RFK’s Make America Healthy Again (MAHA) agenda is a really big deal and I am fascinated by it.
The media coverage (about both RFK and his plan) has been pretty negative.1
Lots of doctors with big platforms on social media have been outspoken in their criticism.
But my impression of this agenda isn’t really negative, and I’m a bit surprised at my reaction veering into lukewarm-positive territory as I’ve been thinking about the MAHA project.
I would separate MAHA into 3 major buckets - the first is the global critique of the way that our country’s biggest medical organization (the CDC, the FDA, the NIH) develop policy, spend taxpayer money, and are influenced by industry.
The second is the specific critique that too many people in our country suffer from chronic disease caused by our poisonous food system and lack of physical activity.2
The third is the direct policy prescriptions - take fluoride out of the water, reconsider routine vaccinations, stop the war on hydroxychloroquine.
RFK gets a lot right about the first bucket.
There are a lot of things that are completely broken about our big medical agencies that can’t be fixed without some major changes.
The second bucket - chronic disease and obesity run rampant due to our food system and lifestyle - is true, and doesn’t need much probing here (and I’ve certainly written about those topics many times in this newsletter).
But when it comes to direct policy prescriptions, RFK shows that he doesn’t know how to interpret scientific evidence well3 even if he does have some sound individual health promotion instincts.
Let me explain why I’m more optimistic about MAHA than most of my colleagues seem to be.
The CDC, the FDA, and the NIH have major problems
These organizations really failed in a lot of important ways during the pandemic,4 but they’ve also failed us in really important non-Covid ways.
The pandemic failures
The biggest way that I think we were failed during the pandemic is that the people in charge never required a high level of evidence before widely recommending major public health interventions.
A few examples:
No randomized trials on masks, despite recommending that kids as young as 2 wear them.5
No randomized trials on how school closures impacted community spread of Covid.
No randomized trials on social distancing, indoor air filtration, or any of the other nonpharmacologic interventions recommended to flatten the curve.
No randomized trials on Covid boosters, despite the fact that we’re giving billions of taxpayer dollars to Pfizer and Moderna and getting ongoing recommendations to get more of these vaccines.6
The Covid vaccine booster question is really the place where my skepticism of these organizations grew with concern how they don’t always serve the public good.7
The FDA approved boosters with weak scientific evidence: they never required more vaccines to demonstrate reduction in severe illness or disease transmission before approval.8
Then the CDC recommended getting more boosters after approval and never required better data before making that recommendation.
I’ll never understand why they didn’t require a higher level of evidence on these really important issues.
Non-pandemic failures
The non-pandemic failures of these organizations are also really frustrating. Some of the biggest ones:
Bizarre FDA drug approval standards that feel increasingly arbitrary and capricious
A cancer drug landscape where low quality evidence is the norm. See Dr. Vinay Prasad’s book Malignant for a detailed accounting of this issue.
The cost and length of time required to obtain FDA approval for a drug. Even with these issues, we still have the major drug approval issues above.
A lax regulatory process for medical devices where high quality data are almost never required for very high risk devices before approval, but a very challenging bar to clear for direct-to-consumer devices that have a much lower risk
The NIH grant allocation process is time consuming, does not promote innovation, and allocates limited to no funding to replication studies
Very notably to me, very little of the criticism of RFK defends these practices, either related to the pandemic or on matters unrelated.
Even people who are vigorously opposed to RFK being Secretary of HHS should be open to engaging with the major issues that have an impact on the health of Americans.
RFK is right about the food system and right about chronic disease
About 3 out of 4 adult Americans are overweight or obese.
I’ve written about this in a lot of detail before, with one the article that I think is worth drawing attention to entitled “The Medical-Pharmaceutical-Agricultural complex:
RFK’s points about the food system and about the amount of chronic disease are important because he has a platform and he’s using it to draw attention to this issue.
But let’s not confuse the fact that RFK is talking about this problem as evidence that he’s a leading mind on the topic.
Michelle Obama was talking about this topic with a similar platform 15 years ago, and she was advocating positions on healthy eating and exercise that seem pretty similar to what I’m hearing from RFK today.9
Exercise, eating healthy, sleep, building relationships, and stress reduction are foundations of a healthy lifestyle.
Consider me a firm supporter of these concepts, regardless of whose mouth the ideas come out of.
But I’m not going to be fooled into thinking that RFK talking about chronic disease is going to change the lifestyle habits of millions of people across the country.
When it comes to evidence interpretation, RFK misses the mark
One of the biggest red flags for a doctor is the inability to interpret evidence well.
If someone is frequently using low quality studies to influence their clinical practice, it’s a gigantic alarm bell that I can’t trust that person understands how to interpret evidence.
And if you can’t trust the way that someone interprets evidence, then you probably can’t trust their ability to come up with a balanced perspective in a novel situation.
Arguably the most important thing to understand about the person in charge of an agency like the Department of Health and Human Services is how that person interprets evidence, and unfortunately, evidence interpretation is RFK’s biggest flaw.
He doesn’t apply the same standards to the things he believes in as he applies to the things that he’s skeptical of.
I think it’s worth taking a look at this Tweet of his with a list of things about public health that he wants to change:
When you look at the list, there are some totally reasonable things here.
But if you’re putting psychedelics on the same list as hydroxychloroquine, I simply don’t trust that you know what you’re talking about.
Psychedelics are promising compounds that are being researched for mental health disorders that are notoriously difficult to treat. The research on psychedelics has been greatly slowed by the way that these drugs have been classified as controlled substances and how the FDA permits their study.
Contrast that with hydroxychloroquine, which has been extensively investigated and doesn’t work for Covid. The stupid controversy around this drug at the beginning of the pandemic is actually one of the things that made me start writing this newsletter. We were giving hydroxychloroquine to every single patient admitted to the hospital with Covid and they were all still dying from Covid.
As a consequence, when RFK puts together a list like that I struggle to think it’s because of a rigorous investigation into the scientific evidence.
And while we’re here, I have a few specific thoughts on some of the items on that list
Psychedelics - a really promising area of investigation for treatment of a myriad of mental illness. Psychedelics are starting to be appreciated by mainstream science, but have certainly had the scientific inquiry slowed by the way that these drugs were regulated. The regulatory scheme is changing, but you could argue it’s not happening fast enough.
Peptides - a weird gray zone where the status quo is perplexing. For one thing, Ozempic is a peptide. So the drug that may be the best selling pharmaceutical ever actually falls into a class of things that RFK supports. But distinctions between peptides that are good and peptides that are bad seems arbitrary, a prime example of this is a peptide like BPC-157.
Raw milk - the risks of raw milk are exaggerated a bit, and I think it’s unnecessary that raw milk is banned. I also think it’s sort of absurd that raw milk is purported to be so much healthier than pasteurized milk. Sure, this is possible, but I think it’s far from proven.
Chelating compounds - a fascinating story, specifically in cardiovascular disease. Chelation has a positive clinical trial from 2013 - the TACT study - and then a neutral trial in 2024 - the TACT-2 study. I think it’s fair to argue that this is an area worthy of more study.
Hyperbaric therapies are used medically for a handful of different conditions. But it’s absurd to suggest there’s an FDA objection to them, when the FDA has an article describing their utility.
Sunshine is good in the right dose. Most people are vitamin D deficient and vitamin D supplements have been well studied with unimpressive results. But the dose makes the poison and too much sunshine probably causes wrinkles. Bad sunburns also seems to increase risk of bad skin cancer.
Clean foods - by clean foods, RFK doesn’t mean eating healthy. He means free from food additives that are banned in other countries, like some of the coloring compounds used in Froot Loops. This seems like such a silly thing to focus on. The problem with Froot Loops isn’t the yellow 5, it’s the Froot Loops.10
As far as fluoride in the water question, I think it’s actually quite complicated and RFK may be right
Too much fluoride decreases IQ, too little increases dental problems.
Like with many things, the dose makes the poison.
Read Leana Wen’s columns on this for a reasonably balanced perspective.
RFK’s vaccine skepticism
Having more measles, hepatitis B, and polio around seems pretty bad to me.
The vaccines for these conditions are safe, effective, and have revolutionized public health.
And the evidence seems abundantly clear that routine childhood vaccinations don’t cause autism.
RFK is pretty wrong about most of what he says about vaccines.
And so while you may hear him saying some sensible things about Covid boosters, we have to question whether he’s getting the right answer because he correctly appraised the evidence or because his preformed opinion just happened to be right.
I spend a fair amount of time reading about different perspectives on health, both traditional and nontraditional, and one of my important rules for determining whether someone is a voice I can trust is whether their opinion on a topic is formed before they know any of the evidence on the topic.
Here’s what I mean by that: if your brand is vaccine skepticism, and a new vaccine comes out, I can be pretty confident that you’re not going to trust that vaccine, and it doesn’t really matter what the evidence says.
And many people, particularly smart people, can come up with creative reasons why their perspective is correct, no matter what the next trial shows.
So a lot of the skepticism about the Covid vaccine could feel “vindicated” as evidence came out about young men and myocarditis, or boosters not preventing multiple infections/long Covid, or about vaccines not leading to a reduction in disease transmission.
But the problem is that a lot of that skepticism started before we had any data to back up that opinion.
Even a blind squirrel finds nuts sometimes.
TL;DR: the MAHA agenda seems surprisingly reasonable, but I worry about the method behind the conclusions
Every new public situation is going to have new evidence about benefits and new evidence about harms of any intervention.
My biggest concern about RFK is that whether he forms his opinions by looking at evidence, assessing costs and benefits, and then trying to figure out what makes sense.
Too often, it seems like he has an opinion about something and then reflexively justifies that opinion with selective evidence.
Much of his perspective tends to be skeptical of big business - big pharma, big agribusiness, big medicine.
This is a pretty reasonable perspective.
But does he know how to interpret evidence well?
Is he willing to look at a complex issue from a nuanced perspective and carefully weigh risks and benefits?
Or is he going to blindly rely on the naturalistic fallacy to guide all of his policy prescriptions?
Just because the people currently in charge aren’t doing a consistently great job of interpreting scientific evidence and applying it to policy doesn’t mean a different approach is going to be better.
And so when it comes to MAHA, consider me cautiously optimistic.
But I’m willing to be open to new evidence on the agenda as it comes in and adjust that perspective.
A better adjective for the media coverage might be “histrionic.” Although I think that’s a word you can use about a lot of media coverage.
This is a pretty mainstream position shared by many people in traditional medicine. It’s also not all that different in spirit than Michelle Obama’s Let’s Move campaign had when it was started way back in 2010.
But one of the low-key compelling pro-MAHA arguments is that a lot of the people in charge don’t seem to interpret evidence well either.
I’m going to avoid focusing on the way that they may have led us into the pandemic. I think the most plausible explanation for Covid is lab leak, which may be related to work funded by the NIH on viral gain of function in coronaviruses. And there’s some smoke to the idea that some of the most highly placed public health officials during the pandemic covered up their knowledge about viral gain of function work being done in Wuhan.
The way that our public health organizations have ignored the well being of children during the pandemic is beyond tragic. Schools closed, social isolation, learning loss, mask recommendations for toddlers. It’s been insane, depressing, and infuriating.
There’s also been a bizarre unwillingness to engage in an honest conversation about how risks and benefits differ for different demographic groups. And once it became clear that vaccination didn’t stop community spread, there was no real interest to change recommendations around the need for more boosters.
It’s pretty astounding to contrast boosters with the initial Covid vaccines, which are among the greatest scientific achievements of all time and easily saved thousands (and perhaps millions) of lives.
The vaccine recommendations for kids are also based on incredibly weak evidence, which is particularly galling because kids are at very low risk of bad outcomes with Covid and we don’t have any evidence to suggest that vaccination stops community spread.
If you recall, Let’s Move was a childhood obesity initiative. And, to be clear, I don’t want to live in Michelle Obama’s nanny state any more than I want to live in RFK’s nanny state.
The way RFK focuses on food additives is a great example of missing the forest for the trees. It’s interestingly a problem a lot of really smart people have, even in medicine. I can’t tell you how many really smart doctors I’ve met who just can’t seem to focus on the big picture when the micro-details are so interesting.