MAHA, Medicalization, Karma, and Control

The Make America Healthy Again movement (MAHA) wants Americans to be concerned about medicalization. The MAHA report released earlier this year specifically focuses on the overmedicalization of children, but it’s clear from their communications and other statements by HHS Secretary Robert F. Kennedy, Jr. that medicalization is a problem for all Americans.  The report describes quite accurately that pharmaceutical companies have undue influence on medical providers, particularly when it comes to prescribing drugs for children: “The distortion and influence of medical education, medical knowledge, and therefore clinical guidelines and practice, has led providers to over-diagnose and over-prescribe, and over-use by children, while largely ignoring the potential population-level impact of diet, lifestyle, and environment as focal points for health, healing, and wellness.” While their sentence construction could use a little smoothing out, the research they marshal to make their point absolutely supports their conclusion: for decades, pharmaceutical companies have used slick advertising and massive piles of cash to influence how healthcare providers write prescriptions. In America, this has led to rates of prescription for drugs like amphetamines for ADHD that dwarf comparable developed nations.

It’s not just psychiatric medications for kids:. Even before Trump won the 2024 election, now-Health and Human Services Secretary Robert F. Kennedy Jr. was obsessed with the idea that doctors need to learn more about nutrition in medical school and wanted to threaten schools with the loss of federal funding if they did not increase curriculum time dedicated to nutrition. MAHA wants Americans to stop eating garbage and start exercising more because it’s clear that these negative health behaviors contribute to chronic “lifestyle” diseases like hypertension and diabetes. One possibility that RFK Jr. has suggested is that doctors’ rush to use pills for things that could be cured by diet and exercise is making the problem worse.

However, the overaggressive use of pills for psychiatric problems and lifestyle diseases is just one facet of medicalization. (Even the word “caused” is not entirely accurate here, as bad health behaviors will raise the risk of such diseases and an early death, but there has never been a perfect correspondence between the two.) Medicalization isn’t just about coming up with new diagnoses like Restless Legs Syndrome or trying to convince everyone who feels a little nervous speaking in front of people to “talk to your doctor about whether Paxil is right for your Social Anxiety Disorder.” As Peter Conrad writes in his book The Medicalization of Society, medicalization is “a process by which nonmedical problems become defined and treated as medical problems, usually in terms of illness and disorders.” The problem isn’t just Big Pharma’s skulduggery—such malfeasance is merely the visible tip of the iceberg for a deeper cultural and social problem where we define any possible problem in terms of medical diagnoses so that we can be treated by experts. As Ivan Illich warned us in his prophetic 1978 book Medical Nemesis, such medicalization opens the door to iatrogenesis—the harms caused by medicine itself.

Most MAHA advocates are familiar with the idea of iatrogenesis—resistance to vaccines, for example, is primarily a desire to avoid potential iatrogenic harm because vaccines do carry a risk of side effects, including some very dangerous side effects. I myself nearly died because of one such vaccine side effect. MAHA recognizes quite rightly that allopathic medicine (the institutions of mainstream medical practice) is full of hidden dangers that are obscured by a desire to help and that sometimes the cure is worse than the disease.

The problem with MAHA is that it treats all chronic diseases as if they can be fixed with health behaviors and casts blame on simple villains that can be vanquished with the right top-down policies. Even though it wants to push back against medicalization, many of its solutions are either insufficient or making the problem worse by contributing to medicalization. Rather than creating a milieu in which diagnostic inflation is rebuked and “expert” busybodies stop telling everyone what to do, MAHA is simply adding more potential diagnoses and treatments in a crunchy-coded quest for health and substituting their own experts to rule over everyone in the name of “health.” By over-emphasizing things we can control in order to promote our own health, MAHA feeds a medicalized desire to control everything in life.

Fallible Doctors and the Dangers of Medicalization

The meteoric rise in doctors’ social status over the past few centuries was the result of scientific breakthroughs in the late 19th and early 20th centuries that helped transform medicine into what historian Paul Starr calls “the rise of a sovereign profession.” Illnesses that killed or crippled our ancestors can be cured with a few pills or a simple surgery; such miracles led society to treat doctors more like priests than most of us would like to admit. However, not all problems are vanquished as easily as pneumonia or obstructed labor.

The priestly power and social status has gone to the heads of doctors and other health authorities, who have come to relish the opportunity to treat any possible problem as a matter of “health” that can then be acted upon even as the number of problems that are susceptible to technological solutions have diminished. The more aspects of our lives that are medicalized, the more holes we find in medicine’s grand edifice. Conquering infectious diseases and maladies susceptible to surgery has left us with countless chronic diseases. Many of these can be treated with various drugs and other interventions, but some remain devilishly resistant to technological solutions and many others are managed because doing so reduces the risk of big, nasty events like strokes or heart attacks that we are trying to prevent. It's hard for medicine to keep up the same pretensions to priesthood, for Jesus never said to anyone, “Go, for your 10-year risk of a major cardiovascular event has now been reduced from 16% to 9%.”

Even more perplexing are the chronic illnesses that cannot be straightforwardly diagnosed and treated. Some of them are more easily categorized and treated within allopathic medicine and others are decidedly not. There’s one for nearly every organ system: pseudoseizures, chronic fatigue syndrome, Irritable Bowel Syndrome, chronic Lyme disease, fibromyalgia, mast cell activation syndrome, and the new kid on the block, Long Covid. The vast majority of the time, the standard battery of blood tests and imaging studies are normal in these conditions. MAHA offers sufferers an explanatory frame—it’s the medical system itself, alongside of the many environmental toxins our children are exposed to—as well as a variety of solutions.

MAHA is appealing in no small part because it points out that there are, in fact, downsides to medicalizing all of life. The movement also likes to emphasize the truth that a healthy diet and regular exercise are good at both preventing and treating an enormous number of chronic conditions that ail us. MAHA simply wants people to embrace this truth and avoid giving people medications for things that diet and exercise could cure, while also investigating the dangers of things like environmental toxins and ultra-processed foods. Thus, the ascendance of MAHA is a rebuke to the over-medicalized world and the arrogant health authorities who sought to control our lives while wearing the priestly garb of the white coat.

Misguided Solutions

However, many of MAHA’s solutions are either unhelpful or contribute to medicalization—in no small part because they overestimate the power that their control could effect. A movement as diffuse as MAHA is difficult to pin down, so this essay will limit itself to the official pronouncements through the Department of Health and Human Services and things that RFK Jr., the man who attempted to trademark the phrase, has said. There are a few proposals in the MAHA report that deserve unqualified praise because they will directly address a contributor to medicalization, such as banning direct-to-consumer pharmaceutical advertising. The MAHA pitch in its simplest form—get people to engage in healthier behaviors—is also a good thing.

Some of MAHA’s danger is due to sheer incompetence and scientific ignorance. For example, you can tell that the original executive order establishing MAHA was written in part by a terminally online dilettante because it mentions selective serotonin reuptake inhibitors, antipsychotics, mood stabilizers, stimulants, and weight-loss drugs but does not mention other classes of psychiatric medications like benzodiazepines, which are second only to opioids in the number of overdose deaths yearly. The original MAHA report was also notable for its AI-hallucinated fake citations that, as far as I know, resulted in zero disciplinary consequences for the people who failed to check them before publication. Getting artificial dyes out of Froot Loops and high-fructose corn syrup out of Coca-Cola are the land acknowledgements of public health—a symbolic gesture that means nothing to our collective problems of nutrition as long as people are still consuming too many empty carbohydrates.

Other ideas are similarly thin on value and heavy on medicalization. RFK Jr. told Congress that he wants all Americans using “wearable” devices that monitor values like heart rate or blood glucose. Besides the major concerns about privacy,  the idea that one’s day-to-day life ought to be surveilled and analyzed using technology is about as extreme an example of medicalization as we can get. Constantly monitoring these values does not have clear health benefits for healthy people (their benefits are primarily for people who are already ill and they are usually adaptations of devices like glucose monitors that have already been on the market for years), which means that promoting the use of such devices is pushing people to put more of their lives into the panopticon of “health.”

MAHA supposes that doctors jump to prescribing pills for diseases like hypertension and diabetes because they have been brainwashed by Big Pharma, but this is only half the story at best: if doctors are quick to prescribe drugs for problems that might benefit from lifestyle modifications, it’s because patients themselves are uninterested in being told what to do by their doctors. Nutrition advice delivered by doctors has not been demonstrated to be especially effective, and the patients who are most in need of dietary changes are usually the least likely to listen to their doctors. The idea that doctors might effectively harangue their patients about what they eat more effectively if they had more nutrition knowledge is thoroughly soaked in the worldview of medicalization, seeing an individual’s behaviors through the lens of the care they receive in 15-minute doctor’s visits.

Some of this is simply a mismatch between populations, as there’s a huge discrepancy in agency between the average MAHA enthusiast and the people who are suffering the most profoundly in our chronic disease epidemic. The former want to control their lives, perhaps a little too much, while the latter lack agency to make any positive changes for themselves. Their poor diet and lack of exercise are just one facet of their disordered, chaotic lives and their interactions with the healthcare system tend to be very expensive and minimally helpful. 

Changing a population’s health habits has long resisted top-down, bureaucratic solutions and the current HHS is no better prepared than previous administrations to crack the problem. Ultra-processed foods are ubiquitous because they taste good and producing large quantities of them is cheap and easy. People do not walk as much as they should because our lives are designed around driving everywhere and screens are constantly encouraging us to be more sedentary. Cultural, social, and policy changes are necessary if we want to see things change—but they have to be the right changes.

It has been noted many times that if a pharmaceutical company could somehow cram the medical benefits of diet and exercise into a daily pill, our society would spend billions on that drug (interestingly enough, Ozempic and other GLP-1 agonists are the closest thing to such a pill, which is why the developed world is going nuts for them.) A public figure (or even a doctor) can pontificate all day long about the dangers of ultra-processed foods and lazing about in front of a screen all day, but people rarely change their behavior as a result of authoritative pontification. Taxing unhealthy food and drinks seems to have some effect on their consumption, but such taxes tend to be unpopular politically and the MAHA report does not even mention the possibility of such taxes.

The recent budget bill cuts food assistance for the poorest Americans as well as billions in Medicaid spending. If MAHA really wants SNAP recipients to get “MAHA boxes” of fresh vegetables, healthier school lunches, or better food in hospitals, the government will have to spend more money on them. Taxing junk food and building more walkable cities are probably the most concrete policy options that will produce results, but they are not especially popular among the Republican base. A Presidential administration that is unwilling to enforce a ban on TikTok that Congress voted for is unlikely to do anything else to reduce children’s screen time.

No Guarantees When it Comes to Health

Any cultural movement that gets people to eat healthy food and exercise more is worth encouraging, for health behaviors are closely linked to various diseases and health outcomes. The question is how closely are they linked. The same goes for environmental toxins—we know that breathing polluted air or drinking contaminated water can cause certain illnesses. We don’t always know what percentage of illnesses are attributable to toxins and what percentage would have happened in a perfectly pure environment.

Every health care professional remembers the man who jogged 5 miles every morning and never touched a Twinkie in his life but still died of a heart attack at age 53. They also regularly meet 80-year-olds who have subsisted on a steady diet of cigarettes and potato chips for decades and yet don’t seem to suffer for their irresponsible decisions. MAHA takes a true statement—healthy behaviors decrease your chances of getting sick—and turns it into a karmic worldview that people who get sick must have done something wrong.

The other possibility in the MAHA worldview is that something wrong must have been done to the sick person through environmental exposure. There are real concerns about things we don’t know enough about like microplastics, and perhaps actions like banning certain food dyes might marginally decrease the rates of certain illnesses. (I hope that MAHA wins the fight against deregulating certain chemical pollutants, but they’ve got an uphill battle.) Yet most of these policy changes aren’t going to have a huge effect on Americans’ health because the environmental exposures themselves tend to have relatively small effects in the first place.

Medicalization took root in no small part because we want to prevent illness and be healthier. That’s a good goal, but MAHA takes it further by assuming that there must be a preventable “root cause” to all or most illnesses. Such an assumption is certainly consistent with RFK Jr.’s advocacy for “miasma theory” that views all disease as the result of failures in nutrition. (It has not been clarified whether or not he disbelieves entirely in germ theory, but the evidence suggests that he does not.) At times, the MAHA worldview sounds like a nutritional-medicinal Prosperity Gospel: only the bad people who put bad things into their bodies get sick.

The recent declaration about Tylenol’s associations with autism is a perfect example of making medicalization worse through this obsession with root causes. While the evidence base for RFK Jr.’s claims about acetaminophen are thin, the announcement has the potential to induce enormous amounts of fear in pregnant women about the safest pain reliever available to them. Pregnant women are already overburdened with recommendations about things to avoid in order to reduce their risks of rare but catastrophic outcomes; adding Tylenol to the list only makes a natural process that requires minimal surveillance in order to have a healthy baby into a period of intense medical scrutiny. Assuming that pregnant women must act perfectly in order to have a healthy child is one of the worst ways that medicalization is making people unnecessarily anxious with little benefit to the population as a whole.

Neurologist Suzanne O’Sullivan writes: “We are not getting sicker—we are attributing more to sickness.” RFK Jr. has spoken about his concerns with rising rates of autism for years and is eager to find causes for this rise. However, he does not seem to entertain the possibility that rates of autism are on the rise because the diagnostic criteria for autism have been significantly broadened and more adults have been encouraged to self-diagnose. By encouraging people to view their own experiences and the experiences of their children through a medicalized lens and directly correlate these diagnoses with external causes, this obsession makes our medicalization problem far worse.

Going back to the chronic illnesses that defy traditional medical explanation, it is clear that many of them are what Dr. Peter Robinson calls software problems that look like hardware problems. Emphasizing the widespread nature of our “chronic disease epidemic” only encourages people to view symptoms that might otherwise be attributable to transient stress as evidence of environmental toxins, food dyes, or vaccine injuries. O’Sullivan has marshaled research in her book The Age of Diagnosis to demonstrate that patients will conform their symptoms to whatever diagnosis they are given and can even become sicker once their symptoms have a name and a label. 

If every aspect of our health is controllable, every sickness becomes a personal failing—or a nefarious consequence of corporate greed that fills our bodies with illness-inducing toxins. This worldview is bad for us because while it may encourage people to act wisely in regards to their bodies, it ignores the reality that some illnesses aren’t preventable and some “root causes” are inscrutable. This makes health a matter of control, measurement, judgment, and shame rather than a gift that we steward.

Modifying MAHA

The federal government does have responsibilities towards the health of its citizens, although one of the more dangerous ideas floating around these days is the impulse to find as many possible opportunities for the government to control our health. While there are certainly nudges that the government can put into place and areas where Big Pharma’s corruption ought to be cleansed, the first step in making Americans healthier is to surrender the notion that all root causes can be found and expunged and the impulse to believe that the right policy will make people start eating healthier and exercising. A wise ruler will recognize the limits of what his power can accomplish, and few things are more foolish than thinking that the elimination of certain root causes is just a matter of political will.

MAHA’s strength as a cultural movement, then, is worth deconstructing and then putting back together. People should be encouraged to believe that they can take responsibility for healthy behaviors without believing that healthy behaviors alone will determine their body’s destiny. Good food may be critical to our health but, as farmer Garth Brown puts it, is not magic. If RFK Jr. really wants to tell people important truths that they don’t want to hear, he should start by telling Americans that our dependence on cars makes us less likely to walk everywhere and that sin taxes on junk food are probably the best that the government can do when it comes to eating well.

I would also like to see our current HHS secretary give up his obsession with doctors delivering nutrition advice. If we are going to have professionals telling people what to eat, why not pay for community health workers and nutritionists in communities that need them the most? The story of Sam Runyon, a community health nurse working in West Virginia, illustrates just how dire some patients’ stories are and the sort of long-term relationships that are necessary to help people live healthier lives. It would also be great for HHS to figure out how to ensure more continuity in general so that people can develop a relationship with a primary care provider that’s right for them.

In my work as a doctor, I am constantly tugging individuals in one direction or another when it comes to their health. In Room 1, I meet someone who needs to be told that they can, in fact, make better choices and decrease their likelihood of chronic illness and death. In Room 2, I am helping someone else make peace with a diagnosis that will be lifelong—and perhaps the life they have remaining will be short. In Room 3, I am trying to convince someone that, despite their best efforts, their disease has progressed to the point where they need pills (or injections) in order to survive. A healthcare system that does not recognize each of these stories and provide solutions for the individuals they describe is bound to leave people floundering in sickness.

Gage Skidmore, CC BY-SA 4.0, via Wikimedia Commons