decision. You should not make this decision." We have to find better ways to say that, and we have to be willing to keep saying it, because none of us wants to say, "Okay, wait until a certain number of children have died, then people will be scared." That's just not a satisfactory answer. That's a terrible answer.

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Emily Silverman: We get rid of cholera and phantom, summer diarrhea. We get rid of diphtheria. We get rid almost of polio, globally, we're close. We get rid of scarlet fever, rheumatic fever. We have antibiotics. We get rid of measles, mumps, rubella, tetanus, pertussis, and so pediatricians need something to do. They start talking about car seats. They start talking about swimming pools, firearms, ways to prevent harm to children. There's also the well-child and people coming to their pediatrician asking questions about normal development, child behavior, parenting.

Then you start to get personalities like Dr Spock, and these days, there's Dr Becky, and other similar personalities who become gurus, almost in this way. Some of them are pediatricians, some of them are not pediatricians. I'm just wondering if you could bring us into that for a bit. Leaving the disease behind just for a minute and talking about the well-child. Should pediatrics be talking about the well-child, or is that better outsourced to PhDs and parenting experts, or should that be medical? How do you think of people like Dr Spock, or some of the more modern, contemporary gurus, and how that plays out in our society today?

Perri Klass: Well, I read about Dr Spock in the book. I think he's interesting. One of the things I did was go through the first edition of his book on baby and childcare from the 1940s and actually look at what he said about tuberculosis, diphtheria, and polio, all of which were issues when he was writing. That was interesting because he is a bridging figure. He's originally writing, say, before there's a polio vaccine. One of the questions he's got to answer in his book is, "Could this be polio, Doctor?" That was interesting in itself.

I would say that he's part of a very, very long tradition of giving child-rearing advice. That you can find best-selling books on the care and feeding of your infant, going back not just to the beginning of the 20th century, but well into the 19th century. Many of them are written by men who have clearly never spent 24 hours taking care of a small child, but are basically telling mothers and nursery maid what to do, which is an interesting question in itself. There's actually a wonderful book called Raising America about child-rearing advice. The advice that you get in any particular era obviously reflects the thinking of the times, but it's a very long tradition.

Where I would go from that is just to say to you, even before we had the vaccines and we were in control of many of these diseases, child rearing is hard. Most parents have a lot of health-related questions and concerns along the way. You've got small children, I don't know whether you have, but between, I don't know, rashes and stomachs and development and speech, there's still a very strong component, which is about making sure that everything is running smoothly, and, of course, keeping an eye out for the more unusual but still serious things.

It is also true that once you clear this vaccine-preventable disease, mortality and morbidity out of the way, you do have some breathing space. What it turns out that parents want to talk about often has a lot to do with behavior and development, and safety. Those have become very, very much part of pediatrics and during the first two years of life, especially, we are probably the most likely people to see all the children across socioeconomic spectrum in different fields.

We're taking advantage of the fact that if you have a happy, healthy baby, we're still going to see you within a couple of days of your discharge, and certainly at 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15, 18, because that's the immunization schedule, even if you have no other issues, and it makes sense to talk about health, but it also makes sense to talk about development. That gets to what I think is the other really, really, really important truth that we don't always stress enough in pediatric training, but that every pediatrician knows, which is that babies are really different. You've had two?

Emily Silverman: Two, yes.

Perri Klass: How different are they?

Emily Silverman: They're pretty different. Their temperaments are different. One of them is a lot rashier than the other. [laughs]

Perri Klass: I think that's really interesting and that therefore, on the one hand, obviously, the parent is the expert on this particular baby, but that your first baby doesn't necessarily leave you feeling like an expert as you're dealing with the second, and I think that very often what parents need is a sense of what's the range of normal. It helped me a lot, and I was a pediatrician, to have a pediatrician for my child who had been doing this for a couple of decades, and could say to me, "It's normal."

Emily Silverman: One of my babies does this thing where she kind of butts you with her head. She does it sometimes in a way that feels affectionate, but sometimes when she's irritated, she'll

do it in a way that's like an I'm irritated head butt. I did call up my friend who's a pediatric neurologist, and I said, "Is this normal, or is she losing her neck tone? Should I

worry?" I described it, and she was like, "That sounds normal to me." I was like, "Oh, phew." Yes, such a bizarre kind of question to be calling up a friend and asking, but--

Perri Klass: It makes total sense. Partly what you're taking advantage of is that, because you've got a friend who's medical, she's seen the stuff that's not normal. That's why I

think there's real value both to the fact that you do see a lot of things during residency, especially in a pediatric hospital, that you're not going to see every day, but you've seen them. You aren't just looking at what's healthy and what's normal, and then at small variations, you're actually saying, I've seen what this looks like when it goes wrong, and this is not that, or occasionally, I'm worried this might be that. Let's follow it up.

Emily Silverman: How do you think about the Venn diagram, though, between the responsibility of the pediatrician and the Dr. Spock parenting development, behavior circle in the Venn diagram? Are there ever questions where you think to yourself, like, "Actually, that's less a pediatrician question and more a question for your grandma," or more a question for the lady down the street who had eight kids? Or, do you feel like pediatrics needs to be taking more ownership over those types of development, behavioral things, or do you actually see the pediatrician's role as being more medically circumscribed and some of those other parenting questions being outside the scope?

Perri Klass: I think when we do it right, it's bigger. It's more of a role. That is to say, you've got a three-year-old, and yes, immunizations are perfectly up to date, but the child's not talking. What does that mean that you needed to talk about? You needed to talk about whether anyone was talking to the child. You needed to know where the child was developmentally. You probably need a sense of what's going on in the family, whether the parents are struggling with either economic issues or mental health issues, the business of children is to develop, right?

If, in adult medicine, you ask the question, "Can this person work? Can this person function?" Children's business is to develop and learn. That's how you know that everything's working. Talking about behavior, talking about learning, talking about language, talking about development, if you lose sight of it, you can miss things which are actually really important. I think you have to be careful.

You can't do everything. You're going to need colleagues. You're going to need a team. You're going to need other people who can do-- If there's something that has to happen every day or every week, or work with families in other ways. If your goal is really to see the child healthy and the child developing as well as the child can develop, then you're going to have to think about all of this, or you're just not doing even your most basic job.

Emily Silverman: I think this is a great place to end. I feel like we could talk for two more hours. I love speaking with you, but we have limited time, so maybe just to end. What's next for

you? What are you thinking about these days? Do you have any other writing projects lined up, and what's next for you?

Perri Klass: Right now, I am actually with two friends and colleagues editing a kind of textbook for the American Academy of Pediatrics on pediatrics in underserved populations. The kind of hospitals that I've worked in all my life, and that my colleagues do as well, in which we try to come to terms with a whole range of problems the children can encounter, and we think there's evidence and expertise of how to better serve the children who are growing up in areas where reasons of poverty for other social reasons, they may be at higher risk, or they may be more difficult to get them services.

There's some wisdom, and there's some good ideas about how we can best serve those families. That's the current project.

Emily Silverman: We'll be sure to keep an eye out for that. Perri Klass, thank you so much for coming on The Nocturnists podcast and speaking with me today. It's been so much fun, and I've taken a lot away from this conversation.

Perri Klass: Thank you so much. It's been a pleasure and an honor. I love the podcast.

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Emily Silverman: This episode of The Nocturnists was produced by me and producer and head of story development, Molly Rose-Williams. Our executive producer is Ali Block, and Ashley Pettit is our program director. Original theme music was composed by Yosef Munro, and additional music comes from Blue Dot Sessions. The Nocturnists is made possible by the California Medical Association, a physician-led organization that works to ensure the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org. This episode of The Nocturnists conversations is sponsored by the Physicians Foundation, which supports physician well-being practice, sustainability, and leadership in delivering high-quality, cost-efficient care.

The Nocturnists is also made possible by donations from listeners like you. In fact, we recently moved over to Substack, which makes it easier than ever to support our work directly. By joining us with a donation of $2, $5, or $10 a month, you'll become an essential part of our creative community. I'm your host, Emily Silverman. See you next week.