Vinay, Casey, and the Problem with Vibes-Based Politics
A reluctant essay on partisanship, health policy, and my own blind spots
The recent appointments of Dr. Casey Means and Dr. Vinay Prasad have revealed a deeper truth about American political discourse: many of us no longer respond to ideas themselves, but to the team presenting them. In addition, there’s increasing support for people and policies based more on affiliation than the substance of their ideas. I wanted to talk more about this…
Dr. Casey Means was recently named surgeon general. The social media response has been fascinating and has broken along party lines. The majority of the right is overjoyed, while the majority of the left is unhappy.
Some that support her are excited about her focus on diet, nutrition, exercise, reducing of environmental toxins and getting away from pharmaceuticals (“a pill for every ill”). She practices functional medicine, which emphasizes health promotion, clean eating, and physical activity over pharmaceuticals. But many just support her because of who appointed her.
Those that don’t support her have been focusing on her lack of formal credentials - she did not complete a medical residency, she has no board certification and she practices “functional medicine” which many physicians feel is non-evidence based and not ready for prime time. They say functional medicine physicians recommend interventions like continuous glucose monitoring and avoidance of exposures of everyday products that are not based on evidence. In addition, many physicians are upset that she doesn’t have the usual credentials. Despite having supported nurses that became surgeons general, this specific physician without board certification is a bridge too far. Yet, many just oppose her because of who appointed her.
What is further fascinating is that the ideas themselves seem to have switched political parties! It was very “green” or “crunchy” to eat organic, avoid processed foods and to be anti-pharma. The very same people that used to make fun of this lifestyle are now becoming adherents or at least, supporters of it. The people that actually have lived this way for decades appear to be upset by her appointment. And, now, there are those on the right that are upset with her, as well, but it has nothing to do with her ideas about health and wellness.
Time and time again, administrations appoint “cookie-cutter” agency heads that are part of the revolving door between academia, government and industry. Dr. Means certainly has her own conflict of interests — she founded a company that markets CGM devices to be used in healthy people, promoted and sold supplements without evidence - but is this any worse than other recent appointees? Dr. Scott Gottlieb (former FDA head) was a consultant or board member for multiple pharma and biotech firms, including GlaxoSmithKline and Vertex Pharmaceuticals. After leaving government, he joined Pfizer. Radonc’s very own Dr. Steve Hahn (former head of FDA) was a CMO at the nation’s largest cancer hospital and forged many financial relationships with pharma. Dr. Vivek Murthy was appointed Surgeon General, but also was a co-founder and involved in the operations of TrialNetworks, a company that developed software and services to streamline clinical trial processes, yet there was limited concern about how this firm could influence federal research. None of these people have faced the same level of vitriol she has.
Vinay Prasad was recently appointed to a role at the FDA evaluating biologics. Personally, I find his communication style to be abrasive, provocative and in line with “own the libs”. He’s known for blocking critics and for a style that feels more combative than curious. He often appears to put his fingers into his ears when he hears something that contradicts his own views. While I don’t view him as an intellectual in the traditional sense—someone who welcomes complexity and adapts in response to new information—I also recognize that this particular role may not require that type of intellectual flexibility. This is just not a strength of his, but I think it is possible adapt over time. This isn’t a role that demands creative problem-solving or intellectual fluidity—it’s more about technical competence and regulatory rigor. He has been given a bureaucratic position, and when viewed through that lens, his appointment makes more sense. His career has focused heavily on critically analyzing clinical trials, regulatory standards, and the incentives that shape oncology drug development. In that domain, few people are as prolific or as willing to ask hard questions. His critiques of surrogate endpoints, financial conflicts in medicine, and inflated drug prices resonate with many oncologists and health economists.
It does not help that his politics differ substantially from mine. But, this is a job for a medically trained bureaucrat that sees the world as black and white, with limited ability to see gray. It requires someone with no or limited ties to industry and someone who is immune to external criticism. This is not an insult veiled as a compliment. He feels that our clinical trial endpoints are terrible, that there is too much profit incentive for pharma and for clinicians, as well as investigators. There are few people in oncology that disagree with this take. Yes, he has said things that are probably out of line or even incorrect, he picks fights for no reason and he blocks people indiscriminately.
(I even had my own minor run-in with him. Several years ago, I had complimented his accomplishments and tweets regarding oncology drugs. But, then I boosted a quite funny Vinay parody account. He DM’d me complaining about this. Then, I was blocked.)
The world has changed. He is 42 and he is EXTREMELY ONLINE, similar to many millennials. I don’t like what or how he tweets, but I also despise looking at someone’s social media to determine who they are as a human being. His book Malignant raises important concerns about the “pharma-oncology industrial complex,” surrogate endpoints, and the cost-benefit imbalance in many cancer therapies. These are not fringe ideas—they’re widely shared concerns among clinicians who care about evidence-based, patient-centered care. Despite his outward “right shift,” these specific ideas should not be considered partisan.
Tyler Cowen has described these reactions to ideas as “mood affiliation” - the tendency of people to adopt beliefs or make arguments not based on evidence or logic, but because those beliefs feel emotionally congruent with their mood, values, or identity:
It seems to me that people are first choosing a mood or attitude, and then finding the disparate views which match to that mood and, to themselves, justifying those views by the mood. I call this the “fallacy of mood affiliation,” and it is one of the most underreported fallacies in human reasoning. (In the context of economic growth debates, the underlying mood is often “optimism” or “pessimism” per se and then a bunch of ought-to-be-independent views fall out from the chosen mood.)
This is not “one side is the problem” but it also isn’t “everyone else is stupid except me”. I am guilty of it, too. I lean left and find myself irritated with certain proposals that I would likely support if my team was doing it. As a recent example, as someone who is a high earner but also very grateful about what America has given me, I tend to be okay with higher taxes on higher earners. My thinking has been - “I have received so much from this country and experience a wonderful life, so it is okay to contribute a little more.” Now that the current administration is discussing raising the highest rate back to pre-2017 levels, I reactively felt that this was wrong - that I already pay more than my fair share, that the wealthy already contribute too much. It took a moment to remember that going from 37 to 39% on the marginal rate is not going to affect me meaningfully and that if it helps middle income people keep more of their money, I should be okay with it. I also study integrative medicine and Dr. Means views on nutrition, exercise and toxins align with my views, yet I experienced a visceral response to her appointment due to her association with particular people.
This is not just in health policy - the party that was anti-tariff is now in favor of tariffs for everything. The party that was pro-tariff is decrying Liberation Day and saying we are headed towards recession and possibly end times. The party that was pro-TikTok a few years ago now wants to save it. The party that stated “the era of Big Government is over” and initiated government efficiency programs during from 1992 to 2016 now no longer feel that way and feel DOGE is an incoherent wrecking ball. The party that has complained about free speech restrictions due to “wokeness” now is instituting it’s own restrictions on free speech by limiting protests, changing historic names and chilling discussion about race, gender and other identity variables.
There is a very small sliver of the population left that adheres to ideology. It appears that the vast majority now behave tribally - or, to use a sports example, cheer for those wearing the right jerseys, even though they were formally despised rivals. Instead of using logic, rational thinking, people are now relying on emotion. I know I am not going to be able to change this, but hopefully some of you will keep this in the back of your mind when critically assessing ideas, separating them from who is saying them.
I have no idea how this will all pan out. I have significant doubt that Americans will suddenly be more conscious about diet and exercise. This information is not new and is not hard to believe. If one person can make the American people mindful about what they eat and to get them to engage in 150 minutes of moderate intensity exercise per week, that would be amazing, but I am not holding my breath. I have significant doubt that pharma’s influence will wane and the “revolving door” between industry and government is not closing any time soon. Does Vinay have biases that may be in conflict with what I feel is the best policy for biologics? Sure. But, have prior appointees also had biases that affect policy? Abso-freakin-lutely. Even if I find both of the appointees personally not to my liking and a bit too “MAGA Warrior” for my tastes, I think they are just as appropriate as other people that may have been considered and I don’t understand the hysteria against them … or, for that matter, the euphoric celebration of appointing a bureaucrat.
So yeah, I don’t expect a national diet and exercise revolution, nor do I believe pharma’s influence will vanish. But these appointees reflect genuine critiques worth engaging. Instead of fixating on tribal signals, let’s evaluate their evidence, ideas, and track records—not their vibes, affiliations, or hashtags.
Love you all,
Sim
I like this one! As far as national diet and exercise...I wish we could figure out how to get people to do hard things, because changing your diet and exercise are hard things. So is thinking critically 🙃