Malcolm Gladwell on trust in medicine and the devaluing of primary care

This week I’m back in Washington DC, attending and presenting educational sessions at the American Academy of Family Physicians FMX (Family Medicine Experience), the first in-person version of this conference since 2019. For me the highlight of this conference is usually the invited celebrity speaker, someone with an inspirational story outside of medicine: past speakers have included political pundits Mary Matalin and James Carville and Aron Ralston, who survived a canyoneering accident in which he had to cut off his own arm to save his life. But this year’s speaker, the author and podcaster Malcolm Gladwell, topped them all. I’ve been a huge Gladwell fan since I read The Tipping Point, avidly listen to his Revisionist History podcast (and featured a past episode on philanthropy on this blog), and couldn’t wait to hear what he had to say yesterday to an audience of family physicians who have spent the past two plus years fighting pandemic misinformation.

The theme of his talk was that the decline in trust in medicine and public health that has manifested as tenacious resistance to Covid vaccination among certain demographics and/or areas of the country may have less to do with true anti-science sentiment and more to do with people having a hard time adjusting to strange new things. He shared several examples of this phenomenon in other fields: focus groups panning pilots of television sitcoms that ended up becoming classics (e.g., the Mary Tyler Moore Show, All In The Family, Cheers, and Seinfeld); the near rejection of the prototype of a mesh office chair that ended up earning billions of dollars for its inventor; and the Marines transforming its service from the misfits of the U.S. military to “the Few, the Proud” elite branch that we know today. Gladwell noted that trust in a profession doesn’t always correlate with its effectiveness, and that pouring billions of dollars into amazing technological solutions to the pandemic (vaccines and antiviral treatments) while neglecting to support the family doctors whose job it is to persuade patients, based on preexisting trusting relationships, to accept these medical innovations was “nuts.” (I made a similar point in an editorialĀ in the Annals of Family Medicine last year). It’s no wonder that many of our patients turned to the well established – but totally ineffective – drugs hydroxychloroquine and ivermectin instead.

Public health holds many stories of initial mistrust in effective interventions. Gladwell talked about how despite clear evidence showing that supplementing water or salt with iodine eliminated goiter, there was widespread public resistance to the idea (“I’ll take my chances with the goiter”). The same thing happened when health officials proposed adding fluoride to water to prevent dental caries. This time, though, one official got clever and announced that fluoride would be added to the municipal water supply on a certain date, then when numerous people experienced adverse effects from drinking water on that date, mentioned that he had actually delayed the date but forgotten to tell anyone. So there is reason to hope that one day, receiving annual flu and Covid-19 vaccines will be less about one’s partisan allegiances and more about following your doctor’s common sense recommendation to protect yourself and others against severe illness and death.

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