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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:

[Music]

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.

[Music]

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.

The cast of Saturday Night Live has said lots of things over the course of the show’s 50-year history that have drawn wild cheers from its audience. But two Saturdays ago may have been the first time the person drawing shrieks of delight had been arrested for a cold-blooded assassination.

The spontaneous ovation was for Luigi Mangione, the 26-year-old charged in the December 4 killing of UnitedHealthcare CEO Brian Thompson. The husband and father of two teenage sons was walking to an investor meeting in Manhattan when he was shot in the back and leg. Police called the shooting, to which Mangione has pleaded not guilty, a “premeditated, preplanned, targeted attack.”

So how did Mangione become a folk hero? It’s not just the crowd attending SNL. An Economist / YouGov poll shows that 39 percent of people between the ages of 18 and 29 view him favorably, while an Emerson College poll shows 41 percent of that cohort finding the assassination acceptable. At least a hundred people even showed up at a court hearing to support Mangione.

The primary explanation for the lionization of Mangione is the rage directed at America’s health-care system in general and the health-insurance industry in particular, for its high costs, its profits, and its denial of coverage. To many people, Thompson embodied a system they consider not just broken but evil. They saw his killing as a strike against a system that exploits them. No one can plausibly argue that the murder of Thompson will do a single thing to fix the problems in America’s health-care system. Yet for some, his murder seemed cathartic, while others greeted the development with open glee.

Hours after Thompson was killed, UnitedHealthcare posted a statement on Facebook: “We are deeply saddened and shocked at the passing of our dear friend and colleague Brian Thompson.” Within a couple of days, more than 71,000 people had responded with the laughing emoji.

The journalist Taylor Lorenz told Piers Morgan she felt “joy” at the news of the shooting. (When Morgan responded with shock, Lorenz backtracked, saying, “Maybe not joy, but certainly not empathy.”) A professor of bioethics at St. Louis University shared her own story of frustration with UnitedHealthcare, declaring that while she was not celebrating Thompson’s killing she was also “not sad” because “chickens come home to roost.” One person, commenting on a video of the shooting online, said, “Thoughts and deductibles to the family. Unfortunately my condolences are out-of-network.” Another wrote, “My only question is did the CEO of United Healthcare die quickly or over several months waiting to find out if his insurance would cover his treatment for the fatal gunshot wound?” A road sign in Seattle said, “One Less CEO. Many More to Go.”

THEN THERE ARE people like Jia Tolentino, a staff writer at The New Yorker, who says she holds “anti-capitalist views” and believes “the American health-care system is profoundly immoral.” In an appearance on Amanpour & Co. to discuss an essay she’d written about the Thompson murder, Tolentino said, “There are lots of different kinds of violence. Someone shooting someone in the street is one. I think our health-care system is quite clearly another.”

Tolentino went on to invoke Friedrich Engels’s concept of “social murder,” his term for a society withholding the conditions that are necessary for its people to live. For Tolentino, “social murder” describes America’s policies on the minimum wage, housing, and, in particular, health care. She said: “I just think there are a lot of ways to unjustly and immorally end someone’s life before it should have ended. One of them, the kind of violence that we fixate on in this country, is a single person with a weapon that intends harm upon another person and then causes it. But there’s a lot of other ways to end a life early and unjustly and immorally, and denying people health care is one of them.” Mangione was being celebrated as a folk hero, she explained, “for taking someone out that was seen to be a danger to public safety.”

But Tolentino wasn’t done.

“If people want to make CEOs of profoundly immoral companies, if we want to make their lives miserable”—at this point, she smiled and chuckled—“we can do that without shooting them.” She went on to advocate for “obstructive forms of protest” that “are not violent and murderous.” So while Tolentino wasn’t endorsing brazen murder, you could be excused for suspecting her of being sympathetic to those who have turned an Ivy League graduate accused of brazen murder into a folk hero. After all, in her own estimation, the man Mangione shot in the back, Brian Thompson, was himself responsible for “social murder.”

WHAT A LOT OF PEOPLE who are celebrating Thompson’s death and demonizing UnitedHealthcare don’t seem to understand—or don’t seem to want to understand—is that in every modern health-care system, some institution is charged with rationing care. In some, it’s a government bureaucracy. In others, it’s a private for-profit or nonprofit insurer. In America, it’s a mix of all three. Many insurers, such as Blue Cross Blue Shield and Kaiser Permanente, are nonprofits. The biggest insurers are Medicare and Medicaid, which are single-payer public programs. So is the Veterans Affairs Department. Other insurers are for-profit companies, like UnitedHealthcare.

You don’t have to be a fan of the way that UnitedHealthcare makes its decisions to acknowledge the difficulty of mediating between providers and patients. Private insurers make their rationing decisions in ways that are relatively transparent but always far from perfectly simple or fair. But if they didn’t do it, someone else would need to, Yuval Levin of the American Enterprise Institute told me. The reality of scarcity is not their fault, nor is it “social murder.”

As the intermediary in the health-care system that plays the requisite role of rationing care, UnitedHealthcare surely makes some horrifying decisions and outright mistakes, and even when it rules out coverage based on a defensible calculus of costs and benefits, that can be a devastating thing for patients and their loved ones to hear. So there’s legitimacy in the frustration and anger many people feel. Nevertheless, turning to lethal violence is horrifying and ominous. So, too, is applauding and justifying assassinations.

The American health-care system certainly has its flaws, but those are hardly the fault of UnitedHealthcare alone. Nations such as the United Kingdom, which offer the sort of single-payer public health care that Tolentino extolls, have long wait lists for treatment, significant staff shortages, and outdated hospital infrastructure. Public satisfaction with the U.K.’s National Health Service is at a 40-year low; only 29 percent of the British public is “quite satisfied” or “very satisfied” with the NHS.

Alan Milburn, who was a member of the Labour Party and England’s health secretary, years ago conceded what is still true: “The NHS—just like every other health system in the world, public or private—has never, or will never, provide all the care it might theoretically be possible to provide. That would probably be true even if the whole of the UK gross domestic product was spent on health care.”

NOW CONSIDER WHAT HAPPENS when the logic of those who are celebrating Mangione is applied to a different issue. Some Americans believe that abortion is murder, and that those who facilitate abortion deserve to be punished for their complicity with evil. Imagine if, after an attack on an abortion clinic, a journalist were to say “I just think there are a lot of ways to unjustly and immorally end someone’s life before it should have ended. One of them, the kind of violence we fixate on in this country, is a single person with a weapon that intends harm upon another person and then causes it. But there’s a lot of other ways to end a life early and unjustly and immorally, and aborting an unborn child is one of them.”

And, they might continue “there are different kinds of violence. Someone shooting someone in the street is one. I think organizations that facilitate abortions is quite clearly another.”

The list of organizations and individuals who could be targeted because their critics on the left or on the right believe they support policies that lead to suffering or death is endless: gun-rights lobbies; those who want to defund the police; individuals opposing childhood vaccinations, and those who administer them; groups that want to cut funding for the global AIDS initiative; those that want the United States to withdraw from the Paris climate accords; those that oppose a higher minimum wage. So who decides which Americans are guilty of “social murder”? Staff writers at The New Yorker? And what actions will we justify against those deemed to have committed murder by omission rather than commission—in the words of Engels, “disguised, malicious murder, murder against none who can defend himself”?  

ON DECEMBER 9, the family and friends of Brian Thompson gathered at Lord of Life Lutheran Church in Maple Grove, Minnesota, to mourn his loss. Thompson grew up in a working-class family in Jewell, Iowa; he appears to have been liked by pretty much everyone who knew him.

“He was just a farm kid living out in rural Iowa,” Taylor Hill, a close friend of Thompson’s from childhood, told The New York Times. “Everybody got along with him and he got along with everybody else. He was just a great, silly, funny, smart guy to be around all through the years that I have known him.”

At Jewell’s South Hamilton High School, the Times reported, Thompson was valedictorian, a star athlete, homecoming king, and class president. A teacher described Thompson as an excellent student, a model person, “a super kid.” As a corporate leader, he kept a low profile; friends and colleagues remembered him as mild-mannered and humble, down-to-earth and self-deprecating. He was a passionate advocate for the Special Olympics and a devoted father to his sons, Bryce and Dane. His obituary described his love for his sons as “limitless.”

“Brian was an incredibly loving, generous, talented man who truly lived life to the fullest and touched so many lives,” his wife, Paulette Thompson, told Fox News.  

“A lot of people are judging him, not knowing him at all,” Hill told the Times. “And it’s not right. That’s not him. It’s just a sad thing of what has happened and even more sad of what people have tried to turn him into.”

Thompson’s funeral service was attended by those who loved him. But it also required the presence of a dozen state troopers, a drone flying overhead, and a police sniper stationed on the roof of the church. A security code was needed to get into the church, and Thompson’s home received fake bomb threats after he was assassinated.

Celebrating a murder and turning an accused killer into a sex symbol and a cult hero, a modern-day Robin Hood, requires an astonishing level of dehumanization; it is only slightly less appalling when journalists covering the story find ways to excuse the people doing the celebrating, on the grounds that they are displaying a social conscience. But when angry mobs of social-justice activists get riled up, their righteous anger needs targets, some figurative and some literal.

In the meantime, Bryce and Dane Thompson just spent their first Christmas without their father.

His four years in office were fraught, bedeviled from the start by double-digit inflation and a post-Vietnam-and-Watergate bad mood. His fractious staff was dominated by the inexperienced “Georgia Mafia” from his home state. His micromanagement of the White House tennis court drew widespread derision, and his toothy, smiling campaign promise that he would “never lie” to the country somehow curdled into disappointment and defeat after one rocky term.

Yet James Earl Carter Jr., who died today at his home in Plains, Georgia, surely has a fair claim to being the most effective former president his country ever had. In part that’s because his post-presidency was the lengthiest on record—more than four decades—and his life span of 100 richly crowded years was the longest of any president, period. But it’s also because the strain of basic decency and integrity that helped get Carter elected in the first place, in 1976, never deserted him, even as his country devolved into ever greater incivility and division.

[James Fallows: Jimmy Carter was a lucky man]

During his presidency, Carter was a kind of walking shorthand for ineffectual leadership—a reputation that was probably always overblown and has been undercut in recent years by revisionist historians such as Jonathan Alter and Kai Bird, who argue that Carter was a visionary if impolitic leader. But his career after leaving the White House offers an indisputable object lesson in how ex-presidents might best conduct themselves, with dignity and a due humility about the honor of the office they once held.

Not for Carter was the lucrative service on corporate boards, or the easy money of paid speeches, or the palling around on private jets with rich (and sometimes unsavory) friends that other ex-presidents have indulged in. After leaving office at age 56, he earned a living with a series of books on politics, faith, the Middle East, and morality—plus several volumes of memoirs and another of poetry. With his wife, Rosalynn, he continued to live modestly in Plains, Georgia. He forged what both participants described as a genuine and enduring friendship with the man he beat, Gerald Ford. (In his eulogy at Ford’s funeral, in 2007, Carter recalled the first words he had spoken upon taking office 30 years earlier: “For myself and for our nation, I want to thank my predecessor for all he has done to heal our land.” He added, “I still hate to admit that they received more applause than any other words in my inaugural address.” It was a typically gracious tribute, and a typically rueful acknowledgment of wounded ego.)

Carter promoted democracy, conducted informal diplomacy, and monitored elections around the globe as a special American envoy or at the invitation of foreign governments. He taught Sunday school at his hometown Baptist church, and worked for economic justice one hammer and nail at a time with Habitat for Humanity, the Christian home-building charity for which he volunteered as long as his health permitted. In 2002, he won the Nobel Peace Prize for his work “to find peaceful solutions to international conflicts, to advance democracy and human rights, and to promote economic and social development.”

True, he sometimes irritated his successors with public pronouncements that struck them as unhelpful meddling in affairs of state. He backed the cause of Palestinian statehood with a consistency and fervor that led to accusations of anti-Semitism. He retained a self-righteous, judgmental streak that led him to declare Donald Trump’s election illegitimate. His fundamental faith in his country was sometimes undercut by peevishness regarding the ways he thought its leaders had strayed. But he never seemed particularly troubled by the critiques.

[Read: The record-setting ex-presidency of Jimmy Carter]

Indeed, one of his most criticized comments seems prescient, even brave, with the hindsight of history—not so much impolitic and defeatist, as it was seen at the time. In the summer of 1979, Carter argued that his country was suffering from “a crisis of confidence” that threatened “to destroy the social and the political fabric of America.” That pronouncement seems to have predicted the smoldering decades of political resentment, tribal anger, and structural collapse of institutions that followed it.

“As you know, there is a growing disrespect for government and for churches and for schools, the news media, and other institutions,” Carter said then. “This is not a message of happiness or reassurance, but it is the truth and it is a warning.” Weeks later, the New York Times correspondent Francis X. Clines forever tagged Carter’s diagnosis with an epithet that helped doom his reelection: Clines called it the president’s “cross-of-malaise” speech, a reference to William Jennings Bryan’s 1896 warning that the gold currency standard risked mankind’s crucifixion “upon a cross of gold.”

Just how much Carter’s own missteps contributed to the problems he cited is a legitimate question. His communication skills left a lot to be desired; he could be prickly and prone to overexplaining. His 1977 televised “fireside chat,” in which he urged Americans to conserve energy by turning their thermostats down, was politically ham-handed: It seemed stagy and forced, with Carter speaking from the White House library in a beige cardigan sweater. But his focus on the environment (he installed solar panels on the White House roof) was forward-looking and justified, given what we now know about climate change. His insistence on the consideration of human rights in foreign policy may have struck some as naive in the aftermath of Henry Kissinger’s relentless realpolitik during the Nixon and Ford years, but few could doubt his convictions. It was a bitter blow that his atypically hawkish effort to rescue the diplomats held hostage in the American embassy in Iran failed so miserably that it helped ensure Ronald Reagan’s election. (In the fall of 1980, when it seemed unlikely that the hostages would ever be released on Carter’s watch, undecided voters fled to the former California governor.)

But Carter clocked substantial achievements too: the peaceful transfer of ownership of the Panama Canal; the Camp David peace accords between Israel and Egypt; full normalization of relations with China; and moves toward deregulation of transportation, communication, and banking that were considered a welcome response to changing economic and industrial realities.

“One reason his substantial victories are discounted is that he sought such broad and sweeping measures that what he gained in return often looked paltry,” Stuart Eizenstat, Carter’s former chief domestic-policy adviser, wrote in October 2018. “Winning was often ugly: He dissipated the political capital that presidents must constantly nourish and replenish for the next battle. He was too unbending while simultaneously tackling too many important issues without clear priorities, venturing where other presidents felt blocked because of the very same political considerations that he dismissed as unworthy of any president. As he told me, ‘Whenever I felt an issue was important to the country and needed to be addressed, my inclination was to go ahead and do it.’’’

In his post-presidency, Carter went ahead and did it, again and again, with a will that his successors would do well to emulate—and that, to one degree or another, some of them have. Carter tackled the big problems and pursued the ambitious goals that had so often eluded him in office. He worked to control or eradicate diseases, including Guinea worm and river blindness. His nonprofit Carter Center, in Atlanta, continues to advance the causes of conflict resolution and human rights, and has monitored almost 100 elections in nearly 40 countries over the past 30 years. And he never stopped trying to live out the values that his Christian faith impelled him to embrace.

Carter’s model of post–White House service almost certainly served as a guide for the bipartisan disaster-relief work of George H. W. Bush and Bill Clinton, and for Clinton’s global fight against AIDS. George W. Bush works to help post-9/11 veterans through the Bush Institute. In many ways, Barack Obama is still establishing just what his post-presidential identity will be, though his My Brother’s Keeper initiative promotes opportunities for boys and young men of color. Carter showed the country that presidents’ duty to serve extends well beyond their years in office.

During his presidency, Carter kept Harry Truman’s The Buck Stops Here sign on his desk as a reminder of his ultimate responsibility. Truman left office with a job-approval rating of just 32 percent, close to George W. Bush’s, Trump’s, and Carter’s last ratings—the four worst in modern times. Truman lived for almost 20 years after leaving office, but he still did not live long enough to see the full redemption of his reputation as a plainspoken straight shooter who did his best in troubled times. Carter, who left office a virtual laughingstock but left this earthly life a model of moral leadership, did.

In 1829, the Presbyterian minister Sylvester Graham invented a cracker made from coarse wheat that he believed would help restore American health. He lamented the “miserable trash” that made up the average diet, especially white bread, and thought his eponymous crackers would curtail masturbation, which he deemed deleterious to both moral and physical well-being. (As someone who condemned sweet treats, he would have seen the s’more as an abomination.)

Graham was, in many ways, what we might today call a wellness influencer. Nineteenth-century Americans opened Grahamite boarding houses so that travelers could eat his chaste and bland foods, and catch up on that week’s copy of The Graham Journal of Health and Longevity. And like many of today’s wellness influencers, he advocated for an ideology that mixed truth and nonsense. Yes, it’s healthy to eat fiber; no, pleasurable foods are not linked to deviant sexual behaviors. Robert F. Kennedy Jr., a wellness influencer who is also President-Elect Donald Trump’s pick for secretary of Health and Human Services, is similarly inconsistent. Kennedy has correctly identified an association between the ultra-processed American diet and high rates of chronic disease, but he’s also an anti-vaccine advocate who has suggested that AIDS deaths are caused by poppers and that seed oils are poison.

Over the past weeks, journalists, doctors, and scientists have rushed to correct Kennedy’s false statements. More than 75 Nobel Prize winners signed a letter this week asking senators to oppose Kennedy’s confirmation, given his “lack of credentials” in medicine, science, and public health. But a better way to understand his appeal is to situate him, with Graham, in a long lineage of American wellness figures waging a battle against conventional medicine. For more than a century, alternative health practices—what we now call wellness—have seduced Americans not because of the accuracy of their claims, but because of what else they offer: a sense of certainty, an outlet for mistrust, a pseudo-religious belief in the “natural,” and an affirmation of modernity’s limits. Because it satisfies those needs, wellness has a pattern of success in presenting itself as a replacement for the failures of medicine, even though the goals of wellness radically diverge from those of public health. The history of wellness suggests that the best way to defuse Kennedy’s power is not by litigating each one of his beliefs, some of which are irrefutable health truisms, but by understanding why the promise of being well has such lasting appeal.

Our Goop-ified world may seem fundamentally modern, but there is a direct line between today’s wellness industry and the 1800s, when what was then called “irregular” medicine exploded in popularity. Through the early 20th century, people sought out homeopathy, osteopathy, naturopathy, water cures, and chiropractors. Religious and spiritual movements such as New Thought and Christian Science promoted the idea that bodily health came from the right state of mind, not medicine.

[Read: I Gooped myself]

These health interventions were largely a response to disillusionment with 19th-century medicine, which was, by today’s standards, painful and ineffective. Doctors depended heavily on bloodletting, vomitive drugs, and other “heroic” treatments that shocked the body into purging its contents. A commonly used drug, calomel, was made of a mercury compound and caused the gums to bleed, the mouth to swell, and teeth to fall out. Irregular medicine offered another option, with conspiratorial undertones: There was a gentler cure that conventional doctors weren’t telling you about. (And unlike calomel, irregular treatments wouldn’t cause your teeth to fall out.) A 1903 osteopathic text decreed, “The world is becoming too intelligent to be drugged and hacked in a search for health when more agreeable methods can be obtained at the same price.”

In response to the unregulated health products being distributed by irregular practitioners and conventional physicians alike, as well as uproar over the unsafe food-handling practices revealed in Upton Sinclair’s The Jungle, the contemporary American public-health apparatus was born. The FDA was created to enforce the Pure Food and Drug Act of 1906, which, among other things, required safe practices for manufacturing food, drugs, medications, and liquors as well as labels that included a product’s dangerous ingredients. Laws limiting the practice of medicine to those with proper licenses became more widespread and more consistently enforced; Benedict Lust, the father of American naturopathy, had to pay hundreds of dollars in fines and legal fees after giving one of America’s newly minted medical detectives an electric-light bath, a treatment that involved sitting in a cabinet with incandescent lights pointed at the body.

As part of their advocacy for the natural, Lust and other irregular doctors also vehemently opposed vaccines. Lust called compulsory vaccination the “most heinous of all crimes.” He even helped nominate a chiropractor for president in 1920 and joined him to promote what they called the American Drugless Platform. Lust was remarkably similar to Kennedy, who decries pesticides, opposes fluoride in tap water, and has long stoked baseless fears about vaccines. Kennedy has said doctors should recommend gym memberships and “good” food to diabetic patients. He has proposed that people who are dependent on antidepressants or opioids could recover on “wellness farms,” an idea remarkably similar to Lust’s well-known naturopathy retreat in New Jersey, which opened in 1896. “His arguments are variations on the same theme that’s been present in public discourse about health in the Western world for a long time,” Colleen Derkatch, a rhetoric professor at Toronto Metropolitan University and the author of Why Wellness Sells, told me.

Many of Kennedy’s most popular crusades are easy to debunk—just as irregular medicine was at the turn of the 20th century. Horace Fletcher, a trendy nutritionist in the early 1900s, told Americans to chew their food until it was liquid before swallowing, and proposed that this would be the solution to starvation and poverty. He inspired the celebrity doctor John Harvey Kellogg, whose name still graces our cereal boxes and who promoted electric-light baths and 15-quart water enemas. Bernarr MacFadden, another immensely popular health figure, and a bodybuilder, thought that the 1918 Spanish-flu pandemic was caused by poor diet. Even at the time, these ideas were fringe among experts. But they caught on because they spoke to people’s real concerns: about rapid urbanization’s effects on health and lifestyle, and about medicine’s inability to prevent widespread death.

The concerns of modern wellness adherents are no less valid than their 20th-century counterparts. Medical treatment in general has become more effective, but still has sins to atone for: The pharmaceutical industry fueled an opioid epidemic that has killed 800,000 Americans and counting, all while drug prices in the U.S. are nearly triple what they are in other well-off countries. Most of the food available at the average American grocery store is ultra-processed. Some aspects of the public-health response to the coronavirus pandemic, such as shutdowns and school closures, led to distrust of public-health officials—just as happened after the flu pandemic of 1918.

“Low institutional trust is central to RFK Jr.’s popular appeal,” Stephanie Alice Baker, an associate professor at City St George’s, University of London, and the author of Wellness Culture, told me. Kennedy provides what irregular medicine did: an outlet for feelings of betrayal at medicine’s failures, plus the promise of reclaiming control through “natural” means, such as the right diet and supplements. “It’s an empowering message,” Alan Levinovitz, a religion professor at James Madison University and the author of Natural: How Faith in Nature’s Goodness Leads to Harmful Fads, Unjust Laws, and Flawed Science, told me. “It means you don’t have to be scared of getting sick if you eat the right foods.”

Irregular medicine began to fade out only once the U.S. entered the “golden age of medicine,” when conventional treatments became more effective and less terrifying. The first antibiotic was discovered in 1928 and was widely available after World War II. The polio vaccine was released in 1955, and two years later, annual cases had dropped almost 90 percent, making older arguments against “germ theory” far less compelling. Practices like homeopathy and osteopathy took a back seat to “wonder drugs” that could address infectious diseases such as smallpox and tuberculosis. But after these successes, medical and public attention shifted to chronic, noncommunicable ailments: cancer, diabetes, heart disease, and the like. The golden age of medicine was ill-equipped to counter these maladies, and once again, as the luster of conventional health expertise waned, wellness surged.

Halbert L. Dunn, the chief of the National Office of Vital Statistics, coined the term wellness in 1959 when writing about health-care providers’ dissatisfaction with the ability of medicine to care for the “spirit.” He helped to reignite interest in alternative medicine, and its emphasis on vegetarianism, exercise, and natural living. Alternative medicine became a national trend in the 1970s, entwined with the antiauthoritarian countercultural movement. Crucially Dunn considered wellness not a replacement for or foe of medicine, but its complement. Medicine was a reaction to illness; wellness was a practice you engaged in when healthy. But doctors rushed to defend the ways of conventional medicine. In the late 1970s, the prominent physician Lewis Thomas wrote a commentary in The New England Journal of Medicine warning that the new field of lifestyle medicine was “wide open for magic.” Today, an evidence-based cohort of conventional doctors are still set on debunking wellness practices, while wellness figures decry the failures of medicine and the corruption of Big Pharma.

The pull toward the “natural” can be especially enticing when the world seems designed to make people sick. There’s concern about “forever” chemicals while food comes wrapped in plastic, and wildfires send smoke pouring across continents. Levinovitz has argued that, in the wellness world, the term natural assumes a pseudo-religious status. It provides comfort, ritual, and community. If wellness is a church that views “clean” or “natural” food as sacred, and additives or vaccines as profane, then Kennedy fits neatly within it. Religious beliefs famously cannot be dispelled through arguments over evidence, which does not bode well for anyone who wishes to wrest the American public out of Kennedy’s grasp.

[Read: The sanewashing of RFK Jr.]

Like religion, wellness doesn’t captivate by empirically proving its truth to adherents. But it does meet certain psychological needs. By contrast, the crucial project of the U.S. public-health apparatus is not to soothe its citizens’ existential woes, but to make policies that address the health of the masses. An administration that prioritizes the sacraments of wellness above all—especially if it undermines the efficacy of vaccines, cuts funding for infectious-disease research, and reduces regulation around raw milk—won’t make Americans healthier. This country reckoned with the limitations of wellness’s promises in the last century; perhaps, in this one, Americans can resist substituting wellness for what public health has to offer.