RFK Jr.’s fuckups, idiocies, and crimes have been amply documented by others and still, like a catastrophe unfolding in slowed-down trauma time, we’ve watched his confirmation grind obstinately to what has seemed to be its inevitable conclusion. This feels like one more defeat in a long, long streak of losing battles for “science.” Crying foul over the offensively stupid and harmful shit he’s said and done, chronicling the troubling resonances (with, for example, 19th century eugenic race science) in his own statements and in the priorities of the broader MAHA movement, have come to nothing. Calling Senators to voice objections has proven to be the weak tea it has always tasted like. And now, the lightworkers will have their day. In a grotesque parallel to the administrative takeover of the federal payments system by 22 year old groypers, RFK Jr. is (if I had to guess) going use his authority to use the federal government to arrange a broad patronage network for supplements hawkers, reiki practitioners, illiterate homesteaders, and 5G psychos. Grim. 

The framework that we’ve mostly been using to understand what has been happening here – the strange alignments that put Meister Brain Worm in charge of Medicare and Medicaid, for Christ’s sake – has been something like a “crisis of misinformation,” characterized in terms of a fragmentary information ecosystem and mounting distrust of experts through the Covid pandemic. A recent (and helpful, as far as it goes) post from popular Substack Your Local Epidemiologist says about as much. They recommend: 1) “Recogniz(ing) that top-down information doesn’t work anymore,” 2) “Meet[ing] people where they are,” and 3) “Tell[ing more stories.” I don’t necessarily disagree with any of this. I do, however, think that this analysis locates responsibility for the crisis with people we don’t understand – antivaxxers, TikTokers, lightworkers –  and specifically inside their heads, somewhere in their information-processing cortex, where it’s inaccessible to political analysis. As such, I think that while the tone is appropriately serious, the post actually underestimates what is really happening here, and thus the scale of the problem we are facing. What’s really happening here, in my view, is a seismic process in the struggle to construct hegemony. I am suggesting that MAHA, and RFK Jr. as its figurehead, signal a serious and ongoing rearrangement of the power stakes of science.

When I say the power stakes of science, I am not talking about the administrative relations and the legal rules that govern how science is carried out in the USA. (Of course, this is important, it’s just not what I’m talking about right now.) To bring in Bruno Latour (I’m so, so sorry), science is a social activity that fabricates reality itself. This does not, as vulgar “social constructionism” would suggest, mean that everything is a social construct and thereby somehow fake or not real. It is meant to be an accurate description of what science is, as a process and as an attempt to make human understanding of the world, separate from the abstract construction of Science as an arbiter of objective reality. Latour wrote a 2004 book whose English title is The Politics of Nature that treats exactly this topic. I’m not going to attempt a comprehensive summary of it here (in true Continental fashion, a concise or clear summary is all but impossible), but I am going to pick up on some key themes and ideas from it because I think they help to illustrate one way of thinking about what’s happening with MAHA.

Latour essentially uses Plato’s Cave (Lord), through a lengthy and painstaking procedure, to allegorize what he calls a “bicameral” relationship between science and society. One of the houses, science (or Science, as distinct from “the sciences” as people actually practice them), is the domicile of objects, objective reality or ontology if you’re nasty, and “facts,” which are real and bear some ultimate truth but are silent. The other is where dwell subjects, the social world, “politics,” social constructions, and the sense people make of things (epistemology) – these can speak, but their contact with ultimate reality is mediated and compromised by the meddlesome presence of messy human subjectivity. The figure of the scientist can pass between these houses, endowed with the special power to make objective reality legible to the subject-world. This is heady as fuck, I know. I’m not going to go down the rabbit hole of arguing for the “truth” of Latour’s metaphor or his assertions. I just want to lay out the basic template of his thinking to help us to get thinking this way.

Stuart Hall writes a lot about how Thatcherism is so successful because it manages to touch the real experience of people’s lives, and articulate something of that truth in a rightward direction, or maybe more precisely to articulate something of it as rightist ideology. Hall’s accounting of “authoritarian populism” feels especially, uh, relevant right now, but there’s something to this more tangible than the construction of historical categories. There is an emotive experience of everything that is “going on,” and that necessarily happens in a personal register. 

Or rather, maybe, there’s a weird double emotional register of events like what we’re living through right now. First, there’s the register of public performance. This is the register of the brave face, the sweeping statement, the performance of courage. It’s also the register of comparison and ranking. It’s where you have to rank your experience of your problem according to the miserly moral calculus of progressive discourse so often presented, dishonestly, as progressive values. I catch myself doing this all the time. I’ve caught myself doing it this week, in the middle of the abject panic about my future and my stability that is finally catching up to me. Of course my fear is nothing compared to the suffering of Gazans, or the terror inflicted on trans youth in our own country, and so on. I would never try to pretend that it is. However, it is there. It exists in the second register, the personal one, where catastrophe takes on a specific and personal shape. 

In my experience it is considered a progressive virtue to conduct our affective performances of politics entirely in the first register (the register of Posting). I do think this has drawbacks in and of itself, but I think it also has a secondary effect which is insidious and which few recognize. It ensures that personal catastrophes remain personal, never crossing the threshold into politicization. This is a particular problem for scientists, who struggle to politicize their experiences in the first place. (Don DeLillo in Libra: “The purpose of history is to crawl out of your own skin.”)

I think this helps to explain some of the intense ambivalence and psychic paralysis I’m feeling lately. I am terrified for my job (the threat of losing my job is very much experienced, by me, as personal catastrophe, in ways that I can’t/won’t go into) and at the same time I can’t believe that we’re really going to the fucking barricades for NIH indirects. But of course, we’re not going to the barricades at all, which furthers my indifference. Rather than a broad-spectrum assault on civil society, rather than an illegal attack that will fuck up thousands of people’s livelihoods, for no reason, at a single keystroke, scientists are articulating their opposition to this in terms of the particular merit of their own research. To put it bluntly: a lot of research is simply not good. Universities are not good. The system of funding is not good, it’s certainly not meritocratic, it’s a source of endless frustration and wasted time and administrative burden to everyone, it’s actually a principal reason I left academia (was this smart or dumb? I don’t know). 

I am not going to attempt a thorough overview of everything that has happened here. I’ll refer you to this post by Derek Lowe in Science for that. I’ll also engage with some of the content of the post in a more critical way in a little bit, but it’s a good overview of the basic timeline of what has happened and when with scientific funding and the freeze thereupon in the last two weeks or so. 

Today, I just wanted to quickly write this to address, in extreme brief, a practical aspect of what is going on. Specifically, I want to prepare you for the possibility that your primary point of political leverage, if you are a scientist or trainee affected by these actions, is not the content (or quality, or intrinsic value to humanity) of your research or research in general. Your primary point of political leverage is your role in the complex public-private interface of the university system. 

Lenin’s famous pamphlet What Is To Be Done? stresses (in extremely abbreviated and simplified terms here) the importance of a revolutionary vanguard in developing class consciousness among the laboring masses. While I’m not going to opine on the finer points or the operational virtues or drawbacks of the  vanguard/party formation, in Lenin’s time or our own, I will note that Lenin’s underlying thesis is correct, and has proven to be correct time after time after time: what we call “class consciousness” does not spontaneously arise from the harsh realities of class conflict. It has to be prepared, educated, and cultivated via thorough and ongoing study – not of abstruse points of Marxist theory, but of the concrete political and economic situation as it confronts us. (Gil Scott-Heron: the ‘revolution will not be televised’ because the first revolution is the one that takes place in your mind, when you suddenly understand how things really are). 

The funding freeze confronting scientists today is unprecedented in our lifetimes and highly disorganizing. What passes for leftist analysis of it is, as far as I have seen, mostly just creative catastrophizing, and ever more impassioned exhortations about the dire consequences to follow if research operations are more or less defunded. It’s not that I disagree with these exhortations, but they are further disorganizing and demobilizing. While understandable, they spring from a failure to understand the concrete political and economic reality of a scientific researcher or trainee in the US today, and the mistaken idea that there is some authority “out there” to be appealed to. 

I said in my previous post that we are going to start at the molecular level – and I really mean the most basic molecular level there is – and work our way up to the concept of reassortment today. Reassortment is in the news because another strain of avian influenza, H5N9, has just been detected on a duck farm in California. One possibility is that this H5N9 is the result of a “reassortment event,” which is a bad sign, although it doesn’t yet change the public health risk to humans (H5N1 and H5N9 are both avian flu viruses, which do not readily infect humans and can’t spread between humans). We will learn why this is and what all of this means by the end of this post.

But first, I’m going to start with some outdated high school-level biology. This is a paradigm called the “central dogma,” which was already crude and out of date by the time I learned it 20 years ago. I am mentioning it here for sheer pedagogical utility – I think it is the quickest way to bring everybody onto a level playing field with this stuff. So here we go. Living things are made of cells, and each cell contains genetic material. In humans, our genetic material is DNA. There is a similar molecule called RNA which makes up the genomes of some organisms, like influenza (is influenza “alive”? Sort of. We’ll see.). The central dogma that we were taught is that life functions occur via the twin processes of transcription and translation. The DNA encodes “instructions” in the form of codons or genes; this information is copied into so-called messenger or mRNA (transcription). Then the mRNA transcripts are “read” to assemble proteins and other macromolecules that do whatever the cell needs to do. As I’ve said, this is a hugely incomplete and simplified picture, but this is the basis for how we are going to understand what a virus does.

At the most abstract level, viruses work by getting into your cells and taking over (much popular science writing uses the term “hijacking”) this cellular machinery of transcription and translation; instead of making the macromolecules needed for whatever cellular function, though, the virus directs the machinery to just make more and more copies of itself. Those copies then bust out of the cell and find other host cells to infect, repeating the process over and over again. Viruses have genetic material, but little else – they are generally just some DNA or RNA wrapped up in a rudimentary membrane, as in this image:

Some requisite housekeeping: I have been sick, depressed. Physically sick but also spiritually ailing, it has been bitterly pipe-freezing cold and the SAD is SAD-ing, as the youth would say. So I’m way behind where I would want to be in terms of writing, and most of the days lately I find I need to recalibrate my expectations way down to simply existing and getting done what must get done. This is all to say, I hope the micro-conditions of my daily existence improve soon, and I have good reason to think they will – the sun is out, I’m sitting in the library (not at home!), it might be warm enough to take a walk this week! 

Of course, the macro-conditions are absolutely rancid. I don’t want to rehash everything that has been going down at the federal level or pretend I know what it all means. But I am considering this the first in a series of posts about an issue of serious public import (avian flu) that takes the ignorance of the general American public as the object to be worked on directly rather than as an unfortunate constraint to be accommodated. Am I calling you, dear reader, ignorant? Not exactly. What I’m thinking is more like – our slop-world information environment is increasingly dominated by takes and preprocessed interpretation that presume increasing unfamiliarity with any kind of subject matter. I have noticed this even doing the small amount of “pitching” I’ve done in my life over the past few years: it seems increasingly the case that a successful pitch is one that is written to the level of the zero-information reader. I hope to do something different here – wild, I know – and use the medium of writing to convey information that any given reader may or may not have. 

Basically, I want to do this in the spirit of popular education as an end in itself, even if (especially if?) not a remunerative one. It’s hard to break out of the strictures imposed by the valorization imperative, especially in these lean, mean times. There’s just not any money floating around the economy to support any kind of independent work of any kind, and people no longer really have much wiggle room to do things for free. I am going to try. It’s not that I have the right answers, which I don’t. It’s that I have some stupid education that I paid for. I think there is shit going on in the world that you should know about, and I think that the more educated and informed the general public is, the better for us as a society. I’m under no illusions about how many people this newsletter reaches – it’s not many – but let a hundred flowers bloom and all that. 

I want to offer some context for how I am thinking about public health in terms of the evolving threat of avian flu. I feel like we’ve all well demonstrated how capitalism impacts public health. It’s kind of the whole thesis I and Nate have been working out on our respective newsletters over all this time: social murder, in all its various faces, is the expression of population health under conditions of capitalism. As Trump’s second term gets underway, I can already feel the popular discourse lurching in more of a “libbing the fuck out” direction, and thinking of capitalism in very moralizing terms. This is very good in terms of generating outrage, which drives subscriptions and engagement on the dominant platform model, but it is pedagogically empty and politically worse than useless. It’s demobilizing, which is just about the worst thing it could be.

I wanted to get something quick out because at least one person has asked me what is up with AQI (the EPA’s “air quality index”) and this is well within my wheelhouse. Progress on other posts and other projects is slow because I have a stupid life and a little bit of a stupid cold. (I feel fine, but it takes forever to make a million cups of black tea with orange and lemon, to keep refilling the hot water bottle, to keep myself stocked with clean spoons in a day.) So, thanks for bearing with me. Also, news of a ceasefire deal has just been announced; I haven’t posted about this because I am resolutely morally opposed to ambulance-chasing a fucking genocide for content, but I did want to at least register this. Fuck Joe Biden and free Palestine.

All air pollution is bad, but air pollution from the urban fires like those in LA recently is especially bad. This is because (duh) in these types of fires, it’s not just vegetation burning, but structures, and all the nasty building material they’re made of: paints, adhesives, asbestos in some cases, and every kind of plastic under the sun.

If you go on to websites like airnow.gov, you’ll see maps of the Air Quality Index. The Air Quality Index has five components: carbon monoxide, sulfur dioxide, nitrogen dioxide, ground-level ozone (colloquially known as “smog”), and fine particle pollution. The first four are gases at ambient temperature; the last is an umbrella term referring to the size of particulate matter that makes up the pollution. The two particulate pollution measures you’re likely to see are PM2.5 and PM10; “PM” stands for “particulate matter” and the number refers to particle size: PM2.5 is less than or equal to 2.5 microns in diameter (a micron, sometimes denoted µm, is a millionth of a meter or 1/10,000th of a centimeter) and PM10 is ≤ 10 microns in diameter. The size matters because smaller particles can penetrate into the tiny air sacs inside your lungs and really fuck up your lung function — smaller is worse. (A respirator like a KN95 or an N95 will protect you from particulate matter, but not from gaseous material.)

This essay was supposed to be about loneliness, somehow. The texture of it, the quality of its light. This essay was supposed to connect the experience of loneliness to the moods and soundscapes of New Age music. The kind of abstract idea that would work as a poem, that sounds good as an essay, until you start to get into the actual writing of it. I’m not a poet, after all. I ordered a Vivian Gornick book, a collection of essays about being lonely and a woman, and then experienced a moment of panic because the book won’t arrive until later this week. I originally wrote “panick” in my notebook (anticipating “Gornick”), which I’m noting because I like it. Panick would be my Crowleyian religion. But really, it’s okay. What does a single woman in NYC (let alone in 2015 or whatever) have to tell me about loneliness? I’ve already lived that story, and found it a bit trite. NYC as Personage, Event, Catastrophe, Cultural Device intrudes, bullies. NYC as the fifth character in Sex and the City, the old one, the dying one, the ugly one, the one who’s rotting bottom-up and inside-out, starting from her reeking, decaying bowels, spraying sewer water on commuters. 

Is William Basinski’s Disintegration Loops perhaps the only piece of cybernetic 9/11 Art? By cybernetic I mean not representational (no exoticized terrorists or ticking time bombs or clash of civilization grand narratives here) and emerging from process – in this case, from the process of magnetic tape decaying.

“When the going gets weird, the weird turn pro.” - Hunter S. Thompson, Fear and Loathing in Las Vegas, 1971

I’ve been pretty frustrated by the internet chatter this past week around RFK Jr. Right up top: we shouldn’t try to “work with” RFK Jr. The lib politicians who are saying this (like professional bozo John Fetterman, apparently) are as full of shit about this as they are about every other thing. What’s frustrating about the discourse, though, is that it leaves a critical implied question dangling unanswered. What are we going to do instead of “working” with RFK Jr.? Nobody who gets paid to have opinions about this sort of thing is getting paid to follow through on this. I want to suggest that “whatever it is we’ve been doing” is not good enough.

It’s a very uniquely 21st-century feeling, the heart-sinking that one gets watching a Voltron of loosely connected Takes cohere, via repetition and amplification, as Facts. Online, of course, where nobody has any power, not even close. Noncollaboration is a good start, a good first principle, a noble rhetorical stance, but let’s never forget that at the level of actual lived life for just about every single one of us, it’s the default option, requiring the least effort. We (posters on Bluesky, public health commentators, slingers of takes) don’t actually have any meaningful input into the confirmation process, let alone any way to meaningfully influence HHS policy from the top down. So what actually comes next? What should we actually be doing?

The below thread by Gregg Gonsalves (the GOAT) on the topic is, in my opinion, extremely illuminating. (I’m sorry this interface insists on embedding it rather than just letting me link.)

What follows here is rather sketchy, not particularly thought-out or fleshed-out – I am still in Holiday Dysregulation Mode, getting my sleep schedule back in order, feeling juiced, trying to make sure to take walks, eat properly, fold my stupid laundry. In other words, not my best work, as real life is intruding in a particularly drab way, but hopefully interesting, and hey, this newsletter is free. 

Obviously, I’ve been doing more reading about the Unabomber over my short holiday break. In particular, I really enjoyed this from RH Lossin, published in The Nation in 2022. As a starting point for my line of speculation, it’s important to mention that Lossin runs through the familiar antecedents to the Manifesto: Jacques Ellul in particular, Marcuse’s One Dimensional Man, even hoary old Adorno and Horkheimer. The passage he plucks out of Marcuse is particularly interesting:

The technological universe… is the latest stage in the realization of a specific historical project—namely, the experience, transformation, and organization of nature as the mere stuff of domination.

Since my academic field is (was?) public health, this clearly puts me in mind of public health and statistics – high-modern technoscientific projects to dominate, exploit, subvert, and harness nature to serve the ends of Kaczynski’s System. Public health doesn’t understand itself this way (doesn’t understand itself at all, which engenders a lot of confusion in other quarters), but it is a part of this system of technological domination and rationality. In my estimation, this is a big part of why public health remains completely unable to answer to MAHA in its own idiom, or in any idiom that is intelligible to the general public on an experiential level. In fact, these concerns in their own idiom would mean, for public health, admitting something inadmissible and completely repressed, something essentially true that comes out in the Unabomber manifesto. Lossin: “we seem reluctant to fully acknowledge what Kaczynski proved: we cannot live beyond the reach of our technologies.” (Me: “some points were made.”)

I wanted to write about something fun but with the flurry of news about H5N1 yesterday, it is with a heavy heart that I have decided more people would want and might benefit from some notes about the bird flu.

Here's the TL;DR: H5N1 is not spreading human-to-human at this time. This is subject to change, and I really hope it doesn't. If it does change, it will become apparent pretty quickly. (This is an epidemiology thing, you can deduce how something is spreading from its patterns of spread. They make you do endless exercises on this in public health grad school; my takeaway from that is, never eat the mayonnaise-based salad at the cookout. It’s always the mayonnaise-based salad.)

There are outbreaks in many herds of dairy cattle across the US, some of which have caused human infections; these human infections have generally been mild, not the terrifying level of severity we usually associate with bird flu. The strain of H5N1 circulating in cattle herds is clade 2.3.4.4b, genotype B3.13. Another strain of H5N1 (2.3.4.4b genotype D1.1) is circulating in wild bird populations. This strain, not the cattle strain, is the one responsible for two severe human cases (that I am aware of), a teenager in British Columbia who remains in the hospital and an adult in Louisiana whose hospitalization was reported on yesterday.

What do you, as a member of the general public who does not work with potentially infected animals, do to protect yourself against H5N1 at this point? Two things: 1) do not drink raw milk, and 2) avoid contact with wild birds, especially dead ones; avoid contact with birds in general.

I hadn’t planned to write anything but as always, the shower is Where The Thoughts Catch Up With You. This morning I was thinking about a few pieces of media related to the shooting that I have consumed lately. The first is this New York Times interview with three columnists; predictably, Dr. McMillan Cottom’s remarks are the worthwhile ones. She mentions the concept of moral economy, which I have written about here, taking inspiration from Nate’s (apparently) idiosyncratic reading of E.P. Thompson.

Though the term predates Thompson, we’re working with it as developed in Thompson’s 1971 essay, “The Moral Economy of the Crowd in the Eighteenth Century” (which I really ought to read, for how much mileage I get out of it). I’ll keep it short and sweet — Nate and I have been using it as a way of reading the moral valence around the economy, which is similar to but different from how Thompson used it (to describe the feudal economy based on common values of mutual obligation, rather than the capitalist economy based on abstract values of supply and demand and the like). Dr. McMillan Cottom is also using it in a similar sense as Nate and I: “markets have moral economies” and “our moral economy sucks.” Indeed!

I’ve also listened to a few podcasts about this that have been interesting. The most recent TrueAnon episode with Joshua Citarella (I'm sorry for no direct link but linking to SoundCloud is so annoying here, I'll figure it out later) is an interesting deep dive into Mangione’s background, online activity, and trajectory of radicalization. This Canadian critical theory podcast that I quite enjoy had an interesting discussion as well. Both of these, though, are sort of orthogonal to What’s Really Going On. The TrueAnon episode chronicles the particularly rancid and decidedly not left-wing intellectual environment of the techie “digital nomad” world that Mangione was immersed in, and PillPod tried to scan the event as strategic left-wing action (a failure in that read) or terrorism (perhaps a success in the Baudrillardian sense) and talked at length about ideology, mostly vis-a-vis the media.

But here’s the main thing, I think: on their own, each of chronic pain, dealing firsthand with American health care, and the Online of the past four years in particular are more than enough to disarrange anybody’s brain. The Online point bears emphasizing; McMillan Cottom and others (including me!) have written about the syncretic scramble of the privatized internet, where fringe right and spiritual left really do horseshoe together, oscillating in and out of weird phase space. One of those unlikely superpositions and amplifications happens in particular in the ideology of “tech,” whose creepy focus on self-optimization and human biology seems to take equally from the long and storied lineage of scientific racism and from the LSD-soaked countercultural left.

This has been the week where everyone is scrambling to come up with The Take about Luigi Mangione, alleged shooter of Brian Thompson. In the scramble, an interesting bit of trivia has been overlooked except as a joke among certain kinds of terminally online communities: Mangione’s Goodreads review of Industrial Society and its Future by Theodore John Kaczynski, a.k.a. the Unabomber manifesto. As a long time Manifesto-head, this obviously drew my interest in a more-than-extracurricular way. 

The basic overview of the Manifesto is essentially summed up in its opening line: “The Industrial Revolution and its consequences have been a disaster for the human race.” The arguments, which are not really all that outlandish (or all that original), are that the requirements of industrial society – technologically advanced society organized on a large scale such as we’re living in today – tend necessarily and, for Kaczynski, unacceptably, towards restriction of human freedom and autonomy, mostly (though not completely) via disruption of what Kaczynski terms the “power process.” (The power process is not all that important for the rest of this newsletter, so I’m not going to go into it further.) The terse manifesto (though not as terse as Mangione’s own) argues that the good parts of technological advancement are inseparable from the bad parts; that in the final analysis, there’s no way out but revolution (at best) or individual withdrawal and acts of disruptive violence intended to accelerate the painful demise of the system, which is obviously the route Kaczynski himself opted to take.

It’s hard to think of a technological apparatus that subverts human freedom and corrodes human dignity as efficiently as the US health care system. The exuberant, rattling anger that has bubbled over like boiling milk from a pot in all corners of US society, all ends of the ideological spectrum, and all walks of life following the shooting attest to how much this particular way of organizing advanced technical society degrades and dehumanizes people – and pisses them off.  Horror stories abound. So too does reporting on the bottomless evils of the health insurance industry. Everyone knows. In particular, the highly technified aspects of this industry have come under scrutiny in recent years, though as I will ultimately argue, that scrutiny (much like Kaczynski’s manifesto) is more than slightly misguided.

Just last year, United Health Group got in trouble for issuing so-called “algorithmic” denials of care in its Medicare Advantage programs (for last week’s post with more info on Medicare Advantage, see here). Here’s how Stat News summed up the lawsuit:

Just a quick note about something I’ve been thinking about… saving the Big One (my manifesto, if you will) that gets into similar topics in a lot more depth for tomorrow. Or perhaps later in the week — just depends on how productive I can be.

For anybody that doesn’t know (I do have some readers outside the US, weirdly enough), the US does have two “public” insurers, Medicare which primarily covers people over 65 and Medicaid which covers very low-income people. The Medicare Advantage program, which began in 1999 — although it wasn’t named Medicare Advantage until 2003 — essentially amounts to a privatization of Medicare. Medicare Advantage allows private insurers to offer all the same benefits that traditional Medicare offers, as well as some other stuff that isn’t covered by the core components of traditional Medicare. Enrollment in Medicare Advantage plans really started to take off after the passage of the Affordable Care Act in 2010, and has been growing especially quickly in the last few years. By 2018, the share of Medicare beneficiaries enrolled in Medicare Advantage private plans had risen to 37%, to 48% in 2022, and finally to 54% of all Medicare beneficiaries in 2024, some 33 million people.

The Medicare Advantage “space” is dominated by a small number of private insurers, with Humana and United Healthcare insuring nearly half (47%) of all Medicare Advantage enrollees in the country. I am going to write more about the behemoth that is United Health Group (which has an insurer, United Health Care, and another business unit, Optum, which aggregates a number of different businesses under its aegis), but briefly: United Health Group has grown via aggressive acquisitions over the past 10-20 years to make up a huge portion of the health care industry itself, and its profitability depends in large part on paying itself via deals between its different business subunits, a practice euphemistically termed “flywheeling” in the business press. More on this later — again, perhaps tomorrow. For now, I’m going to focus on the insurance side and Medicare Advantage.

The majority of enrollment in United Health Care has come from Medicare Advantage in the last 10 years, and Medicare Advantage is extremely profitable. According to this post, United Health Care “now takes in nearly twice as much revenue from the 7.8 million people enrolled in that program as it does from the 29.6 million enrolled in its commercial insurance plans in the United States.”

On the urging of a close friend I’ve been listening to and really enjoying the TrueAnon podcast. This past weekend I listened to an episode from Back in April (sorry the embedding is so weird here, I can’t just link it):

with Erik Davis, author of High Weirdness: Drugs, Esoterica, and Visionary Experiences in the Seventies and the Blotter: The Untold Story of an Acid Medium. It’s actually a two-parter but I think the second part may be paywalled.

Since Trump’s election and the appointment of his anti-science MAHA cabinet, there’s a Carl Sagan quotation I’ve been seeing floating around the internet in meme format:

One of the saddest lessons of history is this: If we’ve been bamboozled long enough, we tend to reject any evidence of the bamboozle. We’re no longer interested in finding out the truth. The bamboozle has captured us. It’s simply too painful to acknowledge, even to ourselves, that we’ve been taken. Once you give a charlatan power over you, you almost never get it back.

This is from Sagan’s 1995 book The Demon-Haunted World: Science as a Candle in the Dark. Sagan was writing in the middle of a specific New Age moment in the mid-1990s. His book reads like a tart episode-by-episode rebuttal of Art Bell’s Coast to Coast AM from the same year – topics addressed and dispatched as pseudoscientific or “baloney” (to use Sagan’s word) include UFOs, witchcraft, extra-sensory perception, angels, channeling, and so-called “recovered memories” (which featured heavily in that decade’s Satanic Panic). The core of Sagan’s argument is fashioned into what he calls a “baloney-detection kit,” essentially a popularized Scientific Method that readers can use to distinguish real science from pseudoscience and woo, to use logic to defang superstition, and ultimately, to widen the small pool of light, cast by reason, against the oppressive, encroaching darkness of ignorance and delusion.

It sure does seem like we need Sagan’s baloney-detection kit more than ever now. I’ve written extensively about the MAHA cabinet on this newsletter, and about the issues they’re concerned with, like anti-fluoridation and raw milk, from a very debunk-ey perspective that jives with Sagan’s project. I definitely intend to continue – anybody interested in whatever the hell is really up with seed oils? But even as I’m doing this, I’m doubting myself. I’ve been on this tip since the early 2000s, when I was rattling off facts about thimerosal, the preservative in vaccines that the now-retracted cornerstone paper of the anti-vaccine movement spuriously linked to an increase in autism spectrum diagnoses, about the need for preservatives in multi-dose vaccine vials, about how vaccines themselves work, to anyone who would listen. What did all this accomplish? Not shit.

Last week, Trump announced the appointment of Jay Bhattacharya to head the NIH — we all knew it was coming. I didn’t have any kind of plan or destination in mind when I started writing this a few hours ago; it’s not heavily considered, chewed-over, or edited, just some general thoughts about where I’m at today. Read in that spirit.

I don’t know what to say about Bhattacharya that I haven’t already said. Way back on October 11, 2020, Justin Feldman and I published a deep dive into the now-infamous Great Barrington Declaration, of which Bhattacharya was one of the three fringe authors — joke’s on us now, I suppose. I’ve done some smaller-scale investigations into Bhattacharya’s discredited COVID “seroprevalence study” (discredited and also corrupt — remember how a JetBlue executive funded it? to show that COVID was already widespread, mostly asymptomatic, and not very deadly, and thereby undercut the case for nonpharmaceutical interventions?) of Santa Clara County, CA. I could note that the scientific arguments characteristic of Bhattacharya’s COVID career explicitly contradict some of his earlier research, such as this 2010 NBER influenza modeling study that highlights the effectiveness of early adoption of “avoidance measures,” a.k.a. nonpharmaceutical interventions. If anyone reading this would be interested in a deep dive analysis of Bhattacharya’s scientific publications, email me. I’m happy to do it if people would find it useful. I’m not sure I find it useful for myself at this point.

I’ve talked about COVID as a political defeat. This is it. I’m so glad I didn’t become a professor of epidemiology. Don’t get me wrong — what I really want to be doing is teaching and writing. I’m still trying to figure out a way to do that; being a professor of epidemiology would not have helped. While teaching and writing are what professors in most disciplines do, it’s not the case in epidemiology. What professors in epidemiology do is write grant applications to the NIH to fund their own salaries and their universities. (As an aside, I think this contributes to the structural tendency of epidemiology programs to produce astoundingly ignorant graduates and to the structural tendency of the discipline as a whole towards irrationality, ignorance, and myopia. Since grant writing is the only metric of success, no one is trained or hired for their ability to think, write, or teach, only for their “demonstrated track record of securing extramural funding,” to use the tired stock phrase of every academic job description.)

Bhattacharya is about (to try, anyway) to take an axe to the NIH, which means that a lot of people’s careers are about to get a lot more precarious. It’s way more than just long COVID research that will be affected if Bhattacharya and the interests he was appointed to represent get their way — my intuition tells me infectious disease research, particularly of a population/epidemiologic bent, is possibly in big trouble. The experiences of the past several years have made me a bit of a nihilist about the science the institutions produce as well as about the institutions themselves. But this is really pretty bad. My guess is that a lot of academics who maybe signed the John Snow Memorandum out of some vague sense of wounded expert authority are going to suck up to Bhattacharya and reconfigure their research agendas to be more attractive to Bhattacharya’s NIH, once it becomes clear what the funding priorities of the institution will be under him. It’s understandable, but it’s sad.

Trump appointed Marty Makary as head of the FDA. Marty Makary is one of the peripheral D-list conservative baddies of the COVID era, kind of a Trump administration gadfly who came out hard against vaccine mandates especially. Here’s how PBS describes him:

Makary gained prominence on Fox News and other conservative outlets for his contrarian views during the COVID-19 pandemic. He questioned the need for masking and, though not opposed to the COVID-19 vaccine, had concerns about booster vaccinations in young children. He was part of a vocal group of physicians calling for greater emphasis on herd immunity to stop the virus, or the idea that mass infections would quickly lead to population-level protection.

The Centers for Disease Control and Prevention estimated that COVID-19 vaccinations prevented more than 686,000 U.S. deaths in 2020 and 2021 alone. While children faced much lower rates of hospitalization and death from the virus, medical societies including the American Academy of Pediatrics concluded that vaccinations significantly reduced severe disease in the age group.

Before surfing the COVID waves to minor Fox news celebrity, Makary was most famous as the first author of a 2016 “study” purporting to show that medical errors are “the third leading cause of death in the US.”

What is in Makary’s paper? I put “study” in scare quotes above because it is not, in fact, a study. The authors (Makary and someone named Michael Daniel) neither collected nor analyzed any data. They did not systematically review any literature, either quantitatively (pooling the data from each selected paper and analyzing it as in a meta-analysis) or qualitatively (as in a narrative review of the existing literature, its strengths or weaknesses). None of that shit. The paper is a two page — literally, two page — overview of four other papers on medical error.

Pour one out for Raw Farm and CEO Mark McAfee, whose business and livelihood depend on making people wretchedly ill with his company’s raw milk products. Santa Clara, CA county public health officials just detected H5N1 (bird flu) in a retail sample of Raw Farm raw milk taken from a Fresno. It’s nearly 9 PM where I am, so I am going to keep this brief, but: this is very bad. Perhaps I will do a longer post soon explaining in more detail just why this is bad. For now, suffice it to say, this indicates tangibly increased risk of a so-called spillover event. Right now, H5N1 isn’t very good at infecting humans, and the people that have been infected have been (overwhelmingly but not totally) people who work very closely with infected animals. Viruses, as we have seen with COVID, increase their “fitness” to infect humans (and spread human-to-human) with increased transmission; one critical driver of this is the rate at which the virus’s genetic material mutates. (Mutation = variability, and variability is what the process of natural selection works on.) Not awesome news for us, influenza mutates very fast and very often. It’s a probabilistic game: any given individual mutation is unlikely to turn the virus into an airborne superbug, but every transmission — from bird to bird, bird to cattle, cattle to human — is an explosion of roulette spins, new opportunities for the virus to mutate. The risk gets higher and higher, the more the virus circulates, that one (or more) highly unlikely things might happen.

This is a huge reason why factory farming of chickens is the worst idea ever. It basically creates a crucible for breeding ever-more pathogenic strains of bird flu. Mike Davis (Z”L) wrote an entire book about this back in 2003 (it’s called The Monster At Our Door and it is quite good, maybe I’ll review it on here). Factory farming in general creates optimally hellish conditions for sparking off an influenza pandemic by concentrating different species of animals together in abject close quarters — influenza loves to recombine in nasty ways in pigs in particular. Conditions for human laborers on factory farms are nearly as dangerous and atrocious as the conditions for the animals — it’s an educated guess that there’s not a lot of PPE for these workers that would help confine any animal infections to the animals. (And American news has the gall to sniff about “wet markets” in Asia. Get a fucking GRIP.) Then, on top of this, in the dumbest possible timeline, we are getting dragged over the event horizon of another terrifying pandemic by scientifically illiterate kundalini cult Erewhon girlies who want to shit their brains out 24/7, the closer we are to Gwyneth, amen.

Pour one out for Emily Oster, who just last week wrote a New York Times article dismissing concerns about bird flu in commercially available milk. You know what would have killed the bird flu in this sample of Raw Farm milk? Pasteurization. Fucking dipshit. Pour one out for Jennifer Nuzzo, public health mediocrity (even by public health standards) and COVID waffler now at the helm of “The Pandemic Center” at Brown who is quoted in the LA Times article downplaying the risks of drinking raw milk but impelled by… some glimmer of conscience, maybe? (are you there, Gwyneth?) to say that “I personally would avoid drinking it.” Ya don’t say. (Nuzzo: “This isn’t surprising, given how quickly H5N1 seems to be spreading among farms in California and given the fact that these outbreaks on farms are being discovered in large part due to bulk testing of raw milk from farms.” How else would you propose we discover it, Jennifer? Might you put on, I dunno, your “pandemic preparedness” cap to think about this?)

Lmfao. I’ll let Mark McAfee — we NEED a deep dive into this dude and his whole deal, can anyone point me in the right direction? — have the second-to-last word here.

In my youth I was a punk and I especially loved the Dead Kennedys. The Dead Kennedys’ arguably most famous song is California Über Alles, a sendup of Jerry Brown’s (first) hippie-rightwing tenure as California governor from 1975-83 (“your kids will meditate in school,” Jello Biafra, in character as Brown, threatens in his warbly singing voice as the song reaches the chorus, “YOUR KIDS WILL MEDITATE IN SCHOOL!”). After Reagan’s election, the band recorded an updated version of California Über Alles for their 1981 In God We Trust, Inc., inserting some jazzy, louche, lounge-singing interludes between the blasts of power chords (waiting for Bon Appétit to release a recipe for the “Tricky Dicky Screwdriver,” which Biafra entreats the listener to enjoy: one part Jack Daniels, two parts purple Kool-Aid, and “a jigger of formaldehyde from the jar with Hitler’s brain in it”) and revising the lyrics to skewer the Great Communicator himself. The song also gets a new title: We’ve Got A Bigger Problem Now.

Well, folks, here I stand at The Limits of Rhetoric thinking to myself… we’ve got a bigger problem now. For years, I’ve been writing and speaking about what I see and believe in as “leftist” public health, a complicated, difficult story about public health and what it’s doing in the world, historically and in the present. I’ve been complicating the narrative to death, interrogating flashlight-in-face style the faulty assumptions of public health and biomedicine, arguing in an increasingly shrill and angry voice for a collectivist idea of public health that is regulatory, precautionary, organized around something other than the “valorization of value” (aka the profit motive) at the heart of the capitalist logic of everything. And I’ll be brutally honest, I didn’t really see MAHA coming, I didn’t take it seriously enough, I just ascribed it to more of the same in our fucked up economy of health.

Which, it kind of is, but with a sinister new twist. I have another post coming and mostly drafted about what it would mean to actually take this shit seriously rather than dismissing it out of hand as for a) crackpots, b) losers, c) stupid people, d) health economics-brained liberals. There’s a lot in there about science and science communication, but I’ll save that for later. Right now I think I’m going to try to back the fucking truck up and see clearly where we’re actually at now that RFK Jr. is in charge of HHS, Dr. Oz is in charge of CMS, and so on.

I’ve been investigating the Means siblings, Calley and Casey means, brother-sister team of health entrepreneurs that are some of the most visible proponents of the MAHA movement. (That’s Make America Healthy Again, for anybody that doesn’t know.) Apparently Calley is launching a newsletter on 12/19 which I will absolutely be signing up for. In looking at Calley’s webiste, I was really struck by something, though. Even though I know this dude is just an alternative health grifter, here’s how he summarizes what he has learned on his “journey”:

I promised a post about fluoridation. This is it. This may be the first of several; I won’t pretend to be familiar with any of the literature on this, whether on the health effects (detrimental or beneficial) of water fluoridation or on how fluoridation fears are an entry-level conspiracy theory. (Although, I have some anecdotal evidence — long ago I lived in Austin, TX and thought the Alex Jones/Infowars people who camped out in front of city hall protesting fluoridation were kind of campy and funny. Little did I know where we were headed.)

Leana Wen and Emily Oster both wrote about fluoridation last week, Oster in her New York Times piece and Wen for Amazon house rag The Washington Post. Their points are almost identical, which should alert you to the level of effort these brown-nosers are putting into their public intellectual output.

Both mention that European countries stopped recommending fluoridation. Hmm, can we think of anything that is different between European countries and the US of A? Here’s one: nationalized health care. In the US, dental insurance is separate from health insurance, and both are private. (Fun fact, I got two wisdom teeth extracted with nothin’ but shots of Novocain because I had no dental insurance — paid out of pocket for the extraction — and my crappy health insurance didn’t cover nitrous oxide.) Dental care is a crisis in the US, and if the legislative panels convened to worry over it don’t convince you, may I point you in the direction of the huge repository of memes about teeth as “luxury bones”? In this context, where kids go to bed suckling on bottles of Mountain Dew (is RFK gonna do anything about those Big Ag corn subsidies or are we just gonna get some kind of funky MAHA remix of the soda tax?) and many can’t go to the dentist at all, might the value of something like public water fluoridation be evident?

Anyhow, this post isn’t going to focus on that. This post is going to focus on how to read a study. Both Oster and Wen cite the same study, from JAMA Pediatrics (scoffing here because people think JAMA is some kind of prestigious journal when in reality the statistical review is shit-tier and the journal publishes mostly dreck from unqualified clinical personnel under tremendous pressure to churn out research, no matter what it says, in order to move up the rungs of competitive medical training), purporting to show an association between prenatal “fluoride exposure” (this is, I will state up top, not what the study measured) and child IQ.