President-elect Donald Trump's nomination of Robert F. Kennedy Jr. to head up the Department of Health and Human Services (HHS) is causing much wailing and gnashing of teeth in Atlanta and suburban Maryland. Why? Because the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH) are headquartered in those places. As HHS secretary, RFK Jr. would be able to shape the priorities of these agencies.
In fact, the CDC, the FDA, and the NIH have long needed drastic reform. But is putting RFK Jr. in charge of HHS the right way to fix these dysfunctional public health agencies?
First, let's take a quick look at what's wrong with each agency. The timid bureaucrats at the FDA stifle medical innovation to the detriment of patient health. These regulatory shortcomings have prompted calls for abolishing the agency and adopting competitive systems for assuring the safety and efficacy of medical treatments and diagnostics.
The NIH is the world's largest public funder of biomedical and public health research, with a budget of $47 billion, most of which is used to support research at universities and academic medical centers. The agency has long been criticized for being way too risk-averse when it comes to choosing which research projects to fund. "The NIH's extramural research is systematically biased in favor of conservative research," concluded a 2022 Emergent Ventures analysis of the agency's research grant process. "The NIH may be hamstringing bioscience progress, despite the huge amount of funds it distributes, because its sheer hegemony steers the entire industry by setting standards for scientific work and priorities."
The CDC, as the federal agency whose main charge is to detect and manage public health responses to infectious diseases, utterly failed during the COVID-19 pandemic. Distracted by fighting "epidemics" of obesity, smoking, and violence, it massively botched its response to an actual epidemic when it struck.
So what does RFK Jr. plan to do with each agency? Like all politicians, RFK Jr. tailors his remarks to his audiences, but here are some of his statements with respect to how he plans to handle these three agencies.
Back in 2017, RFK Jr. talked with then-President Trump about setting up a vaccine safety review commission. During a Science interview about the prospective commission, he declared that the CDC "is the locus of most of the most serious problems with the vaccine program, the two divisions at CDC: the Advisory Committee on Immunization Practices and the Immunization Safety Office, which is where the scientists are."
During an NBC interview, RFK Jr. asserted: "I'm not going to take away anybody's vaccines. If vaccines are working for somebody, I'm not going to take them away. People ought to have [a] choice, and that choice ought to be informed by the best information."
Being informed by the best information is certainly the right goal. But RFK Jr.'s long history of anti-vaccination agitation suggests he is not a source of the best information for the safety and efficacy of modern vaccines. This includes false assertions that vaccines cause autism; that they are not tested using placebo-controlled trials; and, contradicting the previous claim, that COVID-19 vaccines killed more people than did a placebo.
Again, the CDC needs fixing, but RFK Jr.'s skepticism about the safety and efficacy of modern vaccines would further undermine what should be the CDC's main focus: the prevention of the spread of dangerous infectious diseases.
"FDA's war on public health is about to end. This includes its aggressive suppression of psychedelics, peptides, stem cells, raw milk, hyperbaric therapies, chelating compounds, ivermectin, hydroxychloroquine, vitamins, clean foods, sunshine, exercise, nutraceuticals and anything else that advances human health and can't be patented by Pharma," he posted on X in October. "If you work for the FDA and are part of this corrupt system, I have two messages for you: 1. Preserve your records, and 2. Pack your bags."
First, there is nothing on the list that a libertarian would prohibit, but you take them at your own risk. However, the FDA in August refused to approve using the psychedelic MDMA to treat post-traumatic stress disorder. The FDA also does have a role in deciding which controlled substances should fall under the jurisdiction of the Drug Enforcement Administration. To his credit, RFK Jr. in 2023 said that as president he would legalize psychedelics and marijuana while regulating access and taxing them.
By peptides, RFK Jr. likely means substances ranging from growth hormones and steroids to the new semaglutides that are successfully treating diabetes and obesity. Interestingly, semaglutides appear to be peptides that he disdains. While some stem cell therapies show promise, most have not undergone clinical trials for safety and efficacy. Pasteurized milk is a public health triumph, but if you want to risk various foodborne illnesses, knock yourself out.
Four years into the post-COVID era, most research has found that ivermectin and hydroxychloroquine provide no treatment benefit for the infected. In April, the Journal of Infection published a report about a randomized controlled trial that concluded, "Ivermectin for COVID-19 is unlikely to provide clinically meaningful improvement in recovery, hospital admissions, or longer-term outcomes." For the most part, the FDA does not regulate vitamins, clean foods, sunshine, exercise, or nutraceuticals.
The main reform the FDA needs is getting out of the way by speeding up its drug and treatment approvals processes. Given his deep skepticism of the modern pharmaceutical research and development enterprise, RFK Jr.'s demands for more safety testing and his opposition to FDA user fees risk even further delays in getting new treatments to patients.
"I'm going to go to NIH my first week and I'm going to call all of the division heads and I'm going to call all of the bureau chiefs and I'm going to say, 'We're going to give drug development and infectious disease a break—a little break, a little bit of a break—for about eight years. And we're going to study chronic disease," he said before suspending his presidential campaign.
Giving drug development and infectious disease an eight-year break seems inadvisable. After all, the death rate for cancer has continued to drop from 2016 to today, partially as a result of lower incidence stemming from lifestyle changes, but also because of better and more widely available pharmaceutical treatments. Recent calculations show the value of medicines to patients far outweigh the profits the drug companies rake in. And, as ever, infectious diseases lurk in the background waiting for us to lower our guards or seeking just the right mutation to enable them to jump into the human population.
RFK Jr. is correct that the incidence of chronic diseases among Americans has been on the rise. A 2023 analysis of chronic disease trends noted, "Cardiometabolic causes of multimorbidity were highly prevalent, especially obesity, hyperlipidemia, hypertension, and diabetes." In other words, a good bit of the increase in chronic illness is related to the rise in obesity. Just this week, another study in The Lancet reported that nearly three-quarters of U.S. adults are overweight or obese. As one result, the prevalence of Type 2 diabetes has doubled in the past 20 years.
RFK Jr.'s solution to stemming the tide of chronic illnesses is better diets and physical fitness. History suggests government interventions will have little effect on either. After all, the federal government has been periodically issuing dietary guidelines since 1979 and promoting physical fitness since 1956. The Lancet authors agree with RFK Jr.'s aspirations but suggest in the meantime that "regulations need to be put in place to eliminate barriers to accessing new-generation obesity clinical treatments, ensuring the availability and affordability of these options to the broader population."
Hopefully, RFK Jr. will not model his public health efforts with respect to fighting chronic illnesses on those of New York City Health Commissioner Thomas Frieden. "When anyone dies at an early age from a preventable cause in New York City, it's my fault," declared Frieden in 2006. To protect New Yorkers from themselves, he required mandatory electronic reporting of the glycosylated hemoglobin A1c values of all diabetics tested by all city laboratories to the Department of Health and Mental Hygiene. Those whose readings were too high got notifications and educational materials and were reported to their physicians. Frieden later served as head of the CDC for almost eight years under President Barack Obama.
Parsing Trump's announcement of RFK Jr.'s HHS nomination, Cato Institute Director of Health Policy Studies Michael Cannon posted on X that it amounts to "a call for more regulation. To have government make even more of our health decisions."
The FDA needs streamlining to speed biomedical innovation, the NIH needs greater risk-taking in research, and the CDC needs to be laser-focused on preventing infectious diseases. None of these appear to be high on the agenda of possible incoming secretary of health and human services.
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