Why Might RFK Jr Be Good for US Health Care?

The proposed appointment of Robert F Kennedy Jr as secretary for the Department of Health and Human Services (HHS) has provoked howls of outrage from many prominent figures in the US medical, bioethical and public health establishment. No doubt it was intended to do so. One does not have to accept his answers to many of the key questions in US health policy – and I mostly do not – to recognize that these issues have long been around and unresolved, not least by some of the most vocal critics.

The starting point has to be that, by international standards, US health care is staggeringly poor value for money in terms of population health. The US has, for as long as I have been a medical sociologist – and previously, spent vastly more on its health system than any other developed country. The outcomes are, however, at best mediocre. A handful of privileged individuals get superlative technical care but many middle-income countries do better on maternal and child health, chronic disease and end-of-life care. Even if we strip out the administrative overhead of the patchwork of payment systems, the expense of debt recovery and the costs of litigation in a country with limited social insurance against catastrophic events, we are left with an under-performing system. As for social care, the less said the better.

One criticism should be dismissed very quickly, that RFK Jr lacks domain expertise. The claim is that only a physician, or someone who has worked in the medical-industrial complex, should be eligible for secretary of HHS. This position is about the social and political accountability of health care. In Europe it would not be unusual for it to be held by a career politician with no previous knowledge but an ability to ask hard questions about where money is going and what is being delivered. Before becoming notorious for racist speeches, one of the most successful UK health ministers was a celebrated scholar of classical Greek with an outstanding career in military intelligence during WWII. The idea that biomedical elites should determine health policy is responsible for many of the governance failures of the Covid pandemic.

There are two big dragons in the closet of US health policy: Big Pharma and Big Food. This is not exactly news – but who else has yet successfully tamed them?

One of the policy achievements of the European Union has been to ban TV advertising of prescription medicines, in the teeth of political and lawfare opposition from Big Pharma. US consumers are bombarded with advertisements to encourage self-diagnosis and requests for expensive versions of medications. Supplier-induced demand has been recognized as a problem for US health care since the early 1970s. It has never been effectively checked and contributes to massive over-prescribing, even where there good reasons to be more restrained, as in preventing antibiotic resistance.

RFK Jr also has a reputation as a critic of vaccination. I certainly do not share his position on many childhood vaccines, especially MMR, or on HPV, which is gradually eliminating cervical cancer in Europe and will reduce oral cancers as more boys are vaccinated. However, it may reasonably be asked why the US has adopted many more vaccines in many more doses than any other developed country. It seems that, if there is a vaccine, everyone must have it, regardless of the cost/harm/benefit calculus. Is it time for a comprehensive review of the whole lifelong vaccination schedule rather than constantly adding to it? Is it realistic to try to prevent every infection? Who is making money out of this excess?

The other target is Big Food. RFK Jr has signaled an intention to take on chronic illness and obesity, which are increasingly severe public health problems. Again we might question the scale of food additives used in the US and their potential role. Most other developed countries are far more restrictive. They also regulate more strictly the claims that can be made in advertising. Critics have fastened onto RFK Jr’s willingness to permit raw milk as some kind of touchstone of eccentricity. Most European countries permit this. It is a minority taste and comes with health warnings. Crucially, however, it can be widely used in cheese production. I remember discussing the issue with artisan cheesemakers in Wisconsin. They were hugely frustrated by their inability to match classic European cheeses because they could not use raw milk. Is this ban really in the interests of consumers or of Big Cheese that can continue to peddle its bland and unpalatable products on a mass scale?

RFK Jr’s concern with the revolving door between government advisers, regulators and industry is widely shared. Some critics may go too far in wanting to build a border wall between government and industry – why would we not want the best scientists to be available to all parties? Nevertheless, the interpenetration is so extensive that it is not difficult to see why it might sustain conspiracy theories.

Perhaps some of RFK Jr’s critics should acknowledge that they have had a very long time to do something about US health policy – and not achieved very much. It is, of course, questionable how much a new broom can accomplish in the face of the political clout of Big Pharma and Big Food, especially as expressed through a Trump Administration. However, it might be more productive to focus on mobilizing support for the shared goals, and debating the means, than simply trashing a man who was previously something of a liberal hero for his work on environmental justice.