The Case for Finding Common Ground With RFK

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Democrats need to build a bigger tent to be competitive. But building a bigger political tent means compromising—and that compromise usually means making someone inside your tent angry.

Take, for instance, Colorado Governor Jared Polis, who surprised many and angered some by announcing that he was “excited” by the nomination of Robert F. Kennedy Jr. to lead the Department of Health and Human Services. Asking people to hold off on mocking or disagreeing with RFK Jr., Polis pointed to issues like pharmaceutical reform, nutrition policy, and the use of pesticides. After facing backlash, Polis clarified that he was pro-vaccines, but it left me thinking: What might it look like to open the Democratic tent to vaccine-skeptical Americans, of which there are a growing number?

Today’s episode of Good on Paper is with Dr. Rachael Bedard, a practicing physician who writes publicly about her work, including a recent op-ed arguing RFK Jr.’s critics need to acknowledge the “seeds of truth” to some of his critiques and sit with the fact that many Americans are skeptical of our public-health institutions.

“The pandemic provided this entrée into politics for a kind of person where the combination of sort of the fear of the moment and the trauma of the moment and this sense that people’s bodily autonomy was being violated in some ways by government incursion,” Bedard argues. “There are people who reacted really badly to that, and it changed the dynamics of this conversation.”

The following is a transcript of the episode:

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Jerusalem Demsas: Robert F. Kennedy Jr. has said “there’s no vaccine that is safe and effective” and has argued that vaccines cause autism. His nomination to run the Department of Health and Human Services has spurred opposition from some physician groups and Nobel laureates in various scientific fields.

So it was surprising to come across a New York Times essay by a pro-vaccine, left-leaning physician arguing that instead of spending “four years simply fighting his agenda” opponents should seek to find common ground with RFK Jr.

The author of that piece, Dr. Rachael Bedard, is not just your run-of-the-mill doctor. She’s one with experience treating patients of very diverse backgrounds. The first time I learned about her work was when she wrote an essay about being a physician on Rikers Island during the COVID-19 pandemic.

Bedard’s argument is not just one about the political necessity of compromising with people you disagree with. It’s also a warning that, in their zeal to oppose RFK Jr.’s false claims about vaccine safety, opponents risk dismissing and alienating people who have a healthy skepticism of Big Pharma, overmedicalization, and just a generalized distrust of the medical system.

[Music]

My name is Jerusalem Demsas. I’m a staff writer at The Atlantic, and this is Good on Paper, a policy show that questions what we really know about popular narratives.

Today’s episode is rooted in Rachael’s own experiences as a doctor, and it contains some controversial advice for public-health officials and political activists worried about RFK Jr.’s rise.

Rachael, welcome to the show!

Rachael Bedard: Thank you. Thank you for having me.

Demsas: I am so excited to have this conversation because you are an actual doctor, so I don’t just get to rant with someone who doesn’t have real, lived experience.

Bedard: I am an actual doctor.

Demsas: (Laughs.)So I think most college-educated liberal people have a sort of knee-jerk reaction to RFK Jr. and his arguments about everything from vaccines to fluoride, and sort of his orientation towards science and public health. And I think that reaction is a combination of fear and dismissiveness. I mean, you’re a doctor who’s worked with a variety of populations, and, you know, you’re supportive of vaccines and public health, and yet you wrote an article that I think might surprise some people.

In the Times, you wrote about how people should react to RFK at HHS, and you wrote that you think that there’s common ground between people like yourself—medical researchers and scientists and clinicians—and Kennedy. So what are those areas of common ground?

Bedard: There are a few assumptions in what you said, which I do think is sort of the conventional wisdom around this topic, that might be wrong or deserve to be unpacked. One of them is the idea that most liberals have this knee-jerk reaction to Kennedy.

And what I think is really important to recognize is: Really until the pandemic, a lot of what Kennedy talks about—the idea that government and Big Pharma are in cahoots with one another, and that we’re overprescribing medications to ourselves, especially to our kids; the idea that we’re poisoning the environment with toxins; the idea that food companies are tempting kids with high-sugar, high-fructose, dyed products that then are contributing to a childhood-obesity epidemic—all of those things, I think, coded as liberal critiques of the medical establishment until very recently.

The other thing is the really specific sort of point of dissent between liberals and conservatives in this conversation now, which is around vaccines. Until the pandemic, who did you think of as being sort of anti-vaccine?

Demsas: The crunchy mom who sends her kids to Montessori.

Bedard: Right. And specifically, what color is that mom? That mom’s white—so high-socioeconomic-status, white women who had anxieties about not putting poisons into their children’s body, who didn’t feel themselves to be vulnerable to infectious diseases and didn’t see themselves as sort of responsible to the commons to protect others.

What’s really interesting is that Kennedy was on the same team as those folks until fairly recently. And then what happened in the pandemic is: The pandemic provided this entrée into politics, I think, for a kind of person where the combination of sort of the fear of the moment and the trauma of the moment and this sense that people’s bodily autonomy was being violated in some ways by government incursion—whether or not that’s valid, whether it’s valid to say being told you had to wear a mask in the airport was some kind of huge violation of your civil rights—there are people who reacted really badly to that, and it changed the dynamics of this conversation so that there was this flip.

So instead of being sort of the crunchy mom, it’s now very bro-coded, I think, to be an RFK guy, right? But it’s all the same kind of body-purity politics. So the first thing I would just say is: RFK is who he’s always been, in some ways. And what’s changed a lot is the partisanship of who agrees with him.

Demsas: I think what I would ask you then is: How do you think about how liberals should now engage with this, given that it used to be there was this small fraction of, like, white moms who are kind of preventing their kids from getting some, if not all, childhood vaccines. And now it’s, like, this broader skepticism of public health in general. So what’s your argument then to how Democrats should respond to an RFK?

Bedard: There are sort of two levels in thinking about how you answer that. First of all, there’s a really important distinction to be made between public health and medicine, right? Public health is the creation of policy and intervention meant to apply to groups of people or universally across a population in the interest of the many. Medicine is the practice of helping people improve their own health that’s practiced individually with the patient in front of you.

What we should be doing at the public-health level is not the same thing as what I think we should be doing at the doctor level, necessarily. But some of what best practice looks like at the doctor level ought to be adopted at the public-health level.

Demsas: Can you talk about that more specifically? Like, what does that look like?

Bedard: Yeah, so vaccine mandates work. They’re really important. They’re the only thing that has been shown to work to get meaningful vaccine uptake in a population.

Without them—so for example, the flu vaccine, right? The flu vaccine is not mandated for adults. Forty-four percent of American adults got the flu vaccine last year. That’s not enough to achieve herd immunity, right? We don’t mandate it, because we’ve decided that it’s not worth the hassle.

So we’re pretty choosy about what we mandate. But the things that we choose to mandate, we mandate because we think they’re really contagious, and the consequences of infection are high. And mandates are the only things that help ensure that enough people acquire immunity to something that you’re going to diminish the population burden of that infection, right?

So I don’t think the Democrats should be doing anything different at the mandate level. And that’s a place where I really differ from, say, Jared Polis, the governor of Colorado, who’s been tweeting in support of RFK with this kind of, like, bizarre zeal and who I think has sort of overstepped where he maybe wants to be. I think he wants to sort of express some understanding of where the folks of Colorado are, where there’s a really growing, pervasive anti-vax sentiment. That’s actually not—it’s bad public policy. It’s a recipe for disease outbreak.

But in communicating with individual patients about vaccines, you don’t tell them that they have to get it, or they can’t come and see you again. That’s not a persuasive way to interact with people, right? At the individual level, when I’m talking to patients, I engage in shared decision making about this. And that starts with offering people the intervention but then really listening to their reactions to it and listening to their fears around it.

Demsas: What sorts of things do you hear when people say they’re scared about getting a vaccine? Is this mostly COVID or other sorts of things?

Bedard: Well, I take care of adults and not kids, right? So I don’t hear people talk about autism and then the MMR vaccine, for example. I talk to adults about the flu vaccine, the COVID vaccine. It’s different, vaccine to vaccine.

So overall, I think one of the things is that people have had the experience themselves of getting the vaccine and then feeling crappy for the next 24 to 48 hours. And they don’t want to do that. The most pervasive thing you hear is, The flu vaccine makes me sick.

Demsas: Yeah. And that’s real. It does make you feel sick.

Bedard: And it’s real. And so one of the most important things to do is to say, Yeah, you’re going to feel bad. We expect that. That’s normal. And if you don’t want to take it today, because you have to go, you know, do something tomorrow, that’s okay. You can do it at your next visit. It’s really, really important with folks to do expectation setting, and then it’s also very, very important to not play down their own experiences or the information that they’re bringing to you.

There’s a great piece that was written by a guy that I work with now, Sudhakar Nuti, who wrote about the phenomena of lay epidemiology. Lay epidemiology is, like, the sort of informal information gathering that people do around how the people in their community and in their lives experience a vaccine. So if you have a brother who got the flu vaccine and got Guillain-Barré syndrome afterwards—

Demsas: And can you say what that is?

Bedard: Yeah, totally. It is a known, very rare complication where—it’s a neurologic complication, but it’s pretty serious, where—people experience sort of temporary paralysis.

Demsas: Wow. That’s bad.

Bedard: It’s bad. It’s a bad thing to have happen. It’s very rare. If it happens, you never get the flu shot again. But if your brother got it or your friend got it, then your sense of danger and your ability to sort of evaluate your personal risk changes a lot.

So people make this decision a lot because of the lay epidemiology in their lives, which is, What have they heard about it? What do they know about it? And around some things, like the COVID vaccine, there was tons of either real or sort of misinformation reporting about people who got the vaccine and then got sick afterwards, had consequences afterwards, right?

The sort of—people thought that Damar Hamlin, the football player, when his heart stopped on the field, right? They attributed that to having received the COVID vaccine. That’s not what did that. But there was all of this fear around myocarditis—inflammation of the heart—especially in teenage boys.

Demsas: But it’s funny. I don’t view the—at least from my perspective, and I’m not a public-health researcher. I don’t view, like, the orientation of public-health institutions as having been like, We’re going to give everyone the information, so they can make the decision for themselves. I view it much more as, like, I’m going to tell you it’s safe because I’ve done the calculation but refuse to explain to you what safe means.

So I do think that in some cases it’s maybe both. It’s like, Yes, you need to engage with that emotional side, but also just say, like—I mean, my own personal experience with this is: I remember when I was trying to get an IUD for the first time, and I went to a women’s health clinic. And I just said, like, Hey. I’ve heard some stuff about birth control and cancer risk. Like, I was young. I didn’t know anything, and I just, like, read something online, and I was just asking for some support.

This is, like, a women’s-health clinic. It’s a place where, you know, you’re supposed to—it felt very progressive and open. And the doctor just kind of looked at me and was just, like, No, that’s fine. Don’t worry about that. And that didn’t make me feel safer. That didn’t make me feel like—

Bedard: Totally.

Demsas: I got the IUD, but I was also just, like, It’s not really clear to me that I feel like you’ve listened to me. I didn’t go back there when the IUD didn’t work. I ended up, like, you know—I went on the pill instead and never went back to that. You know what I mean? So it’s all these things where I’m not really clear, you know?

Bedard: Well, so the thing that I would say about that, Jerusalem, is that’s really—what you’re talking about is an experience that’s really specific to who you are. Right? So you’re a “facts maxer.” You want the info.

Demsas: I’ve never heard that before in my life. (Laughs.)

Bedard: You want the information, right? And you’re a person who spends a lot of your day digesting and synthesizing huge amounts of information—primary research a lot, right? It’s your preferred way of understanding things, is getting lots and lots of facts and reading lots of different interpretations, and then making your own judgment about it.

So if you were my patient, and you expressed hesitancy about getting the IUD, the thing that—and I should say, you know, the reason. I have a really different orientation than lots of doctors, and that’s because my training is actually in palliative care, right? And palliative care is caring for people with serious illness or people who have life-limiting disease. And it’s very much attuned to and preoccupied with not just physical suffering but also existential distress. And because you are working with people who are sick in ways where the sort of calculus about what’s important changes a little bit, we do a lot of shared decision making. And I am trained in sitting with people and trying to decide what’s important to them, and given the options and sort of the constraints of reality, what can we do to meet their goals, right?

So that’s to say that my approach with you, if you were to ask me about getting an IUD and expressed hesitation, would be to delve deeper about, What are your concerns? Where did you read that? Where did you hear it? Do you know anybody in your life for whom that’s been an issue? Try to get really to the bottom of the thing that’s worrying you,and then also try to say, Well, what would make you feel better about it? And what would help you make this decision?

And then, for you, I think it’s probably true that the right thing for us to do would be to turn the computer screen towards you and look it up together, right? And then talk that through.

Demsas: I mean, I agree with you. I am now going to use “facts maxer” as part of my bio.

But I don’t know. I feel like I hear a lot from other people who I think maybe spend less time on econ working-paper sites—I hear a lot from them that they’re like, I just want the facts. I want someone to give me the facts. And I think that I’ve seen a lot of the same stuff that you have about, like, people have a difficult time hearing odds. I mean, I don’t think I’m particularly great at this. Like, one in 1,000 and one in 10,000—like, do you emotionally understand the differences between those numbers? Or does it just seem small but, like, there? Like, I know a thousand people, you know. Like, That’s a person.

And do you hear that the same way when you hear, like, There’s a one-in-a-thousand risk you have cancer, versus, There’s a one-in-a-thousand risk that you’ve just won $1,000? Like, do you understand those things in the same way? So I think all those things are true, but do you think that when people are saying, I want more information, they’re not actually asking for that?

Bedard: I think you have to—this is what I’m saying about, sort of: It’s different to be a doctor with a person in front of you, where I think the task is to try to explore that. Is this a person who genuinely needs more information? It would be clarifying to Jerusalem Demsas if I said to her, Actually, that study has been disproven by this subsequent study. That might be something that for you would be reassuring.

Demsas: That would work.

Bedard: It would do it, right? But I will give you the example of the patients that I took care of on Rikers. So I was a doctor on Rikers for six years. I worked in the jail system. I was there during COVID. The public-health agency that I worked for, that provided health care in the jail system, worked very hard to advocate for our patients—for people who are incarcerated on Rikers—to be among the early groups of folks who would receive the vaccine in 2021.

Demsas: I mean, the outbreaks in jails were astronomical.

Bedard: There was a period where Rikers had the highest prevalence rate in the country, at the very beginning. Jails have the worst possible conditions for airborne viral spread. So it made lots of sense to advocate for this. And also, it really felt like this important equity issue that we were saying, like, Look—these people’s lives matter, and their risk is incredibly high, and they should be prioritized.

New York City also, relatively early on in the vaccination rollout to incentivize people to get the vaccine, was offering people $100 if they got their shot. That was true in the community. We advocated hard to have something commensurate offered to people in jail—that if you accepted the vaccine, like any other New Yorker, you would be compensated with some money put into your commissary account. I don’t think it was $100. I can’t remember exactly what it was.

I walked around the jails offering vaccination to folks with one of our head nurses and one of our head physician’s assistants, both excellent communicators and people who had really great trust with our patients. And we would approach guys and say, Do you want to get the vaccine? And they would say, Hell no. And then we’d say, No, it’s really important. We would give them our spiel. And we would say, And we’ll put—whatever it was—$50 into your commissary. And almost to a man, the guys said, Now I’m definitely not getting it. The government’s never paid me to put anything in my body before.

Demsas: (Laughs.)Wow.

Bedard: And that wasn’t a situation where if I had said, No, no. Let me explain to you why this is happening. No, no. Let’s explore the facts around RNA vaccine safety, that was going to change hearts and minds, right?

That was a situation where I was encountering a resistance that was born from entirely different experience than the experience you’re describing, and with entirely different concerns. It was a low-trust environment. To respond to that, often I would joke back and be like, Well, then you should take it the first time that they do, right? And, like—

Demsas: Did that work?

Bedard: Sometimes. You know, mostly what worked was, like, sparring with dudes in a jokey way, in a way that helped them feel grounded in the idea that I, or my colleagues, were not going to try to hurt them. So in other words, their resistance was born out of low trust, and the right strategy was to try to increase trust between us and the folks we were trying to help.

And that’s just to say that there are lots of different reasons that people are vaccine hesitant. Vaccine hesitancy is not the same thing as being anti-vax, and most people are not strongly anti-vaccine. Most people who are in this RFK universe are vaccine hesitant, which means that they’re in this state of sort of vulnerable ambivalence about it.

And what you want to do, as an individual doctor, is sit with someone and try to explore where that ambivalence comes from and then address the source of that ambivalence. That’s really hard to do at the public-health level, right? It’s very different to do that at the policy level. At the policy level, mandates work. And so what you want to do is sort of, I think, have the mandate in place but think about how your communication makes it easier for people to live with those mandates and accept those mandates and feel aligned with them.

Demsas: So you brought us back to RFK and to mandates. And another part of your op-ed is that—and I don’t want this to just be about vaccines—but you say that “there are seeds of truth to some of what Mr. Kennedy says.” And I want you to overview. I mean, you’ve mentioned the mandates here, and you’ve talked a little bit about kind of some of the nutrition stuff, but what are these seeds of truth that you think we should be seeing in what he’s talking about?

Bedard: You know, I think the concerns about the relationship between pharma and government and drug regulation are really valid. They’re concerns that any liberal doctor would tell you they agree with, up to a point.

So when I say that there’s seeds of truth, common ground—the common ground stops at some point, where it’s not like Anthony Fauci traveled to China in order to engineer the COVID vaccine himself or whatever. Like, that’s just absolutely not true. But the idea that there is too cozy a relationship between pharma, pharma-sponsored patient-advocacy groups, the FDA, and the committees that provide drug approvals, and then provider associations—like, that’s definitely true. And there are lots of recent examples of that.

There’s, you know, sort of famously: In 2021, there was a really controversial, high-profile case of approval for a drug for Alzheimer’s that had just been shown not to work, basically. And Alzheimer’s—very common disease, incredibly devastating to families. People are desperate to believe that there is something that they can do for folks. We don’t really have good treatments right now. This was the sort of treatment that had received a lot of hype in advance.

The data was just not supportive of the idea that it was effective. And, in fact, it did obviously cause harm in some small number of patients. It got pushed through the FDA approval process anyway, largely, in part, due to pressure from the Alzheimer’s Association, which was receiving money from the drug company. That is a perfect-storm setup for an RFK-type critique. And it’s true. And at the time, I wrote an op-ed criticizing that process. So that’s a place where he and I totally agree.

There is a lot of truth, I think, in questioning the balance in terms of how much we’re thinking about treating diseases versus preventing them. He talks a lot about prevention. He talks a lot about lifestyle. He talks a lot about working on things upstream before they develop into sort of full-blown organ failure, right? So tackling childhood obesity by changing the food environment and encouraging exercise—it’s pretty hard to disagree with that, right?

Whether that means that, you know, I am a huge booster of the GLP-1 drugs, of Ozempic and its brethren, RFK is not, right? And that’s a place of disagreement. But it’s not a place of disagreement because I think that his premise is necessarily wrong. I think it’s a different idea about what’s realistic in terms of addressing a current prevalent issue.

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Demsas: After the break: How I learned to be skeptical of fluoride in children’s toothpaste.

[Break]

Demsas: I think my Oh my gosh—there’s a seed of truth in something he’s saying moment was when I was reading an article from the Atlantic by our fantastic science reporter Sarah Zhang about fluoride. And the article is titled Why I Buy German Toothpaste Now.

And it’s about how, you know, she buys German fluoride-free toothpaste for her daughter. And it’s because at very high levels, fluoride can lead to fluorosis, which is when your teeth become mottled or structurally weak, but also that high levels of fluoride have been linked to lower IQ in children. And toothpaste contains, you know, 1,000 times more fluoride than recommended in drinking water, and you know, young kids don’t spit that out reliably.

And she talked to a researcher recommended to her from the American Dental Association, which is obviously a pro-fluoride group. And she told her that she would also choose fluoride-free toothpaste for her children. I also learned from that article that Canada recommends holding off on fluoride for most kids under age 3.

And it’s just this moment of just realizing, like: I’m not saying that we should all listen to RFK, but I think it’s strange that that’s the only space where I’m hearing anyone question some of these things. And so then it raises this problem of, like, Oh, is this tamped down? But then, you know, it’s also a weird reaction for me to have that, because I just read this in an article in The Atlantic. So is it being tamped down at all?

So I wonder why you think that dynamic happens, where sometimes, you know, the public is talking about it? Like, these are people who are parts of the public-health establishment who are talking to journalists. Journalists are reporting that. They’re giving people facts. And yet, it feels like the only truth tellers are RFK Jr. and people on these bro podcasts. Like, what is that coming from?

Bedard: I think the operative word is question, right? It’s not necessarily that you feel definitively after reading Sarah’s article—that you understand, with total certainty, what the deal is with fluoride. What you took away from that article was, There’s more uncertainty around this intervention than I initially appreciated.

And what feels difficult is that to learn that, then subsequently makes you feel betrayed, right? That that uncertainty had never been introduced to you before and, in fact, that you had sort of felt, perhaps—I’m projecting, but I think this is probably true—sort of encouraged to assume that anybody questioning fluoride was coming from an anti-science place, was a crank, right? And then you think, I don’t want to be sort of blindly following things that there isn’t good evidence for.

It’s really, really hard for public health to effectively communicate around uncertainty. The pandemic was an incredible example of this. This has been discussed ad nauseam. Lots of mistakes were made, right? Initially, we didn’t appreciate that it was airborne, right? Initially—but even before that, we told people that they didn’t actually need to wear masks, and then we said, Actually, you need to wear a mask all the time, and you can never take your mask off, and you have to wear your mask even when you’re jogging in the park. Then we said, Don’t worry—you’ll get the vaccine, and nobody will get COVID after we have the vaccine. And then we vaccinated everyone, and the Delta wave happened, like, six weeks later.

The way that the public experiences that is as a series of reversals that feel like betrayals, I think. What I think we should do differently, regardless of whether it’s Kennedy or somebody else in charge, is communicate with the public differently about uncertainty—do different kinds of expectation setting.

Another good example is: At the beginning of the pandemic, when people went into what we’re calling lockdown—although lockdown was never really lockdown in the U.S., the way it was in some other places—initially, people sort of said, right, Go in for two weeks, and we’ll flatten the curve. Or, Go in for a couple of weeks, and we’ll flatten the curve.

And actually, we didn’t know what it was going to take, right? We didn’t know how long it was going to take to make a difference or to be safe. We didn’t totally really know what go inside had to mean. Did it mean that you couldn’t go outside at all? There were certainly people who did that. Did it mean that schools shouldn’t open for two years? Did it mean that once we sort of had enough epidemiologic data about average risk of serious illness in kids, we would make a different decision about schools?

There was very little transparency around that decision making. And essentially, there was very little transparency around the uncertainty around that decision making, right? There was a real feeling and sense that the public had to hear clear messaging: You have to wear a mask or it’s unsafe. But actually, everything is sort of a risk-benefit calculus, right? And once some of the things that people were initially told turned out not to be true, they experienced those reversals as a betrayal, and then they were pissed, and they didn’t trust anything going forward.

And that’s what I think sort of your fluoride experience is like a microcosm of, which is this sense of, like, I’ve been duped—and not because you’re convinced now that fluoride is, for sure, bad but more because you think, I thought this was settled matter, because you guys told me it was, and now I realize it’s not, and it makes me wonder what else I should be questioning.

Demsas: I think a lot of, you know, public-health folks have felt really attacked, maybe, post-COVID or even during a lot of the COVID experience. And one pushback I imagine that they would raise to our conversation, and to conversations like this happening everywhere, is that they actually do debate a lot the ethics and need for vaccine mandates all the time.

There’s one study I came across when researching for this episode in the Journal of Medical Ethics, and it was asking whether universities should mandate third-dose COVID-19 boosters. And they estimate that to prevent one hospitalization over a six-month period, you’d have to vaccinate between, roughly, 31,000 to 42,000 young adults. In order to do that, you’re getting a handful of adverse events and up to 5,000 adverse reactions that would “interfere with daily activities.” And as a result of that, they conclude that university booster mandates are unethical because they don’t take into account the low risk this group faces with Omicron, which was the wave at the time, and they’re just not proportionate, among other reasons.

And that’s the exact sort of balancing that I think that a lot of people feel like, I wish public health was like this. And I myself did not know that this was a way that bioethicists were interacting with this question. And so I guess part of that makes me feel like it’s a bit hopeless. Like, is this a problem of whether it’s social media? But also, just the way that you’re kind of describing the scientific iterative process reads as a series of betrayals rather than just, you know, a scientific iterative process, where you’re learning and changing your mind and updating. How optimistic are you that this balance is even possible?

Bedard: A few things. One thing is that I think what you’re describing there, in terms of the really painstaking decision-making process that goes into things like vaccine mandates—that’s the standard, right? And that’s how everything works, with the obvious caveat that in emergency situations where you’re dealing with a circumstance where there’s a ton of uncertainty and unsettled evidence, you have to make decisions anyway that are your best guess in the moment, right?

And so the pandemic, I think, was a little bit of an outlier situation—compared to, say, the way that we think about vaccine mandates for a childhood vaccination—where, in March of 2020, the U.S. government had to make a lot of decisions really quickly with imperfect information. And they had to do that without being able to do all of the modeling you just described, right?

And so, again, what I wish we had done differently then is been more transparent about that uncertainty and talked about how we would then potentially revise that decision making in the future as more information came out. So, This is what we’re saying you should do today based on what we know. As we learn more, this guidance may change. Here’s what we’ll tell you that will help you feel like that change makes sense. If we are wrong, there are potential consequences, and we might do something differently sooner than we’re saying, right? Like, you can sort of—there’s no character limit, right? You can say it all.

Demsas: You can only tweet your public-health pronouncements, and you can’t get premium. (Laughs.)

Bedard: Yeah. Exactly. There was and often is, I think, this sort of mistaken sense that the public needs to hear short, clear, decisive messaging, even when the circumstance that you’re in necessitates a totally different kind of communication. So that’s the caveat case, I think, is that there are lots of times when you don’t have that information that you just sort of described around—by the time Omicron came around, we had tons of information about what the real risk was to 22-year-olds, right? We didn’t have that at the beginning.

But for childhood vaccination, for example, we do have that information. The childhood vaccine schedule is something that has been created with a ton of thought and a ton of data, and a ton of thought and data that’s balancing lots of different considerations—not just safety and efficacy of the vaccines themselves, but information about how often people are willing to come to the doctor, right?

There was a really great piece written in 2009 by Danielle Ofri, who’s a doctor at Bellevue, here in New York. And 2009 was when the H1N1 swine flu outbreak happened. And she wrote this piece about what she calls the “emotional epidemiology of the H1N1 influenza vaccine.” Her patients—patients who generally did not accept the flu vaccine—when H1N1 first broke out began calling her office, being like, When is the vaccine going to be available? When is the vaccine going to be available? And she was surprised because they were generally folks who had not accepted the seasonal flu vaccine in the past.

It took a little while—and by a little while, I really mean months, not a year, right—for an H1N1 vaccine to become available to her patients. In those intervening months, many of those patients who initially had this sense of urgency lost it and, in fact, changed their minds and ultimately didn’t want the vaccine once it became available. And she talks about—I just want to read this quote that she has in here: “Emotional epidemiology does not remain static. As autumn rolled around,” which is when the vaccine became available, “I sensed a peeved expectation from my patients that this swine flu problem should have been solved already. The fact that it wasn’t ‘solved,’ that the medical profession seemed somehow to be dithering, created an uneasy void. Not knowing whether to succumb to panic or to indifference, patients instead grew suspicious. No amount of rational explanation—about the natural variety of influenza strains, about the simple issue of outbreak timing that necessitates a separate H1N1 vaccine—could allay this wariness.”

I think that this void that Ofri is identifying is really important. When you aren’t communicating consistently with the public in a way that makes the work that you’re doing transparent to them, the thinking that you’re doing transparent to them, and in a way that is in some ways responsive to their feelings, then it feels as though there is a void, and into that void people project all sorts of things and end up relying on information from other sources and changing their mind or deciding that they don’t trust you anymore.

Demsas: So I think it’s an interesting kind of tension, though. Because, you know, I wrote this article in 2022, and the headline was, “Is the FDA Too Cautious?” And part of what the article talks about is that the FDA is way too conservative when assessing clinical trials for therapies of, quote, “terminal illnesses with no existing therapies such as pancreatic cancer.” So these are areas where you would want the FDA to be overly willing to approve therapeutics, because the risk of death and disability are already high for the individual patients.

And there’s this anecdote from Henry Miller, a former FDA physician, that I’m going to read quickly. He says, “In the early 1980s, when I headed the team at the FDA that was reviewing the NDA [New Drug Application] for insulin … we were ready to recommend approval a mere four months after the application was submitted. With quintessential bureaucratic reasoning, my supervisor refused to sign off on the approval—even though he agreed that the data provided compelling evidence of the drug’s safety and effectiveness. ‘If anything goes wrong,’ he argued, ‘think how bad it will look that we approved the drug so quickly.’”

So earlier in our conversation, you mentioned the Alzheimer’s drug, which I think, universally, everyone was kind of condemning as being a situation where the FDA had rushed something through approvals, even though there was not good evidence that it was going to be beneficial for people who needed that drug.

And then when I wrote this article, there were a lot of people who were like, Yes, it’s so important. There were scientists, outside individuals, public-health researchers from the outside who were like, Yes, it’s really a problem that the FDA doesn’t behave this way. There’s tension that we have in this conversation that I can imagine is very frustrating for people in government, where they’re being told, Hey. Why won’t you approve these tests quickly? Even though you’re not sure that they’re good, why won’t you act with greater degree of concern for people who need something right now, rather than trying to get the perfect thing later?

And on their end, they’re saying, We need to increase trust. And trust means provide people things when they’re ready, provide people things when we can actually defend them clearly. And on the other hand, they’re being told and criticized for not doing that. And there’s, obviously, this dynamic here, where you get blamed for things that go wrong much more than you get blamed for things that you don’t do, because people often don’t see those sorts of things.

And so I guess I ask you: You’re, obviously, trying to get to a point where there’s a lot more of this democracy, openness, talking about these individual problems, but it seems to also open up a lot of these institutions to kind of daily critique about how they’re not actually getting things right on a day-to-day basis. Like, Well, yesterday you said this, and now you’re saying this. So I mean, how do you think about that problem?

Bedard: So the first thing I would say is: The science actually matters a lot here. So there are examples, like the one that you just gave, where there are things—there are discoveries, breakthroughs, drugs, whatever—where the evidence is just sort of incontrovertible right out the gate, right? Like, way before sort of a study’s expected end point, it’s very clear the benefit is there, and people are tolerating it well enough, and the condition is serious enough that we should try to expedite it.

Expedited approval really came to the fore during the AIDS crisis, when this was a huge issue, right—where AIDS patients, understandably, were like, We’re dying today, so it doesn’t make sense for us that you have to go through this bureaucratic approvals process. We’re willing to try therapies that are promising, that may not work, even that may have risks, now because—

Demsas:We’re dying.

Bedard:We’re dying. The natural course of our disease is such that we don’t have the time to wait for your process. That’s clearly reasonable, and Anthony Fauci, in response to those very complaints, adjusted the clinical-trials approval process to have a fast-track option. There’s compassionate-use-case approvals, where for diseases that are rapidly terminal, seriously debilitating, etcetera, the threshold to be able to let people try something that’s in development is much lower.

There’s also always the possibility of enrolling in clinical trials, right, as a way to try therapy. And that’s an example of sort of just—there’s both sort of a rigorous system around deciding whether or not somebody is eligible for something, but there are opportunities before something has been proven safe, or not 100 percent, to let people try it. The flip side is that there are lots of things that pharma is working on that don’t work that well, that are for problems that aren’t that debilitating, right, and where rushing approval for those things doesn’t make any sense, because the risk even of sort of minor adverse effects way outweighs the sort of tepid benefit that they might offer.

And so, to me, the challenge for the agency is less about whether they look good or bad, and more about trying to sort out those types of problems, right? When does it make sense for us to err on the side of being as conservative as possible in approving something? Versus, when does it make sense for us to err on the side of being as open to risk as possible because the alternative of continuing to live in an environment without treatment is so devastating to people?

The way that the FDA and other public-health agencies—the NIH, etcetera—have tried to get at this issue that you’re talking about is by having patients involved at sort of every step of the drug-approval process, the research process, etcetera, etcetera. That doesn’t work all that well, I don’t think, because there’s a little bit of an elite-capture problem there, which is that: Any patient who ends up sitting on the committee for drug approval stops actually being a representative of that patient population, knows too much, is sort of influenced by lots of other factors, etcetera, etcetera. And I don’t think just involving patients along the way really sort of solves the problem that you’re talking about, but it’s the way that the agencies try to do it now.

Demsas: So I can imagine that there are people who are very afraid of RFK’s ascent and, like, kind of the increase in skepticism around basic public-health measures that are listening to the conversation and just going, I feel like you’re just sane-washing. People who are serious trust the science people or public-health researchers, or if you’re serious about preventing long-term disability from COVID reinfections—I mean, if you really care about those things, then what you should do is just constantly sort of oppose that.

And so how do you think about the risk of sane-washing, instead of just going, like, Hey—we’re just saying we agree that sometimes Big Pharma is way too involved in the regulatory process. That doesn’t mean we think that X conspiracy theory is true. So like, what is the balance there? Who’s responsible for making it?

Bedard: So I’m a little bit different, I think, than lots of doctors because of my background and my practice experience. One thing is about being a palliative-care doctor. The other thing is that I have always worked with marginalized populations where there’s a high prevalence of substance-use issues. And because of that, I’m very sort of seeped in the harm-reduction approach to problems.

And I don’t think that advocacy from the public-health community or doctors is going to be what prevents RFK from getting through the Senate and being approved to become an HHS secretary. I think he’s gonna end up getting the job. And I also think—because of the sort of way that he is ensconced in Trump World and the fact that he comes with his own constituency that Trump sort of needs—in the outcome where, like, a couple brave senators stand up and decide that they’re not going to vote for him, I think he gets made health czar or something like that. Like, I don’t think he just goes away.

So part of the harm-reduction ethos is just about being real about what the challenges are. And to me, the fact that I don’t want RFK to be anywhere near in charge of the federal government’s health apparatus, it doesn’t make it not so. And my sort of principled opposition to that doesn’t feel like an intervention that has a lot of juice.

That’s really different, I will say, than I felt in 2016 with the first Trump administration, where I sort of felt like there was lots of reason to believe that resistance was the path. I don’t feel that way, and I don’t think we’re seeing that, generally, now, right? Like, we’re seeing a lot less sort of resistance stuff and a lot more trying to figure out how to make the reality of this situation less harmful.

I don’t think it’s sane-washing him to say, Look—if this guy’s gonna be in charge, what does it look like for us to recognize who he is and where he’s coming from, recognize that he has a growing movement of people behind him, who aren’t just going to go away because we yell at them? What does it look like to try to achieve something that doesn’t even have to be consensus but is understanding between us so that the entire sort of public-health apparatus doesn’t just get dismantled?

Demsas: That seems a perfect place to ask our last question, which is: What is something that you once thought was a good idea but ended up only being good on paper?

Bedard: Okay, I have two answers to this.

Demsas: Okay.

Bedard: I thought about it a lot.

Demsas: Lots of “good on paper” problems in your life. (Laughs.)

Bedard: And they were, like—these are not necessarily good on paper just to me. I think that there are two things that I think. The first is the Manhattan Project.

Demsas: What?

Bedard: It’s hard for me to think of anything cooler in the world than taking the best scientists in the country—like, the best scientists from around the world, basically—and bringing them all to the desert and being like, Figure out the hardest scientific problem of the moment, and we’ll give you unlimited resources to do it. Unbelievably sexy proposition. Turned out really bad. You know what I mean?

If I think about the Manhattan Project still, I’m very seduced—maybe you’re not at all, but I’m very seduced by it. It’s also like: You think you’re beating the Germans. It feels really important.

Demsas: Yeah.

Bedard: The other thing that I was going to say is: small plates. (Laughs.)

Demsas: So Manhattan Project and small plates.

Bedard: Manhattan Project and small plates.

So I think one of the major millennial failures is the invention and then rollout of small plates to, like, every yuppie restaurant in every city in the country—which is like: You go. You sit down. There’s, like, this menu of items that are all very expensive and very tiny, and they’re supposed to be for sharing, but they’re not big enough to share.

And then the waiter comes and, like, does this whole explanation, like, Have you ever been here before? Let me explain to you how the menu works. Things at the top are small, and things at the bottom are bigger. And then the menu proceeds from, like, $18 for four anchovies to, like, eventually you get to, like, a whole fish. You know what I mean?

And, like, (1) it’s insane. Like, you can’t—

Demsas: The sharing part is the most annoying part, where there’s, like, three things, and there’s five people at the table, and so you’re cutting each one—

Bedard: Of course! If the concept is you should be sharing, so you can try lots of things, then everything has to be family style. It should be big, not small. Big plates is what you need!

Demsas: Big plates. Wow. This is very attractive to me as an Eritrean because our food is the biggest of plates. It is one big, shared plate. So you know what? Sure.

Bedard: That’s the right approach!

Demsas: Yeah. Not the tapas way—the Eritrean way.

Bedard: Tapas was never meant to be a meal. Tapas is, like, an hors d’oeuvre situation. It’s not supposed to be that, like, it’s 7 p.m., and I’m starving. I’m sitting down with another couple, and we’re, you know, gingerly ripping apart one piece of sourdough between us.

Demsas: You know what? You’ve convinced me. I’m going to launch a tirade against this next time I’m at a restaurant to a poor, unsuspecting waiter. Well, Rachael, thank you so much for coming on the show. This was fantastic.

Bedard: Thank you, Jerusalem.

[Music]

Demsas: Good on Paper is produced by Rosie Hughes. It was edited by Dave Shaw, fact-checked by Ena Alvarado, and engineered by Erica Huang. Our theme music is composed by Rob Smierciak. Claudine Ebeid is the executive producer of Atlantic audio. Andrea Valdez is our managing editor.

And hey, if you like what you’re hearing, please leave us a rating and review on Apple Podcasts. I’m Jerusalem Demsas, and we’ll see you next week.