It’s been a week since Joe Biden won. Now what for medical science policy?

A week ago this Saturday, after four days of ballot counting, tabulation, speculation, commiseration, and angst on all sides, it became clear that Joe Biden had won Pennsylvania, and with it the necessary Electoral College votes to put him over the top for the Presidency. True, there have been (and probably will still be) be recounts and legal challenges, but most agree that President Trump doesn’t have much of a leg to stand on legally, and thus far his legal challenges have been shot down like Japanese Zeroes during the Battle of the Philippine Sea. (Look it up if you’re not big on WWII history. It’s even a bit of a Thanksgiving reference.) It is also unlikely that recounts will change the results in enough states to flip the election back to President Trump. What this means is that, barring a truly unexpected development, on January 20, Joe Biden will take the oath of office and become the 46th President of the United States.

I’m not interested in discussing the politics, mechanisms, or machinations of the election itself so much, though. Regular readers know my politics (particularly if they follow my Twitter feed, which is a lot more explicit about my leanings). Still, on this blog, I strive to remain nonpartisan, although, contrary to what some try to tell me I should be, I’ve never been apolitical, given my support for science-based health policy, such as cracking down on quackery, not legitimizing homeopathy with FDA approval, and supporting strong school vaccine mandates. That being said, this election season has been very painful to watch and participate in (at least for me), and, I’m sure, nerve-wracking for some of my friends in the UK, Europe, Australia, and other countries around the world to watch from afar. Regardless of party, what I am interested in is what the new administration will mean for science and science-based medicine in terms of federal law and policy. Unfortunately, these days it is impossible not to be at least somewhat partisan, given the policies of the two parties with respect to science in 2020.

In any event, I can’t help but note that I did the same thing four years ago, commenting on what I thought might be the consequences after Donald Trump had first become President-Elect. Interestingly, many of the predictions at the time were fairly prescient, although none of us who made them can take that much credit for brilliance given how much the Trump campaign had telegraphed its hostility to climate science, environmental science, and what it perceived as excessive “regulation” by the Food and Drug Administration (FDA) over drug approval and development. It didn’t take much knowledge to produce at least a rough outline of what would be coming.

Scientists’ reactions to 2016 versus real-life outcomes

In 2016, blogger Jann Bellamy noted that Trump’s victory had “stunned scientists“, citing a number of them saying things like:

Also:

“With a climate skeptic as President and a creationist as vice-president, scientists can only be worried.” —Albert Descoteaux, a biologist studying host-parasite reactions at McGill University in Montreal, Canada.

And:

“Trump will be the first anti-science president we have ever had,” Michael Lubell, director of public affairs for the American Physical Society in Washington, D.C., told the journal Nature. “The consequences are going to be very, very severe.”

Perhaps the most telling reaction cited was this one:

“I am confused, angry, depressed. I feel much like I do when I receive the comments on a rejected paper that the reviewers have torn apart. This morning I realized that I don’t actually know a Trump supporter who I could talk to about the election. How can I reach the public if I’m only speaking to my own circle?” —Peter Peregrine, an anthropologist at Lawrence University in Wisconsin and the Santa Fe Institute in New Mexico.

Therein lies part of our problem as scientists. I’ll have more to say about that near the end of this post, but for now I want to start by mentioning that my reaction to the election of Donald Trump as President focused primarily on its potential effect on science policy with respect to SBM. (Surprise! Surprise! I’m a surgeon, translational scientist, and my main hobby is blogging about SBM and its opposites!) For example, one of my posts right after the 2016 election concentrated on Trump’s (and, let’s face it, the Republican Party’s) obsession with “deregulation” and its definite sympathy towards the “health freedom movement” and what that might mean for “right-to-try,” given that Trump would be entering office with control of both Houses of Congress as well. It turns out that, in retrospect, I was correct about a lot of things, and a federal “right-to-try” law was passed in 2018 (although it didn’t really do much of anything, other than allow for the exploitation of desperate patients, as it was intended to. I was also correct about the push to loosen drug approval standards at the FDA, which began immediately, when Trump floated the names of Peter Thiel-backed libertarians to head the FDA, one of whom thought that the free market should decide which drugs are effective and that the FDA should only make sure they are safe before approving them, the other of whom thought that online rating systems, an “Uber” or “Yelp” for drugs if you will, would be a fine idea to evaluate the safety and efficacy of medications. Scott Gottlieb, who was ultimately chosen, turned out to be the “least bad” choice in that he at least was competent. However, he was a genuine “pharma shill” with deep ties to the pharmaceutical industry who believed in “streamlining” the FDA drug approval process further than it had been “streamlined” already, even though arguably the process had already become too lax.

Meanwhile, Trump chose Dr. Tom Price, a member of the medical crank organization disguised as a medical professional society (the Association of American Physicians and Surgeons, or AAPS) to be the Secretary of the Department of Health and Human Services (HHS). Recall that AAPS has long promoted a wide range of conspiracy theories, including antivaccine pseudoscience (including Andrew Wakefield), and has since pivoted to promoting COVID-19 misinformation and conspiracy theories. This reminds me, the Trump administration was already quite awful with respect to federal policy relating to SBM even before the COVID-19 pandemic. Every year, it proposed slashing the NIH budget starting immediately upon taking office, for example. Fortunately, every year, even the Republican-controlled Congress didn’t oblige him and even significantly increased the NIH budget. In addition, his first CDC Director, although refreshingly very pro-vaccine, had a history of selling quackery, while there were reported attempts to censor the CDC’s budget requests by flagging it for words that should not be said.

COVID-19 intervenes

Regular readers will likely have noticed that over the last several months the COVID-19 pandemic has come to dominate the blogging here at SBM. This is no surprise, of course, given that the pandemic, our responses to it in terms of policy, the search for treatments and a vaccine, and the political response to federal, state, and local policies represent the single largest ongoing story related to medicine in 2020 and will without a doubt continue to be so well into next year, if not for the full year. How could it be otherwise? Basically, the COVID-19 pandemic is not going away any time soon, the wishful thinking of President Trump notwithstanding, and the US has had disproportionately more cases and more fatalities than any other nation on earth. That last part is just a fact. The US represents only 5% of the world’s population but accounts for nearly one-fifth of the world’s deaths from COVID-19, roughly 237,000 so far as of the time I write this, and we are racking up over 100,000 new cases per day. By any reasonable measure, things are not going well with respect to COVID-19 in the US. As a nation, we are not handling the pandemic well.

There are many reasons for this, not the least of which is how COVID-19 has unleashed conspiracy theories all over the world, but in particular in the US. The antivaccine movement rapidly joined forces with COVID-19 conspiracy theorists, minimizers, deniers, and cranks, an unholy alliance that developed very early in the pandemic, to become a major force in resisting public health interventions to slow the spread of COVID-19 and mitigate its massive harm. Antivaccine conspiracy theories merged with COVID-19 conspiracy theories and then with QAnon to produce a toxic soup of seemingly unstoppable misinformation and disinformation that millions, ensconced in their social media bubbles, have come to believe, while antivaxxers launched a pre-emptive disinformation campaign to cast doubt on the safety and effectiveness of COVID-19 vaccine candidates that had rapidly gone into development.

Here’s one area where the Trump Administration, in its hostility to regulation coupled with its desperation to find a quick fix for the pandemic, made things so much worse. First, it named its COVID-19 vaccine initiative “Operation Warp Speed,” a name that implied that speed was being valued above all, including safety, to the point where even pro-vaccine voices (including myself) expressed doubt over whether the FDA would adequately assess and confirm the safety of COVID-19 vaccine candidates before approving them. It took a lot to lead those of us as pro-vaccine as, for example, Paul Offit, Peter Hotez, and myself, to question whether the FDA would adequately assess the safety and efficacy of COVID-19 vaccine candidates, but damn if the Trump administration didn’t manage it.

Then there was the active undermining of science-based responses to the pandemic. Anthony Fauci, Deborah Birx, and others tried to emphasize responses to the pandemic based on the best public health science. True, the disaster that has been the federal response to the COVID-19 pandemic wasn’t all Trump’s fault. (In an event this large, it never is anyone’s fault, solely.) For example, there were missteps coming from the President’s coronavirus task force. Messaging on masks early in the pandemic was borderline disastrous, such as when the main message being promoted was that people probably shouldn’t wear masks routinely unless they were sick. This was likely adopted in an effort to preserve the supply of medical grade masks for frontline healthcare workers and based on the then-current understanding that COVID-19 probably wasn’t contagious in asymptomatic patients, a conclusion that turned out to be tragically wrong when it became clear that asymptomatic transmission of SARS-CoV-2, the coronavirus that causes the disease, is a major means of its spread.

Whatever the reasons in the “fog of war” early in the pandemic for this misstep, the mixed messaging on masks wasn’t entirely Trump’s fault. What was Trump’s fault was his decisions to refuse to wear a mask, to mock those who did wear masks (including his opponent former Vice President Joe Biden) as “weak,” and to politicize the wearing of masks such that not wearing one became a mark of Trump’s “tribe,” while wearing a mask marked a person as being a “liberal,” or the enemy “tribe.” This continued even after the evidence made it clear that masks work to slow the spread of COVID-19. Unlike Fauci, however, Trump refused to change his mind when evidence had by June become pretty definitive that masks work, encouraging the spread of disinformation about masks. (Also, masks don’t make you sicker, nor are shopkeepers obligated under the Americans With Disabilities Act to let maskless shoppers into their stores.) Even after he himself had contracted COVID-19 six weeks ago, thanks to a lack of concern about most precautions other than testing in the White House, and became, I suspect, sicker than was being let on, President Trump continued to attack public health messaging designed to slow the spread of the disease and portrayed himself as having “beaten it”, all while continuing to portray the US as just “rounding the turn” with respect to the pandemic, despite the copious evidence otherwise.

And don’t even get me started on the other—shall we say?—unhelpful things that Trump did. Who could forget his promotion of hydroxychloroquine, an antimalarial and mildly immunosuppressive drug whose efficacy was at the time unproven, as a “cure” for COVID-19? This led to a run on the drug, resulting in shortages for those patients who needed it to treat their rheumatoid arthritis and other autoimmune diseases. Spurred by Trump, all manner of quacks (e.g., Drs. Mehmet Oz, Didier Raoult) and Trump administration officials (e.g., Peter Navarro) promoted the drug as a virtual “miracle cure,” complete with “miracle cure” testimonials of recovery, and portrayed those casting doubt on its efficacy (or even just urging caution and waiting for results from randomized clinical trials) as downright evil people who wanted more people to die. All of this led to a premature emergency use authorization (EUA) by the FDA for hydroxychloroquine to treat COVID-19, an EUA that was rescinded not long after as randomized clinical trials failed to demonstrate efficacy. Even now, hydroxychloroquine is the Black Knight of COVID-19 treatments, its adherents refusing to admit what science has shown and astroturf campaigns still actively promoting the drug, along with the conspiracy theory that big pharma and other nefarious “deep state” forces had “suppressed” evidence that it works.

Meanwhile, the politicization of the FDA and CDC got so bad that last month the Government Accountability Office launched an investigation, charging that “the Trump Administration has reportedly pressured the CDC and FDA throughout the COVID-19 pandemic, repeatedly applying political pressure and imposing orders on career scientists that undermine the agencies’ credibility and independence”. This sort of pressure took the form of political pressure to approve a vaccine by EUA, pressure that led me to ask two months ago if we can even trust the CDC and FDA any more, given how the messaging from the CDC had been affected and the declining trust in the FDA’s drug approval processes, given the obvious political pressure brought to bear on the agency. In the last couple of months, even Anthony Fauci and Deborah Birx were sidelined, in favor of someone who is—let’s face it—a hack, a radiologist who hasn’t practiced in years and has no training or experience relevant to the pandemic in public health, epidemiology, or infectious disease, a Hoover Institution political flack named Dr. Scott Atlas. This is a man who has basically embraced the nonsolution based on likely unattainable “herd immunity” known as the Great Barrington Declaration, whose proponents have a rather inflated view of themselves and their importance.

The bottom line, from my perspective at least in terms of the Trump administration’s record with respect to federal policy related to SBM, is that President Trump was even worse than I had feared. That was even before his disastrous response to the COVID-19 pandemic and doesn’t even count his record on climate change and the environment. He sidelined scientists, prematurely approved treatments, and basically meddled in science-based policy in disastrous ways, leading to damage in the federal scientific infrastructure that could take decades to undo.

Will Joe Biden be better?

All of this leads to the natural question: Will Joe Biden, after he becomes President, be any better than President Trump on science? Certainly, it would be quite difficult for him to do worse, and there are several encouraging signs. For one thing, President-Elect Biden made controlling COVID-19 the centerpiece of his campaign, arguing that the economic damage due to public health mitigation measures can’t be reversed until the pandemic is under much better control. He has promised to listen to scientists and a week ago appointed a COVID-19 transition task force full of real scientists to advise him during the transition.

Another failure of the Trump administration was to refuse to use the resources of the federal government to provide guidance and instead basically leaving each state to fend for itself. Another disastrous decision was to pull the US out of the World Health Organization:

Biden’s administration will also re-open lines of communication with other countries and international organizations in its fight against the coronavirus. Trump pulled the United States out of the World Health Organization earlier this year, criticizing the international agency for supporting China, where the outbreak began. “Joe Biden and Kamala Harris understand that no country can face our current challenges alone and hopefully will re-engage and help re-form key science-based multilateral institutions,” says Marga Gual Soler, an expert in science diplomacy and policy adviser to the European Union.

Regular readers know that we haven’t exactly always been the biggest fans of the WHO, but our criticism has been in response to its naïvété about the antivaccine movement and its too-easy embrace of quackery in the form of traditional Chinese medicine and other traditional medicines, which it’s legitimized by incorporating them into ICD-11. However, when it comes to a global pandemic, not collaborating with WHO on responses to the pandemic was about as bad an idea as there could be.

Again, all of this is just about the pandemic. There are so many other areas of science where a President Biden is very likely to be so much better than President Trump was. Moreover, the horror of scientists over the response of this administration to the pandemic was not primarily due to politics, as Yale epidemiologist Gregg Gonsalves put it:

Precisely. It’s true that most scientists (although not most physicians) tend to lean left in their politics, but many are the scientists who have worked with Democrats and Republicans over the years to craft health and biomedical science policy. The horror of scientists, physicians, epidemiologists, and public health academics over the Trump administration’s response to the pandemic was far more due to the bungling and the hostility towards listening to scientists than it was to dislike of Trump’s politics. Yes, it is true that pretty much all administrations, be they Democrat or Republican, have a problem with “inconvenient science” that conflicts with political imperatives or messaging at some point or another, but never have I seen anything like the war on science carried out by the Trump administration.

This brings me back, at long last, to the reaction of scientists.

Why were scientists surprised in 2020 as well?

As I related, scientists were shocked at the outcome of the 2016 election. At the time, I wondered why, not so much because I myself wasn’t shocked that Trump was actually elected President, but more because so many of the responses were along the lines of, “How could we elect someone so hostile to science and science-based federal policy?” At the time, after some thought, my response was: Because to most voters, science and science-based policy are not the most important determinants of how people vote, often not even close. This was particularly true given the tsunami of misinformation and disinformation that social media served up in the run-up to the election.

So it was that I was rather disappointed to see the same sorts of responses to this election, specifically scientists expressing disappointment that the election was not an overwhelming repudiation of Donald Trump in that it was very close in several swing states to the point that the Electoral College was so close and that the Senate appears likely to remain in Republican hands. Indeed, on the day after the election, Nature published a news report entitled Scientists aghast as hopes for landslide Biden election victory vanish:

“It’s horrific,” says Kim Cobb, a climate scientist at the Georgia Institute of Technology in Atlanta. Cobb has her own fears about the pandemic, the economy and climate change but is trying to understand the anxieties that are driving so many to vote for Trump. “

It is depressing to see that the American electorate have not heeded the evidence of the last four years to give a strong message about the damage being caused by Trump’s actions and behaviour, for their own country as well as the wider world,” says Athene Donald, a physicist at the University of Cambridge, UK.

And:

Michael Lubell, a physicist at the City College of New York who tracks science policy, worries about what the results of the election say about the value that many Americans put on truth. Trump, former host of the television show

, is well known for making inaccurate statements and spreading misinformation to further his political agenda. “What I see is people rejecting reality, and opting more for a reality show,” says Lubell. “And that to me is frightening.”

The Apprentice

You might remember that Lubell was one of the scientists cited at the beginning of this post as having been horrified by Trump’s victory in 2016. As someone who has long advocated science-based health and medical policy, I understand his horror. What I don’t understand is his surprise, however, that Biden didn’t head up a “blue wave.” Again, science is not one of the major drivers of whom voters choose when they vote. Scientists seem not to understand this, which is somewhat understandable in that they are, well, scientists. However, this is not surprising in a nation this politically polarized, with such large segments of the population subjected to conspiracy theories about COVID-19, climate change, vaccines, and many other areas of science to the point where they believe antiscience conspiracy theories. Add to that the sheer number of people who believe in alternative medicine and don’t trust SBM, and I’m surprised that scientists would be so shocked at a close result. By contrast, the reason I was surprised by how close the result was (at least in the Electoral College) was primarily due to all the polling that showed Biden with such a stable and significant lead rather than because I expected the electorate to soundly reject him based on his antiscience attitude and policies. (I’m not bragging, either. I just understand this because I happen to spend so much time refuting pseudoscience and antiscience conspiracy theories.)

The article’s tag line is: “With so many votes cast for Trump in US election, some researchers conclude that they must work harder to communicate the importance of facts, science, and truth.” Personally, I can’t argue with that, but I also can’t help but note that there is still a disdain out there among my fellow scientists and physicians for scientists and physicians who choose to engage in science communication directed at the general public. It’s a disdain that dates back to Carl Sagan and before, an attitude that does not value such activity and even views it as a waste of time compared to other activities. While it is true that science communication is a lot more respected now (or at least a lot less disrespect and disdain are directed at it) by fellow scientists and physicians, we have a long way to go. Also, as much of a bubble as Trump supporters live in, we scientists have to be careful not to stay within our own bubbles so much. If we didn’t, we wouldn’t be surprised at occurrences like the results of the 2020 election.

Over the next several months, I think I’ll try to devote more verbiage to how we as medical scientists can try to promote good science, critical thinking, and reason in the face of the massive waves of disinformation that dominate social media. I’ll have to think about it, though. I hope those of you who share our mission will take the time to reflect as well on what we can do better. While it’s true that having Joe Biden as President will mean better science policy, the forces that elevated Donald Trump to the Presidency and supported his antiscience policies haven’t gone away and will make reversing the damage to federal science very difficult, even after the pandemic is finally brought under better control.

Particularly hopeful is that there are now two vaccine candidates whose companies, Pfizer and Moderna, have reported very promising efficacy, although I am still waiting for the detailed data to be published. It is a near-certainty that a Biden administration will handle the rollout of these vaccines far better than the Trump administration would have.