A colleague of mine made some comments a few days ago that prompted me to put in writing things that I’ve been thinking about for years that, in my estimation, go to the core of some of the issues that trouble many Americans. First, I’ll very briefly review what he said, and then I’ll discuss what are the implications.
My colleague is a fellow cardiologist, Rob Califf, who happens to head the U.S. Food and Drug Administration. He’s worked at Google, Duke, and trained at my alma mater, UC San Francisco, and this is his second time at the helm of the FDA. The occasion was the opening plenary session of the just-completed Annual American Heart Association conference in Chicago, one of the most impactful medical meetings on cardiovascular disease in the world.
He called upon his fellow physicians to address two key issues — disparities in healthcare and misinformation, both of which adversely impact the health of Americans.
He presented a graphic of 23 developed countries compared to the U.S. in terms of health expenditures per capita and life expectancy. All of those countries outperformed us, having average life expectancies greater than 80 years of age (ours was about 78.4, and has been dropping between 2014 and 2018 - even before COVID), and spending about $4,500 per capita (we spend about $11,000). The common denominator of those other developed countries is that they have universal health coverage. We have politicians and for-profit healthcare entities who continue to say that universal healthcare is bad for Americans.
He also showed a map of life expectancies of every county in the U.S. over time. From 1970 to 2016, Americans living in urban and rural areas had about the same life span. But these life expectancies began to diverge in the late 1980s such that by 2016 rural Americans had about a 20% lower life span. Technology can only do so much, since insurance coverage, screening programs, prevention strategies for lifestyle and risk factors, and smoking incidence work against rural and underserved populations. We have devoted extended discussion of these topics in past columns, and will likely do so again. But I want to focus on his second area of concern: misinformation.
The global health status of individuals and the general public has advanced due to development of scientific methods to analyze and evaluate various diagnostic and treatment strategies. These have included meticulous observational and epidemiological studies, innovative and comparative testing of therapies culminating in the current gold standard, the well-designed and executed randomized clinical trial. In a world of unknowns and uncertainties, these tools have served humanity well to help find paths to better care.
But here’s where confusion may arise, often inadvertently, but occasionally by nefarious and vindictive intent. Science uncovers new information that may refine or even contradict prior teachings, sometimes so ingrained as to be dogma. It’s called learning. If new data arise that change a prior precept, it does not mean that doctors were lying before, or were ignorant, or other negative characterizations of experts who alter their positions based on new evidence.
COVID provides an example, seared into our collective memories. We all participated in this test of science. When COVID was first recognized at the end of 2019, almost nothing was known about it. Scientists around the world did not panic. Colleagues and healthcare corporations pivoted and collaborated in ways I have discussed previously, regardless of political affiliations or countries of origin, through open and back channels. That we went from the open publication of the COVID viral genome in January 2020 to validated effective vaccines nine months later was not a sketchy and sloppy rush job, but an all-hands-on-deck worldwide collaboration of clinician-researchers, bench-lab scientists, institutional and corporate support, and regulatory collaboration, utilizing new agile platforms and human common sense based on solid scientific principles.
As predicted, the virus has continued to mutate and evolve for infectivity advantages, and the scientific methods are right behind and looking for innovative ways to control it.
Weaponizing and demonizing the science and the scientists for political gain is not helpful. Indeed, the vast majority of patients dying of COVID are the unvaccinated. Vaccination is indeed a matter of personal choice, but if the information people get comes from their selected echo chamber that just reinforces their ill-informed opinions, they are not likely to change their minds. That’s why there still is a Flat Earth Society.
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And here’s another thing: Validated evidence is not proof of truth, since truth is theoretically immutable. Evidence is actually a validation of one’s confidence, positive or negative, in the validity of a hypothesis. And if evidence accrues and is corroborated by other rigorously conducted research, it’s actually OK to change one’s mind. It’s how science advances. I actually tell medical students and young doctors I teach that if things happen the way they expect them to, they’ve learned nothing. Variance in what they expect is what gives them the opportunity to learn something new, if they ask themselves “why did it happen … or not”.
If one does not give oneself the ability to learn and change one’s mind, one would still believe everything they learned in elementary school. Some still do.