Halle Tecco: Investing in Women’s Health

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.‌

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. Our guest today is Professor Halle Tecco. But first we like to check in on current or hot topics in health and healthcare. Harlan, you have, I think, just come back or maybe you’re even still at the American Heart Association meeting, but it’s a really huge meeting, as I understand it. So a lot of people I know have been there who I was surprised.‌

Harlan Krumholz: Yeah. No, it’s a major meeting in the heart world and yeah, I just finished. I will tell you, I actually think these meetings are shrinking a bit, but still, a lot of people show up. It’s a lot of great energy. And I was going to share with you a couple of studies that came out that I thought you might find interesting.‌

Howard Forman: Yeah, I’d love to hear that.‌

Harlan Krumholz: Yeah. So I think that several of them have direct implications for how we understand or manage cardiovascular disease or how we might live our life. The one that has gotten a lot of attention that you might have seen that I tweeted about was this study on sedentary behavior.‌

There have been a fair amount of studies on sedentary behavior. You’ve heard this—“don’t sit so much”—but a lot of these are based on self-report.‌

This is based on a study of nearly 90,000 people who all had wearables. So this was about direct sensor measurement of activity. The interesting thing about this study is that it found the people who were sitting more than, believe it or not, very precisely, 10.6 hours a day... after that, the risk sharply increased. There was an inflection. They divided this into quartiles, and they basically were saying something like, “The people who were most inactive, maybe there’s something going on with them.” So they compared them to the people in the second quartile, which were about, I don’t know, an hour or so, more active, not sedentary, as the group that was most sedentary, the 10.6 and above, and they had a 45% greater risk of heart failure and a 62% higher risk of cardiovascular death.‌

Now, these are observational studies. These are linkages. But it seemed to go along with what we might have expected, the people who are sitting still.‌

But there are two things about this study. One, this database, the UK Biobank, and you should know that that has issues around generalizability and so forth, has a lot of data that you can use to control for the effects. So you can really try to isolate, is it really about sedentary behavior?‌

And secondly, you know that we recommend people get maybe 150 minutes or more of moderate to vigorous physical activity a week. And what they found was that it’s good when people are doing that physical activity, it did lower the risk, but still the sedentary behavior was on top of that.‌

So even if you did engage in that kind of vigorous activity, if you were sedentary for that many hours, you still had this increased risk. It was slightly mitigated but not completely.‌

It may get us to the point where we’re really starting to recommend that people do get up and move. It’s like in this binge-watching culture we have, people are more and more sedentary, and that’s probably counter to the best thing for our health. So that was one study.‌

Hey, let me just get a couple more because I think you might find these interesting.‌

So there was a study that was done about a decade ago published in New England Journal of Medicine in 2013 that was looking at the effect of intensive lifestyle intervention for people with type 2 diabetes and overweight or obesity.‌

Remember, this presaged, this was before these new drugs came out and at that time, really, this was the best that we could do. They put together a really blockbuster intervention that helped people to lose weight and to feel better. They followed these people almost for a decade. And guess what? No effect on health outcomes. No effect on health outcomes. So that was interesting.‌

But they have gone back to that data and looked at biomarkers, their markers of heart health, heart stress, heart damage, and the troponins which are somewhat indicative of heart damage suggested that there might be some benefit. But the heart stress biomarkers actually got worse in the first year with this intensive lifestyle intervention.‌

This study just reminded me that just we were reflexively saying, “You should really go on these rigid diets,” and people should really try to improve their health and here’s a study that said that strategy didn’t really work. It’s juxtaposed to, again, these drugs which are helping people to lose weight, fight obesity, and it’s improving their cardiometabolic health.‌

Which gets into another study that was published here called the SUMMIT Trial, which looked at patients with a certain type of heart failure, that heart failure where the heart’s pump function, the squeezing function is normal. They’ll call it heart failure with preserved ejection fraction. It’s squeezing well, but it doesn’t seem to be relaxing as well and people end up getting fluid backups in the lungs and in the peripheries, sometimes can get edema, and this can be also just as dangerous as the other kind of heart failure where the heart isn’t pumping as well.‌

There had been a previous study that said if you treat people with this—and many of these people have obesity—with these new drugs like semaglutide, that it can improve their health status, how far they can walk, how they feel. This study looked not only at that but whether or not it actually reduced heart failure hospitalizations and cardiovascular death and a whole range of other heart outcomes.‌

It was another winner, Howie. It showed that people felt better and actually, these events reduced, the outcomes improved substantially. This is added importantly to the literature on the value of these meds.‌

And then finally, in JACC... By the way, the sedentary behavior paper was in JACC and, oh, the weight-loss paper was in JACC, so I’m pumping JACC today. But in JACC, there was a sub-study it—‌

Howard Forman: We welcome it!‌

Harlan Krumholz: ... where they looked at CMR [cardiac magnetic resonance], they looked at magnetic resonance, they did imaging of the heart over the course of this study in a subset, and believe it or not, Howie, it’s really, really interesting because this is remodeling of the heart. It’s not just improving symptoms, but you can actually see changes in the heart structure. And so there was a reduction in left ventricular mass. These patients had had thickened hearts that became less thick and pericardial fat, which are also both critical contributors to heart failure. Interesting.‌

I keep saying these are heart health drugs. They’re not just drugs that have people lose weight, but somehow they’re having an effect on the heart. Of course, they’re probably working through the brain too and how they’re being mediated.‌

Anyway, these studies showcase a couple different aspects, one, with sedentary behavior and what people might do. Another one really is saying that maybe these extreme lifestyle interventions, which can produce benefits may or may not actually translate into long-term benefit. And then two studies that are focusing on the drugs themselves, semaglutide, in this case... tirzepatide. Oh, my goodness.‌

The heart failure one was tirzepatide, the previous one was semaglutide, I think that was... I misspoke.‌

Howard Forman: Which, again, the Lilly drug is tirzepatide. The Novo Nordisk drug is semaglitide.‌

Harlan Krumholz: That’s right. These are both these new anti-obesity drugs that are being used.‌

The previous study was semaglutide show people felt better. This one showed that but also the outcomes. And we’re really progressing here in terms of, I think, having a really strong tool to treat many new diseases that escaped our ability to make a difference before.‌

Howard Forman: Yeah. Well, when we do the outro segment, I’m going to talk about the fact that I think you and I are willing to acknowledge that what we learned 10 years ago may not be exactly true today, but it doesn’t mean that we have to be skeptics about every single thing and believe the opposite of what we find. So it’s really important that we continue to follow the evidence wherever it leads.‌

Harlan Krumholz: Yep. Yep. Yep, yep. And great.‌

We got a wonderful guest today, Howie. Let’s move on to the next segment.‌

Howard Forman: Halle Tecco is a healthcare investor, innovator, entrepreneur, podcaster, Substack newsletter writer, professor at Columbia Business School and Harvard Medical School, and much more.‌

She’s a graduate of Case Western, where she majored in finance, the Bloomberg School at Johns Hopkins, where she concentrated in women’s and reproductive health, and Harvard Business School, where she got her MBA and founded Rock Health, an advisory and investing company in the digital health space.‌

And I could go on and on but suffice it to say that she’s an extraordinary individual who I first met when she keynoted Yale’s Healthcare Conference approximately a decade ago. She continues to illuminate, educate, innovate, and inspire. And I’m so delighted to have her on the podcast today.‌

And I want to start off because you are a particular pedigree that I have spent the last 14 years cultivating, which is the MBA-MPH, and I have gotten to see my students go off in many directions, but I don’t think anybody has had a more determined influence on digital health, women’s health, and promoting women in health investing and life sciences. So can you just tell us when you first got the fever for this? Was it back in Ohio? When did that start?‌

Halle Tecco: Well, thank you. First of all, thank you for having me and that kind, generous introduction. I’m excited for our conversation today. Where did my spark start is a good question.‌

As I’m writing a book, which will be out next year, I’ve been trying to tap into some older origin stories of mine. And it’s funny because it started in a very random way.‌

I was a finance major but I minored in Italian. I’m Italian. I’m an Italian dual citizen, and I am not good at language learning and was doing just okay in my Italian class. My professor gave the students an opportunity to volunteer as part of a clinical trial that was happening at the Cleveland Clinic around language therapy. They were using language learning as a modality, and I was like, “Okay, I’ll do it.” I just wanted the extra credit. I actually think that’s what started my interest in thinking about healthcare differently. I think I never... I had a lot of friends that were pre-med—Case is very big pre-med school; my mom was a secretary at the Cleveland Clinic for decades, but I never felt called to be a provider. In fact, I always thought that was the only role in healthcare was on the clinical side, and that never appealed to me. I think that was the first time where I looked at healthcare as maybe something that I could do in my career as a field that I could be part of.‌

I ended up then finding an internship at St. Luke’s-Roosevelt in New York, Columbia University’s health system. I worked with a doctor there who was doing research on music therapy and spent the summer with her as she was using music for PTSD and ADHD. She had this brain wave reader that would then put music that would bring you to your most relaxed state. It was very interesting.‌

I don’t really talk about those experiences. I was so young, and I have had such a small piece of the work that was being done but for me, it was the moment that I realized that healthcare was really big, and there were a lot of opportunities within healthcare to be part of it no matter what your background is, no matter what your interests are, there’s something in healthcare that you can be part of.‌

Harlan Krumholz: I’m always happy to have someone from Ohio on the program, Howie.‌

Halle, I grew up in Dayton.‌

Halle Tecco: Are you from Ohio?‌

Harlan Krumholz: I grew up in Dayton, but we always had an inferiority complex for people in Cleveland because Cleveland was such a big metropolis and...‌

Halle Tecco: Yeah, but you’re the City of Flight, right?‌

Harlan Krumholz: We’re the City of Flight, City of Innovation. As I learned about what you have done, it’s just so amazing the trajectory and path that you have been on. Can you just talk a little bit about Rock Health? Because it seems like you got involved with that pretty soon after you graduated from business school. What was that path? People are looking for jobs at that point, but you’re actually co-founding something that turns out to be a dominant influence in digital health.‌

Halle Tecco: Yeah. Well, no one wanted to hire me, so I had no choice. I love school. Obviously, I love school. And actually when I wrote my business school essay, I stated that I wanted to combine my interests in healthcare and social entrepreneurship and probably one of the few people that actually followed through with what they said they wanted to do, because you don’t really know what you want to do when you’re 24 years old applying to grad school, but that’s what I wanted to do.‌

At the time, all the healthcare programs at the business school were geared towards folks that wanted to work in one of three places: hospital, a health plan, or pharma. There wasn’t a health IT track. There wasn’t a lot of interest in healthcare innovation from a digital health perspective.‌

But one of my professors, Bob Higgins, who founded Highland Capital, was one of the original investors in healthcare and health IT and just did some independent studies with him around the opportunity at the time, specifically around mobile health and how the phone was really going to change healthcare.‌

The summer between my first and second year, I had the opportunity to intern at Apple, where they asked me to cover the healthcare segment, and I say, that has much less to do with the qualifications, my qualifications to run the healthcare segment and more to do with how little they cared about healthcare at the time. But it was an awesome experience, and I was able to really be on the ground with app developers and healthcare.‌

And my biggest takeaway from that experience was that as a 25, 26-year-old intern, I was overseeing a category that was part of the biggest industry in the United States. Almost 20% of GDP going into healthcare.‌

It’s the largest sector, but the number of apps were completely outnumbered by other sectors, by gaming and lifestyle and social networking. So not only did they have more apps than healthcare but they also had higher-quality apps. It just made no sense to me.‌

These developers that were building gaming apps were just pouring so much love and heart into these apps. They were using every native feature of the iPhone just wowing us. They’d come in and just have the coolest new products. And the healthcare apps were very much check-the-box strategies, outsourced to third-party developers in Uruguay or Ukraine, and really felt like they were done because someone on the board of hospitals said, “We need to get an app,” and not because a team of folks tried to understand the unmet need within mobile health. That was when I decided to start Rock Health. At that moment. I was like, “This is bonkers. There is such a huge opportunity.” With my business hat on. “Enormous market opportunity here, so why isn’t it happening?”‌

So then I immersed myself into the problem. The problem of why are we not bridging technology and healthcare? Everybody I talked to on each side wanted to sit at the same table, they just didn’t know how.‌

Talking to hospitals who ended up being our first backers, Mayo Clinic, Kaiser Permanente, these were our very first backers. I was a very young, inexperienced person with a pitch deck, and they backed us, took the risk on us because they were like, “Yeah, we want to connect with folks who are entrepreneurial, folks who understand software and user experience.” And then on the other side, founders were like, “I’m a little scared of healthcare because I don’t really understand it, and I don’t feel like I’m going to be able to break in because they’re all these incumbents.”‌

And so the idea for Rock Health was really to bring these worlds together.‌

Howard Forman: Can you speak to... Rock Health right now does advisory, it does not-for-profit work or social enterprise, I guess, and it does investing. When you started it and when you first were working at it, was that the conception for it? And what area do you feel like you’ve had the biggest impact?‌

Halle Tecco: Yeah. Everything grew organically.‌

The first thing we wanted to do was just back startups. We started with just giving grants. We were just like, “We just want really smart people working on important problems and give them a little bit of money, office space, and access to the expertise that they would need.” Our very first group of startups, Omada Health, probably the most successful of that very first batch that we backed. That’s what it started off as. And then we eventually raised a fund, a real venture funds. We were able to write bigger checks and take equity.‌

Very early on, we started the research arm. It was actually a suggestion from my husband, who said, “You should be tracking all the deals, so you know what’s going on, what investors are looking at, and make these industry reports.” And so very early on, probably a few months into the organization, we started tracking and now have the biggest database of digital health funding. So every deal since 2011, when we started tracking. We look at things like the founder, where the company is based, the gender of the founder, which helped us do some gender work, understanding what the company does, how they do it, how much they’re raising, who is backing them.‌

That’s turned into its own now full advisory group that does research and consulting. They did spin that out after my reign.‌

And then conferences. Just bringing people together. That was core of what we were doing anyways, and we just wanted to make them bigger and bigger. So have been running... there are three main conferences that we started that continue today. One is the Rock Health Summit, which just is a digital health conference that brings together people inside and outside of our portfolio and community, and a CEO Summit that’s specifically for CEOs to get together to talk about the challenges that they’re facing. And then a Women’s Health Summit, which is really around supporting women founders and specifically women founders working in women’s health.‌

Harlan Krumholz: That’s a segue for me to ask you a little bit about Natalist. It’s really interesting to me. You guys write that this is led by a team of moms and doctors on a mission to reduce the historical shame, misinformation, and outdated product offerings women’s experience on their path to parenthood. Maybe this was paralleling what was going on in your life, but you start this thing in 2019, it’s acquired in 2021, it’s very successful. Can you just talk a little bit about that journey?‌

Halle Tecco: Yeah. At the time when I was starting Natalist, I had been struggling to conceive. And so as I was buying all these products...‌

The average person spends about a hundred dollars a month when they’re trying to conceive on everything from supplements to pregnancy tests, and the average person takes three to six months to get pregnant, and the average person has two kids. So there’s a very specific window when you want to help someone. I think because of that it’s become a very disjointed experience. And so even just going to the drugstore to get all these products, you needed them all to get pregnant, they were all the same purpose but they were in different aisles, they were made by different companies.‌

And so I saw the opportunity to bring it all under one brand and be just the fertility and pregnancy brand and also just make the experience less cold and medical and more warm and loving. I was looking at the products compared to my beauty products in my bathroom and just wondering, “Why don’t we deserve to use products that have instructions in plain English and look nice?” That was the premise of starting Natalist. I started it in 2018. We launched in 2019. Great time to start and sell a company in that era. So it was a very good journey for us.‌

Everly Health, the company that acquired Natalist, I think has helped it continue to grow and evolve as a brand, which has been really fun to watch, but it was really a project born out of my own frustrations.‌

Howard Forman: Could you say a word or two about Cofertility, which I wasn’t aware of until I was preparing for this, but I just thought it was fascinating, and just wondering how far along that is and what you learned there.‌

Halle Tecco: After I sold Natalist, there’s basically a 90-day window where you can shift earnings from one investment into another for a tax benefit. And so I was like, “All right, I have 90 days to start a new company.” I had a colleague who I had known for years, Lauren Mackler. She started and ran Uber Health for eight and a half years. I don’t know if you know the Uber Health story, but it’s really cool. They provide rides for hospitals and make it super easy for them to coordinate rides and care for patients that can’t otherwise get to appointments. She built that into $150 million business in a year and a half, and it’s just an extremely good operator. She was thinking about starting something in women’s health and fertility based on her own experiences. She has a rare abdominal disease that made it so that she needed to figure out her family planning much more quickly than she had intended to because of some surgeries that she had to have. ‌

Her and I were noodling on opportunities. I knew I never wanted to be the CEO again. I’m not an operator. I learned that about myself at Natalist. I enjoy supporting leaders but I’m not the operator. I knew that Lauren, I could be her cheerleader and supporter, investor, and now I’m chair of the company but I really helped her get it started and grow it into the business that it is today now three years later.‌

Cofertility, the premise is we have an egg sharing program. The best time to freeze your eggs as a young woman is unfortunately also when you can usually least afford it.‌

One of my biggest regrets in my life was not freezing my eggs when I was younger. I suffered from infertility. I have one miracle child, but I had hoped to have a bigger family than I was able to. I’m a really big proponent of giving women more options to control their family planning timeline. But the cost is prohibitive.‌

We have an egg sharing program where women can freeze their eggs for free when they donate half to a couple that can otherwise conceive. We’re serving gay dads, we’re serving women who have infertility, age-related infertility, went through cancer treatment and weren’t able to conceive after that, and have helped a ton of families over the years now grow their families through egg sharing.‌

Egg sharing is actually a very common procedure and agreement in the U.K., where you can’t sell gametes, so they’ve come up with this workaround. So we have decades of research out of the U.K. showing that egg sharing donors have very high levels of satisfaction and very, very low levels of regret. And so, being able to take that data knowing that these arrangements are a win-win for everyone and bring that to the U.S., which really, there were some clinics that were doing it on their own, but at a national level had not been done.‌

We’ve had over 100,000 women apply to the program, have had thousands and thousands freeze their eggs through the program, and are just offering an alternative for people who don’t necessarily want to donate their eggs for cash. That doesn’t sit right with everyone. Actually, there’s a Harvard study on donor-conceived people that show that donor-conceived people are not comfortable with the fact that money was exchanged at the beginning of their conception. There’s some conflicts with the cash compensation-egg donation market. And so we’re trying to smooth out some of that to create a more ethical human-centered egg donation plan that includes keeping your own eggs and having those in case you need them when you’re older and want to build your family.‌

Howard Forman: Given what you know now about the world and your experience, somebody who’s interested in the MPH-MBA pathway, what excites you? What would you tell young Halle Tecco to look at now?‌

Halle Tecco: My advice for people who specifically want to do the MBA-MPH, well, my advice is... they usually come to me saying, “Should I do an MBA or an MPH?” And I say, “Why not both?” Such a great, it’s a killer combo. Obviously. I did it in an unusual order. I did my MBA early in my career, two years out of school without much direction or expertise or experience. And then I did my MPH at... I was 35. My son had just been born, he was born in September, and I started the program in November, which is crazy to think about in 2017. So I was a good more than a decade out of undergrad.‌

For me, it was just when I needed it. I felt like I needed my MBA earlier in my career for a lot of reasons. I felt like that was my calling at the time. And then at some point, I looked and I said, “I think I’m a pretty good businessperson. I understand all this stuff, but I’m not here just to build businesses. I really do want to make a difference. I really do want to fix healthcare. This is nagging me. This is all—”‌

Howard Forman: And you’re having it. You’re making a difference.‌

Halle Tecco: Well, I’m trying to. I’m dedicated to it. Sometimes, some days, I feel more accomplished than others. There’s a lot, but... I really wanted to just be good at what I was doing, and so that’s why I went back and did an MPH program and loved it. It was so much fun.‌

I learned so much, and I feel like I was able to step back, look at the problems from a public health lens and what is the impact this company, this solution, this product could potentially have, understand any negative externalities. I don’t think that ever occurred to me before. Just thinking about, “Okay, what are some second-order impacts that this might have on our healthcare system and how to look through things through an impact lens?”‌

I am so glad I did both of the degrees. They’re so different. I actually have an article on my blog about my perspectives of the difference between the MBA and the MPH, and I think depending on where you want to go and what role you want, one might be better than the other. But if you can’t decide, I don’t know, do both if you can.‌

Howard Forman: I agree.‌

Harlan Krumholz: My final question, is there a change in healthcare that you’re impatient to see? Because for all the innovation and everything that’s happened in the last decade, we are still anchored in an old time, I think, in healthcare. And I wonder what is it that bugs you the most?‌

Halle Tecco: So many.‌

Harlan Krumholz: What is it that you would really yearn to see change? Is there an area?‌

Halle Tecco: So many things. Yeah. I actually usually ask my guests, “If you could wave a magic wand and change anything in healthcare, what would it be?” I have never answered it, but I’ll answer it because this is basically your question.‌

I think we’re just so limited by the fact that most of us, our health insurance and our health plan is tethered to employment. I feel like the fact that people stay at a job for two to four years and they don’t necessarily have the incentives to invest in long-term preventive health solutions for patients does a massive disservice. And so I’d love to see an option where maybe your employer gives you tax-free dollars. Ultimately, you go pick which insurance you want and you stay on it for a long time. You pick the one that works for you, maybe it’s a public plan, maybe it’s a private plan, but have real market competition for that.‌

I think we’re starting to see things like QSEHRA [qualified small employer health reimbursement arrangement] and ICHRAs [individual coverage health reimbursement arrangements] that are pointing to a more consumer-driven model. But to me, just getting away from employer-sponsored healthcare which creates job lock, which is regressive for many reasons, would be my wish.‌

Howard Forman: I will say you’re prescient in that way. I talked to one of my undergrads this morning about her final paper and that was one of the big themes that she wanted to talk about.‌

Halle Tecco: Love it. Oh, you have to send it to me when she writes it. I’d love to see that.‌

Howard Forman: But look, we couldn’t thank you enough for joining us and for really everything that you do. We didn’t even get to talk about how much you have appropriately promoted and elevated and sponsored women in healthcare so that... the transformation in the last 20 years has been dramatic even as women are still underrepresented, but they’re dramatically more represented than when you entered this. So thank you for everything that you do.‌

Halle Tecco: Thank you.‌

Harlan Krumholz: It’s been a delight to talk to you.‌

Halle Tecco: Thanks for having me. It was great talking to you guys.‌

Harlan Krumholz: Yeah, it’s terrific. Thank you.‌

Halle Tecco: Great.‌

Harlan Krumholz: Howie, that was a terrific interview. I’m so glad we had her on the show. I’ve been—‌

Howard Forman: Yeah, she’s amazing.‌

Harlan Krumholz: ...looking forward to this episode for a long time and it didn’t fail to deliver, so thank you for scheduling her because this really was your... you know her and you were able to get her on.‌

Howard Forman: I’m glad that she was able to do it.‌

Harlan Krumholz: Yep. Hey, let’s get to your segment, one of my favorite parts of the show to hear what you’re thinking this week.‌

Howard Forman: Yeah. I would love to stop talking about health politics but right now, it’s impossible, and I’m going to try to do my best to explain this in the most balanced way for our listeners, but it is a time of great uncertainty. I want to state upfront that I personally for all of us, I want us to embrace the idea that we can and should have a healthier nation.‌

You and I have talked a lot about the things that are the impediments to that and the things that we might do to get to a healthier nation. But today I’m going to focus on Robert—‌

Harlan Krumholz: Are you saying we should make America healthy again?‌

Howard Forman: Make America healthy again.‌

If we would, I would love that.‌

Harlan Krumholz: I’m not sure when America was healthy, but okay.‌

Howard Forman: Right, right. But we’ll make him healthy again anyway.‌

I’m going to focus on Robert F. Kennedy, Jr., and look, at 30,000 feet, his desire to see a world that is healthier, safer from adverse events, and free from the influence of corporate interest is noble. I don’t object to any of that.‌

And I do also think, as we talked about in the intro, I think skeptics have an important role in society and then governments. So when he asks legitimate questions, I sincerely want to give him the benefit of the doubt, but his questions are all too often predicated on anecdote or even worse, and they don’t really come across as questions. They’re more like leading statements. I’ll just give a brief sample of these.‌

He has recently questioned whether HIV causes AIDS. He has wondered aloud whether Wi-Fi—wireless—causes cancer. He has asked whether contaminated water has led to more children identifying as transgender. He has spoken about antidepressants causing school shootings, and he has recently questioned whether the SARS-CoV-2 virus might have been engineered to harm Blacks and Whites and spare Jews and Asians.‌

He seems less interested in answers. He continues to believe, for instance, that ivermectin and hydroxychloroquine are effective treatments for COVID-19. He has never stepped away from implying that many vaccines cause harm and particularly autism, and there is voluminous evidence to the contrary.‌

Again, to be clear and going back to our opening segment, you and I have spoken many times about “facts,” findings, and research studies that turn out to be wrong over time and evolving evidence that informs our recommendations as physicians.‌

But the pattern with RFK Jr. and other conspiracy theorists is that they don’t just ask questions agnostically. They ask the question in such a way as to imply that there is a vast effort to suppress something that they know is the truth. And that’s the danger, I think, in this current situation.‌

And he goes a step further and takes authoritarian steps and makes proclamations about what he will do if given the opportunity. This disturbs me even more, and it should disturb anyone, irrespective of party affiliation.‌

He’s already talked about firing hundreds of employees of the NIH and other health agencies, not because they don’t do a good job, but because they propagate answers that don’t align with his beliefs. He has talked about suing journal editors—and you’re a journal editor—and publishers if he feels they’re spreading misinformation or alternatively not publishing the data he thinks they should have published. He wants to force the removal of food products even when the evidence of their harm is lacking.‌

Look, I’m going to still take a step back from this. I don’t want to panic. I’m choosing to hope that cooler heads will prevail.‌

The campaign is over and governing is hard, and there are good reasons to ask questions, but only if you’re willing to surround yourself with trustworthy people who will tell you the truth even if it conflicts with your own biases. So while I’m not going to panic, I do hope, I am concerned, I’m going to watch carefully, and I’m going to count on the fact that the scientific community is going to remain resolute in answering questions and sticking by those answers.‌

Harlan Krumholz: Well, it’s reassuring you’re not going to panic because we need you to stand strong.‌

Here’s my question to you, which is... There are a lot of loony things that he has said, which are, to say “disturbing” is to understate them, really. He may indeed be the HHS secretary. So what’s your strategy?‌

I know that some people have reached out to you to somehow broker support for areas that you believe you can support or to push things that you think you can push.‌

We’re in a week, by the way, where Joe and Mika go... Mika Brzezinski and Joe Scarborough go and talk to Trump. They were calling him Hitler—‌

Howard Forman: Right.‌

Harlan Krumholz: ...and now they’re down in Mar-a-Lago talking to him.‌

Howard Forman: Right.‌

Harlan Krumholz: This is going to be the group in charge, assuming he makes it through maybe a recess appointment, I don’t know, but let’s say someone of his ilk, and in any case, it’s going to be someone that for which there are many issues potentially with regard to this. What’s your strategy? How do people who think that there are concerning views being expressed help both change to occur in positive ways but mitigate the potential harms?‌

Howard Forman: Right, so I think at the current moment, I feel strongly that he should not be secretary and I’ll continue to make the case to people about why I think there are better people, and by the way, there are people that you and I disagree with who I have much greater faith in these roles. Even if we disagree with them, even if they have a different lens to look at things, they’re at least scientifically based. If he becomes secretary, then my strategy changes at that point. Then my strategy is to acknowledge when he makes good moves, because he will make good moves. He will hopefully put together thoughtful committees to look at questions around food dyes and other additives and maybe answering questions that we haven’t asked properly.‌

I don’t want to dismiss anything he does just because it’s him. But at the same time, I also will highlight things when he’s taking positions that are not minority positions but are just overwhelmingly contrary to the evidence that exists at the time and hope for the best, hope that people will not be afraid to speak out when they have important facts to present.‌

Harlan Krumholz: Yeah. It’s such a mixed bag. For example, I think there should be more research into vaccines. Why not? We should be learning more about—‌

Howard Forman: That’s right.‌

Harlan Krumholz: ...that doesn’t mean we don’t understand the net benefit, but it’s about understanding these and other drugs and so forth, post-market surveillance. There’s lots of areas that we could be doing a lot better. He seems to be in favor of that. He does say these things that are frankly at odds with everything I know about science.‌

When your students are saying to you, if I get a chance to enter this administration, and there are people like this who may have those kinds of views, what do you recommend to them?‌

Howard Forman: Yeah. At a junior level, I recommend that if people want to take positions that I have no... I don’t think there’s a reason to object if you can think that you can have a positive change. If you think that the job you take is contrary your ethics, values, morals, then obviously, don’t take it. But in many jobs you’re doing good work and you’re supporting government, I have no objection to that.‌

I do think that there are certain positions where very quickly, if you’re higher up, and people have asked me about higher-up positions, if you’re higher up, very soon you’re going to be faced with being asked to say something or do something that is at odds with your personal beliefs, and at that point, you must be willing to say no, you must be willing to push back even though it means you’ll get fired almost immediately. And for some people that I know, they’re like, “Yeah, that’s okay with me. I’ll do it until I can’t do it. And I will know what that line is.”‌

Harlan Krumholz: Yeah. The one thing I’ll say is that I have heard on the news a lot where people will say that, “Gee, this person is just going to do just what Trump wants. They’re not going to stand up to him.” That can be for any of these positions, and they’re not going to push back on them. And I keep thinking, he’s president. He was elected. Actually, these positions are indeed to pursue the president’s agenda and policies.‌

Howard Forman: That’s right.‌

Harlan Krumholz: So I do think if people feel that they can do that, then they can go into government and have a good effect. If they feel, like you said, that these views or what’s likely to be asked of them is at odds with what they believe is right, then they probably shouldn’t enter government because they shouldn’t be entering government to fight the president. That’s not going to end well.‌

Howard Forman: That’s right.‌

Harlan Krumholz: It’s just a question whether or not they think that there are opportunities where... that there’s enough alignment in what’s going to be done that they can contribute.‌

Howard Forman: Just a reminder. In the first term, CDC could quibble with a lot of things but it was generally well run. CMS was very well run. NIH was well run. So it does not have to go down the drain here.‌

Harlan Krumholz: Well, let’s hope it doesn’t. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.‌

Howard Forman: So how did we do? To give us your feedback, keep the conversation going, email us at health.veritas@yale.edu or follow us on any social media, including Bluesky. And our guest today is on Bluesky and Harlan’s on Bluesky, and we’re using it a lot more right now.‌

Harlan Krumholz: I’m going to be learning more about Bluesky and trying to figure out because obviously, there are a lot of people who are now going to Bluesky and it should be in our portfolio.‌

And we do want to hear your feedback, any questions, your experiences, anything on the topics. If you’d like, rate us, review us. That helps people find us, and we always appreciate it.‌

Howard Forman: And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/EMBA.‌

Harlan Krumholz: Health & Veritas is produced by the Yale School of Management, Yale School of Public Health. Thanks to our researchers, Ines Gilles, Sophia Stumpf, Tobias Liu, and to our producer, Miranda Shafer, they are terrific. It’s such an honor to work with them every week.‌

Talk to you soon, Howie.‌

Howard Forman: Thanks very much, Harlan. Talk to you soon.‌