RFK, Jr.: The Secretary of Health and Human Services is Dangerous to Your Health!

It can sometimes seem like the public health and medical communities are “ganging up” on Robert F. Kennedy, Jr., with ongoing criticism and attacks on his beliefs and, more important, his policies. The rebuttal is that this man, whose thinking is wildly unscientific and fringe, is the incredibly powerful Secretary of Health and Human Services, in charge of the second biggest department in the US government (after Defense) in budget and staff, and responsible for the diverse, varied, and highly important components of that department. These include Medicare, the health insurance system for the aged and disabled and Medicaid, the federal/state partnership that provides insurance for many low-income Americans (mostly children and their mothers in number, mostly long-term care in dollars). It also includes the Centers for Disease Control and Prevention (CDC), which studies and intervenes in both infectious and chronic disease, the Food and Drug Administration (FDA) that oversees the safety and effectiveness of our – food and drugs, the National Institutes of Health (NIH) that funds and supports most medical research, and other major agencies, including the Indian Health Service (IHS) that provides health care on Native American reservations, the Health Resources and Services Administration (HRSA) that funds community health centers and many other major service delivery and educational program, and the Substance Abuse and Mental Health Services Administration (SAMHSA) that supports addiction and mental health services. It’s a big, responsible, job.

And, so, there are a lot of things that can be screwed up. And a lot things are being screwed up. By him. In part, this may be because of his general incompetence and lack of actual knowledge about health care (knowing little about their portfolio is a common thread among those Trump has selected to lead federal departments). Kennedy is not a health professional, although he is a health “profess-er” – he professes a lot of opinions.  A lot of the screw up is the result of the DOGE-created cuts of 10,000 people from the HHS workforce in all of these agencies. Some of it is the administration’s political antipathy to programs (like Medicaid) that help people in need instead of the wealthiest in society who don’t need help at all. And no small part of it is because the beliefs that he has about health that come from fringe proponents of every bizarre remedy from ivermectin (good for worms, not for COVID) to hydrogen peroxide to Vitamin A to prevent measles, and opponents of many of the health interventions that we know really work to save lives. Let’s look at some of these.

Measles is a bad disease. It causes a great deal of morbidity. I come from a generation of children who almost all had measles – and varicella (Chicken Pox) and rubella (German measles), and mumps. Most of us survived, without even being hospitalized. But some did not. About 20% (1 in 5) people/children with measles are hospitalized, which means they are very sick. From 1-3 per 1000 die. That is a lot. Not as many as currently die from, say, being shot at school, but a lot. The thing is, though, that measles is preventable by vaccine. Per the CDC:

A vaccine became available in 1963. In the decade before, nearly all children got measles by the time they were 15 years old. It is estimated 3 to 4 million people in the United States were infected each year. Among reported measles cases each year, an estimated:

·       400 to 500 people died

·       48,000 were hospitalized

·       1,000 suffered encephalitis (swelling of the brain)

 

After the vaccine, measles went from being an endemic disease to one that was essentially eliminated. Until many people stopped vaccinating their children, based on unfounded fears of side effects, especially autism, being promoted by unscientific “experts” – like Kennedy. He has commissioned a new study on the link, to be done by discredited physician Andrew Wakefield, and thus is ignoring hundreds of studies with over 3 million children that show no link! Kennedy has also promoted using Vitamin A to prevent or mitigate measles. While in countries where there is widespread Vitamin A deficiency, this is a good strategy, there is no significant prevalence of Vitamin A in the US. And taking more to “be safe” is a bad idea since Vitamin A, a fat-soluble vitamin, accumulates and causes toxicity. So now, in addition to over 700 cases and at least 3 deaths (which suggests the number of cases is an underestimate) from measles, we have children being hospitalized for Vitamin A toxicity! And measles is only one serious condition; I have written about infections in children with Hemophilus influenza B and even worse polio (Raw milk, vaccines, and RFK, Jr: Some dates worth remembering, November 15, 2024) and was reminded of its effects on a recent episode of “Call the Midwife” which featured a man in an iron lung. Let’s not bring polio back!

Kennedy has also angered many Native American tribes, simultaneously calling for greater attention to their health status (good) and cutting the programs that benefit them, as covered by the Arizona Star (RFK Jr. says chronic disease in tribes a focus as program to do that gutted). He has also made the possibly not serious but nonetheless insulting proposal to move laid-off health workers from CDC and other HHS agencies to reservations (NY Times Kennedy’s Plan to Send Health Officials to ‘Indian Country’ Angers Native Leaders).

While on many of these issues, such as opposition to vaccines, Kennedy is simply wrong (and dangerous, see the recent NY Times article The many ways Kennedy is already undermining vaccines), on others it is less clearcut, which is why his opinions get traction. For example, he advocates strongly for the importance of diet and exercise to health. Those are generally are good. Most people should get more exercise and eat more healthful foods (and fewer unhealthful ones). But that is not a panacea. A healthful diet will not prevent measles – or COVID or smallpox or Hemophilus influenza B infections or cancer – although having good general underlying health will likely make one relatively able to weather such conditions better. Kennedy employs many logical fallacies in his pronouncements, including setting up “straw men” to knock down, using misdirection to keep you from looking at what he is saying, data-dumping to overload you, appeal to (false) authority (like Wakefield), and others. Some of these are discussed in the NY Times piece, From ‘Data Dumping’ to ‘Webbing’: How Robert F. Kennedy Jr. Sells Misleading Ideas and by Dr. Jessica Knurick. “Your Local Epidemiologist”, Katelyn Jetelina, discusses the Progress on Make America Healthy Again (MAHA), his signature plan. It has made a lot of progress, although it has been in reverse, making America less healthy. For more on his strategy, check out Paul Offit, MD, of the American Council and Science and Health, who describes the RFK Jr. Playbook. And, of course, he has traded on his family name and the reputations of his father and uncle John, who would (like most of his surviving family) be outraged by his positions.

Kennedy’s ideas and actions are both unscientific and damaging to the public’s health, leading the American Public Health Association (APHA) to call on him to resign or be fired in a statement enumerating many of his most damaging actions and dangerous pronouncements. All the “charges” it lists are accurate, and serious, and he should be gone. He is a real danger to our health. But the things he has championed, his hypocrisy and sleight of hand, and the false relativism he promotes that is dangerous, would unfortunately not be likely to be better with any HHS Secretary nominated by the current President. Most of Trump’s Cabinet and other senior-level picks have been unqualified, uninterested, and incompetent at best, and evil at worst. It has been said that their only “qualification” needs to be obsequious loyalty to Donald Trump, but a serious commitment to ruining the lives of as many American people as possible also seems to be important.

And, of course, that is the intention.

Self-centered Syllogism: Bad in public health, bad anywhere

I recently met someone who had seen a couple of my blog posts, was interested in public health, and asked a few interesting questions. My answers – or, really, comments – were things I have said and written about before, but his questions forced me to put them together, and in my opinion, the issues bear repeating.

The first question he asked was “why do we put so much emphasis on smoking but not on alcohol? After all, smoking never caused someone to beat their children or spouse, or to drive impaired and have an accident, or get into a bar fight and beat, shoot, or stab someone else.” That is true, and it raises the issue of the impact of substance abuse on the individual versus on the society (although second-hand smoke causes a lot of deaths). But the real answer is the incredible mortality caused by smoking. The CDC page identifies tobacco as the cause of nearly a half-million deaths in the US annually. While the data is from 15-20 years ago, and (hopefully) the mortality rate from tobacco has decreased as its usage has decreased, this is an astonishing statistic. Deaths from tobacco exceeded the total of deaths from alcohol, plus illegal drugs, plus accidents, plus homicides, plus suicides. It remains, even as smoking has decreased, a major health problem. The CDC says, “Tobacco is the leading cause of preventable mortality in the United States”. It was, therefore, the focus of public health efforts because of its tremendous impact on mortality.

However, of course, alcohol is also a major problem, causing both death and severe morbidity (bad outcomes besides death). It is, as my questioner noted, highly associated with violence against both family members and strangers, with automobile deaths, with homicide and not-homicide violence. It also, of course, kills people who use it, from diseases such as cirrhosis and heart disease as well as many cancers that are more common in heavy drinkers. We all have heard someone who did something very bad (commit violence against family members or strangers, have a car wreck, etc.) say “It was the alcohol. I wouldn’t have done it if I were sober”. But they were not sober, they had been drinking, and probably had often been.

The American Addiction Centers alcohol.org estimate that 88,000 people die from alcohol-related violence and abuse and accidents. The site also notes that “The American Society of Addiction Medicine notes that between 28% and 43% of violent injuries, and 47% of homicides, alcohol has been estimated to be involved.” That is a lot, and it could be an underestimate, but it is the closest I can get to quantifying the attributable risk for violence from alcohol. The concept of “attributable risk” in public health can be understood as the percentage of “bad outcome X” that would go away if “risky behavior Y” went away. This is different from the amount that it increases an individual’s risk; some behavior “Y” may increase your risk a lot but, because it is relatively uncommon, account for less attributable risk. Examples include asbestos and lung cancer (very high increase in risk but a lower percent of cases, compared to smoking). Or, looking at it inversely in terms of what disease a risk factor causes, smoking and lung cancer vs. heart disease. Smoking increases the risk of lung cancer more than it does heart disease, but because heart disease is so much more common, the attributable risk from smoking, the number of lives that would not be lost if people didn’t smoke, would be more from heart disease than lung cancer. An example of “smaller percentages of larger numbers can be greater than larger percentages of smaller numbers”.

So what did I say about alcohol? He identified the fact that there is a very large industry of alcohol manufacturers and sellers, which have great influence. I noted that there was (is) also a great industry of tobacco manufacturers and sellers. He said that in addition to the manufacturers, there were also many businesses, restaurants and bars whose existence depended on the sale and use of alcohol. The current emphasis we see in “alcohol reform” is “don’t drink too much”, a common “PSA” from alcohol manufacturers. The implicit message, however, is “do drink!”.

I think most of the members of our society, including many of those still smoking, recognize that any amount of smoking is bad for you, and more is worse, but I do not think that the same is true for alcohol use. The general attitude, even among medical and public health professionals, seems to be “a lot of drinking is obviously bad, for you and for others, but a little – like I do – is not.” What could be wrong with a couple of beers? A couple of glasses of wine? Especially if you’re not driving? Aren’t there studies that show a little red wine is good for you?

There are such studies but they are dated, poorly done, and wrong. Pretty much, while more is worse, there is no amount of alcohol consumption that is good for your health, and any amount is somewhat bad. We disparage those who use other drugs (heroin, cocaine, crack, meth, even still cannabis) for entertainment, but much of our society is actually built around alcohol as the “social lubricant”. Restaurants, bars, parties. Family events like weddings and funerals. Most of such entertainment revolves around alcohol. Perhaps the only place where alcohol is not the key component of “having fun” would be at an AA meeting! This issue is seriously joined by Holly Whitaker in her book “Quit Like a Woman: The radical choice not to drink in a culture obsessed by alcohol”.

The key here is that so many people drink (if “responsibly”, by which they usually mean “not too much” and “not when driving”) that they have to justify themselves by saying it is OK. I call this the “Dirk Gently Phenomenon” from Douglas Adams’ book “Dirk Gently’s Wholistic Detective Agency”. The lead character, who dies on the first page, was a millionaire who made his money by essentially developing syllogisms that took you from the data you had to the conclusion you had foreordained (his biggest client was the US Department of Defense). This is pretty much what we do in lots of areas, including alcohol use; we decide on what we want the answer to be and then look for evidence that supports it.

My new friend noted his son had been in a public health program a few years ago when the big emphasis was on obesity and its health effects. I nodded, but it not so much any more. Obesity has big health effects, yes, but it is also easy to disparage people who are overweight. This is a manifestation of another common tendency among people (including among health professionals): to be critical of people who do (or don’t do) things that come easily to you to do or not do, and conversely minimize the significance of the negative behaviors that you do (or don’t do). If you are naturally thin and have an no difficulty keeping weight off, it is easy to criticize those who are overweight. However, if you like your fancy wine or craft beer or expensive single-malt scotch, you don’t think drinking is such a bad thing. Or, for that matter, being self-righteous.

Public health is good and important. In the US, it is grossly underfunded compared to individual medical care (about 1% of health care dollars). But, like much of medicine it is also subspecialized. To a large degree, public health researchers go where the money is available for grants – in obesity, or smoking, or violence prevention, etc., and become specialists in that area. It is (or should be) different in primary care. As a family doctor, I can measure and counsel you on your blood pressure, but I cannot ignore your diabetes or lung disease and just refer you to another specialist. Similarly, while public health specialists “do obesity” or “do child seats”, this is not an option for the family physician. I need to help you to stop smoking, but cannot ignore that you need to use a seatbelt. Or get vaccinated. Or would have a greater probability of better health outcomes if you lost some weight. Or did not drink so much. Or at all.

Judging others for doing (or not doing) what we find it easy to not do (or do) and minimizing the damage caused by what we ourselves do is a big logical flaw, as is the “Dirk Gently” fallacy. They are not attractive, appropriate, or helpful or good for anyone, and are especially dangerous coming from medical or public health professionals.

The People's CDC: Getting out accurate information, not what is popular

I think I’ll start with the following message:

COVID is not over. Even if you want it to be. You can still get sick, get hospitalized, and die. People who are more vulnerable are even more likely to. Masks still are protection. Even if you don’t want to wear them.

I’ll say it again later. I think I’ll keep repeating it. It’s good, and nice, to want positive things. There are a lot of things that I want. World peace, for one. A reversal of global warming. An end to world hunger. They are not happening. And, unlike COVID, people could end them if they wanted to, as a group, as a world. COVID is a virus and doesn’t care what we do, but there are things that we can do to decrease its threat to health and life. We mostly know what they are – immunizations, wearing masks. Limiting interpersonal interaction, especially with large groups and groups with people we don’t know. We’ve been doing it for several years.

But we’re tired of it. We don’t want COVID to be around. We don’t want to wear masks, especially those uncomfortable N-95s (i.e., the ones that work best, the ones that protect you from others; most masks only protect others from you). We want to get together with our families, most especially around important events like the holidays, even if we’re not sure if they’re infected, or were vaccinated, or even if we know they haven’t been. Or if they have been exposed by going to places – like school and work – where they are more likely to be exposed. And we want to, some of us, go out like we used to, to movies and museums and clubs. We want to party. We want to go back to what we think of as normal. But…

COVID is not over. Even if you want it to be. You can still get sick, get hospitalized, and die. People who are more vulnerable are even more likely to. Masks still are protection. Even if you don’t want to wear them.

And so we get infected, and maybe do ok. Especially if we have been immunized. Especially if we are relatively young and healthy and not immunocompromised. It’s not fun, but I survived, right? Oh, yeah, Uncle George didn’t. And Cousin Minnie, who had cancer, and my friend Kim, who has diabetes, almost didn’t, they were hospitalized on a ventilator. And yes, I admit it, I got sick after a small Christmas – or Chanukah, or Kwanzaa or New Year’s – party where I thought I knew everyone and they were my ‘pod’ and I was safe. And, yes, a bunch of people got it. So lucky that none of them have been really sick!

You get the point. But the other point is that we want it to be over! We don’t want  to wear masks! We want to get back to normal! And the government, including the CDC, hears you. They want you to be happy. They want you to support their policies so you will vote for them in the next election. So they say things that are more likely what you want to hear. Like most people don’t need to wear masks indoors in most situations (read: you don’t need to wear a mask. People who do are overreacting). Like you are non-infectious after 5 days, and can go back to work, and if you are infectious still, too bad. Like “the pandemic is over”, comment that President Biden made in a television interview, this past September. Hopefully, you are not coming into contact with people who are susceptible and vulnerable. They want you to like them!

COVID is not over. Even if you want it to be. You can still get sick, get hospitalized, and die. People who are more vulnerable are even more likely to. Masks still are protection. Even if you don’t want to wear them.

To say that “the media is complicit” sound trite, like a bad meme, like what you hear from the right-wing fringe. Whether it is or not might, I suppose, depend upon what you mean by “complicit”, but most of the media certainly reinforces this “it’s gonna be all right!” message. This particularly takes the form of disparaging those who point out danger. Recently, for example, the New York Times ran a piece called “The Last Holdouts”, about those folks who continue to wear masks. It was on page 1 on December 26. However, in the same issue ran another story updated from December 13 titled “It’s Time to Wear a Mask Again, Health Experts Say: A high-quality, well-fitting mask is your best protection against infection from the coronavirus, influenza and R.S.V.”. That, in the print edition, was at the bottom of page D6! What is the message? If you ever found the latter story, you might be convinced, but the main big story was that masks are for sick people, immunocompromised people, paranoid people – not you!

And now the New Yorker magazine has entered the arena with a piece about the “People’s CDC”, a group of physicians, epidemiologists, public health professionals and others who, very concerned about the upbeat “Pollyanna” messages from CDC, have gotten together to try to disseminate accurate, if often unpopular, information. By writer Emma Green, under a head “Annals of Activism”, the title is “The Case for Wearing Masks Forever”. Well, good. But is that title sincere or snarky? Maybe the subhead gives a clue: ‘A ragtag coalition of public-health activists believe that America’s pandemic restrictions are too lax—and they say they have the science to prove it.’ Oh, they’re ‘rag-tag’! Like internet conspiracy folks! Well, no. They are people like

‘Mindy Thompson Fullilove, a professor of urban policy and health at the New School…who has spent her career studying epidemics: first AIDS, then crack, then multidrug-resistant tuberculosis. She has seen how disease can ravage cities, especially in Black and working-class communities. From the beginning, Fullilove was skeptical of how the federal government handled the coronavirus pandemic. But these new recommendations from the C.D.C., she said, were “flying in the face of the science.” Not long after the announcement, she sent an e-mail to a Listserv called The Spirit of 1848, for progressive public-health practitioners. “Can we have a people’s CDC and give people good advice?” she asked. A flurry of responses came back.’

That doesn’t sound negative. But, overall, the tone of the article is snarky and dismissive of the People’s CDC. It is also laced with red-baiting as well as “realism” in the form of comments from former CDC director Tom Frieden. While he praises ‘the organization’s [People’s CDC] guide to self-protection for immunocompromised people, and agreed that some of their recommendations, like universal masking in times of high COVID spread, were good ideas in theory,’ he added

“But is that going to happen? Absolutely not,” he said. The next best thing is to try to get people vaccinated and boosted and to increase access to high-quality masks and Paxlovid. “If you’re giving recommendations that no one’s going to follow, that’s not only nonproductive,” he said. “It’s counterproductive, because that undermines your credibility.”

Let’s do polling and find out what people want to do and recommend that! Of course, if they get sick and die, your credibility could also suffer…

One of the big things the  article sees wrong with People’s CDC, apparently, is its emphasis on collective action and the health of the community, including efforts to protect its most vulnerable members. This, of course, is contrary to the idea that “it’s all about me”. However, despite its tone and basic support for the current “it’s gonna be all right”, the article is worth reading for the perspectives and data-driven information provided by members and supporters of the People’s CDC, who say things like “There’s a struggle going on right now for the soul of public health.”

People’s CDC takes issue with the way that the C.D.C. emphasizes individual choices over collective action. The current CDC director, Rochelle Walensky, has said, “Your health is in your hands.” Well, as much as I wish it were not, and that CDC and Walensky and the rest of the government, federal, state and local, were doing what needs to be done, I guess it is. And if it is you should wear a mask when you’re indoors with others. Preferably an N-95,

COVID is not over. Even if you want it to be. You can still get sick, get hospitalized, and die. People who are more vulnerable are even more likely to. Masks still are protection. Even if you don’t want to wear them.