Ep 4. RFK Jr.: The Good, The Bad, and the Ugly

In this episode, Drs. Amar Rewari and Anthony Paravati discuss the nomination of RFK Jr. as the head of the Department of Health and Human Services. They explore his controversial views on vaccines, public health implications, agricultural policies, and the pharmaceutical industry. The conversation delves into the complexities of chronic disease management, the debate over fluoride in water, and the potential impacts of RFK Jr.'s policies on public trust in science and health.

The RFK Jr. Nomination Overview

Well, Anthony, I thought maybe this time around, we haven't had a political episode in all of two episodes, so I figured we'll jump right back in since there's a lot going on. I thought maybe we could talk about the RFK Jr. nomination. I believe we can talk a little bit about RFK—the good, the bad, and the ugly.

On the good side, we both have talked about how we believe that he could create positive initiatives and reforms potentially in the pharmaceutical industry, in the agricultural industry, for example, subsidies, and also in chronic disease management. But we are worried on the bad side or the neutral side. What about some public health impacts from raw milk, lack of fluoridation in the water?

And then the ugly side: what could this potentially do to the trust in the scientific community? Vaccine denialism and so on. A lot of issues all packed into one episode. Let's get right into it. A lot has happened since our last episode. The last one we made was before the election. The election has happened and the President-elect, Donald Trump, has made a long list of nominations already.

And you and I, as physicians, are obviously most interested in who he's nominated to run the Department of Health and Human Services. None other than Mr. Robert F. Kennedy Jr. We understand that this is quite a controversial pick. Some people feel very strongly for it and some people feel very strongly against it, and other people may not know much about him. So we're hoping to give our listeners and viewers just some more information about the man, his policies, what effects they may have, and try to be as balanced as we can and just give the facts.

That's right. This is an interesting guy. He's an enigmatic character, I would say, who certainly has some positions that I think are timely for the United States healthcare landscape, but a long history of many other positions that I think deserve a close look, especially given the massive role that he's been nominated for, which essentially oversees 13 agencies from the CDC, FDA, CMS, and many others.

Right. With 80,000 employees and 144 billion in discretionary funding, 1.7 trillion in mandatory funding. So, yeah, it's a big, big, big task. Incredible. The size and scale.

I'll say there's some of his things I agree with, and there's some of his things I strongly disagree with, and there's things that I think could go either way. But then he'll also face a lot of challenges, and I think we'll try to cover a lot of that in this episode.

RFK Jr.'s Background and Environmental Work

Well, let's start on a positive note so we can remind our audience, you and I are both cancer physicians and we are saying our own opinions. It doesn't represent anyone we work for or affiliated with. But I thought maybe even before we get into it, we could tell a little bit about what RFK Jr.'s background was.

Right. So he comes from a law background, obviously from the Kennedy clan, from RFK's son, so a long history of Democrats. He was an environmental lawyer, did a lot focused on issues around clean water, pesticides. He was involved in Monsanto lawsuits in creating a nonprofit that promotes clean water around the world. And then also stuff on children's health where his controversial views on vaccines originate. And then obviously ran for president as an independent and then endorsed Trump and now is nominated to lead the HHS. So kind of a little background there.

The Samoa Measles Incident

Yes, that's helpful. And yeah, I think obviously his experience in law, environmental law, is what transformed into his interest in certain public health topics. I was going to perhaps suggest we start off with something that you and I might consider a positive attribute of his views. But since we got right away to talking about his background and how that transformed into public health interest, that obviously has me think: what has more of a massive impact on public health than vaccines? Probably nothing. And such a concerning aspect of his past.

There's an episode from a couple of years ago before COVID that involved American Samoa where measles vaccine was prepared in an incorrect way and it was essentially reconstituted with a muscle relaxant. Obviously, that vaccine given to children resulted in side effects related to them getting an improper dose of a muscle relaxant which they shouldn't have received at all. And two children died from that.

Exactly. Two died directly from this improper preparation of the vaccine. And he was quick to speak out and say, "Gotcha, this vaccine caused their death." And that transformed into a whole massive controversy where essentially vaccine rates plummeted and 6,000 Samoans ended up with measles and about 80-some children died from that whole episode. He was a major instigator in people not getting vaccinated.

Vaccines and Autism Claims

Right. And he states—this is from research we've done on his own words on podcasts he's spoken out and articles and interviews he's given—he says he's not anti-vax. But that being said, he has many contradictory statements over the last two decades, particularly around links between vaccines and autism. The rising rates of autism we see in our society, which I believe some places have quoted as high as like one in 36 children or something like that are now potentially developing autism. But correlation is not causation.

Right. That's what they teach us in medical school. This supposed link between vaccination and autism came from a particular British scientist who published a bunch of papers. They were high profile papers. All that work was completely made up, all those papers were retracted. And no link between vaccination and autism has ever been replicated in a reputable work that is still essentially in the published literature. Because technically the way it works is that stuff is—I mean, you could find it, but it's retracted.

Right, and since he's made these statements over the last two decades, there's more and more conclusive research that shows no connection between autism and the chemicals that are used in these vaccines. The CDC estimates that almost 21 million hospitalizations are prevented from vaccine usage and 730,000 deaths in the US alone from use of vaccines. So the worry is: is his rhetoric around vaccines going to translate to any change in policy around vaccines, or will it further create increased distrust in the scientific rationale around vaccines in our country?

The Real World Impact of Vaccine Skepticism

The thing I would say is that because many of us who are adults, many of us who practice medicine, have always been in this world where we've had, in the West anyway, access to any and all vaccines that we could possibly want for disease prevention. As a result of that, maybe not no one, older people might remember what it's like to see a paralyzed child who's got polio or what it's like to take care of a child who dies from measles. But the memory of the greater US population is short in this regard. To result in that kind of mortality and morbidity because we take a policy of minimizing the importance of vaccination is a massive risk.

True. And we don't have to go as far as Samoa. Like in New York in 2019, there was a measles outbreak caused 1200 cases. And we see more and more of these outbreaks, whether pertussis or measles, easily treated diseases as the herd immunity decreases because not enough people are getting the vaccines.

Exactly. And one other point about that is I did my pediatrics rotation as a medical student at Children's Hospital of Orange County. And then I did my residency at University of California, San Diego where we happened to spend a good deal of time at Rady Children's Hospital, obviously providing cancer care to pediatric population. But even then, and that's years ago now, there was a great deal of vaccine skepticism in a particular corner of Orange County, by the way. It was like no one was getting vaccinated, which to me it was just unbelievable.

Coastal Southern California, one of the richest places in the world. They have no concept basically that other parts of the world would gladly take the vaccines that they're refusing. That to me was such a poignant moment that I have such a contradiction that stuck with me and I hope it doesn't become mainstream across the United States. But vaccines are just one problem. I'm just going to rattle off a couple of things here and you tell me what's interesting to you.

Other Controversial Scientific Views

So in addition to the—let's call it vaccine denialism or scientific denialism, we could use that term because that maybe more encapsulates some of the other concerning positions. I mean, he suggested that the AIDS syndrome is not actually caused by the HIV virus.

Okay, what else?

There is no confusion in the scientific community around that.

Exactly. There is 100% correlation between HIV and the development of AIDS. Other things claiming that Wi-Fi causes some kind of condition. I actually don't know what this means. Leaky brain syndrome. That's another one.

Yeah. And 5G chemicals in the water causing sexual dysphoria.

5G. Yeah, that's right. I forgot about that one. That's an important one. And then I'll stop and I'll let you—I want to hear your views on this or any commentary you have.

Evaluating Scientific Consensus and Policy

I mean it's a lot of conspiracy theories. But I don't want to dismiss the man just because of what he says. His argument is that he says he can review the science articles themselves because that's what he used to do as an environmental lawyer. The issue is how he's reviewing them. Is he taking away some of the same conclusions? Is he only looking at certain literature even though there's higher quality literature and a larger amount of literature that he's ignoring?

So he's kind of picking and choosing and taking away conclusions which aren't necessarily acceptable conclusions from some of the scientific literature and then reframing it in these things that could sound like conspiracy theories, which is definitely concerning.

Right. But in his role, if he does get confirmed as HHS, I personally don't think he'd be able to ban vaccines, nor does he say he wants to ban vaccines. But that being said, he could slow play the approval of new vaccines depending on who he hires to be on certain panels that review the literature, who he'll work with with the FDA.

And also the other thing he could do is just kind of figure out ways to maybe reduce the prevalence and availability so maybe children under age 18 won't have access to let's say a Covid vaccination booster or something like that, even if their parents wanted to. So it's not just reducing mandates. It's actually could affect new vaccines and availability of existing vaccines. That's the worry.

No, I think you summarized the point very well. I was also going to mention some of his other positions. There's actually too many to even list. He's not the only one, but he's obviously a major figure and the subject of this episode is him thinking that somehow that Anthony Fauci and that Bill Gates had some kind of nefarious intentions with COVID-19 and prolonged the pandemic. Just trying to include his sort of let's say CV here on these issues. And then some other ones. So apparently, tell me about this: he's apparently said he wants to fire hundreds of NIH employees. Do you know anything about what his position is?

Proposals for the NIH and Medical Journals

Fire 600 NIH employees. I did read about that. But maybe you can elaborate more, Anthony, because I don't remember exactly what was the rationale behind it.

I think it has something to do with identifying science that some portion of the NIH scientists put out and he's claimed that it's not real science. Because the reason I bring these two things together is because in doing research about him, those two points were connected: that desire to fire 600 NIH employees and also prosecute medical journals for not publishing, quote, "real science."

Oh, I did remember about that with especially there was something in Lancet, which is one of the main British medical journals. He wanted to prosecute like the editors or the journals themselves for publishing pseudoscience. He may have a beef with them because they retracted the autism work. That's where that stuff was original.

Exactly. So it all comes back full circle.

Exactly. So I think those were some of the main things we wanted to talk about with the negatives.

Raw Milk and Avian Flu Risks

Yeah, I think so. I mean, there's other delicate and complex issues like the prevalence of bird flu in the U.S. livestock population. Because the reason why that matters is because he has spoken many times that he wishes to relax restrictions on raw milk. And if you relax restrictions on raw milk with that rising incidence and prevalence of bird flu, then you can have individuals that contract bird flu by way of raw milk. So that's an area where there's a connection there that people have to make. And I get it that people like this idea of raw milk, but you have to understand that in that food product there could be bird flu that is otherwise not gonna be there if the milk is pasteurized.

Right. And I think a lot of this comes down to—and there's some good rationale behind it—which gives rise to then some of this twisted ways of interpreting it. So, yeah, there's a huge agricultural industrial complex and lobbying efforts and big farms and all this money that pours into government to promote whether it's corn and soybeans. And I'm sure that's probably influenced how he thinks about the dairy farming too. However, just because there may be bad aspects of corporate influence in our agricultural policies and that should be changed doesn't necessarily mean that the good things about pasteurization and its effect in reducing diseases like listeria and others should be just left behind. This is established science that saved so many lives over the last hundred years. Louis Pasteur, I don't know, what is that like 200 or 300 years old? So I get giving people a choice.

Right, but the worry is it's not just giving people a choice. You would have to make sure that if there was raw milk and everything like that, I mean, how are these places being regulated? How are they checking for these type of diseases? What's going into the milk these people are consuming? Those are all the worries. And your point about listeria as well is well taken because for me there's nothing of greater importance than preventing illness that can occur or be transmitted in utero or immediately at the time of birth. Because the negative impact on the fetus and then the newly born child is so massive and so totally avoidable that compromising those protections is just unacceptable.

Ultra-Processed Foods and Obesity

And I'm going to tie onto the raw milk and pivot a little bit. So I'm a big, I guess, gym-going guy. So I like to go to the gym a few times a week and I've been doing that for many, many years. And there's a whole community at the gym and I follow a lot of fitness influencers and all that. And I will say in that whole community, the raw milk thing is quite popular, along with this whole concept of wellness and eating unprocessed foods.

So there's a lot of aspects about what RFK is proposing in this "Make America Healthy" thing that are good for health in terms of decreasing our intake of highly processed foods. But then, many times what he's also doing is he's tying in other fringe aspects like the raw milk. And then people who don't know any better and who are following all this stuff kind of think it's all one thing. So it's like, well, if you want to be healthy, not only do you need to minimize your intake of highly processed foods, you also should be drinking raw milk.

Yeah, it's easy to confound elements of wellness. It's easy to extrapolate early phase studies—so studies that are either retrospective or based on a very small number of subjects—and turn them into, let's say, science that's ready for prime time. And that's where this idea of ignoring the experts, ignoring people who are in a position to help provide guidance to the greater public about the relevancy of a given study to health decisions that people might make every day, that's where the experts have a role. But I think you're absolutely right to connect the whole raw milk thing to the greater approach to food and agriculture reform. Because there really is a problem. The consumption of ultra-processed foods, as it's been now called, is off the charts in the United States compared to peer countries.

The rate of the US population that is obese—forget just overweight, but obese—is many times higher than other peer countries. And if you want to talk about real science, science done the right way, that connects those two things outside a study, this has been talked about. It was even featured on 60 Minutes some years ago because the study was published in 2019 and it was done by the NIH, which by the way, RFK Jr. will ultimately run.

They randomized them to a diet that was high in processed foods. The other arm got a diet low in processed foods. And they each had menus with the exact same number of calories. But they said to the subjects, "If the menu doesn't satisfy you and you're still hungry, you can have other stuff." And what the study showed is that while the subjects were eating the ultra-processed diet, which more or less approximates the diet that many Americans are eating, those subjects ate 500 more calories a day than those eating a well-balanced diet, which is low in processed foods.

So that is probably the highest quality evidence we have to show that ultra-processed food is a big problem. It obviously has become so common in the US diet because of our agricultural subsidies of things like corn and soy. And it's had a real influence in metabolic syndrome and a host of negative health consequences that come from being obese. So no matter what the body positivity movement says or others say, it is a big problem physiologically, endocrinologically, musculoskeletal health. It is a big problem to be obese. And Americans are fighting that. So that's one aspect of RFK Jr.'s belief system that does make sense, at least to some degree. Of course, the devil's always in the details.

Chronic Disease Management

No, and it was actually interesting when he was nominated for HHS because given his strong held views and his prior experience working in the agriculture industry, I really thought maybe they were going to nominate him for Secretary of Agriculture to focus a lot of the stuff around crops and pesticides, which is all things that I think the vast mainstream medical community all agrees with. But yeah, to your point, the other aspect, another positive thing on his platform is looking at chronic diseases and the management of chronic diseases.

We know in this country the metabolic syndrome, which is pretty much the aggregate of obesity and other chronic conditions like diabetes and hypertension and cholesterol altogether, have really played havoc on our mortality and our life expectancy compared to other developed countries. And so he really wants to put an emphasis on that. And this is similar to a lot of the other influencers in this space, whether it's the Casey and Calley Means, the Hubermans, the Dr. Attias, all kind of are saying the same concept about wellness, management of chronic diseases.

But it's not something that I feel like people think is something new. And I think people feel like doctors don't believe in this, the way it's being portrayed. I, as a doctor, believe in promoting wellness and promoting this type of healthy lifestyle management of chronic diseases. Anthony, I'm sure you do as well. So it's not fair to say that it's something outside the mainstream medical establishment. The way it maybe is being presented. I think it's something universally agreed upon. The question is, how do we actually do it? It's easier said than done.

Cultural Shifts and Lifestyle Factors

I think if we're up for it, if we're up for the challenge as a country, we can look to places like France, places like Italy, other wealthy countries, particularly in Europe, who have it right. And a key aspect of it is certainly going to be to remove—it's not going to be easy because there's going to be intense lobbying—but to remove, dismantle, reduce the agricultural subsidies that greatly distort what we produce and consume in this country. Because I can tell you that in those places I just cited, similar subsidies do not exist.

Some subsidies that do exist are dedicated funds to promote education and nutrition education and healthy lifestyles from the beginning of mandatory school. And that weaves into the culture an appreciation for that part of one's life, for taking responsibility for what one eats, knowing how to prepare food for oneself. Those are things that culturally are normal in certain parts of the world. And I think from my perspective, would be key ingredients, no pun intended, to achieving a healthier diet for the American population.

Right. And as cancer physicians, when I speak with my patients, I do try to talk about the full aspect about also reducing stress. So reduce some of those cortisol levels and all the disruptors that can come from high stress and that cascade effect on your health, increasing physical activity, obviously like we said diet. So all these things are all part and parcel and it's not just about prescribing drugs.

Pharmaceutical Industry Influence

Which gets us to our next topic, which is that the other thing with the management of chronic diseases—the other criticism and this is probably valid—is how much influence are the pharmaceutical companies having on creating an effect where there's direct-to-consumer marketing. There's a lot of incentives for these pharmaceutical companies to continue, whether it's through longer patents and these aspects, to continue to use drugs to manage these chronic conditions. Because it's a profit for that.

No, that's another aspect. Yeah, it's another positive aspect of his thinking. I remember some interesting data and this received a little bit of coverage in the popular press years ago. How pharmaceutical companies lobby for shifting the definition of normal versus abnormal results in things like laboratory studies. They more or less invented the modern idea of so-called "low T" or low testosterone in men. And obviously, there are reasons why a man may have low testosterone for his age and there's obviously treatments for that. But in moving the goalpost, let's say, in what is considered low testosterone, that was done by pharmaceutical lobbying. And obviously, their medicines to treat low T, the goal of that is to sell.

So there's all sorts of ways that that happens and it happens not just in the healthcare space. It happens in virtually every major sector of the economy. Lobbying specifically in that way. And he seeks to, I believe he calls it, reduce sort of "corporate regulatory capture." So reducing the amount of regulation that flows from or that's written effectively by major corporations in the healthcare space. So another thing I wanted to mention about him is an interesting element regarding pharmaceutical benefits management and how he may impact some of that with rebates, which kind of ties into some of our earlier episodes too which is positive.

Pharmacy Benefit Managers and Drug Costs

Sure. There's a tremendous influence on what Americans pay for their drugs that is driven by the pharmaceutical benefit manager middleman. They have a great deal of influence on the entire value chain of how pharmaceuticals get from the manufacturer into the patient's hands and a great deal of influence on the final part, which is the pharmacy itself. And so what is paid at the point of obtaining the drug.

There's great damage in PBMs and how they conduct business to the small pharmacy. That's why a lot of Americans who used to 20, 30 years ago rely on a community pharmacy or they had a trusted relationship with folks who were in their communities for years, now in many places they don't have that anymore. They have to go to a large retail pharmacy. Just to take CVS for example. CVS is a retail pharmacy that has a PBM that had a great deal of influence on what you actually paid for the drug that you just obtained into your little white bag from the CVS retail pharmacy.

So, yeah, RFK Jr. has rightly targeted this as an area for government action to clean it up to the benefit of the Americans so that again, when they're going to get their medicines, they are paying much less. There's a huge opportunity there. I don't know the extent to which he fully understands all of this, but hopefully if he does become the HHS director, that he has good people around him who can make sure that he does understand it.

The Fluoride Debate

I was going to mention a complex issue that not necessarily a negative or a positive, but related to fluoride in water here in the United States, which has been mainstream for many years. But the reason why it's interesting is that there are many countries around the world that have moved away from fluoridation and have made sure that they provide it to children who stand to benefit the most from fluoride in other more targeted ways and taking it out of the general water supply. So that's why I say there's a lot of evidence to suggest that nowadays fluoride in the water may not have the benefits it once had. And so worth I think looking at.

Yeah, it's a definitely complex topic because I think a lot more research needs to be done. Fluoride was started in the early 19th century and it was a huge public health success in decreasing dental caries for children. But as you said in the 1970s and 1980s, fluoride was added to the toothpaste and so it's hard to tell. Now the ADA does still recommend it in the water but many other organizations, like you said, other countries have been not using it.

The worry about it is: are there any kind of cognitive impairments from too high a concentration of fluoride in the water? Currently, anything less than 1.5 milligrams per liter is considered acceptable. And there's been other conditions also associated with excessive fluoride exposure, musculoskeletal in particular.

Certainly an area where neither you nor I are expert. Certainly is an area where lots has been written about it. And it's one of these areas that's very helpful because you can simply look at what other reasonable, transparent countries are doing and come to a conclusion. Flow and in this country like it is very variable. It's about 37% of the country gets fluoridated water. But certain places like Washington D.C. get 100%. Kentucky gets 93% but Alaska, it's like 3%. I would be interested to look at the data of the rate of cavity development of children in Alaska where the fluoridated water is so rare. That would be quite interesting to look at. We haven't done that research before the episode, but that could be something to follow up on.

Yeah, they did do a study like that in Calgary I believe once they defluoridated the water and they did see the level of dental cavities increase in that population there.

Reforming Medical Coding and the AMA

RFK Jr. just recently mentioned—and you happen to be one of the foremost experts on this—that the way that procedural codes for delivery of healthcare in this country are developed with a very strong influence and control over it by the AMA is something that he seeks to completely dismantle. So talk about that. Because there's no person, neither patient nor provider of medical care in this country who is not impacted by what he said he wants to do.

The way currently things work is that the AMA owns the CPT codes. CPT codes are the codes that are attached to each procedure that any physician does. So whether you're doing a colonoscopy, whether you're doing radiation treatment, whatever—not drugs, but procedures. So there's a code associated with each of them and the AMA owns those codes. The valuation for those codes comes from a panel called The RUC.

But a lot of it comes down to the expenses associated with it and the time that goes into it and how intense the work is. All that's kind of built in. But ultimately it's physicians who are acting independently of their specialties who sit on that panel, who come up with these rates and they survey the medical profession where the procedure is done to get accurate inputs. This is all in theory how it's supposed to work. Is it perfect? No. Is there variability and error and are all these inputs 100% accurate? No, but it's the best system we have. It's the system that's been around since the early 90s.

And there's a lot of vested interest, money, and inertia interest in keeping it the same way. All the procedural codes in all the electronic health systems for every hospital and medical facility in the country are attached to this. So just trying to change it and thinking we can just get rid of that system and change it to something else so easily will take a mountain to move. Now that being said, I do think it can be reformed and I hope maybe he can work to create some good reforms to it, like maybe more accurate pricing for some of these expensive equipments. But just to think it's going to completely change seems very unrealistic and unreasonable for somebody who doesn't actually necessarily know how the bureaucracy works and how things are done in medicine.

Bureaucratic Challenges and Corporate Lobbying

Which brings me to one of the worries I have: even if he does get confirmed, how is he going to navigate a bureaucracy of 13 agencies with no prior experience working in that setting? It's not easy to do something like that.

No. The complexity of the executive work that lies before him is so great and the kinds of changes that he has signaled he wishes to make are similarly great. Those two things from a probabilistic standpoint, both being effective in this, is a multiplication that results in a low rate of actually happening. And maybe I'm tipping my hand here for the audience, but maybe this is wishful thinking on my part that those two low probability skill sets again multiplied together, making them even less probable, is a good thing for stability in the US health care system. But I think it is, to be quite honest.

But the downside is the things of his agenda we really appreciate, which is reforms around pharmaceuticals and reforms around agricultural practices, subsidies, pesticides, are all the industries with the largest lobbying groups which have the most incentives to not see things change. And so like, even if he really does want to push this through, if he says we don't want direct marketing of Ozempic to patients on TV and then next thing you know, Trump gets a phone call from the CEO of that pharma company saying, "This is something that we want to continue and we're funding all these PACs that support your interest"—will the administration still proceed that route or will they back off?

Yes, and that is the wild card here. And even whether he will be confirmed or not is how motivated will these particular interests be in stopping the nomination and then how responsive will the senators who have a vote to confirm him or not be to that pressure? I suspect it will be pretty significant.

Yeah, no, 100%. One is the lobbying groups supporting the different candidates. But also the other thing is the people from the vaccine side and on that side with the pharma as well, because once again, vaccines are produced by pharma companies. Right after he was nominated, the stock prices for Moderna and Pfizer all plummeted. And so it's all connected. And so stay tuned. I guess we'll see if this confirmation goes through.

Summary and Outlook

So to sum it up, on the good side, we think there are definitely reforms that could be done around pharmaceutical and agriculture and health and chronic disease management. But we are concerned about the effects on public health and scientific legitimacy and vaccines. And then there's things we're still unsure about, like fluoride. Is it good or is it bad in the water? We don't know.

Yeah, it's a great summary. The nutrition of Americans needs to get it together one way or another. We as Americans and as healthcare voices need to help clean that up. That's absolutely true. The fluoride piece, as you say, is an area for further investigation for me. Really looking at this, those are, let's call it silver lining. The vaccine denialism, the connection, the statements about HIV and AIDS, Wi-Fi chemicals and sexual dysphoria, the COVID-19 conspiracy theories and the rest of it for me are a lot to get past. I'll be quite honest, but I don't have a vote. No one's going to ask me, so we will see.

Sounds good. Till next time.