RFK and MAHA - glass half empty and glass half full

I’ve been pretty struck by the confidence that I see in the takes on the impact of RFK being confirmed as secretary of HHS.

Some people are certain that he’s going to reduce chronic disease by removing harmful toxins from our food system and inspiring Americans to live a healthier life.

Some people are certain that he’s the end of science as we know it.

I don’t know what’s going to happen, but it seems clear that there will be major changes in our most important public health organizations.

I thought it would be interesting to look at this with some uncertainty since I have no clue what agenda is going to be prioritized and what the focus is going to be.¹

But I think it’s clear that the variance here is high - there’s a big difference between the best case scenario and the worst case scenario.

So this article isn’t a prediction, it’s more of a hypothetical look at the ways that MAHA could go well and a look at how MAHA could go poorly.

Let’s make the generous case with an optimistic perspective and then counter it with a more cynical and negative view.

A bull case for RFK and MAHA - we need a healthcare system revolution

In his book on The Structure of Scientific Revolutions, Thomas Kuhn argues that most scientific progress doesn’t just come from an incrementalist approach to answering questions or understanding the universe.

Instead, progress comes when the status quo becomes fractured by a paradigm shift that totally upends the approach to problems that have become intractable, but, importantly, preserves the concrete problem solving ability of its precursors.

And so the most generous case for MAHA leans heavily on the idea that the status quo of our current healthcare system requires disruption - we can only significantly improve a broken system with a total shift in our priorities.

This idea - American healthcare is irredeemably broken and needs to be totally rethought - isn’t new.

The previous people that have been in charge of our biggest public health and healthcare organizations haven’t been focused on change, they’ve been focused on incrementally improving the status quo.²

There are a lot of mainstream voices that have been sounding the alarm on our “sick care system” for years.

The MAHA perspective isn’t particularly novel.

Look at where the money goes with so much spent on expensive chemotherapy, end of life care, and questionably effective medical devices.

As a consequence, non-sexy but completely lifesaving things like controlling blood pressure, managing diabetes, and preventive medicine often go under-emphasized.

When you look at the President’s Executive Order on the establishment of the Make America Healthy Again Commission, you’ll see some inspiring things:

• Concern for the rising numbers of children with obesity and fatty liver

• Attention being paid to the rising number of autoimmune and inflammatory diseases Americans are dealing with

• The tragic way that our life expectancy lags behind other developed countries and our overwhelming burden of chronic disease

• The way that huge amounts of health care spending on chronic disease may be crowding out investment that we could be making in other areas

• A call to action for a cross disciplinary group of health leaders to tackle these huge public health concerns

Maybe the MAHA movement leverages it’s new political power into a multi-industry, cross disciplinary effort to increase payment for management of chronic diseases,³ change our food environment, reemphasize physical activity as a pillar of health, and get rid of conflicts of interest in medicine.

Of course, the devil is in the details, but from their press release, that seems to be part of the agenda:

To fully address the growing health crisis in America, we must re-direct our national focus, in the public and private sectors, toward understanding and drastically lowering chronic disease rates and ending childhood chronic disease. This includes fresh thinking on nutrition, physical activity, healthy lifestyles, over-reliance on medication and treatments, the effects of new technological habits, environmental impacts, and food and drug quality and safety. We must restore the integrity of the scientific process by protecting expert recommendations from inappropriate influence and increasing transparency regarding existing data. We must ensure our healthcare system promotes health rather than just managing disease.

Picture a push to pay primary care doctors more⁴ and incentivize young doctors to choose primary care over dermatology, the MAHA 5K, a newly emphasized Presidential Youth Fitness Program, or even Let’s Move without the angry backlash.

And maybe this paradigm shift will extend to our other large public health organizations:

• Instead of focusing on draconian, sudden, arbitrary, and untargeted cuts to the NIH budget, we will see reform for the current NIH grant system with reduced bureaucratic demands placed on grant submissions and more emphasis on funding high risk but potentially more impactful research instead of incremental progress

• Instead of simplistic public health messaging, the our public health recommendations will embrace nuance - emphasizing the level of confidence we have in recommendations as well as the quality of evidence that supports them

• The FDA will update their approach to psychedelics, avoid missteps like approving Aduhelm, and revamp the post approval surveillance system to ensure Americans’ safety after drugs are in the marketplace

• The NIH will start funding more studies in the oldest Americans, who consume the vast majority of healthcare spending but for whom we have very limited evidence about the risks and benefits of various treatment options.

• And maybe we’ll even have the fluoride critique lead to high quality dental research to answer a mundane question like whether fluoride is better than hydroxyapatite for preventing dental carries.

It’s not hard for me to understand why some people are really excited about the potential for an agenda like this.

Thinking that the bull case for MAHA is possible doesn’t require you to ignore the concerns that have been raised about RFK’s scientific literacy, honesty, or past positions.

The optimistic case just requires that you think that RFK is going to spend his time and political capital thinking about how to fight chronic disease rather than dissuade people from getting their kids vaccinated for measles.

And that’s a good place to take the flip side and look at how this might be a disaster.

The bear case for MAHA - measles comes back, we stop funding good research, and grifters make bank

There are a lot of really smart and detailed critiques about RFK - his previous policy positions, his interpretation of scientific, the way that he’s made money off the anti-vaccine cause.

But you don’t need to invoke a bunch of different explanations of why RFK’s has so many fringe beliefs, you just need to understand that he doesn’t believe in germ theory.⁵

Germ theory is the idea that infectious diseases are caused by microorganisms like bacteria and viruses - in other words, a foundational perspective for almost all of modern medical care.

And so the bear case for RFK and MAHA is pretty simple - this guy has no idea what he’s talking about, a lot of what he says is just a scam, and he believes so many things that are obviously incorrect that any good decisions he makes are going to be the result of dumb luck rather than thoughtful analysis of data.

Just look at some of the news that we’ve seen and consider the worst case scenario or what it might mean:

• “We’re going to investigate the child vaccine schedule” doesn’t mean a good faith critique of how the US vaccine schedule differs from countries like Denmark, it means a pseudoscientific committee provides a superficial and scientifically illiterate rubber stamp on eliminating recommendations for any childhood vaccinations.

  • When you’re thinking about whether the current vaccine schedule is good or bad, keep in mind that basically everyone who studies vaccines get their kids vaccinated. Remember, even RFK got his kids vaccinated.

  • Measles is literally the most contagious disease that we are aware of - and there are some alarming canaries in the coal mine about what might be happening even before RFK gets his hands on our vaccine recommendations.⁶

• “Overhauling dietary guidelines” doesn’t mean demanding higher quality research on important nutrition questions that can’t be answered through the bad studies currently being done, it means healthwashing junk food fried in beef tallow. Or, more likely, the seed oil thing is just all a scam, because a seed oil lobbyist is now the Chief of Staff at the USDA.

• “Ensure transparency” doesn’t mean flagging biomedical conflicts of interest and discouraging the revolving door between regulation and industry, it means eliminating expert viewpoints in favor of people who don’t know what they’re talking about.

• “Addressing the root cause of chronic disease” doesn’t mean doing hard science to better understand the accumulation of visceral fat or implementation science to understand how to incentivize healthy population behaviors, it means grifters can more easily sell you supplements that don’t help you and functional medicine doctors can sell you a battery of tests you don’t need.

• “Ending the over-utilization of medication” doesn’t mean inspiring people to exercise and making healthy food cheaper, it means antidepressants are no longer FDA approved and an Ozempic prescriptions are frowned upon so you should just take unproven peptides instead.

• “Let’s overhaul the way research is done at the NIH” doesn’t mean a thoughtful change to the way that NIH grants are allocated, it means that we should stop giving our government money for basic science even though the critics simply may have no idea what they’re talking about.

It’s impossible to separate the PR from the policy

As I said before, I don’t really have any idea what’s going to happen, but as you’ve read, I can picture this going well and I can picture it going poorly.

The things that are prioritized are going to be the things that get done and so the more we hear about vaccines being “studied,” the more pessimistic about the MAHA agenda I’m going to be.

Particularly when it comes to scientific areas that are cross disciplinary in the way that public health recommendations tend to be, the fundamentals of how someone interprets evidence are incredibly important in whether their conclusions are sound.

But - and this is vital to remember - sound scientific literacy doesn’t automatically mean sound policy decisions.

And while I think too many of RFK’s supporters in mainstream medicine have an overly credulous and unnecessarily generous perspective about his errors in scientific interpretation, my level of confidence that MAHA will be a net negative isn’t very high.

I’m pessimistic, but I’m open to being wrong.

And so I’ll be paying attention to the news and I’m going to hold out hope that MAHA decides to focus more on the importance of exercise and less on the measles vaccine.

As a wise person once said, we’ll see:

1. The initial steps taken will be a revealing window into priorities, so I’ll be paying attention to the first few actual policy steps that are taken.

2. The question of incrementalism versus radical change isn’t unique to health care, but every health policy debate requires an understanding that major change disrupts the actual medical care of people who are currently sick.

3. The reasons that we have so much subspecialty care and such challenges with primary care can be directly traced to how much specialists get paid versus how much primary care doctors get paid. This is a complicated topic, but any serious effort to address chronic disease would look at the career choices of physicians as a major explanation and thus an important target of intervention.

4. And glorify the important work that they do to treat and prevent chronic illness.

5. I would recommend reading this piece from Dr. Paul Offit on RFK to look at just how scary it is that someone can be confirmed as head of HHS while not believing in a clearly true scientific perspective that has led to some of our greatest public health successes and enabled essentially the entire field of surgery to exist.

6. Measles isn’t just bad because it can infect and kill children. There’s also the possibility of long term catastrophic and unpredictable consequences. When I was a medical resident, I took care of a young woman who developed subacute sclerosing panencephalitis from reactivation of measles during pregnancy and subsequently became the equivalent of braindead. It’s absolutely terrifying to think that ignorance may lead to more measles everywhere. More measles doesn’t just mean more dead children (although it does mean that), it also means more long term consequences from a virus that’s really nasty.