What Will It Take to Sustain Our Interest in Gun Control?

Two days after the May 24 Uvalde school massacre that claimed the lives of 21 people, two major league baseball teams did an unusual thing. Instead of tweeting about the game they were playing against each other, the New York Yankees and Tampa Bay Rays chose to tweet a series of facts about gun violence, including “Firearms were the leading cause of death for American children and teens in 2020 ” and “Every day, more than 110 Americans are killed with guns, and more than 200 are shot and injured.” Each statement was accompanied by a citation from a credible source, like the Centers for Disease Control and Prevention (CDC).

         Every time there is a mass shooting involving school children, we see a spike in media attention to gun violence and an increase in calls by politicians for federal gun control legislation. What the Yankees and Rays baseball teams did was laudable, but it raises the question of whether this kind of recitation of facts about gun violence immediately following an incident has any impact. At the time, we wondered whether the latest surge in interest in gun violence would last, whether it would lead to any action, and exactly what kind of action might actually work to decrease gun-related deaths and injuries.

Politicians Wait Out Public Outcries Against Guns

         Here’s a fact about guns: according to Monika L. McDermott of Fordham University and David R. Jones of Baruch College, CUNY, “Nearly half of the public lives in a household with a gun.” That’s the U.S. public, of course. Most other high-income countries have much stricter gun laws than the U.S. and far lower rates of gun-related deaths and injuries. McDermott and Jones point out that although a “slim majority” of Americans favor stricter gun control legislation, “that support tends to spike in the short term after events like the recent mass shootings [Buffalo and Uvalde].” Congress can thus size up that a lot of people own guns and only a small majority favors restricting access to them. To avoid taking any action it can just wait a bit until the furor over the most recent killings subsides. That means that a gesture like that taken by the baseball teams has a short-lived effect that won’t translate into any meaningful action.

         As we move farther away from highly publicized gun violence incidents like those in Uvalde, Texas and Buffalo, New York we see more and more doubts expressed about whether gun control legislation would even be effective in reducing gun violence. After all, there are already millions of guns in the hands of Americans—an estimated 120.5 for every 100 citizens—so some argue further restricting sales and access will have no meaningful impact.

         We also see other doubts about the effectiveness of gun control laws cropping up. For example, in an analysis in the Washington Post, Glenn Kessler concluded from work done by gun researchers that “mass shooters are very determined individuals and that even with an average of seven or eight mass shootings a year, new laws might only reduce the number by one a year.” Later in the article, Kessler does acknowledge a now lapsed law banning large-capacity magazines “may have been effective in reducing the death toll” and that universal background checks “could have an impact on mass shootings.” Still, the tone of the article casts doubt on the likely impact of some of the most prominently proposed gun control laws, like bans on assault weapons.

         It is not only politicians who lose interest in gun control legislation over time, but all of us. We are shocked and horrified by the deaths of innocent children during a mass school shooting, we talk about nothing else for several days, and then the memory fades and we move on to other pressing topics. “A dramatic event like a shooting attracts reporters’ attention, provokes a great deal of coverage, and then fades from view when the news media move on to the next big event,” wrote Sarah Binder last May in the Washington Post. “What’s more, public pressure for change typically fades as well, letting opponents off the hook.”

The Science About Guns Is Clear

         But the fact remains that the Uvalde shooter purchased his guns legally just days before the massacre, right after his 18^th birthday. Laws banning the purchase of assault weapons and raising the legal age to buy a gun from 18 to 21 across the country might have prevented him from obtaining the weapons he used. We can debate the likely effectiveness of gun controls laws endlessly, but perhaps what we need more of are headlines like the one that appeared on May 26 in Scientific American: “The Science is Clear: Gun Control Saves Lives.” Scientists love to debate all the details and nuances of available data on every topic, and pieces like the one cited above in the Washington Post that carefully dissect the evidence supporting gun control laws are important. Still, what we need to know is that scientific consensus supports gun control. The piece by the Scientific American editors does not equivocate:

The science is abundantly clear: More guns do not stop crime. Guns kill more children each year than auto accidents. More children die by gunfire in a year than on-duty police officers and active military members. Guns are a public health crisis, just like COVID, and in this, we are failing our children over and over again.

The clear gun science the article’s headline refers to is summarized as follows:

…in 2015, assaults with a firearm were 6.8 times more common in states that had the most guns, compared to the least. More than a dozen studies have revealed that if you had a gun at home, you were twice as likely to be killed as someone who didn’t. Research…tells us that states with higher gun ownership levels have higher rates of homicide.  Data even tells us that where gun shops or gun dealers open for business, killings go up…The science must not be ignored.

         We need definitive, bold statements like those made in the Scientific American article. While of course we always need more research on almost every topic and gun violence research has been woefully underfunded for many years because of federal funding restrictions, we have enough data right now to justify consideration by Congress of steps like renewing the bans on assault weapons and large capacity magazines, universal background checks for gun purchase, and raising the age limit for gun purchases from 18 to 21. It is true that so long as U.S. residents who are not active military or law enforcement personnel are permitted to have guns, none of these laws will eliminate gun homicides or suicides. The data tell us they may, however, reduce the number of gun-related deaths and injuries and that should be more than ample justification for pursuing them.

         What we will need to make federal gun control legislation happen is to keep our attention level about this issue sustained at a high level. We must not think that gun violence is isolated to the relatively rare school massacre: according to Pew Research, in 2020, the most recent year for which complete data are available, “45,222 people died from gun related injuries in the U.S.,” slightly more than half of which were suicides. The Pew report from last February also notes that “Regardless of the definition being used, fatalities in mass shooting incidents in the U.S. account for a small fraction of all gun murders that occur nationwide each year.” Firearm-related deaths and injuries occur daily in communities across the U.S.

         Media attention to every gun-related death in a community runs the risk of inuring the public to these tragedies and blunting our resolve to do something about them. Rather, we need sustained, targeted attention throughout the year to the problem. Articles like the one we cited above in Scientific American need to appear on a regular basis throughout traditional and digital media, not just after mass shootings involving children. Unless we remain outraged about gun violence and press for new gun control laws, Uvalde will simply fade away from our memories. It is for this reason that we are writing about gun violence and the data supporting gun control legislation two months after the Uvalde school massacre. We hope the Yankees and Rays and lots of other influential organizations will tweet and post about this problem again and again. Critica will do what we can to keep our attention focused on the gun violence issue and its potential solutions.

How many crises can people handle at the same time? The Covid-19 pandemic continues; there is a war in Ukraine; inflation is out of control; and people who are refugees, members of marginalized communities, or live in occupied territories continue to suffer around the world.

         Looming over all of this is global warming and the ongoing climate crisis. As massive floods, unprecedented heat waves, and other environmental disasters become ever more common across the globe, we seem to put this at the bottom of our list of concerns when we respond to surveys and vote for elected officials. Yet this problem is not going away—indeed it is getting worse, with more carbon dioxide being pumped into the environment now than ever before. Why are we so willing to look the other way when it comes to the climate emergency we are now facing?

It Isn’t Hopeless

         One reason is the sense of hopelessness and despair engendered by just what we wrote in the paragraph above, that the climate crisis is getting worse. It now seems inevitable that we will exceed the threshold of an increase in global temperature of 1.5⁰ Celsius over preindustrial levels and that will surely bring us more floods, heatwaves, and misery. If it is hopeless, then the best we think we can do is to try not to think about it at all.

         Yet in fact hopelessness in the face of the climate crisis is entirely misplaced because scientists assure us that we now have the technologies necessary to operate our power grids with clean, sustainable energy from fossil-free sources. In a heartening article published in Physics in April, Mark Z. Jacobson of Stanford University noted that “10 countries—Iceland, Norway, Costa Rica, Albania, Paraguay, Bhutan, Namibia, Nepal, Ethiopia, and the Democratic Republic of the Congo—produced 97.5 to 100% of all their electricity from WWS [wind-water-solar] resources. Some of these countries even produced excess electricity that they could sell to their neighbors.”

The cost of wind and solar power have declined dramatically in recent years to the point that it is now practically and economically viable to develop them as our main energy producers. Fears that without burning fossil fuels the lights will go out all over the world are unsupported by the facts: Jacobson tells us “I’ve studied the use of [renewable energy] technologies in 143 countries and 50 states and found that the grid can stay stable everywhere in the world with 100% WWS.”  Iowa, for example, now gets most of its power from the wind. Batteries to store electricity generated by wind, hydro (water), and solar sources are also becoming increasingly more sophisticated and cheaper, although there are issues with the environmental and human effects of mining the minerals like cobalt and lithium that are needed for them.

Just as climate scientists give us the disheartening news about the devastations we face if we continue to extract and burn coal, oil, and gas, they are giving us increasingly upbeat news that we absolutely have the technology right now to rectify the situation and move to fossil-free energy.

The Climate Situation is Life and Death

Relieving the world of the pollution caused by fossil fuel combustion is in fact as much a life and death emergency as is getting the Covid-19 pandemic under control and ending the war in Ukraine. In vulnerable neighborhoods around the world, people breathing in the pollutants emitted by truck and car exhaust and from incinerators and other polluting facilities suffer a plethora of adverse health outcomes, including lung and heart disease. Low-income neighborhoods are especially burdened by pollutants emitted from vehicles and facilities. That creates the impression that poverty is the cause of this environmental injustice, but studies show that the real cause is racism.  As reported in Nature, Dylan Bugden of Washington State University in Pullman found in a survey that “Most Americans do not think that Black people are any more likely to be affected by pollution than white people, despite significant evidence that racism is a root cause of environmental injustice in the United States…” Neighborhoods with high concentrations of Black people were subjected to redlining by federal authorities for almost 40 years, a practice that resulted in restricted mortgages to those neighborhoods and concentration of highways, incinerators, and other pollution-causing facilities.

Here again, there is some hope on the horizon. New Jersey now has the strictest regulations in the U.S. to limit this kind of environmental insult by taking into consideration a community’s cumulative burden in granting permits to facilities that will cause pollution. At the federal level, President Biden’s Justice 40 initiative mandates that 40% of the government’s investment in climate and clean energy will go to disadvantaged communities.

Technologies exist to mitigate the climate crisis and thereby save lives. The situation is urgent, especially for people living in vulnerable neighborhoods who are the victims of racist practices that concentrate polluting vehicles and facilities in their communities. The issue is whether we and our elected officials have the will to take advantage of these technologies and of the examples set up by all the countries that are already using them to put an end to fossil fuel combustion and bring us renewable energy. We also need to see whether other states will take New Jersey’s example and move boldly to restrict further placement of pollution-causing facilities in already overburdened communities.

As an editorial in Nature recently put it “World leaders must listen to the research community, and accept the evidence and narrative offered to help them to navigate meaningful change. Environmental sustainability does not impede prosperity and well-being—in fact, it is vital to them. People in power need to sit up and take notice.”

When a person contemplates terminating a pregnancy by induced abortion they may go online for information. There, they will find an incredible array of misinformation and disinformation.  Online platform companies like Meta, the parent company of Facebook, Twitter, and Google, struggle to monitor and police online misinformation in general, but those challenges seem especially complex for them when it comes to abortion. These platforms claim to encourage free speech and because abortion is felt by some to be a political, religious, and ethical issue the platforms appear confused about when something posted is in fact misinformation.

The online platforms often neglect to recognize that induced abortion is a medical issue and that there are many things being posted about it that are clearly incorrect. “Perhaps no medical procedure is subject to more misinformation than abortion,” wrote Jenna Sherman in the Scientific American in June, “and social media and search engine companies have been too stagnant in their efforts to stop the spread.”

         So it is important to get the facts straight about abortion and then to do all we can to counteract misinformation and disinformation about it. There are two ways to accomplish an induced abortion, by taking medication and by surgery. Despite what one may read on the internet, both are safe. In fact, having an abortion is safer than having a baby. A study published ten years ago showed that a woman is 14 times more likely to die during childbirth than from complications of having an abortion.

Half of Induced Abortions are Medical

         About half of induced abortions in the U.S. are now accomplished by medication according to the Guttmacher Institute and that rate may go up with the recent overturning of the Roe v. Wade decision by the U.S. Supreme Court. Contrary to misinformation often posted on the internet, the “morning after pill” is not the same as the “abortion pill.” Experts agree that morning after pills, which contain the hormone progestin and must be taken within a few days of unprotected intercourse, interfere with ovulation and fertilization and do not cause abortion. Medical abortion on the other hand involves taking two drugs, mifepristone and misoprostol, and is approved by the FDA for use up to 10 weeks of pregnancy. Medical abortions are safe and effective.

         There is some concern that medications for preventing pregnancy and for medical abortion will become less available in the U.S. after the recent Dobbs decision that overturned the constitutional right to an abortion. There has been an increase in online chatter about alternatives to FDA-approved medications for abortion, including a variety of herbs. However, no herb has ever been proven to be an effective abortifacient and in fact taken in high doses there have been reports of severe toxicity and even deaths.

         The alternative to medical abortion is surgical abortion. More than 90% of surgical abortions in the U.S. are performed before the 13th week of pregnancy by an aspiration procedure. Fewer than one percent of induced abortions occur in the third trimester, although these abortions later in pregnancy seem to get the most attention from anti-abortion activists. Abortions after 21 weeks are sometimes done because of the detection of severe fetal abnormalities or because the life of the mother is threatened.

Medical and Surgical Abortions Are Both Safe Procedures

         Claims that induced abortion increases the risk for infertility, breast cancer, and mental health problems are incorrect. We know this from many studies, the most important of which is probably the Turnaway Study, which followed more than 1000 pregnant women for five years, beginning in 2007. Prior to the Turnaway Study, a number of reports in the literature suggested that there were increased mental health risks for women who had undergone elective abortion, but these studies were all fatally flawed. A key reason for the problem with them is that they did not control for preexisting mental health problems in women who underwent abortion and therefore could not determine if the abortion itself was really associated with any increase in risks. The Turnaway Study handled this problem in a very creative way: by comparing women who had an abortion to women who sought an abortion but were denied one because their pregnancies had gone beyond the time limit that the facility where they sought an abortion allowed, the investigators were able to assemble very well-matched groups for comparison.

The leader of the study, Diana Greene Foster, professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, recently wrote about the findings of the study in the journal Science: “Women unable to obtain an abortion said they had more symptoms of anxiety lower self-esteem, and lower life satisfaction. They were more likely to report ‘fair or poor’ health than those who had received abortions.”  In a series of more than 50 papers published by Turnaway Study investigators, Foster noted it was also shown that women who were denied abortions were more likely to have lasting financial problems, to be unemployed, and to live below the federal poverty line compared to women who were able to obtain abortions. There is no link between having an abortion and future fertility problems and abortion does not increase the risk for breast cancer.

         One thing that is also clear is that restricting access to abortion will have its greatest adverse effect on people who belong to traditionally marginalized groups. According to scientists from the University of Pennsylvania, “it is well-established that anywhere from a quarter to a third of people who receive an abortion annually are Black, and the majority are low income.” The maternal mortality rate for Black women in the U.S. is more than double the rate for white women, meaning that unwanted pregnancies among Black women will cause, among other adverse outcomes, a disproportionate increase in maternal deaths.

         Regardless of one’s political, religious, and moral opinions about induced abortion, there are several things we know from research studies that belie rampant misinformation. Both medical and surgical abortions are effective and safe. There is no increase in maternal physical or mental health problems associated with having an abortion. In fact, childbirth is far riskier than having an abortion. Women who are denied an abortion suffer increased risks for unemployment, poverty, and ongoing financial and other social problems. The adverse outcomes associated with being denied an abortion disproportionately affect women of color, women with low-income, and members of traditionally marginalized groups.

         While there will be differences of opinion about induced abortion, it is critically important that the available science not be distorted in these debates. Evidence tells us that abortion is safe, and that restricting abortion causes physical and mental health problems as well as a host of poorer socioeconomic and life satisfaction outcomes. We hope that people contemplating an elective abortion will have access to accurate scientific information and that this information plays a prominent role in legislative and judicial proceedings about abortion.

Editor’s Note: We are indebted to Professor Lara K. Smetana of Loyola University, Chicago for spending time with us to tell us about the exciting developments that have occurred in science education in the last decade. Despite a number of challenges, there is now reason to believe that science education at the elementary, middle, and high school levels has been significantly improved.

Are you old enough to remember when science class in elementary, middle, and high school involved almost entirely the memorization of “facts?” Even through introductory classes in college, students were required to replicate the periodic table of the elements by heart, memorize the anatomy of frogs and other animals, and know the equations that govern the forces of nature, like gravity. It was generally quite tedious work, and many students were completely turned off to science as a result. Those classes created the misperception that everything about science is already known and that the only role of science learners is to memorize what scientists have already proven.

         At some point a few decades ago educators realized that this approach to science education was not creating a cohort of students eager to engage in scientific and engineering careers. Why be a scientist if everything is already known? So the concept of teaching science “by doing science” was introduced. Scientists work in laboratories doing experiments, it was reasoned, and therefore students should have the experience of conducting “experiments” in class to demonstrate to them how scientists actually developed all these “facts.”

         The problem with this approach, however, is that it more closely resembles what an amateur cook does in the kitchen than the work actual laboratory scientists pursue. Students were given “experiments” in which a carefully prescribed set of steps were to be performed leading to a “correct” outcome. Deviations in the protocol would yield the “wrong” answer and therefore students, like people following recipes in a cookbook, needed to carefully replicate every step of the exercise. While this might be a bit more fun than memorizing the periodic table of the elements, it once again hardly mirrors what scientists really do. The point of experiments is that you never know the outcome until you’ve finished the study. Sometimes, you get results that match predictions you made before you started; more often things happen that don’t match your initial hypothesis and you need to do another experiment and then another. Gradually over time something that looks like a fact might emerge.

Traditional Science Pedagogy Had Adverse Consequences

         The approach to teaching science as a set of already known facts and outcomes is consequential, as we have seen clearly during the pandemic. The face mask saga is a case in point. There is no question that recommendations on the benefits of face masks to reduce the likelihood of acquiring and transmitting the virus that causes COVID-19 changed substantially over the last two years. Part of the reason is there was a paucity of good data about face masks prior to the pandemic. Once the pandemic was underway, scientists scurried to study whether they are helpful or not, quickly finding that this is not an easy thing to research. Clinical trials in which people are randomized to either wear or not wear face masks are exceedingly difficult to pull off and subject to a myriad of complications that can make findings difficult to interpret. Other kinds of studies, called observational studies, finally did yield convincing data that face masks are effective for reducing the spread of COVID-19 and that has resulted in health officials recommending we wear them when in high-risk situations, like crowded indoor spaces.

         For many people, however, the uncertainty and changes in guidelines meant that the “scientists don’t know what they are talking about,” leading some to reject face mask recommendations. Many observers believe this attitude derives in large part from the way we have been teaching people about science. The notion that science is a constantly evolving process in which findings build upon each other and that every scientific concept is subject to revision when new data emerge is something left out of traditional science education. “Scientific progress as reflected in reports and public debate during the COVID-19 pandemic offers vivid examples of teachable aspects of the nature of science,” wrote Wei-Zhao Shi recently in Nature Human Behaviour. Unfortunately, as educators Sherry A. Southerland and John Settlage wrote earlier this year ”the culmination of so much of our recent global experiences suggests that the public does not share a robust understanding of how science proceeds, nor a recognition of the features of the knowledge it produces—and these factors work together to limit the utility of science’s use in problem solving at a time when our problems have become most fearsome.”

These problems with how science is taught extend to the college level. In their recent article “Redo college intro science” published in the journal Science, David Asai, Bruce Alberts, and Janet Coffey wrote “Far too often an introductory course asks students to merely repeat what they ‘know’ instead of to explain what they think. With so many facts and concepts to cover, faculty have little time to engage students in what should be the most important learning goal: to understand how the scientific process advances knowledge and arrives at evidence-based judgements on issues such as clean drinking water, climate change, and vaccination”

         The three scientists go on to call for a complete restructuring of college introductory science courses that “replace their standard ‘cookbook’ laboratories with course-based research experiences…” All of this, they say, is in the service of “preparing citizens to engage with evidence to make informed choices.”

New Science Curricula Emerge

         Teaching students at all levels how science really works is the focus of what seems to us a revolution in science education that began 10 years ago with the publication of “A Framework for K-12 Science Education: Practices, Cross Cutting Concepts, and Core Ideas” by the National Academies of Sciences, Engineering, and Medicine. The report, which led to publication of the now widely used Next Generation Science Standards in 2013,  begins with the dramatic statement that “The overarching goal of our framework for K-12 science education is to ensure that by the end of 12^th grade, all students have some appreciation of the beautify and wonder of science; possess sufficient knowledge of science and engineering to engage in public discussion on related issues; are careful consumers of scientific and technological information related to their everyday lives; are able to continue to learn about science outside school; and have the skills to enter careers of their choice, including (but not limited to) careers in science, engineering, and technology.”  

         This Framework articulates an approach to science education that has been adopted by schools across the United States and is the subject of a great deal of research and scientific publication. It calls for helping students understand how science actually works. No longer is science to be represented as a set of immutable concepts or cookbook “experiments” but rather as a dynamic process in which questions about the natural world are investigated, data accumulated, and theories developed, only to be subjected to further testing and revision. Students are encouraged to wonder about things, to question how things work and are, and are guided through hands-on exercises they develop that do not have pre-set outcomes but rather can be used to develop ideas for further work. After all, as one tool for science teachers points out, “Uncertainty in scientific activity motivates scientists’ engagement in practices…Children can be supported to engage with scientific uncertainty from the earliest years of schooling.” As the face mask example illustrates, adults have difficulties dealing with the uncertainty that is the natural course of science, especially science that is forced to develop as rapidly as was the case during the pandemic. Instead of defaulting to an attitude that uncertainty means absolute lack of knowledge and rejecting evidence-based recommendations, even young students can be taught to not only tolerate uncertainty but to welcome and work with it.

         Now, elementary school students are working with their teachers to design experiments that interest them. In a typical scenario, the teacher might pose a question like “why does something seem louder the closer it is to us” and invite her students to speculate about possible reasons for this phenomenon and consider ways to explain it. Some of the resulting designs do not work out as planned, but according to one study, elementary teachers using a new curriculum to teach engineering are now “more comfortable preparing students for design failure experiences, and responding when design failure occurred.” Given that design failures happen with great regularity in real-life laboratories, this kind of experience helps students understand how science really works. “If an observer were to ask students ‘why are you working on this?’” explain scholars from Northwestern University, “at any point, students should respond in terms of what they are trying to figure out and why that matters to them—not in terms of accomplishing the demands of the teacher or textbook.”

Learning the Nature of Science

         In their book Teaching Science to Every Child: Using Culture As a Starting Point, John Settlage, Sherry A. Southerland, Lara K. Smetana, and Pamela S. Lottero-Perdue (Routledge, 2018) describe teaching children about “the nature of science,” which they define as “both actions of science and the characteristics of the knowledge produced through these activities” (p. 28). In addition to acknowledging that science is an empirical undertaking, they emphasize two additional aspects of the scientific enterprise: creativity and social relationships. With respect to creativity, they write “Far from being a mindless and mechanical gathering of evidence, the work of science benefits from personal creativity and the ability to shift from data to explanations” (p. 37). With respect to the social aspect of science they note that “A common caricature of a scientist is someone working in almost complete isolation…With this common stereotype, is it any wonder that many students fail to see any appeal in the prospects of becoming scientists?” (p. 40). In fact, modern science is done by teams of scientists across academic and industrial centers, who meet frequently at conferences to share data and ideas, and who interact with each other on a regular basis.  

         To be sure, the road to implementing the new approaches to teaching science has challenges. One major obstacle will be the critical shortage of qualified science teachers in the U.S. According to Steven Yoder writing in Undark magazine, “Data show many of the 69,000 U.S. middle school science teachers have no scientific background. Almost a quarter have neither a science degree nor full certification to teach science…” Furthermore, Yoder writes, “few middle school science teachers report feeling confident about all the material they are responsible for teaching.” The impressive work to advance a new model of teaching science to children is thus threatened by the lack of qualified science teachers.

         There is also clearly a lag in realizing the benefits of the new science curriculum. It is now less than ten years since the Next Generation Science Standards were introduced, so that most current adults experienced the previous generations of science education approaches, approaches as we have pointed out that emphasized memorization of supposedly established facts and deemphasized creativity, wonder, social relationships, and uncertainty that are all part of real-life science. Hence, it is no wonder that we hear many complaints about the ways in which people still lack the ability to tolerate scientific uncertainty, misunderstand the ways in which scientific consensus is developed and adjusted, and default to ideas and behaviors that lack scientific evidence. Unlike today’s students, most adults were rigorously turned off to science during their school years. It would be interesting to consider to what extent some of the ideas in the Next Generation Science Standards could be applied to today’s adults via public health campaigns.

         We should also note that as wonderful as the new science curricula are, we lack empirical evidence that experiencing them during childhood and adolescence in fact leads to more scientifically informed health decisions by adults. That is, do new approaches to teaching science lead to adults who can recognize the difference between real and sham science, tolerate scientific uncertainty, and make informed health decisions? Those are important areas for researchers to undertake.

         Reading through the Framework and Next Generation Science Standards gives us great hope that phenomena like today’s anti-vaccination advocates will be displaced by future generations of people who learn to love and embrace science, understand its power and limitations, and represent informed science consumers. Thanks to the hard work of many science teachers and education scholars we now have reason to believe that is a likely outcome.   

Americans view freedom of the press, enshrined in the First Amendment to the U.S. Congress, as essential to the functioning of its democracy. For some people, the notion of government-funded media seems antithetical to that principle.

         Now, however, a study published last December in the International Journal of Press/Politics by two University of Pennsylvania professors calls that notion into question. Timothy Neff and Victor Pickard looked at the state of democracy and at various media funding mechanisms across 33 countries, including the U.S. They found that “high levels of secure funding for public media systems and strong structural protections for the political and economic independence of those systems are consistently and positively correlated with healthy democracies.”

         In other words, countries with independent and publicly well-funded national broadcasting systems had consistently stronger democracies according to the Neff and Pickens study. It turns out that the U.S. scores badly both in terms of the quality of its democracy and how much it spends on public media. According to The Economist’s Democracy Index, the U.S. is now considered a “flawed democracy.” At the same time, the U.S. spends .002 percent of Gross Domestic Product (GDP) on public media, according to a recent report from the Annenberg Center at the University of Pennsylvania, which translates to just $1.40 per capita. That compares unfavorably to countries like the U.K., Norway, and Sweden, which all spend around $100 per capita or more on public media and all have higher ratings than the U.S. on the Democracy Index.  The Annenberg Center report thus quotes Professor Pickard as stating that “there is a growing body of research that suggests substantial social benefits from strong public media systems, including well-informed political cultures, high levels of support for democratic processes, and increased levels of civic engagement.”

Journalism in Crisis

         What journalism we do have in the U.S. appears to be in crisis. As Timothy Karr notes in his article “The Future of Local News Is Noncommercial” that appeared in the March 18, 2022 edition of the Columbia Journalism Review, we have witnessed a precipitous decline in local news coverage in the U.S. during the 21^st Century. “Between 2008 and 2020,” Kerr writes, “more than 1,000 newspapers ceased printing, and the number of newspaper-newsroom employees shrank by more than half.” Although this fall in journalism outlets is often attributed to the rise of digital media on the internet, Kerr makes a strong case that “conglomerate and hedge-fund media” companies are at least equally to blame. “We need,” he argues, “to reinvent the news economy from one that serves a few owners to one that serves the needs of democracy…”

         The decline in print and broadcast media is especially acute for science journalism, where one study showed that between 1989 and 2021 the number of weekly science journalism sections fell from 95 to 19. As the number of full-time science journalists at newspapers and broadcast stations declines, more and more free-lance science journalists and general journalists are called upon to cover the ever-increasing complexity of modern science. High-quality science journalism written by reporters with expertise in scientific specialties is thus in ever-shorter supply, leaving us nowhere to turn except the internet for scientific information about health, climate change, and other vital topics.

Internet Science is Only Sometimes Reliable

Enough has been written at this point about the deluge of disinformation and misinformation in general and about science and health in particular that appears on internet platforms. Thus, if we are forced to look online for information about the latest medical advances, as is happening because of the decline in quality science journalism, we will find some things that are accurate and others that are not. Discovering which online sources are reliable is difficult and we know that many people wind up making unhealthy decisions in part based on inaccurate online information. We thus fully agree with Timothy Kerr that we need to reconsider public funding for high-quality, independent media in the U.S. to fill the severe losses in reliable local news and science journalism that we face.

         Of course, many will raise the objection that government funded media is a slippery slope to loss of a free press and government control of newspapers and airwaves. That is a legitimate concern. Critica Chief Medical Officer David Scales acknowledged this worry when he wrote “I completely agree that we need to be very careful about government funding of media” but he goes on to point out that we could adopt models like the U.K.’s BBC “where the government doesn’t directly fund it at all but puts in place a revenue stream for public broadcasting.” Scales went on to assert that “as the evidence for investing some sort of publicly-supported media in a robust democracy grows stronger, the ideological argument that this should remain an unregulated space to encourage free speech and allow the private sector to innovate grows increasingly hollow.”

         According to Timothy Karr, the non-profit organization Free Press now advocates for a “doubling of public funds for noncommercial news and information.” Still, having the U.S. federal government be the funder for such an effort may be impossible given the robust objections to anything that smacks of impinging on freedom of the press. Therefore, Critica believes that independent foundations should come together to create a steady stream of funds for high-quality media, focusing particularly on, but not limited to, health. The coronavirus pandemic has taught us how vital it is to get clear and trustworthy health information to the public, information that is not sensationalized but rather covers the background information that people need to make healthy and informed decisions. Research shows that publicly funded, high-quality, and independent journalism advances healthy democracies. We will continue to advocate for a plan to bring this concept home to the U.S.

Levels of conspiracy theorizing suggest an array of people believe in them.

On May 14, 2022, an 18-year-old man opened fire at a supermarket in Buffalo, New York, killing 10 people. The suspect, Payton S. Gendron, had apparently been planning the attack for several months. Subsequent investigation of his social media accounts suggested a racist motivation behind the attack, with Gendron having chosen this particular area because it has a high proportion of Black residents. The tragedy was soon labeled a hate crime by the U.S. Justice Department. Of the 13 people shot at the supermarket that day, 11 were Black. The shooting was another in a line of recent White supremacist hate crimes, including recent mass shootings in El Paso, Texas; Charleston, South Carolina; Norway; and New Zealand.

“The Great Replacement”

The gunman in the Buffalo shooting seems to have subscribed to a particular conspiracy theory called “the great replacement.” Between 2010 and 2020, a great deal of demographic change has happened, especially in Western European countries and the United States. During this time, the percentage of Americans who identify as “white only” dropped from 72 to 62 percent, and, at the same time, there were record influxes of migrants from Muslim nations, especially into Western Europe. The “great replacement” posits that this demographic shift has been orchestrated by elite power holders as a kind of “white genocide.” In the United States especially, believers in this theory posit that Jews are bringing in immigrants and promoting interracial marriage to suppress the white population. What’s especially frightening at this point in time is that this seemingly “fringe” theory has become much more mainstream, with one in three Americans now believing some version of this idea.

While some might think about conspiracy theorists as people in tinfoil hats who believe the moon landing never happened or that the Earth is flat, these ideas affect much more than what we think of the galaxy. Especially recently, the tie between conspiracy theories and extremist political and social beliefs is undeniable. QAnon, with its very clear white supremacist undertones, is a good example of this. The beliefs spouted by “Q” and his or her followers are particularly “moralist” in nature, suggesting that the “enemy” is unthinkably evil. This enemy is not only the opposite political party but also very often any group that might be maligned by Q’s followers, including Black people, immigrants, and Jews. After being marginalized from politics for so long, the alt-right, neo-Nazis, and neo-Fascists certainly saw the value of QAnon to help them shoulder their way back into the political mainstream, and they were often successful.

But what about the one in three Americans who believe versions of the great replacement theory? Is everyone who engages with a conspiracy theory an all-out extremist? It is difficult to fathom that this is in fact the case, considering the extremely high percentage of people who believe in at least one conspiracy theory. The vast majority of them will thankfully not act on their beliefs, as the Buffalo shooter did. So what makes the difference between someone who dabbles in these ideas and someone who acts on them?

Susceptibility to Conspiracy Theories

There is good research now to suggest that certain circumstances and personality traits make some people more susceptible to conspiracy theories than others. People who are socially isolated, have high levels of existential doubt and paranoia, and who feel socially and politically powerless and marginalized are especially at risk. More recent research also suggests that openness to new experiences as well as personal traits such as agreeableness are protective against conspiracy theories. “Disagreeable” people, who are more likely to believe in conspiracy theories, tend to have higher levels of Machiavellianism (manipulativeness and cynicism), narcissism, and sadism. These are all traits that are on a spectrum, with everyone displaying some degree of all of them.

Feeling socially and politically powerless and marginalized can especially motivate people to seek out in-groups that will make them feel included. Conspiracy theories offer an automatic, tightly knit group of people who share particularly strong beliefs. The strength of shared beliefs helps make the group relationship even tighter. The personality traits and feelings of overall uncertainty and existential dread can range from being somewhat muted to being quite powerful. Small amounts of these traits and circumstances can push someone to start engaging with conspiracy theories but may not cause them to be completely taken over by them. In instances such as the case of the Buffalo shooter, it is completely appropriate to ask questions about highly pathological traits that may be associated more with mental illness than just with variance from the mean. For example, the Buffalo shooter may have had pathological levels of paranoia, rather than simply a higher dose of it than the average conspiracy-theory adherent.

Understanding What Drives People to Act

Our job is to better understand what drives people such as the Buffalo shooter to do what he did and to make sure that there are more societal safeguards to ensure that a person like this does not carry out what he did. These safeguards might include things like better access to mental health care and less access to firearms. But it is also our job to understand how people with low levels of conspiracy theory beliefs can be redirected. We are gaining a better understanding nearly every day about some of the protective features that may help us here, including open-mindedness and, especially in cases related to science, scientific curiosity.

Public acceptance of extremist conspiracy theories creates the environment for people with pathological traits and beliefs to blossom and flourish. Part of the answer to these tragic events is to better address the fact that many Americans engage with conspiracy theories at a lower level, utilizing the protective factors we already know about and the ones that will continue to emerge as a result of continuing research on the topic. Only then can we disrupt the feedback that ultimately gives extremists the encouragement and motivation to act on their beliefs.

Gun violence and firearm-related deaths are surging in the U.S. since 2020. This paradoxically may lead some people to think that owning a gun is a good idea and indeed gun sales in the U.S. have also been surging since the coronavirus pandemic began. Most gun owners in the U.S. say they own their guns for protection and that they make them feel safer.

         The data on gun ownership actually show quite the opposite. Numerous studies have demonstrated that the presence of a gun in the home increases the risk that a household member will die by firearm-related suicide or homicide. A new study published in April in the Annals of Internal Medicine found that homicides were twice as high among people who lived in households with a gun owner as those who lived in households without guns. The concluding statement from the paper is important:

Homicides and suicides account for 97% of the nearly 40 000 firearm-related deaths in the United States each year. It is implausible that gun access decreases suicide risk, and every rigorous study that has examined this relationship has found a positive association. Nonetheless, if firearm ownership enhanced personal safety in other ways, as many gun owners reportedly believe, tolerating some elevated risk for suicide might be considered a worthwhile tradeoff. This study adds to mounting evidence that no such tradeoff exists, because a gun in the home is associated with higher—not lower—risk for fatal assault. People who do not own handguns but live with others who do bear some of that risk, and the amount they bear appears to be substantial.

More Policing Not Correlated with Violent Crime Reduction

         Believing that owning a gun offers protection is a form of science denial, because the evidence we currently have is clear that it does not. Apparently, owning a firearm does exactly the opposite of what most gun owners believe: it increases the risk that the gun will be used to harm owners themselves or their families. Another belief that many people have is that more policing is a potential solution to stemming the rising tide of gun violence. A recent Brookings Institute report helps us consider if there is evidence to support that claim.

         The report indicates that there is little correlation between increasing police funding and decreasing crime. Even if there were, the report notes that municipalities would still have “to weigh the negative effects that accompany adding more police officers, such as increasing arrests for low-level crimes which contribute to mass incarceration and disproportionately affect Black communities. Exposure to the criminal justice system itself can perpetuate underlying issues that contribute to violent crime and recidivism, such as low socioeconomic status and unemployment, homelessness, and poor mental health.”

         According to the Brookings report, “One of the most evident social factors correlated with violent crime is mental health.” High levels of poor mental health at the community level in aggregate, reflected by measures like overall community levels of depression and anxiety, are correlated with increased rates of violence. Efforts to improve community-level mental health may reduce violent crime. The report notes that “An estimated 20% of police calls are for mental health and substance use crises.” 

         This of course does not mean that most individuals with mental illness are prone to commit violent acts; we know that even though overall people with mental illness are somewhat more likely to to commit violent acts than people without mental illness, the great majority of people with mental illness are not violent. Rather, it suggests that poor overall community mental health and lack of access to mental health care increases the risk for violent crime, including gun-related violence. Furthermore, it begs the question of whether most police officers are properly trained and prepared to deal with the staggering number of calls that involve mental health disturbances.

Police Are Not Prepared for Mental Health Emergencies

         These data suggest that owning a gun is clearly not a solution to dealing with increasing gun-related violence in the U.S. Nor is simply spending more money on policing likely to address the problem. In addition to stricter gun control legislation and addressing the social factors that increase the risk for gun violence, the data indicate that improving access to mental health care facilities may have an impact. Also, we need to develop and evaluate alternatives to standard police responses to mental health emergencies. We have heard people scoff at the idea of “having a social worker respond to a police call,” but in fact there is little evidence to suggest that having police officers respond to calls that involve a person in the midst of a mental health crisis is an effective intervention. Whether police officers can be better trained to respond to mental health emergencies or in fact we should be deploying behavioral health professionals for these calls is an empirical question that critically needs exploring.        

Scientific data alone cannot be the basis for all public policy decisions; these require careful consideration of social needs, politics, and economic realities. But we believe that public policymakers should always ask if there are data relevant to their decisions or if more studies could be useful. Available data tell us that liberalizing gun ownership laws and spending more money on policing are unlikely to lead to meaningful and acceptable reductions in gun violence in the U.S. Rather, we need to consider factors that are known to increase the likelihood for gun violence and design interventions to address them. One of those factors seems clearly to be poor community mental health. Thus, any attempt to reduce gun violence in the U.S. should consider the evidence and include an approach that addresses our police and overall community responses to mental health needs.

The Paxlovid Story

It usually takes, on average, 11 years to develop a new drug. That is one reason why the introduction of an antiviral drug for Covid-19 treatment with the brand name Paxlovid is so remarkable: it was developed in just 20 months. The science that permitted this, as detailed in a STAT news article by Mathew Herper, was impressive indeed. The article quotes Eric Topol, the director of the Scripps Research Translational Institute, as calling the development of Paxlovid “the fastest development of a small molecule drug, with clinical validation and high efficacy, in history—no less in the midst of a pandemic.” In a study of unvaccinated people, Paxlovid reduced the risk of hospitalization for Covid-19 by 89%, leading the FDA to issue an Emergency Use Authorization (EUA) for the drug last December. It is now recommended for people with mild to moderate symptoms of Covid-19 who are at risk for developing more serious illness.

         That impressive science makes the fact that the drug is, by all accounts, substantially underutilized, both perplexing and disturbing. The situation is highly reminiscent of what happened when the vaccines were first rolled out for Covid-19 under FDA EUA rules: brilliant science leading to a safe and effective vaccine in record time and then profound difficulties getting it into the arms of people in the U.S. and around the world. The roll-out of Paxlovid in the U.S. appears to be another story of dysfunctional healthcare and science communication systems.

         Vaccines are highly effective at reducing the risk for serious illness, hospitalization, and death from Covid-19, but especially since the emergence of the Omicron variant it is clear that highly infectious mutants can readily infect even vaccinated people. More vulnerable people, especially the elderly, the immunocompromised, and those with underlying medical conditions like diabetes, are then more likely to develop significant symptoms. Developing drugs that can treat infected people and reduce the risk for this slide into serious illness has been a priority for scientists and pharmaceutical companies. One strategy is to administer antibodies specific to the virus that causes Covid-19, called monoclonal antibodies, as soon as someone is infected, but those require intravenous administration and therefore are not ideal.

         Two oral medications have been granted EUA for preventing serious illness in people who have been infected with Covid-19, Paxlovid and molnupiravir, but the latter does not appear to work as well as Paxlovid. (We are breaking our usual policy and referring to Paxlovid by its brand name because it is not available as a generic drug and its generic name—nirmatrelvir with ritonavir—is a tongue-twister that almost no one seems to be using yet). Paxlovid is a combination of a drug invented by the Pfizer company (nirmatrelvir) and an older drug used to treat HIV infection (ritonavir). They are both in the category of medications called protease inhibitors, drugs that block a virus’ ability to assemble itself inside a human cell and then replicate.

         If Paxlovid is so effective at preventing serious Covid-19 illness, then why isn’t it being widely used at a time when ever more infectious variants seem to be spreading? There are multiple reasons for this failure that fall into three main categories: 1. Lack of drug distribution, 2. Lack of awareness by the public, and 3. Lack of awareness and unwillingness to prescribe it by physicians.

Initial Distribution of Paxlovid was Problematic

         In her New York Times article “Covid drugs save lives, but Americans can’t get them,” Zeynep Tufecki detailed on April 22 the travails people have gone through to find a pharmacy stocked with Paxlovid. Some pharmacies had no Paxlovid while others had stocks of unused doses. “Social media is also replete with stories of despondent patients unable to locate doses or managing to do so after much effort and paying extra when they ended up out of their insurance networks,” she wrote.

         At the end of April, the Biden administration announced it would take a series of steps to increase the availability and use of Paxlovid, but that was four months after the EUA had been issued. It is still unclear why it has taken so long for Paxlovid to become widely available in hospitals, clinics, and pharmacies. The problem could rest with how much was initial manufactured and distributed by Pfizer or with the supply chain that links pharmaceutical companies to pharmacies. It is also unclear why it took federal and state governments so long to make a concerted effort to get Paxlovid to pharmacies. This all needs to be investigated because it seems absurd that a drug this effective should languish for four months off so many drug store shelves.

Public Poorly Informed about Paxlovid

         But even as Paxlovid does become more available, people may not know enough about it to ask for it or know how to access it.  Paxlovid must be prescribed by a physician, nurse practitioner, or physician’s assistant, and it needs to be taken within five days of first exhibiting symptoms. Not all Americans have such relationships with prescribers or even if they do are able to get through to them fast enough to make taking Paxlovid possible. Furthermore, because Paxlovid is not an FDA-approved drug yet but rather only available under the EUA program, Pfizer is not allowed to advertise it, either to the public or to prescribers. That leaves it up to local, state, and national public health authorities to ensure that people know that a pill is available that they can take to prevent serious illness if they develop symptoms and test positive for Covid-19. In some places, like New York City, frequent television ads about drugs to treat Covid-19 are appearing, but this is not the case throughout the U.S., and we are unaware of any systematic CDC or FDA programs to inform the public about it. Thus, the disjointed American healthcare system has not been able to provide sufficient public information about Paxlovid or to come up with a viable plan for getting it to people who need it.

Prescribers are Reluctant to Prescribe Paxlovid

         The prohibition against drug company advertising about Paxlovid extends to prescribers. As Tufekci notes “In the United States, such doctor outreach is often, sadly, left to pharmaceutical companies, which spend tens of billions of dollars each year marketing their drugs to physicians. This has led to heavily promoted drugs getting prescribed even when cheaper, effective alternatives exist.” Once again, there has been a lackluster attempt on the part of public health agencies to educate physicians and other prescribers about Paxlovid. Our healthcare system appears content to default to drug companies to provide physicians with information they need about newly available medications.

         This lack of prescriber education about Paxlovid may explain one of the main reasons physicians appear to be reluctant to offer patients the medication: what are called drug-drug interactions. Most medications we take are broken down (that is, metabolized) by the liver, thus controlling how high the blood levels of the drug can go. The liver has a set of enzymes called the cytochrome P450 system that is responsible for metabolizing drugs. The activity of these enzymes is controlled by our genes, so that activity varies from one person to the next depending on the individual’s genetic make-up. Some people are faster metabolizers of specific drugs than others.

         Some drugs we take can inhibit the activity of these metabolic enzymes, and Paxlovid is one of them. Its ritonavir component inhibits an enzyme called 3A4 in the cytochrome P450 system, making metabolism of a host of other medications less efficient. That means that there are many drug interactions with Paxlovid that can lead to significant increases in blood levels of certain medications. Since elderly people are considered among the important candidates to take Paxlovid and they are most likely to be taking multiple other medications, prescribing Paxlovid can be tricky.

         A doctor or other prescriber about to give someone a prescription for Paxlovid may see the long list of potential drug-drug interactions and become wary. Some of the medications that interact with Paxlovid might be stopped for the five days a person takes Paxlovid, but others, like drugs to control heart rhythm disturbances such as atrial fibrillation, cannot be stopped so easily. There are probably ways to handle these situations (such as temporarily lowering the dose of a drug with which Paxlovid interacts), but prescribers have not been given sufficient information about what to do in such instances and we hear anecdotally that this is discouraging some physicians from prescribing it. How widespread a reason this is for the lack of Paxlovid uptake is unknown at present, but again speaks to the failure of public health agencies like CDC and FDA to conduct timely and meaningful prescriber education campaigns.

         On three levels then—supply, public information, and prescriber education—our healthcare system has failed to get Paxlovid into the hands of people who should take it. This is another example of the shortcomings of the American healthcare system, a system that is based on some of the world’s most outstanding biomedical research but nevertheless routinely fails to make the progress of modern science available to its constituents. In the case of Paxlovid, we see a disjointed drug distribution system and a failure of vital health science communication to both the public and healthcare providers. We also see the results of years of default to pharmaceutical companies for critical public health education to both groups.

         The Paxlovid story is a case in point, then, of some of the things that are wrong with the American system. What should have happened was three-fold. First, the moment Paxlovid was first presented to FDA for an EUA, federal authorities should have planned for the drug’s rapid distribution to pharmacies and hospitals around the country. Second, federal, state, and local public health agencies should have developed a comprehensive plan to provide the public with information about Paxlovid, including who should take it and where to get it. Third, the same public health authorities, along with medical and nursing associations, should have developed an education campaign aimed at prescribers, informing them about the benefits of prescribing the drug and providing them with algorithms for what to do in complex situations such as those that arise because of drug-drug interactions. Once again, we have witnessed the benefits of great science vitiated by poor public science communication.

Here’s what we do and don’t know about Myers-Briggs.

It’s common in many workplaces these days to encounter some kind of personality or “work style” assessment. Many employers ask employees to take these assessments to get a better sense of optimal work settings and workflows for individual employees. For example, naturally introverted employees might do better doing primarily internally-focused research and desk work while someone who is naturally more extraverted might have an easier time working in sales, marketing, or any kind of external-facing work that involves contact with a variety of partners.

The Myers-Briggs Type Indicator is a personality inventory that categorizes people across four domains: introverted versus extraverted; sensing or intuition; thinking or feeling; judging or perceiving. People’s preferences and personality profiles can thus be summed up along these four domains; for example, an INTJ would be someone whose proclivities line up most with being introverted, intuitive, thinking, and judging. While the Myers-Briggs inventory is by no means the only kind of personality or work style inventory that is used in the corporate world (many new assessments have cropped up over the years), it is a very commonly used instrument when people are trying to figure out their general preferences.

But is Myers-Briggs reliable from a scientific perspective?

The test might be popular and pervasive (many readers will have heard of it, and some have probably taken it more than once), but there is some pretty lively debate about whether it is a reliable and accurate instrument. From a purely anecdotal perspective, it is easy to see where there might be considerable flaws in the test. For one thing, we know people who have taken the test once and then taken it again a few weeks later and scored very differently on certain items.

In addition, it is hard to know how to interpret a score that is on the border between two types. For example, it is possible to score right in the middle between being extraverted and introverted. What exactly does this mean, then? It is not clear how to use this kind of information.

A 2018 article in Scientific American offered a relatively harsh view of Myers-Briggs and other personality tests. Among the problems already noted about the test, experts also argue that the questions are confusingly worded, thus making it difficult to know whether people are interpreting the questions in the ways they were intended. In addition, most personality tests were invented in the first half of the 20th century on the basis of researchers’ subjective feelings about the most important components of personality. The result is a wide variety of tests that are not based on solid academic theory about what comprises the most important aspects of a person’s preferences and personality.

In a more recent article in Psychology Today, Dr. Aqualus Gordon argues that claiming the Myers-Briggs has been “debunked” is going a step too far. He argues that calling it pseudoscience is unfair since rigorous academic studies of its efficacy have not been performed. He also points out that people often expect the assessment to predict things that it is not set up to predict, such as job performance. The assessment has a lot more to do with preferences and job satisfaction than with actual performance. Predicting job performance is undoubtedly outside the purview of the Myers-Briggs, but expectations that the assessment can serve this function might lead to more skepticism of the instrument. Furthermore, it is unclear whether the test even does what is within its purview, such as accurately predicting job satisfaction.

Key takeaways

Until we more rigorously study the Myers-Briggs, we cannot make claims about its efficacy or accuracy. Psychometric scales need to be subjected to rigorous validation tests, which it is clear this test has not. Most other personality tests have not been subjected to this kind of validation either. If we want the scientific community to take these tests seriously and advocate for their use, they do need to be properly validated. In the meantime, it probably does no harm to take some of these tests for fun just to get a better sense of how one scores. But putting great stock in their results and making major career decisions based on them may not be warranted without more thorough engagement with the science of psychometric validation.

About three-quarters of Americans have a primary care physician. Having a primary care doctor is associated with better health outcomes. As we have previously noted, Americans tend to trust their primary care physicians more than most other sources of healthcare information.  

         All of this should mean that it might be a wise move to extend primary care to more people and to ensure that primary care doctors have enough time to spend with their patients to take advantage of that trust and help them navigate the many pathways to optimal health outcomes.

In fact, however, according to a recent report from the Commonwealth Fund, the U.S. is failing at providing high-quality primary care compared to other high-income countries. The report is based on surveys the Fund conducted in 2019 and 2020 with primary care physicians in the U.S. and 10 other high-income countries. Among the findings are:

·  U.S. adults have nearly the lowest likelihood of having a regular doctor or place to go for care (Sweden was slightly lower).

·  U.S. adults are the least likely to have a long-standing relationship with a primary care provider (43% versus 71% of adults in the Netherlands or 57% in Canada).

·  U.S. adults are least likely to be able to see a primary care provider after regular office hours

·  Primary care physicians generally do not screen their patients for social needs, but here U.S. doctors are the most likely to do so (30%). The authors of the report speculate, however, that this may be because the U.S. has the poorest social services networks for its citizens, creating a greater need for such inquiries. Only Canadian primary care providers are more likely to have social workers in their practices (42% versus 37% in the U.S.).

·  Only one-third of U.S. primary care physicians have mental health providers in their practices. This is about midway among the countries in the survey, with nearly all practices in Sweden and the Netherlands having mental health providers in their practices, but almost none in Germany, Switzerland, or Norway.

·  Only half of U.S. primary care providers report adequate levels of coordination with specialists and hospitals about changes in their patients’ care plan, putting the U.S. near the bottom in this category. Similarly, only half of U.S. primary care providers are notified when their patients are seen in an emergency department, compared to 85% and 84% in New Zealand and the Netherlands, respectively.

Overall, then, the report makes clear that the U.S. is doing a poor job at primary healthcare. Importantly, the report notes that these shortcomings in U.S. primary health care are not distributed evenly but “affect predominantly Black and Latinx communities and rural areas, exacerbating disparities that have widened during the COV ID-19 pandemic.”

What Do People See Primary Care Providers For?

         An average visit with a primary care physician lasts 18 minutes. According to a Mayo Clinic study, these are the top ten reasons for those visits:

• Skin disorders;
• Osteoarthritis and joint disorders;
• Back problems;
• Cholesterol problems;
• Upper respiratory conditions, excluding asthma;
• Anxiety, depression, and bipolar disorder;
• Chronic neurologic disorders;
• High blood pressure;
• Headaches and migraines; and
• Diabetes.

Now let’s look at the top causes of preventable premature death in the U.S. This list is topped by tobacco smoking and includes obesity, alcohol use, hypertension, some infectious diseases for which vaccinations are available, firearm injuries, and suicide. In the 18 minutes that a primary care doctor has with a patient, how much time is spent dealing with these preventable causes of premature death? Take cigarette smoking, for instance. We know that relatively brief primary care interventions can have a significant effect on increasing the chances that a smoker will quit. The same is true for harmful alcohol consumption. Primary care physicians may themselves be surprised to learn that their paying attention to their patients’ weights can influence obese patients to attempt weight loss, a practice that may be helpful for many people with high blood pressure or diabetes. We can also wonder about the potential impact on mental health and suicides if more primary care practices had mental health practitioners within them.

Do primary care physicians have time to talk to patients about their lifestyle and behavioral issues? Do they keep careful track of their adult patients’ vaccination status? When a patient circles “yes” on the pre-visit form about cigarette smoking, does the doctor recognize that even a few minutes spent talking about options for quitting can save more lives than almost anything else the doctor can do?

U.S. Primary Healthcare Needs an Overhaul

It is clear we need to fix the primary healthcare system in the U.S. Right now, it is a disorganized system that disadvantages people of color. It is also unprepared to deal with the factors that are clearly responsible for most people’s adverse health outcomes. Treating rashes, upper respiratory infections, and backaches is important, but primary care clinicians could have far more impact on the public’s health if they also dealt with tobacco and alcohol use, obesity and lack of exercise, and vaccine hesitancy. Furthermore, their practices would become far more impactful if they included mental health providers to deal with common psychiatric conditions like anxiety disorders and depression and social workers to help with the social determinants of health like food and housing insecurity.

The U.S. clearly has a long way to realize any of these goals. As Kevin Grumbach and co-authors wrote in their September 2021 New England Journal of Medicine article “Revitalizing the U.S. Primary Care Infrastructure”:

More than half of office visits in the United States are to primary care clinicians, yet primary care physicians make up only 30% of the physician workforce and are supported by only 5.4% of national health expenditures, and research on primary care garners just 1% of federal agency research awards.² One in five Americans live in a federally designated primary care Health Professional Shortage Area. Primary care physicians earn 30% less than other physicians, on average, and they have among the highest rates of physician burnout.³

         In its sweeping 2021 report on rebuilding the U.S. primary health care system, The National Academies of Sciences, Engineering and Medicine noted that “The value of primary care is beyond dispute” but at the same time “this foundation remains weak and under-resourced.” Clearly, the first order of business in repairing our crumbling primary healthcare system is to fund it adequately. This is perhaps easier to do in countries that have rational, single-payer healthcare systems (as is the case in all high-income and many middle- and low-income countries, but not the U.S.). What we need, and what the National Academies endorse, is a major rethinking of how we finance medicine.

         Right now, the highest paid medical specialties are mostly surgical. Primary care physicians are way down on the list. If someone does choose a career in primary care medicine, they will be faced with having to see large numbers of patients for short periods of time, day in and day out. There will be endless hours logging all these patient encounters into the electronic health record (EHR), most of which gets done after hours and without compensation. No wonder we have a shortage of primary care physicians and those that do enter the field suffer high rates of burnout. The first order of business, then, in repairing the primary care system is to compensate primary care providers better and make primary care a desirable medical specialty.

         Next, we must compensate those primary care practices to be able to spend enough time with patients to accomplish a public health mission: the prevention of disease. That means not only asking patients to fill out questionnaires about their health and habits (many of which seem never to actually get read by any health professionals) but having the time to actually deal with the responses. If someone smokes, is drinking alcohol excessively, is eating a high sugar diet, or is hesitant to have a flu vaccine, the doctor or another health professional in the office needs to address that problem using evidence-based approaches. The healthcare system must be prepared to pay people to do that.

         All of this will require training primary care physicians, nurses, social workers, and other healthcare providers in a new paradigm of care, one in which attending to the real causes of diseases and the impediments to successfully overcoming them is of paramount importance. For example, primary care physicians must be trained in techniques like motivational interviewing and other evidence-based approaches to helping patients with substance use issues. A mental health clinician trained in cognitive behavioral psychotherapy for depression and anxiety should be part of every primary care practice. Patients who need to lose weight or exercise more should be given help, encouragement, and follow-up support by people they trust, that is, by their primary care doctor. Primary care offices should have social workers who can assist patients in getting assistance with housing, food, and health insurance. We know that doing these things works to prevent disease, but we are stubbornly unwilling to implement them. That needs to change.        

Our primary healthcare system is broken and because of it, Americans are missing out on the chance to benefit from a great deal of science telling us how to prevent many diseases and premature deaths. Fortunately, there is now widespread agreement that funds must be directed toward a bold revamping of how we deliver primary care.