On Flip-Flopping

Or How Does Science Make Up Its Mind

No one likes a “flip-flopper” it seems. We want public figures to stick to one clear message, be they politicians running for office, scientists announcing their latest findings, or public health authorities telling us what we need to do to avoid becoming ill. A change in that message, what we call flip-flopping, is seen at best as a sign of weakness and at worst evidence of lying and corruption.

         Let’s take the recommendation to wear face masks during the COVID-19 pandemic. It is true that at first, even the trusted Anthony Fauci seemed to be saying that only healthcare workers needed to wear them. The rest of us, experts recommended, didn’t need them.

         Several months later, however, Fauci, the U.S. Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and a host of other experts seemed to change their minds; wearing face masks, we were then told, is a vital part of the public health strategy to prevent the spread of the novel coronavirus that causes COVID-19. Most people have complied with that recommendation and wear face masks while in public gatherings, but a constant stream of dissenters insist this change in recommendation means the authorities don’t know what they are talking about in the first place, were lying to us, and were acting out of some bizarrely concocted conspiracy to control people’s lives.

Science Marches On

         We think that what really happened is that scientists made some new discoveries about face masks that altered best practice recommendations. At the beginning of the epidemic we did not have a lot of data about face masks or about how SARS-CoV-2, the virus that causes COVID-19, is spread. In just a few months after the pandemic began in the U.S., however, data emerged on three fronts. First, studies using laboratory animals demonstrated that masks prevent the spread of SARS-CoV-2. Second, epidemiological data began to show that instances in which people wore face masks were associated with lower rates of infection. Third, scientists confirmed that SARS-CoV-2 can be aerosolized and spread through the air over long distances, meaning that face masks that prevent aerosolized particles emitted by coughs, sneezes, and talking can be an important tool in preventing viral spread.

Some people mistakenly believe that the change to recommending we wear face masks while in public represents a nefarious “flip-flop” and evidence of scientific corruption. In fact, it came about because of the gathering of new scientific evidence (image: Shutterstock).

         Those insights gleaned from laboratory and epidemiological studies changed thinking about face masks and led to all of those experts changing their minds and their recommendations. Were they wrong at first to recommend against face masks? A better way to think of it is that they made recommendations based on what was known about them at the time. Was Ptolemy wrong to say during the days of the Roman empire that the sun revolves around the earth? Of course, but it turns out that the idea was based on the best available scientific observations of the time and not on stupidity or an ulterior motive. When Copernicus, Galileo and other later scientists provided new data that proved the earth revolves around the sun, science “changed its mind.” It was very hard in the fifteenth century for many people—including many astronomers at the time–to go along with that kind of momentous change in scientific thinking and it is still hard for us to do so today. We don’t love change, not about which heavenly bodies circle each other nor about whether we should wear face masks to prevent disease spread. Yet we must be able to adjust our thinking to accept new scientific consensus when it emerges. To try to dismiss new scientific consensus by accusing the scientists behind it of lying or dark conspiratorial motives is a defense mechanism against accepting the normal way that science develops.

Science Inevitably Involves Change

         It is the nature and indeed the virtue of science that it is built to provide new insights that change current dogma. We may be about to see a radical change in physics because new experiments show that a subatomic particle called the muon has a stronger magnetic spin than current theory predicts. Physicists seem mostly excited by the prospect of developing a new theoretical understanding of how forces work in nature, even though if that turns out to be the case a lot of textbooks will have to be rewritten. The public seems interested but not particularly upset with this prospect because few of us understand the complex mathematics behind the current physics, so changing it perhaps won’t matter much to most of us. Still, at least one educated person we know queried whether his computer will still work if physics changes its theories.

The nature of scientific consensus is to be established via twists, turns, and roundabouts in the collection of scientific evidence. Change is both common and desirable (image: Shutterstock).

         When it comes to things that affect our daily lives, like how much sugar is safe to consume, whether we need to scrub every surface we come in contact with to prevent getting COVID-19, or whether we should take vitamin D supplements, we want there to be a strong and unshakeable scientific consensus. Sometimes, however, the consensus isn’t unshakeable, as we know with the dietary recommendations for sugar and fat consumption. Sometimes the consensus isn’t strong: experts and guidelines tend to suggest that only people who are clearly vitamin D deficient need take supplements, but what exactly constitutes “deficient” in this case is difficult to define and much debated among experts. That amount of change or uncertainty is unsettling and we tend to default to conspiracy theories rather than accept that change and uncertainty are vital parts of the scientific enterprise.

What Scientists Can Do

         There is an important thing that scientists can do to help people accept that change and uncertainty are natural parts of the scientific process. Scientists need to state much more forcefully when they speak to the media or the public in general that things are uncertain or incompletely known. There is a growing tendency among publicity departments at research universities and medical centers to “sell” the work of their faculties as representing major discoveries and “breakthroughs” when in fact much of what is being promoted is really just a small part of a larger, ongoing scientific process. Press releases from universities, medical schools, and teaching hospitals have become part of an attempt to increase market share rather than to carefully inform journalists and the public about how science works.

         For example, many medical and scientific authorities whom we trust initially spoke about face masks as if there was settled science proving their inability to help block transmission of COVID-19. In fact, they should have said that at that early point in the pandemic there was insufficient information to indicate their usefulness and that further scientific inquiry might alter the recommendation not to use face masks, which in fact happened. That way, the public would not have felt so misled when new data came in suggesting that face masks are indeed a very important part of the effort to contain the pandemic.

         Just as fundamentally important as having the scientific community adopt a humbler attitude about what science in fact “knows,” is the critical need to improve science education so that people are not so shocked by inevitable twists and turns in scientific consensus and public health recommendations. If we persist in teaching children and young adults science by forcing them to memorize “facts” we will continue to create the misimpression that science is set in stone. For those of us who have done experimental work, it is absolutely no surprise that outcomes of even the most rigorously designed studies often fail to support initial hypotheses, that some findings are not replicable by further experimentation, and that there is a continuous need to update what we think we know. Science is our best route to establishing true insights into the way the natural world works, but that route is nevertheless filled with twists and turns and roundabouts. We need to teach people that this is how science really works.

         We should not automatically and derisively call a change in knowledge or recommendation or even political opinion a “flip-flop.” Rather, we should welcome an open-minded approach to science and to politics in which new scientific evidence is accepted and incorporated into existing theories, even if on occasion it means that an entire theory needs to be dramatically revised. No one was lying when they advised that face masks were unnecessary to control the raging novel coronavirus. Admittedly, they were a bit too sure of themselves in saying that, but we should be relieved that scientists were willing to look foolish and change their guidance about face masks as new facts emerged from scientific inquiry. Let’s be a little kinder about the next “flip flop.”

Media Articles About Health and Science Can Inadvertently Frighten People

“Doctor’s death after Covid vaccine is being investigated,” read a headline in the New York Times on January 12, 2021.

         Does that frighten you? Let’s look at the first paragraph of the story:

Health authorities are investigating the case of a Florida doctor who died from an unusually severe blood disorder 16 days after receiving the Pfizer coronavirus vaccine.

         The story so far unequivocally links the Pfizer/BioNTech COVID-19 vaccine to a death. People firmly in the anti-vaccination world had a field day with this news that a physician in Florida died after being vaccinated. Most people are not ardent “anti-vaxxers,” but many—especially back in January—were vaccine hesitant, worried, that is, that the new vaccines were developed so rapidly that shortcuts had been taken establishing their safety. A headline and first paragraph like this one are just what the vaccine hesitant were afraid of—a seemingly clear link between the vaccine and death.

         The story continues in this vein until the fifth paragraph when we finally get some context:

About nine million people in the United States have received at least one shot of either the Pfizer or Moderna coronavirus vaccine, the two [at that time] authorized in the United States. So far, serious problems reported were 29 cases of anaphylaxis, a severe allergic reaction. None were reported as fatal. Many people have had other side effects like sore arms, fatigue, headache or fever, which are usually transient.

So let’s say just for a moment that the doctor’s death was in fact a result of the COVID-19 vaccine. This paragraph tells us that it is one death out of about 9 million people who had received an authorized COVID-19 vaccine by the beginning of last January. How do we convey to people that that risk is essentially non-existent once we consider the risks we accept in our daily lives? The risk of dying in a car crash is about 10.7 deaths out of 100,000 people. The odds of getting hit by lightning in a given year are about one per 1.2 million people. Perhaps more important is the fact that the odds of dying for a 55 year old man if he gets infected with COVID-19 are about one in 10. If you drive a car or walk outside during a thunderstorm you should not worry about the risk of dying from a COVID-19 vaccine. You should be much more worried about getting COVID-19 than about having a COVID-19 vaccine to prevent that from happening.

None of this is laid out for the reader explicitly even in that fifth paragraph of the New York Times story when some data are finally offered. It would not be a big surprise if reading the story increased one’s fear of the vaccines and perhaps even induced the common “wait-and-see” attitude that many people have taken about them, that is, waiting and seeing how others fare from being vaccinated before agreeing to have one oneself.

We do not believe it was necessarily the intention of either the New York Times editor who wrote the headline or the reporter who wrote the story to stoke fears of vaccines or to drive people away from being vaccinated against COVID-19. We also do not question that the public has a right to know if there is a death associated with vaccines. Rather, we are concerned about the way in which this story and so many others like it are written and their placement. We question whether stories about science and health that entail a great deal of uncertainty belong on the front page. Perhaps they should be run in the science section where there may be more room to explain nuance.

Stories are Stickier Than Data

We know that most people do not read newspaper stories beyond the headlines. In order to get readers to go a little farther, editors, who write headlines, need to make them as dramatic as possible, sometimes bordering on what is called “click-bait.” When we read a novel, we expect to have to wait a while, sometimes until the end, to get to the really exciting part. Not so when we read news articles. Journalism students are taught they must put what is the most exciting part of a story in the first paragraph or two, acknowledging that that is about as far as most readers will get.

Our own research, done in collaboration with Fluent LLC, shows that stories about negative events are far more “sticky” in people’s minds than are explanations that involve data. So, for example, when the rare death occurs following a COVID-19 vaccine, we are treated to a lively account of the individual’s life story. This creates a lasting memory. Deaths from COVID-19, by contrast, are typically presented only with numbers; we are regularly told the number of people who have died—562,000 in the U.S. at the time of writing this article in early April. Although that is a tragically big number, numbers don’t stick with us as well as stories. Importantly, we are given very few dramatic stories of individuals who have succumbed to COVID-19 in the news. So, although there are many, many more deaths from COVID-19 than there are deaths following COVID-19 vaccinations—none of which have yet even been definitively attributed to vaccines—the emotional balance is exactly the opposite of this reality, in large part because of the way the stories are told.

We and others have found that stories are “stickier” than data but reports on deaths from COVID-19 are usually put in terms of numbers rather than narratives (image: Shutterstock).

Looking at the New York Times story, then, we see that from a journalism course point of view, it is nearly perfect. The headline is dramatic and makes you want to read more. The first paragraph is similarly dramatic—a death is being linked to the vaccine. The boring stuff about the actual risk of this happening doesn’t appear until paragraph five, before which point many readers will have quit reading.

A Better Example

On April 8, a story in the Atlanta Journal-Constitution began with the headline “Coroner: Man who died after vaccine died of natural cause” and goes on to explain that no link could be established between vaccine and the cause of the Florida doctor’s death. That means that almost two months elapsed between the time the New York Times reported the possible link and the coroner’s report stating no such link could be established appeared in the media. It is impossible to know how many people may have been dissuaded from being vaccinated by the first story and unlikely that the second one restored their faith in vaccine safety. As Miles Parks noted last March in an NPR report, “The odds of dying after getting a COVID-19 vaccine are virtually nonexistent.” That bold fact does not appear in the New York Times story.

Here’s an example of the way we believe these things should be reported. A March 31 headline in the Sacramento Bee reads “Sheriff linked vaccine to death despite experts’ cautions.” This story concerns the death of a California man who died after receiving a COVID-19 vaccine. The local sheriff immediately went on record linking the death to the vaccine even though the local coroner insisted that was premature pending an autopsy. Note that right in the headline there is the warning that the purported link may not exist.

In the very first paragraph of the story, this caveat is again made clear:

A California sheriff announced in January that a man died hours after receiving a COVID-19 vaccine even though his county’s health officials said the declaration was premature and detrimental, The Sacramento Bee reported, citing emails obtained under the state Public Records Act.

One thing we would have preferred is that the opening to the fourth paragraph in the Sacramento Bee story had come even earlier in the story: “Eventually, it would be determined that the vaccination was coincidental to the death…”

         There are of course journalists from some fringe media who deliberately twist the facts about health issues like COVID-19 vaccines, taking things out of context and cherry-picking studies in order to make spurious points. Here, however, we are talking about responsible journalists from mainstream media who want to give the public correct information. These journalists do not generally intend to manipulate readers’ emotions to drive them toward incorrect ideas, such as that there is a link between COVID-19 vaccines and deaths. Inadvertently (and we must acknowledge sometime even here purposefully), however, this is exactly what they sometimes do. 

We fully understand as well that journalists and editors need to have their stories read. Science when properly explained is not generally dramatic. It proceeds at a slow pace as scientists take their time to design and conduct experiments, review and analyze data, and then write their manuscripts. One study rarely is sufficient to change scientific theories or alter the course of treatment patients get for a particular disease. This disconnect between the slow acquisition of scientific knowledge and the need to write stories that are sufficiently dramatic to gain readership inevitably leads to headlines and stories that fail to place things in their proper context. It may sound boring to explain to readers that a one in 9 million chance of death is a virtually non-existent risk but failing to do so makes a very rare death seem much more frightening than it should.

A possible link between the AstraZeneca COVID-19 vaccine and rare deaths from blood clots has been reported (image: Shutterstock).

Recently, there have been reports of people developing blood clots following receiving an AstraZeneca COVID-19 vaccine. The vaccine is not yet authorized in the U.S., but around the world about 25 million people have received it and there are about 18 reported deaths from blood clotting following vaccination. Headlines about this could be written in one of two ways:

AstraZeneca Covid Vaccine Linked to Rare Blood Clotting Disease

Or

         Rare Cases of Blood Clotting Disease Linked to AstraZeneca Vaccine

         Both headlines would be correct, but it is easy to see how the former is more frightening than the latter. The first headline does not put the blood clotting disease in its proper context vis a vis the vaccine; the second one makes clear that serious blood clotting is a rare phenomenon following vaccination.

Guidelines on Reporting

         There is precedent for offering journalists and editors guidelines on how to safely report certain kinds of events. After it was observed that media attention to suicides can increase the risk for further suicides, a phenomenon called suicide contagion, several agencies issued recommendations on how to safely report about suicides in the media. These recommendations include not going into details about the method of suicide and showing that help is available for people with suicidal thoughts.

         Critica is now working on developing similar recommendations for reporting on topics involving health and science. In doing so, we understand there must be a balance between providing the public with information it needs to know in readable fashion with the duty to present accurate information that is put into its proper context. Newspaper stories cannot read like published scientific papers, but they also must not be so dramatized that readers will be misled and frightened. Our recommendations will largely concern the placement of context and use of narratives within a news story. From the headline on through the first few paragraphs a proper news story about a science or health topic must include something about the context and significance of the finding upon which the story is based.

         Explaining risk is not easy and humans are not programmed to grasp risk rationally. We all tend to overestimate small risk and underestimate large risk. In the case of COVID-19 vaccines, it is easy to see how we might come to overestimate the risk of death after a vaccine and underestimate the risk of death from COVID-19 itself. Nevertheless, responsible journalism has to do a much better job explaining risks and telling stories that reflect the real risks. We will keep all of our readers posted as we come up with our own recommendations.

QAnon and Mental Illness

Is the Conspiracy Theory Group Really Comprised of People with Psychiatric Disorders?

One writes about QAnon with some reluctance and trepidation. Reluctance because we do not wish to spread interest in the conspiracy theory group by even mentioning its name. Trepidation because QAnon has now been linked to violent crimes, including playing a role in the January 6, 2021 Capitol Hill insurrection. Nevertheless, an article in The Conversation titled “Many QAnon followers report having mental health diagnoses” did catch our eye and perhaps deserves some discussion.

         Written by Sophia Moskalenko, a research fellow in social psychology at George State University, the article asserts that members of QAnon, which probably now numbers millions, have high rates of mental illness. “I noticed that QAnon followers are different from the radicals I usually study in one key way: They are far more likely to have serious mental illnesses,” Moskalenko writes in her March, 2021 piece. She goes on to state that “I found that many QAnon followers revealed—in their own words on social media or in interviews—a wide range of mental health diagnoses, including bipolar disorder, depression, anxiety, and addiction.”

         As further evidence of this notion that psychiatric illnesses play an important role in QAnon, she cites court records following the January 6 insurrection in which “68% reported they had received mental health diagnoses.”  This is  opposed to the rate noted by Mental Health America of 19% in Americans in general. Moskalenko speaks about a “mental health crisis in the United States” and advises that a solution to the problem of conspiracy theorists like QAnon is “to address the mental health needs of all Americans—including those whose problems manifest as QAnon beliefs.”

The Ideas are Pretty “Crazy”

To be sure, the beliefs espoused by QAnon are bizarre. You can read more about QAnon’s history and beliefs here; their core belief is that a cabal of Democrats led by Hillary and Bill Clinton are running a pedophile ring whose members cannibalize captured children. They hold that ex-President Trump is the savior who was supposed to reveal the pedophile members and arrest them during a second term in office. Although some initially dismissed this, the idea turned violent during the pizzagate affair when John Maddison Welch drove from North Carolina to Washington D.C. with assault rifles hoping to free children allegedly being held by Hillary Clinton’s followers in the basement of a pizzeria. He shot up the restaurant, fortunately without injuring anyone, and was arrested and subsequently sentenced to four years in prison. The incident brought the QAnon conspiracy theory to national attention.

QAnon is a loose organization of millions of people who spread false conspiracy theories (image: Shutterstock).

         It is quite common to see some defaulting to mental illness as the reason behind unsavory behavior. People blame mental illness for mass shootings for example, even though few perpetrators of mass shootings have ever been diagnosed as mentally ill. In this case, there is no evidence that people with illnesses like depression, bipolar disorder, and anxiety disorders are especially prone to believe wild conspiracy theories. People with paranoia as part of their psychiatric illness, such as people with the paranoid subtype of schizophrenia or who have paranoia induced by chronic use of amphetamines or cocaine, might entertain such theories, although the form of paranoia seen in these disorders is most often disorganized and not as intricately detailed as the QAnon conspiracy theories.

Very Thin Evidence for Mental Illness Connection

         More importantly, the evidence Moskalenko seems to rely on to relate QAnon conspiracy theories to psychiatric illness are two-fold: self-report and court documents. The latter are clearly suspicious, of course: as part of a defense to try to stay out of jail many people might try to blame their actions on being mentally ill. These are not a reliable source of information about mental illness diagnoses. Nor can we take self-report at face value. Lots of people suffer from transient feelings of depression and anxiety, for example, without meeting criteria for an actual psychiatric diagnosis. We have no idea from what Moskalenko writes about the rate of true psychiatric illness among QAnon members. To know that would require that mental health professionals examine each individual, obtain a careful history, and make a diagnosis using the accepted DSM-5 criteria.

         If that were to be done, we doubt that anywhere near 68 percent of QAnon members would receive formal psychiatric illness diagnoses. There is now an extensive scientific literature on conspiracy theory belief. At its most fundamental level, conspiracy theories serve basic functions that are part of human cognition, such as the need to find simple patterns in complex datasets. Conspiracy theories also serve to “satisfy unmet psychological needs,” including the need for certainty. With respect to the current pandemic, for example, we are besieged with a constant influx of information to the point that it is easy to be overwhelmed and confused. A simple but terribly wrong way to reduce all of these data to one graspable belief is to embrace the QAnon notion that the coronavirus pandemic is a hoax perpetrated by left-wing politicians in an effort to control the public. Given that one survey showed that 17% of Americans believe QAnon’s most outlandish conspiracy theory—the one about the Democratic pedophile ring—it is not so difficult to understand that many people might embrace a conspiracy theory capable of explaining away all the discomfort and restrictions with which we now have to live because of COVID-19. Importantly, many people with impressive intellectual credentials are part of QAnon, so it does not seem to be exclusively an issue of knowledge deficit.

Believing in a conspiracy theory like the coronavirus pandemic is a hoax is a cognitive maneuver that takes a seemingly overwhelming amount of information and condenses it to one graspable but incorrect fact (image: Shutterstock).

         Certain personalities may be most prone to believing conspiracy theories, including those associated with impulsivity, negative affect, and general distress. Feelings of powerlessness, despair, and marginalization are known to stoke belief in conspiracy theories. These are undoubtedly prevalent feelings, especially during times of economic downturn or crisis as we have now during the pandemic. A person who feels powerless because of a personal economic set back may describe themselves as “depressed” and someone who is worrying about the implications of COVID-19 might say they feel “anxious.” Such individuals are probably more prone to accepting conspiracy theories that at least give them explanations for what is happening and connect them to a social group. They do not necessarily have clinical depression or anxiety disorders, however. As psychiatrists Ronald W. Pies and Joseph M. Pierre point out, belief “in conspiracy theories is distinct from psychosis, and more closely resembles extreme but subculturally sanctioned religious or political beliefs.”        

We believe we are on firm ground asserting that most people who do have psychiatric illness do not endorse outlandish conspiracy theories like those QAnon spreads. Ascribing false and potentially violence-inducing conspiracy theories to mental illness seems another way of stigmatizing people who suffer with psychiatric illness. The evidence that conspiracy theories serve an unmet psychological and sociological need is quite strong, but the evidence that it is part of mental illness or that most of its purveyors are psychiatrically ill is extremely thin. Let’s understand QAnon for what it is, a dangerous organization that foments hate, anti-science ideas, white supremacy, and violence.

The Solution to Coronavirus Variants: Vaccinate

There is a lot of understandable worry right now that “variants” of the coronavirus that causes COVID-19 may somehow elude the available vaccines and dash our hopes for an end to the pandemic. While concerns about variants are certainly warranted, right now we can say that the best approach to confronting them is to get everyone vaccinated as fast as possible and to increase U.S. surveillance for them.

         All available evidence suggests that the vaccines we now have are active in providing immunity to the viral variants. These variates—or mutated viruses–pose, as we will see, a particular threat to unvaccinated people because some of them are more easily transmitted and capable of causing more severe disease than the original coronavirus, which is called the “wild type” virus. So we must redouble all our efforts to convince every adult to get vaccinated as soon as eligible.

How Variants Form

         Let’s first explain what “variants” actually are. Remember that the COVID-19 virus, which is called SARS-CoV-2, is an RNA virus, meaning that its genetic information is contained in a single strand of RNA. That strand of DNA has about 30,000 bases that code for the virus’ 29 proteins. One of those proteins is the spike protein that forms those crown-like projections from the virus, or spikes, that have become familiar to us from images like the one provided here. The three currently available COVID-19 vaccines (Moderna/NIMH, Pfizer/BioNTech, Johnson and Johnson) and a fourth that may soon become available in the U.S. (Oxford/AstraZeneca) all target the spike protein.

The coronavirus that causes COVID-19 has the familiar spike proteins that emerge from the virus particle surface. It is the spike protein that current vaccines target (image: Shutterstock).

         When SARS-CoV-2 infects a person, it latches onto a specific receptor called the ACE2 receptor, that is present on various cells in the body, including the lungs and heart. This enables the virus to enter the cell. The viral RNA then hijacks the human cells’ protein manufacturing system to make new viral particles that then burst out of the human cell in order to infect other cells.

         To be able to make new virus particles, the virus’ RNA strand must be copied or replicated over and over again. Each time a copy is made, those nucleoside bases are assembled in the order needed to make a new viral RNA strand. Mistakes frequently occur, however, and an incorrect base is put into the sequence on the developing RNA strand. Coronaviruses have proteins that are quite efficient in clipping out those mistakes, which is why they actually mutate very slowly (unlike the virus that causes the flu). Nevertheless, sometimes an incorrect base remains in place. Most of the time, these mutations have no consequence, and the viral proteins are assembled in the usual, “wild type” way. Sometimes, however, the mutation does affect the structure of proteins, including the spike protein. This can result in several things: it can make the mutated virus incapable of further replication and it disappears or, ,more ominously, it can make the mutated virus particles able to cling more tightly to the ACE2 receptor, more easily transmitted from one person to the next, or less recognizable to neutralizing antibodies. By the rule of “survival of the fittest,” mutated viral variants that make the virus more “fit”—that is, more able to infect human cells—will ultimately predominate over less fit wild type virus.

The single strand of RNA that contains the instructions for making the coronavirus’ 29 proteins is itself composed of bases called nucleosides. A mistake that puts the wrong nucleoside in a spot on the RNA strand can lead to a mutation that makes the virus more easily transmitted or capable of causing more serious illness (image: Shutterstock).

Where We Stand Now with Variants

         There are three viral variants of particular concern right now, B.1.1.7 first identified in the U.K.; B.1.351 first seen in South Africa; and P.1 that seems to have emerged in Brazil. According to Anthony Fauci, about 30 percent of U.S. COVID-19 infections now involve the B.1.1.7 strain of virus. Each of these three mutated viral strains seems to transmit more readily than the wild type virus, but once again it appears that the available vaccines are able to generate sufficient neutralizing antibodies that recognize the variants’ spike proteins and at least prevent serious disease or death. The Johnson and Johnson vaccine, for example, was tested in both Brazil and South Africa where two of the variants were first seen and still protected people from getting seriously sick or dying.

         Another thing to remember is that neutralizing antibodies, which are produced by one type of immune cell called B lymphocytes, are not the only thing that vaccines stimulate to fight infection. T lymphocytes, which mutated viruses are less able to elude, are also stimulated by vaccines and form an important part of the immune response to viral infection. Right now, scientists know much less about the T cell response to SARS-CoV-2 than they do about the B cell response, but it is likely that T cell immunity plays an important role in vaccine protection against SARS-CoV-2.

         It would be fairly easy for the pharmaceutical companies that manufacture vaccines to quickly update them to cover variants. That might mean we will need booster shots at some point in the future. It is not clear yet whether that will be necessary.

         It is also important to note that viruses do not have an infinite number of possible mutations. As we mentioned earlier, most mutations in the RNA region that codes for the spike protein either have no consequences or render the virus unable to infect human cells. Mutated viral strains mainly arise in unvaccinated people whose immune system response is not robust enough to neutralize or kill enough viral particles, allowing the mutated strains to survive and be passed on to others.  The way to limit this process from occurring is to get everyone vaccinated.

         We cannot be complacent about variants. The U.S. has not been nearly as vigilant at sequencing virus to identify mutations as have other countries, and this needs to be fixed. It is not impossible that a mutation will occur at some point that renders virus resistant to the available vaccines and this would require more urgent development and administration of updated vaccines.

         We should not, however, think of mutations as an endless source of vaccine-resistant virus. “Over time,” writes Dhruv Khullar in the New Yorker, “SARS-CoV-2 is likely to become less lethal, not more.” For sure, the CDC needs to orchestrate a much wider surveillance of viral sequences to ensure we are not missing new strains that are more efficient at transmission or more lethal. The real urgency right now, however, is to get all of us vaccinated. That should dampen the threat posed by viral variants.

Despite the Pandemic, There Is Something We Cannot Ignore

The Climate Crisis Gets Worse

We may have thought there was some good news during the coronavirus pandemic. Because people stayed home and drove less, carbon dioxide release into the earth’s atmosphere went down by about 10% in the last year in the U.S. Smog cleared in some cities, like Buenos Aires, Los Angeles, and New Delhi. for the first time in their residents’ memories. While we suffered under the pale of the pandemic, we at least thought that perhaps we could breathe a little easier even though breathing through masks.

         That is, as many commentators have pointed, a false sense of security. As more people get vaccinated, they will start traveling again and greenhouse gas emissions will inevitably go back up. Long-term, the recent drop in emissions will have no effect on slowing global warming. In fact, this past February we got pretty bad news from the United Nations climate watchers: countries that signed the 2015 legally-binding Paris agreement are still nowhere near the level of commitment to reduce greenhouse gas emission that would be needed to keep warming below the agreed upon less than 20 Celsius (3.60 Fahrenheit). According to the U.N. report, the current level of commitment by countries would only decrease carbon emissions by about 1% by 2030, whereas a drop of about 45% by 2030 is needed to keep the earth’s temperature from going up beyond the 20 Celsius mark.

Although skies have cleared over some traditionally choked cities, our continued insistence in burning fossil fuels for energy defies scientific consensus and poses grave risks to our health and safety (image: Shutterstock).

         The list of disasters that are predicted to occur if we do exceed that mark is overwhelming to contemplate: floods and droughts, heat waves, rising sea levels, and species loss are only some of them. COVID-19 has of course dominated headlines and our minds for a year now, perhaps forcing us to put climate change on the back burner. As journalist Jordan Salama notes in his excellent article “The Earth Is On Fire” in Scientific American last January, “And in the U.S., we’ve somehow become less thoughtful in our daily choices—accepting that extra plastic bag at the supermarket, ordering takeout despite all the single-use containers and, if we’re privileged enough, driving instead of taking public transportation–because, well, ‘it’s a global pandemic.’’’

As an example of how the pandemic forced us to cut back on environmentally-friendly efforts, in New York City, where Critica is headquartered, curbside composting pickup was suspended near the beginning of the pandemic as one of many cost-saving steps city officials said they needed to make because of the expected (now verified) loss of revenue during the pandemic. Composting trash is one of those seemingly small things we are all asked to do to help save the planet, but here is an example of the pandemic pushing that imperative aside. No doubt, similar energy-saving steps have fallen by the wayside as we battle SARS-CoV-2.

We Need Bold National-Level Action

         We know, however, that no amount of individual’s stopping using plastic bags and containers, composting trash, or abandoning leaf blowers–as important as these things are to an overall improvement in the earth’s health–will be sufficient to keep us below the dreaded 20 Celsius rise in temperature and all its consequent disasters. Countries need to make bold commitments to reduce carbon emissions by cutting back drastically on burning fossil fuels, stop cutting and burning down rainforests, and cease pursuing a meat-based agricultural economy. That is what they agreed to in 2015 in Paris, but still have not implemented. 

That is not to say that individual actions are unimportant—if everyone in the world really stopped driving gas-powered cars, for example, we would go a long way to reducing overall carbon emissions. And things like composting and reducing plastic use are critically important for a variety of reasons. Still, it will clearly take action at the national-level to craft policies and laws sweeping enough if we are to have an impact on the climate crisis.

Here, then, science meets politics and public policymaking. The 196 countries that signed the 2015 Paris agreements (which went into effect in 2016) all agree on the science of climate change. The scientific evidence that climate change is the effect of human activities is incontrovertible. Putting that scientific evidence into the hands of policymakers is the crucial task we now face.

Organizations and Countries Mobilize

         On March 11, GreenFaith, an international faith-based climate group, organized a day of action to demand that countries institute policies commensurate with the goal of truly achieving a meaningful reduction in fossil fuel use (Critica president and board chair Jack Gorman is a member of the Board of Directors of GreenFaith). Over 250 events took place around the world and ten demands were made as can be seen in this figure:

It is notable that many of these demands concern what is now being called “climate justice.” People in low- and moderate-income countries, particularly in the Global South, contribute the least to carbon emissions but suffer the most from climate disasters. Among other challenges, this has created huge numbers of “climate migrants,” people forced out of their home communities because of climate disasters like severe drought. Furthermore, reducing the use of fossil fuels will inevitably result in the loss of jobs, and climate justice activists insist this must be compensated for by the creation of alternative employment in “green” industries like wind and solar energy. GreenFaith is one of many organizations emphasizing action on both climate change and climate justice around the world.

         Critica is of course not a faith-based organization, but we can endorse the ten GreenFaith demands and others like it because they call for the kind of sweeping changes that governments must make: stop using fossil fuels for energy, stop burning down rainforests, help low-income countries reach these goals with financial support from high-income countries, and create green jobs and infrastructure.

         This kind of climate advocacy can work. President Biden returned the U.S. to the Paris agreement in February after his predecessor had pulled the country out of it. Several countries around the world have indeed set goals of zero emissions by 2030 or 2050. Satellites now sit in space monitoring the Amazon rainforest and looking for signs of illegal burning, while world-wide pressure is forcing the Bolsonaro government in Brazil to take steps to stop deforestation in the Amazon. Closer to home for us, in 2020 New York State passed the most aggressive climate legislation in the U.S., calling for a 40 percent reduction in greenhouse gas emissions by 2030 and 85 percent reduction by 2050 in the state. Some governments at least seem to be keeping concern about climate change on the front-burner despite the pandemic.

         We will get our next look at how well this is going in November when the world meets in Glasgow at COP26, the U.N. international climate conference where countries will report on their progress and goals in the fight against climate change. By then, experts predict that the coronavirus pandemic will have come under reasonable control and we will have returned to some semblance of normal lives. In this case, however, “normal lives” means a world where climate change, global warming and climate justice were not suspended just because major parts of our daily lives were.

         We may have tried to forget about climate change during the last year. That is perhaps understandable as we struggled to survive through the worst pandemic in a century. Clearly, however, climate change remains the greatest existential threat to our survival and as we crawl out from under COVID-19 we must once again take up the charge to do something—indeed many things—about it. Critica supports bold political action like the proposed U.S. Green New Deal and GreenFaith’s 10 Demands and hopes we all raise our voices to elected leaders to take the urgent action needed. The third of Critica’s missions is to increase the use of scientific evidence in public policymaking. Nowhere do we more urgently and desperately need to see that happen than in our fight against climate change and climate injustice.

Vaccines and Coincidences

People who oppose vaccinations, including the vaccines against the virus that causes COVID-19, like to cite adverse effects reported to something called the Vaccine Adverse Event Reporting System (VAERS). One that caught our eye recently came from an organization called Children’s Health Defense, which recently stated in its newsletter that as of February 12, 2021 there had been 111 reports of adverse events involving pregnant women who had received COVID-19 vaccines, 31% of which were miscarriages or preterm births.

         Such a claim, taken without any other information, would seem worrisome. The article in the Children’s Health Defense publication goes on to describe several heartrending stories of women who allegedly had been experiencing normal pregnancies, received one or two doses of a COVID-19 vaccine, and lost their pregnancies. It takes issue with any recommendation that pregnant women get the vaccines and highlights the fact that at present we have no safety data from formal clinical trials that included pregnant women.

         It does take some unpacking to understand a story like that, something that people at Children’s Health Defense must be fully capable of doing but avoid in order to make their point. So, we will undertake the task for you in order to illustrate just how easy it is to turn an isolated piece of information about vaccines into a dramatic and frightening tale.

Limitations of VAERS Reports

         First, what is the VAERS? It was created in 1990 by federal law and is run jointly by the U.S. Centers for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA). VAERS allows—actually encourages—anyone with any knowledge of an adverse event that occurs after any FDA-licensed vaccine is received to make a report. That includes healthcare professionals, drug companies, and members of the general public. CDC and FDA use VAERS reports to identify vaccine adverse side effects that are too rare to be picked up during the clinical trials of a vaccine that typically involve tens of thousands of people. They are looking for “signals” that might indicate a very rare but clinically important problem with a vaccine.

The Vaccine Adverse Events Reporting System (VAERS) allows anyone aware of an adverse event occurring after a vaccination has been received to report it to federal regulatory authorities. These reports do not necessarily mean that the vaccine caused the adverse event (image: Shutterstock).

         It is never certain, however, that a reported adverse event is actually related to the vaccine. We know of a case in which a previously healthy elderly woman died hours before she was scheduled to receive a COVID-19 vaccine. Had she died a few hours after the vaccine, a report could have been made to VAERS identifying the death as vaccine related. In fact, it would have been a coincidence.

         Most VAERS reports turn out to be just that, coincidence. When millions of people receive vaccines, many things that occur naturally will occur after so many people have received a vaccine. If an illness occurs in one in a million unvaccinated people, then one in a million vaccinated people is probably going to get it as well. Again, that’s called coincidence, two events occurring in close proximity to each other without one causing the other.

Miscarriages Are Unfortunately Common Events

         Now, what about the reports of miscarriages after receiving the vaccine? The article by Children’s Health Defense says that 31% of 111 adverse event reports following a COVID-19 vaccine in pregnant women involved miscarriage or preterm birth, so we will assume that is 34 cases. It turns out that between 10 and 20 percent of all pregnancies end in miscarriage. That means that if just 340 pregnant women received vaccine, we would expect that by chance between 34 and 68 of those pregnancies would result in a miscarriage.

         In fact, as of February 3, about 10,000 pregnant women received a COVID-19 vaccine. So, if the vaccine were associated with a higher than expected risk for miscarriage, we would expect to see more than 1000 to 2000 miscarriages to that point. In fact, as Children’s Health Defense notes, only 34 were reported to VAERS.

Miscarriages occur during 10 to 20 percent of pregnancies, so it is inevitable that some will occur by chance after large numbers of pregnant women receive COVID-19 vaccines (image: Shutterstock).

         Like the elderly woman who died hours before getting a shot that we mentioned earlier, there are undoubtedly women who unfortunately suffered miscarriages shortly before a scheduled vaccine and others shortly afterwards. We are dealing with very large numbers here and all kinds of events will happen by chance after someone is vaccinated. The fact that only 34 cases of miscarriage were reported following COVID-19 vaccines actually highlights how random the reporting system really is.

         Our calculations do not prove that COVID-19 vaccines are safe for pregnant women, nor do they prove that vaccines are not involved in miscarriages. They only show that picking out VAERS reports to frighten the public about vaccines is a very misleading business. FDA and CDC will have to explore every case of a miscarriage following vaccination that is reported to VAERS to see if there is any evidence that COVID-19 vaccines elevate risk. It is clear that the numbers alone—and the dramatic stories that anti-vaccination activists concoct about them—do not constitute any danger signal in themselves. Miscarriages are upsetting enough without making women blame themselves for having what is most likely entirely unrelated COVID-19 vaccinations.

         There is a case to be made that pregnant women should be given priority to get COVID-19 vaccines because evidence shows they are at increased risk for severe disease and death if infected. Animal studies did not indicate any increased risks for the Moderna/NIH and Pfizer/BioNTech mRNA vaccines on pregnancy outcomes. That is part of the reason the American College of Obstetrics and Gynecology (ACOG) recommends that COVID-19 vaccines “should not be withheld” from pregnant people. The decision about whether to be vaccinated is essentially left up to the pregnant woman according to the ACOG recommendations, to be made weighing on the one hand the fact that safety data from formal studies in pregnant women is not yet available and on the other the increased risk of severe illness and death from COVID-19 among pregnant women. That’s obviously not an easy choice, but misleading women into fearing the vaccine will cause miscarriage by encouraging misinterpretation of VAERS data is clearly not helpful in making the decision.

         Mining VAERS data is a scare tactic that those opposed to vaccinations will undoubtedly continue to exploit. Doing so enables them to concoct dramatic anecdotes of individuals allegedly harmed by vaccines.  How many stories of vaccinated pregnant women who go on to have healthy babies would it take to counteract them? Or do we need to offer dramatic stories of unvaccinated pregnant women who become seriously ill or even die from COVID-19? Scientists have a natural aversion to arguing their case that way, preferring numbers like those we’ve given to anecdotes. Consequently, we have no such stories to offer in defense of COVID-19 vaccines, but we will continue to address every attempt to use VAERS data to cast doubt on them.

Setting the Record Straight

When Understanding Becomes Misunderstanding

March 2021

Editor’s Note: This is the first in an occasional series in which we will address the many instances in which our attempt to create understanding of a science or health topic results in misunderstanding.

         One of our key missions at Critica is to increase the public’s acceptance of scientific consensus. That means we believe it is always best when people understand the scientific basis for those consensus views. It is a scientific consensus, for example, that available vaccinations prevent serious diseases and have a favorable risk to benefit profile. We would prefer that people not only embrace that statement but understand at least the fundamentals that support it.

         Sometimes, however, misunderstanding is a result of our attempts to create understanding.. We will explore four examples of this and then suggest ways to remedy the risk that understanding will become misunderstanding.

An Army of Antibodies

         Let’s start with the example given above, that vaccines are a safe and effective way to prevent the diseases they are specifically made to target. It seems a good idea that people understand something about how vaccines actually work so that they do not seem so mysterious. After all, it is not obvious how getting a shot today can prevent us from getting a disease later on. So, we try to explain that our immune system works partially by learning how to fight off foreign invaders to which it is exposed. It does this, again in part, by creating a memory system once it has seen a segment of a bacteria or virus. Then, if ever presented with the whole live virus or bacteria again it is ready to produce antibodies that neutralize the pathogens and prevent illness. Vaccines, then, are harmless versions of real viruses and bacteria that train the immune system to remember and produce those antibodies later on if a real infection occurs. Thus, vaccines don’t cure disease, they prevent it. Of course, what happens when we get a vaccine is a lot more complicated than this explanation, but it seems at first glance sufficient to give people some understanding of the basic mechanisms behind vaccination.

         Many people have accepted the idea that vaccines somehow train the immune system to produce antibodies and that antibodies are supposed to attack foreign invaders. Although that is true, it creates the image of armies of tiny soldiers circulating in the bloodstream ready to fight against intruders. We all know that armies make mistakes and sometimes attack the wrong target, so couldn’t that happen with antibodies as well? In fact, there are well known human diseases in which antibodies mistake cells of the body for intruders and attack, causing things like lupus, Crohn’s disease, and rheumatoid arthritis. So, could it be possible that all those antibodies raised by a vaccine could similarly go awry and attack a person’s own tissues and organs?

         The true answer to that question is that such an occurrence is extremely rare with vaccines. Nevertheless, it is not hard to see how someone could examine the protein structure of the part of the virus that causes COVID-19 that vaccines target and then examine the protein structure of different tissues in the body. Doing so led someone to think that the structures—technically known as the amino acid sequences—of the spike protein on the coronavirus and on a protein found on human placentas had some similarity. From that, it was wrongly assumed that the same antibodies that are created by vaccines to attack the viral spike protein might also attack the placentas of pregnant women, therefore making pregnancies impossible to develop and causing infertility.

         It turns out that the amino acid sequences of the spike protein and the placental protein are really not similar enough for antibodies to make that mistake and that COVID-19 vaccines do not actually cause infertility. The myth of female infertility grew out of a partial understanding of how vaccines work. Understanding that vaccines stimulate antibodies that recognize protein sequences became the misunderstanding that the COVID-19 vaccine could create antibodies that attack a protein on the human placenta. That myth spread widely on the internet and has been very difficult to dislodge.

Beware the Word “Genetic”

         A second example of understanding turning to misunderstanding involves the concept of DNA damage. It was only in 1953 that scientists first proposed the structure of the genetic molecule, DNA, but today most people know about the double helix in which two strands of DNA twist around each other. People also know that our genes are on these strands of DNA and that these genes code for proteins that do the body’s work. We have also been successful in explaining that mutations in those genes can cause a variety of abnormalities and diseases, like sickle cell anemia, Tay-Sachs disease, and cystic fibrosis.

         People also understand that damage to our DNA can cause disease and that this is the way known carcinogens like tobacco, asbestos, and ultraviolet (UV) radiation from the sun can cause cancer. Unfortunately, this has made the public nervous about anything that has the word “genetic” in it. When people heard that some COVID-19 vaccines are composed of a piece of genetic material from the coronavirus called messenger RNA (mRNA) there arose in some circles the myth that this could alter a vaccine recipient’s DNA and cause disease. Similarly, the fact that foods grown from seeds that have been genetically altered are commonly referred to as genetically modified organisms (GMOs) again makes people think that eating them can somehow damage their own DNA.

         mRNA-based vaccines and GMOs don’t actually alter people’s DNA the way too much sunlight or smoking cigarettes do, but that word “genetic” lingers in the mind. We understand the basics of how genes work and that mutations in them, either inherited or caused by carcinogens, can cause a variety of abnormalities, so it is not hard to see how we might broaden that understanding to the misunderstanding that anything “genetic” must be harmful.

The Flu Shot Actually Works

         Our third example concerns the annual influenza vaccine that everyone (with just a very few exceptions) should have. Every year the CDC urges that everyone over 6 months old get a flu shot. We are also told every year that the flu shot is, depending on the year, anywhere from 10% to 60% effective. That means it is possible to still get the flu even if you’ve had the flu shot.

         Understanding that the flu shot needs to be given every year and that it isn’t 100% effective has led people to the misunderstanding that the flu shot doesn’t work. Although this is a well-known problem, we were somewhat surprised to see the extent of this misunderstanding during a series of online focus groups Critica held earlier this year. A lot of people don’t get the flu shot because they believe it doesn’t work.

By telling people that the flu shot isn’t 100% effective, some people have the misunderstanding that the flu vaccine doesn’t work at all. In fact, people who have the flu shot cut down their chance of getting the flu and also have milder symptoms if they do get the flu (image: Shutterstock).

         It would be hard to argue with that sentiment if it were true—it makes sense to shun an injection of something that doesn’t work. Except that the flu shot does work. In a year when the flu vaccine is, let us say, 50% effective your chance of getting the flu if you get the vaccine is half that if you don’t. Those are actually pretty good odds—in that year getting the flu shot means I have only half the chance of getting an illness that can be quite severe and even require hospitalization. Furthermore, even if I get infected with the virus that causes the flu, if I’ve had the vaccine it is very likely that my illness will be less severe and I won’t develop serious complications like pneumonia or need to be hospitalized. Understanding the limitations of the flu vaccine has led to the misunderstanding that it doesn’t work.

We Don’t Need Vitamin and Mineral Supplements

         A final example involves what we know about vitamins and minerals. We are taught from an early age that we need vitamin D for bone health, for example, and that the best way to get that is to go outside and absorb some (but not too much) sunlight. The need for vitamin C merits drinking some form of citrus juice from time to time, being careful to remember that some drinks with vitamin C in them contain more sugar and calories than is good for us. There is a long list of vitamins and minerals that science has taught us we need to ingest in order to stay healthy.

A multi-billion dollar a year industry provides vitamin and mineral supplements, even though scientists insist these are mostly unnecessary (image: Shutterstock).

         It turns out, of course, that healthy people can acquire all those vitamins and minerals from an ordinary diet and that vitamin and mineral deficiencies are very uncommon in high-income countries like the United States. That has not stopped a huge and extremely lucrative industry from convincing millions of people that they need vitamin and mineral supplements. Americans spend billions of dollars every year on mostly unnecessary vitamins, minerals, and other health supplements. We’ve apparently done a great job at helping the public understand that vitamins and minerals are necessary but a very poor job at counteracting the misunderstanding that in order to get enough of them we have to buy supplements.

         Does this represent the situation Alexander Pope envisioned when he wrote “A little learning is a dangerous thing?” We would answer that question with an emphatic “no” because it assumes (as Pope did) that we should not try to help people understand science if we cannot teach them every complicated detail.

         We do, however, have to anticipate the ways in which helping people’s understanding of a health or science topic can lead to misunderstandings that become dangerous to the public’s health. It doesn’t seem all that difficult to have anticipated the following:

·  Giving people the image of antibodies as attacking armies might lead to the misunderstanding that vaccine-induced armies could make mistakes and attack our own organs

·  Introducing a vaccine with genetic material in them could cause some people to worry about damage to their own genes

·  Telling everyone that the flu vaccine is not 100% effective might lead to people thinking it doesn’t work at all

·  Teaching us that we need vitamins and minerals could be misunderstood to mean that we need to take vitamin and mineral supplements.

Because we did not predict that these misunderstandings could occur, we are now left with the much more difficult task of counteracting them. Studies show that even a single brief exposure to misinformation can lead to its storage in long-term memory, making it difficult to dislodge. We are not talking here about organized efforts to mislead the public as is the case, for example, with a large segment of the anti-vaccination movement. Rather, our concern is focused on understandable ways in which the information we provide can engender misunderstandings. Every time we venture to teach people about a science or health topic it is incumbent that we ask ourselves “how might this information get twisted around to cause a misunderstanding?” It is time to do better at anticipating how our efforts to help people understand science may also engender misunderstandings.

Trust in Your Doctor Put to Better Use

Whom do people trust the most for accurate, up-to-date information about their health? In this age of rapid-fire information technology, one might guess Dr. Google or some other online source. In fact, recent studies show that people mostly trust their own personal physicians for health information. A Pew Research Center report issued last year showed that 74% of us have a positive view of medical doctors and 68% have a “mostly favorable” view of medical research. A 2019 survey reported that 90% of respondents endorsed doctors as the most trusted professionals. In another survey, this high level of trust in doctors was seen in both liberals and conservatives. In Critica’s recent online focus groups in which we asked people where they get their information about vaccines and what sources they trusted the most, participants overwhelmingly named their own doctors. Internet sources were used frequently as well but were not cited as often as doctors. Federal health agencies like CDC and FDA were seen as less trustworthy by many.

         It is probably no surprise that people are more likely to believe and follow information they receive from trusted sources. It may surprise some, however, to see that doctors have held on to this trusted position for decades despite the many changes that have taken place in the American healthcare delivery system. The trusted family physician whom patients know for years and who in turn knows everything about them has largely been replaced by large group practices and specialists. Today, the electronic health record knows everything about us, not our personal physician (if we even have one).

         This situation seems ripe to erode the classic patient-physician relationship and drive people to find other sources of health information. If doctors get all the information they need about us from a computer, why shouldn’t their patients do the same thing and turn to the myriad online sources of medical information available today?

Prevention Not Emphasized

         Yet, despite the insidious commercialization of medical practice, people continue to put a great deal of trust in doctors. The critical question becomes: are we putting that high level of trust to the best use? It is clear that even in an era in which the amount of time doctors get to spend with their patients becomes shorter and shorter, doctors are important influencers. Studies show that people who trust their doctors are most likely to follow the advice they give. Hence, it is reasonable to assume that since most people trust their doctors, physicians are in an excellent position to steer people toward health-enhancing practices and behaviors.

Despite the short time primary care physicians can spend with their patients and the commercialization of medicine, people still say they trust their doctors more than any other professional (image: Shutterstock).

         This is not a topic emphasized in medical training. The science of health has grown to such enormous complexity and depth that medical students have all they can handle learning about basic physiology and biochemistry, a myriad of diseases, and seemingly unending numbers of treatments and interventions. As is often noted, doctors are trained to respond to disease, not to prevent it. And patients generally have the same agenda: we generally go to see a doctor for one of two reasons, either we have a new symptom like pain that demands attention or we need scheduled care for a known, chronic illness. During those visits, our doctors focus attention on our “chief complaint,” the reason we tell them we are there. Appropriate history, physical examination, and tests are considered and we are sent home with instructions on what to do about the problem with which, in medical jargon, we “presented.”

Primary care doctors are in fact urged by every medical society and preventative health association to also think during each of these visits about dozens of other things the patient should do to prevent illness or at least detect it at its earliest and hopefully less ominous stages. The gastroenterologists want the primary care doctor to look up whether the patient is a candidate for a colonoscopy; the psychiatrists want her to inquire about mood and suicidal thoughts; the urologists want men to have a test for prostate cancer (PSA); and everyone expects the doctor to encourage good diets and lots of exercise. More than a decade ago the median amount of a time a primary care physician got to spend with a patient was already only around 15 minutes. Those visits have certainly not gotten any longer and make dealing with all of these demands for preventative care a daunting task.

What Preventative Steps Can We Prioritize?

         Perhaps one thing that would help would be to figure out some priorities for doctors to consider at each visit after they have dealt with the presenting issue. What are, say, three things that a physician can bring up during a routine visit that are both critically important to health and for which there is some evidence that brief discussions on the order of five to 10 minutes can make an actual difference in the patient’s life?

         We decided to first consider the ten leading causes of death in the United States. They are:

  1. heart disease

2. cancer

3. chronic lower respiratory disease (such as emphysema)

4. stroke

5. unintentional injuries

6. Alzheimer’s disease

7. diabetes

8. pneumonia and influenza

9. kidney disease

10. suicide

None of these ten leading causes of death is entirely preventable. The causes of many forms of cancer, including some of the deadliest like pancreatic cancer and the type of brain cancer called glioblastoma, are largely unknown and therefore nearly impossible to prevent. We don’t know what causes Alzheimer’s disease either and therefore prevention is not really possible. As tragic as suicide is, it is not a predictable event and therefore also difficult to prevent.

But there are things we can do to prevent some of these deadly diseases and to at least delay the onset of others. Of these, the one that most stands out is cigarette smoking. Tobacco smoking remains the leading cause of preventable death in the U.S. and around the world. Despite the fact that smoking is difficult to quit, brief screening and counseling about tobacco use by primary care physicians works during routine visits. Doctors often fail to realize that asking people if they smoke and advising them to stop is an effective intervention that increases the chances a smoker will actually quit smoking. Moreover, there are several medications that can be prescribed that also increases the rates of smoking cessation. One clear way to parlay the trust in doctors that pays off, then, is to enquire about tobacco use at every visit.

Although rates of cigarette smoking have dropped dramatically over the last several decades, tobacco use remains the leading cause of preventable death in the U.S. and around the world (image: Shutterstock).

A second effective intervention is to make sure adult patients have had recommended vaccinations. Right now, of course, that conversation is dominated by the need to have everyone vaccinated against the virus that causes COVID-19 as soon as possible. For adults, however, vaccination recommendations also include those for pneumonia, influenza (“the flu”), and herpes zoster (shingles). We and others are developing brief interventions that all healthcare professionals can use to reduce vaccine hesitancy and increase uptake of vaccines that clearly save lives.

Our third recommendation concerns obesity, which is implicated in heart disease, Alzheimer’s disease, some cancers, and adult-onset (or type 2) diabetes. Here it is perhaps less clear that a doctor’s brief intervention meaningfully impacts obese patients’ behavior, but there is some evidence that it does. Given the number of diseases impacted by a person’s weight, we include brief interventions to address overweight and obesity as one of our top three.

An immediate objection to our list is that even addressing these three issues—tobacco use, adult vaccinations, and weight—could together double or even triple the length of an average doctor visit. It is obviously not sufficient to merely ask the patient if they smoke and have all their vaccinations and check if they weigh more than is healthy for them. Each of these conditions demands at least a few minutes of conversation between doctor and patient about the options for improvement. Let us assume for a moment, however, that each patient has a problem with only one of these three problems. Given that brief interventions for each have been shown to be effective, then most visits would be lengthened by only the 5 to 10 minutes it takes to discuss these options and make recommendations.

A healthcare system that cannot extend primary care physicians’ visits by ten minutes in order to address even these three leading risk factors for poor health outcomes is clearly working against itself. Those ten minutes counseling someone about smoking cessation and possibly prescribing a medication to help such as bupropion or varenicline will prevent countless numbers of cases of cancer, terminal respiratory disease, and heart disease. Making sure the patient gets their pneumonia and flu vaccines will help reduce the rate of the eighth leading cause of death. Discussing a diet and exercise plan and referral to a dietician will definitely result in some patients losing weight and averting the early onset of a number of diseases on the list. The savings in human suffering and medical costs would, we are sure, far outweigh the costs of those extra ten minutes.

There are so many other things that doctors could, and probably should, address during each visit, but again we need to remember how short these visits are and think about how we can leverage high levels of trust in doctors to make the greatest impacts on public health. We are not for a moment dismissing all the things doctors must pay attention to that are incidental to what the patient has come in seeking help. Obviously, for example, if a person coming to the doctor because of a cough and runny nose has an elevated blood pressure, the doctor should address the possibility that the patient’s real health problem is not his cold but rather hypertension. We do hope our readers will let us know what they think about our top three and suggest others that are critical to add to the list.

What we are trying to come up with is a workable plan whereby doctors use the trust people still have in them to bring up health issues for which they can have impact in a very short period of time during every visit. We conclude that the three at the top of the list are tobacco smoking, vaccines, and obesity. If at every encounter, regardless of the reason for the visit, doctors ask patients if they smoke, if they have had all their recommended vaccines, and if they are taking steps to keep their weight at appropriate levels, we predict that countless numbers of premature deaths will be averted. We wish we could add more things to this list—there is good evidence for instance that screening by primary care physicians for alcohol use problems and depression can also be effective—but we are cognizant of the realities of modern-day doctor visits. Let’s start with smoking, vaccines, and weight and see if these at least can be accomplished. Otherwise, we stand to waste the most trusted source of health information known.

Debunking A Misinformed Video About Covid-19

Editor’s Note: Critica advisor Carrie Corboy recently came across a four-minute video in which an OB/GYN physician named Christiane Northrup promulgates some misinformation and disinformation about COVID-19 vaccinations. What follows below is Carrie’s wrestling with these false statements and setting the record straight on a number of important scientific points. It is a great exercise in confronting scientific misinformation. Note that we chose not to link to the actual video here because we are loath to be the ones to spread these kinds of inaccuracies and conspiracy theories. We think you will get the gist of what Northrup says from Carrie’s rebuttal. In the interests of transparency, we note that Carrie is a registered pharmacist and senior director at the Janssen division of Johnson and Johnson, a pharmaceutical company that is working to bring a COVID-19 vaccine to market. We do not detect in what follows, however, any trace of bias, just the facts.

Well, I finally worked up the nerve to watch the Northrup video on COVID-19 vaccines and boy it’s a humdinger.  I’ve spent about 4 hours on this, because I wanted to look up everything that is said in the video (and she packs an awful lot into 4 minutes!!)—all such pieces string together bits of truth mixed with opinion or worse.  It’s a lot of work and why we won’t see direct responses to much of this on the internet.

Ultimately, what matters is what you and others think about this and — more importantly — how it affects your decision making.

My goal is for you to take away some things that you can apply going forward because there is a lot out there and it’s up to each of us to decide what we’ll do with the information/who we will listen to.  This is true across all subjects.

Credibility Issues

This woman is an OB/GYN.  Not an infectious disease expert, not a virologist, not an epidemiologist.  She’s not a student or expert in nanotechnology or nano robots.  She doesn’t present any reason that would suggest she has any expertise in 5G.  She nevertheless rehearses the completely false notion that the vaccines have antennae in them that transmit via 5G into the cloud and will be used by Bill Gates and others to mount surveillance of the American public. She doesn’t have the credentials to back up her “expert” opinions.  This happens a lot in medicine.  Physicians are given complete credibility across the entire spectrum of science and medicine.  And, unfortunately, some physicians are happy to cash in on that.  When I have a medical issue, I go to a specialist in the area of my issue.  I don’t even ask an opinion of a non-specialist (other than “do you know an excellent XXX that you would go to for this condition?”).  Even when I did have a specific question for my OB/GYN about a GYN concern, she checked with her surgeon colleagues for their experiences and used that to guide me.  Good health care professionals, good anything, know they don’t know everything.  This woman is claiming to know about an awful lot, none of which lines up with her expertise.

It’s clear this woman makes her money on books, TV, and the like.   These things suggest to me this woman is trying to personally capitalize on sensationalism at the expense of the public.

Lack of Details/Specifics

Which vaccine is she referring to?  There are two now with Emergency Use approvals (Pfizer/BioNTech and Moderna) and others in late stage development (Astra Zeneca, Janssen).  There are over 50 other vaccines in earlier stages of R&D.   This woman makes no claim to a specific vaccine (because then she could be pursued for her lies about a specific product).  So she’s spreading this fear about all COVID vaccines in general.  This is something often seen in unfounded claims.

The truth about the patent (which I find interesting she calls out the 060606 portion of the full patent number—trying to conjure a subconscious  connection to Satan?). It’s an outright lie that the patent refers to anything injectable/internal to the body.  Furthermore, the vaccines are not the product of some secret form of nanotechnology. People are understandably confused about what the “nano” means when it is used in reference to some of the vaccines. In fact, genetic material in some of the vaccines is surrounded by lipid (i.e. fat) nanoparticles. That means that the lipid particles are nanometer in size (a nanometer is one-billionth of a meter). No nanotechnology and no antennae.

Toxic metals in vaccines?  Why do I have to go digging to try and figure out what she’s talking about?  I’m *assuming*  she’s referring to aluminum that can be used as an adjuvant (something in a vaccine in addition to the protein we need the immune system to identify, that increases the immune response) By the way, this reduces the number of vaccines needed (e.g., one shot or multiple shots) and ensures longer immunity.  How would she know if (any of) these vaccines (and again, which is she talking about??)  include aluminum (this is not public information yet)?  She’s happy to state this as if it’s fact.  . 

Also, aluminum is pervasive in our environment, foods and medicines.  

She’d have some credibility if she compared the amount of aluminum in vaccines to something we are already exposed to (like infant formula or breast milk or antacids)…but this would not serve the message she’s delivering because we’d quickly see that if aluminum is a problem, avoiding vaccines is not going to fix that problem at all.

Luciferase does not work by shining a light on it…outright lie .  But boy is it powerful to say another word that conjures the devil or Satan.

Non-human DNA…what is this referring to?  Again, how does she know/have access to such proprietary information?  And which vaccine is she talking about?  She doesn’t even know which non-human DNA might be in the vaccine – she just names different animals. Which animal is it, if it’s true?  Again, by not naming a vaccine, she can’t be countered.  In fact, the two currently available vaccines have mRNA from the virus and not DNA. We are unaware of any non-human DNA being a part of any vaccines for COVID-19.  It would be a longer story to explain that, even if there were, it wouldn’t make vaccines unsafe and that DNA from another species does not alter the genetics of humans.

The word is chimera (not “chimer” as she says) and chimera exist naturally and not infrequently—further details here (rather interesting). At first I thought this was an illustration of her lack of expertise in this area, but when I read the reference I had an even more critical impression: she knows what a chimera is and that it occurs frequently in nature, because she’s an OB/GYN and this can often occur during pregnancy and persist in the mother long after she has given birth.  When people talk blindly on topics they are not expert in, that’s one thing (because we can quickly assess expertise).  When someone uses information they are familiar with to mislead, on the other hand, that can cause great harm and to millions of people.

mRNA in the vaccine (and not all candidates are mRNA vaccines) are from the virus (not from another animal) and only a small snippet that creates the protein that we all see as a ’spike’ on the corona-virus pictures/emojis.  This ’spike’ is what the immune system responds to.  So the mRNA makes the spike (and only the spike, none of the material that allows replication of the mRNA is included) and the body develops an immune response without having to get an infection.

The 99.9% recovery claim. What/who is the source for this recovery rate from COVID-19?  What does ‘recovery’ mean?  I have to assume by “recovery” she means “didn’t die from the acute COVID infection.”  She doesn’t define it, so here again, I have to draw assumptions.  Let’s say my assumption is correct.  It’s interesting that she posits a ‘recovery rate’ and not a ‘death rate.’  99.9% sounds so good, so harmless.  Due to the long period of contagiousness before feeling any illness (and those that never feel ill enough to stay home) spreading is fast and extensive.  If you will allow me the assumption that no one (without having been vaccinated, or without permanent social distancing and masking) will avoid COVID-19, then consider that 0.1% of 330 million people (US population) is 330,000 people.  Is it okay with her that 330,000 people in the US (and 7 million worldwide) die that did not need to?  And it’s not going to go away, so that 0.1% deaths will continue forever without a vaccine.  She purposefully spins what is a grim number to sound like no big deal.  

Let me also point out something you well know–a significant factor in ‘recovery’ (again, here I am using the “not dying from acute COVID-19” definition) is access to enough high-quality health care.  So, imagine the scenario where you do not vaccinate because you decide the risk for you dying from COVID-19 is low, yet you travel and in another part of the US, or world, you become ill.  What you may have recovered from here at home, you may not in another location due to different health care capabilities or resources.  In this country, we see that the vast healthcare disparities have made Black, Latinx, and Native American people more vulnerable to acquiring the virus and developing severe illness from it than white people. Then there’s the ethical issue of what you bring with you to other areas that are less equipped to handle the disease.  Again, you may be fine, but quite literally kill others.  That’s a very personal assessment.

Finally, if you want to look around at data, try this site (which has been online and public since the start of the pandemic). If you go to the tab at the bottom of the map called ‘case-fatality ratio’ (note: it is not called a “death” or a “recovery rate”) and click on any of the dots in the screen you can see the case-fatality specifics for that area.  Clearly, if we just look at positive tests and deaths due to COVID, plenty of areas see differences.  You can quickly compare by the size of the dots the differences among countries and states.  For example, in Florida, the case-fatality ratio is 1.83%—quite a bit more than the 0.1% the doctor in this piece is trying to comfort us with.

Biostatistics take effort to learn—people earn bachelors, masters, and PhDs in it–and it’s not possible for people like you and me to be experts.  It is reasonable for anyone using such numbers to explain what is assumed/what is meant by them.  This woman does none of that.  She leaves us to our own interpretations.  What people should minimally do is select scientific sources of information (or several) that are trustworthy due to the expertise.  Here is a source to explain the recovery rates.

I will leave you with another bit of information that this doctor did not mention: just because people do not die after COVID-19 infection does not mean they have resumed pre-COVID-19 life or health.  This is where the importance of defining ‘recovery’ becomes clear. Cancer patients are told that life will be a new normal.  As a cancer survivor, I will tell you it is drastically different, and nothing about it is normal.  And I’m fortunate with not a lot of limitations.  I don’t have a rate for this “no longer infected but still suffering” group of people but if I could protect anyone from this ’new normal life’ with little to no risk to myself, then I’m going to do it.  This article is coverage of an NIH meeting on this topic.  The CDC also has an informative page on long term effects of COVID-19. 

And if the ethical, moral angle on this doesn’t resonate, maybe the economics does.  The people most at risk are the ones we depend on the most in this world, the people with minimum wage jobs or contractors in the gig economy that run the operations as well as the professionals and laborers that staff our hospitals.  You may express concern about locking things down and the economic consequences, and I agree they are real and devastating.  I am convinced, however, that staying open and letting everyone get sick (and die, or not quite recover) is going to be just as devastating to the economy.  There are certainly small countries that have tried this model and they are not faring well economically, either.

In 4 minutes this person spouts a bunch of conflated bits of information, infers that she is qualified to speak of this.  It takes someone a lot of time to unwind, verify and correct what has been said.  No one makes money doing this, so these dangerous bits float about our environment, unchecked.

At the end of the day, vaccination will be a choice.  The non-vaccinated may have consequences to their choices, the most drastic of which is dying from COVID-19 themselves or infecting a loved one who then dies or who is permanently affected and they must care for.

This woman is putting her own fame and financial gain ahead of the health of anyone within earshot.

Do Race or Ethnicity Have Biological Meaning in Medical Practice?

A medical student with white skin is about to describe a patient newly admitted to the hospital to her attending physician. She will start by giving the patient’s age and sex (“A 58-year-old man was admitted to the hospital last night after presenting to the emergency department with slurred speech and weakness in his left arm and leg”). Should she also mention in this opening statement that the patient is a “58-year-old Black man?”

         To think she should would be to assume that race is a fundamentally biological trait that is embedded in a person’s genetic makeup (the genome) and inherited from the previous generation. Here we see a complicated apparent paradox.

         One the one hand, scientists tell us, based on substantial research, that race is really a social construct and has very little if any biological meaning.  On the other hand, there is serious interest lately in the notion that ethnic minorities should be included in higher proportions in research studies because we should not assume that Black, Latinx, and white people will all respond similarly to different medical interventions. That sounds as if there must be a biology somewhere involved in race. How we work out this apparent paradox is critical if we are to begin to undo centuries of healthcare discrimination and abuse of ethnic and racial minorities in the United States.

The Case for Race as a Social Construct

Why do anthropologists tell us that race is not a function of biology? This is because while conventionally assigned  race may be associated with some diseases (e.g. white people are more likely to have cystic fibrosis and Black people more likely to have sickle cell anemia), in these cases race  itself is still only an association (Black people can also have cystic fibrosis and white people also have sickle cell anemia).  If you sequenced the genome of any individual and got their complete genetic code, nucleoside by nucleoside, you would not be able to determine from this information whether they are white, Black, Asian, Latinx, or Native American (although according to some you may be able to determine what geographic region of the world their ancestors came from). Two people with dark skin may identify themselves as Black and two people with light skin call themselves white, but the two Black people and two white people are likely to be more genetically different from each other than either white person is with either Black person. That is, there is often more genetic diversity between two people of the same race than there is between two people of different races.

These three people appear to be members of different racial groups, but there may be nothing in their genes that distinguish one from the other. This is the reason that race is often called a social rather than a biological construct (image: Shutterstock).

         If, then, race has little biological significance it would seem irrelevant for the medical student to mention it when presenting the new case to her professor. Race has been used as an excuse to discriminate against people and to create huge inequalities and inequities among racial groups, so perhaps pointing out that someone is Black in the course of giving a medical report would only serve to perpetuate bias. An oft-noted example is that for the same level of pain, Black patients are systematically prescribed less and lower doses of pain medication than white patients. What if the attending physician harbors latent racist views and is prone to take the complaints of Black people less seriously than those of white people? Isn’t it better to think about the patient’s problems blinded to his race in order to ensure an objective assessment and equitable treatment plan?

         The answer to the above question is probably yes and until medical students and attendings go to see the patient at the bedside to gather more information and perform a physical examination, there is probably no reason to identify the patient as belonging to any one of the conventional racial groups.

In Some Cases There are Biological Considerations

         Yet in other contexts within medicine, we are actually encouraged to consider the possibility that race does entail differences that are biologically meaningful. Recently during clinical trials of vaccines against the virus that causes COVID-19 the concern was raised that research participants should represent the same racial mix as they are in the general population. About one-third of Americans are identified as Black, Latinx or another group other than white and the question raised here is whether we would know if a vaccine worked in Black or Latinx people if they weren’t included in representative numbers in the research studies. But if race is not biological and if two white people are likely to be more genetically dissimilar than a Black and a white person,  why should the racial make-up of a clinical trial make any difference?

         One reason is because some studies have shown that different racial groups, on average, respond to certain medications differently or have different risks for acquiring some illnesses. For example, a category of medications called ACE inhibitors used to treat some cardiovascular problems seem to work less well in Black patients than in white patients. A difference in the genes for an enzyme that metabolizes drugs in the liver between Asians and whites makes the former group more sensitive to antipsychotic medication, therefore making it best for Asians to take lower doses. Black people have a higher rate of venous thromboembolism than people of other racial groups and also have a higher risk for developing systemic lupus erythematosus

         Of course, because of genetic differences within groups, not all Blacks, whites, or Asians will manifest these or any other differences in a given drug’s effectiveness or risk for a specific illness. Furthermore, whether or not a drug works in any individual also depends on many non-biological factors, like whether or not a person can afford to buy the drug in the first place. Nevertheless, race does seem to make a difference in some ways that are biologically meaningful in medical practice.

The Importance of Social Determinants

         Returning to our medical student’s patient, he turned out to have suffered a non-fatal stroke on the right side of his brain. He also had a history of poorly controlled high blood pressure (hypertension), a known risk factor for stroke and heart disease. Now Black people have higher rates of hypertension than whites. Does knowing that this patient is Black make any difference? Probably not much in making a diagnosis and deciding on treatment. The signs and symptoms of stroke are identical across all racial groups and the treatments the same. Perhaps this patient will not be prescribed an ACE inhibitor to treat his hypertension, but there are many other choices that work equally well in Blacks and whites.  The patient’s race may, however, have a profound influence on how he is treated. This would not be because of biology in this case but rather because of prejudice and non-biological factors. 

         Some have stated that ethnicity may be more useful than race in making medical decisions. Our stroke patient appears to be Black to our medical student and attending physician, but his background is complicated. His father emigrated to the United States from Brazil, identifies as  Black, and speaks Portuguese. His mother was born in the United States of parents of Italian ancestry. Our patient speaks a little Portuguese, likes to eat Italian food and practices the Catholic religion. His African ancestry is therefore more remote than his Brazilian and Italian backgrounds. Ethnicity takes into account all of these factors of origin, religion, language, and behavior in addition to skin color. In this context it is very likely that our patient would even have a good response to an ACE inhibitor. Illnesses that are often thought of as occurring in only one racial group, can actually occur in many. Sickle cell disease, for example, while most common among people of African ancestry, also occurs in people of European, Middle Eastern, and Asian ancestry.

         Why do Black people have higher rates of hypertension than white people? Interestingly, black people living in the United States have higher rates than black people living in Africa, so ancestry does not seem the key factor here. Rather, socioeconomic factors are most likely key to understand the differences in rates of hypertension. Living in a low-income neighborhood is associated with hypertension. There is less access to medical care and less money to afford healthy food and medications. The chronic stress of living in an economically deprived neighborhood and of facing racism and racial discrimination is also linked to hypertension. A study showed that when residents of racially segregated neighborhoods move to less segregated communities they experience a decrease in blood pressure. Thus, one’s race profoundly determines the socioeconomic factors that affect one’s health and the healthcare received.

Factors like those depicted here and directed against people of color have more of an impact on health outcomes than do any racial biological factors (image: Shutterstock).

         In coming up with a comprehensive treatment plan for our stroke patient, knowing his skin color is less important than understanding the socioeconomic factors that may influence his rehabilitation, recovery, and avoidance of future strokes. Does he have social support? Is he someone who is usually adherent to prescribed medications? Can he follow a healthy diet and get exercise? Can he afford quality medical care? Is quality medical care even available where he lives?

         These factors, often called the social determinants of health, turn out to be far more important than race in determining medical outcomes. In fact, about 80% of health outcomes is said to be a function of social determinants of health. They are, unfortunately, too often not felt to be part of a physician’s purview, although that is changing rapidly.

         The history of racial discrimination, racism, and inequities has had a profound effect on healthcare in the United States. People of color receive less quality care and have higher rates of morbidity and mortality for many conditions than white people. Because of persistent structural racism, it is definitely important to ensure that racial and ethnic minorities are included in numbers that at least mirror their population representations for things like clinical trials. It is absolutely possible that some Black people, for instance, might react differently to a COVID-19 vaccine than some white people and therefore having them in these studies is critical. Similarly, we should not ignore race as we strive to overcome inequities and inequalities in the provision of healthcare, improvement of health outcomes, and the distribution of healthcare professionals.

         Still, for any individual patient it would seem that neither race nor ethnicity is going to make a major difference in making a diagnosis or selecting interventions. Rather, we need to boost our attention to the underlying factors that create differences in health outcomes among races—the social determinants of health. Our stroke patient turns out to have a loving, supportive family and adequate resources to obtain medical care. He is generally adherent to medical recommendations and prefers to see Black physicians. Factors like these are highly important in determining how well this patient will do. Another patient without social support or adequate resources will not do as well unless these factors are attended to.

When thinking about race, then, it is true that healthcare providers need to bear in mind that there are some instances in which biology may properly influence decision-making. But it is more important for them to understand how decision-making is all too often influenced by irrational attitudes about race of which they may be unaware. These attitudes have led to massive health disparities that it is every healthcare professional’s duty to help remedy.