Is Medical Research One More Victim of Cancel Culture?

BOOK REVIEW

Blind Spots: When Medicine Gets It Wrong and What it Means for Our Health

Marty Makary, MD; Bloomsbury Publishing, 2024

288 pages; $23 (hardcover)

Reviewed by Dinah Miller, MD

The public health messaging around the COVID-19 pandemic made us all too aware that medical recommendations sometimes move faster than research, and the medical establishment is not immune from the politicization and polarization that impacts so much of society. With the pandemic still visible from our windshields, this is a perfect time for Marty Makary, MD’s new bestseller, Blind Spots: When Medicine Gets It Wrong and What it Means for Our Health.¹

It is interesting, Makary notes, that other countries do not have the prevalence of peanut allergies that we see in the United States. In fact, they are unheard of in Africa where infants are fed peanut soup. In response to the increasing awareness of peanut allergies, the American Academy of Pediatricians (AAP) issued a recommendation that pregnant and breastfeeding women, as well as infants and children under the age of 3, should eat no peanuts. Avoidance was assumed to be the key to preventing allergies. This was in the year 2000 and in subsequent years our rates of peanut allergies soared. The troublesome part of this dictate was that there were no studies to support it. Evidence-based medicine be damned, the recommendation had no data. Simple studies down the line showed that very early exposure to small amounts of peanut products actually prevented peanut allergies. In 2015, the AAP changed their recommendations—let them eat peanuts—and science prevailed.

Makary goes through example after example where medicine got it wrong. There was a time when postmenopausal women were being encouraged, even pushed, to use hormone replacement therapy (HRT): good for the heart, brains, bones, and one’s sex life. And then the Women’s Health Initiative (WHI), a large multi-center study with 16,608 women who were randomized to different combinations of hormone replacements, was ground to a halt when women who were receiving HRT were found to have an increased rate of breast cancer. Anyone who was practicing medicine (or taking HRT) during this time is well aware of the shift in treatment recommendations.

Makary relates the fascinating and very disturbing story of how this happened. It was June of 2002 in Chicago and the 40 primary investigators from each site of the WHI trials gathered for a regularly scheduled meeting. As the meeting began, the group was informed that the study’s leaders had determined that HRT was causing breast cancer and the trials needed to be stopped. The results had already been written up and accepted by the Journal of the Medical Medical Association (JAMA). Proof copies were distributed, the researchers were given minutes to read it, and less than 2 hours to make revisions. The revisions did not make it to JAMA on time that day; the journal had already gone to print. And the shocking thing, Makary tells the reader, is that the data did not reach statistical significance! He tracks what happens to the careers of those who were involved and makes a case that HRT should be started in most women.

In subsequent chapters, Makary shares that silicone breast implants were pulled from the market by the US Food and Drug Administration because of a purported link to autoimmune conditions. This allegation was eventually dispelled by studies done later, but not before years of litigation changed our medico-legal environment and caused many women to have their implants unnecessarily removed. The Food Pyramid and its recommendation for a low-fat, carbohydrate-rich diet led to a rise in obesity. Childbirth has been medicalized to a detrimental degree, so that babies were taken from their mothers. There was no clear science behind this practice and skin-to-skin contact with the mother proved to yield better outcomes.

Makary writes about “groupthink”—the idea that it is difficult to buck the establishment. Academia is described as a land of cancel culture where scientists can be shunned, and even fired, for challenging the status quo. Finally, Makary questions some of the things we take for granted—that fluoridated water is good for us, that cancer screening saves lives, that fevers should be treated with Tylenol.

Blind Spots is an easy and compelling read, meant to open the eyes of the public and reveal the flaws in our medical mindset. Books written for the public often have a sensational tone, and Blind Spots is no exception. My tendency is to read books of this genre with a bit of skepticism.

Makary has ideas about what treatments we should be providing, ones he backs with studies. He is an unabashed proponent of HRT, even though the most recent review of the WHI trials published in JAMA in May 2024 do not support routine hormone replacement for postmenopausal women—they recommend the smallest does needed to address postmenopausal symptoms.² He presents compelling evidence for a microbiome that is impacted by antibiotics, yet the studies he cites are correlational. With regard to many of the topics he takes on, contradictory findings get reported in the lay press so often that it is like watching a ping pong match. It is no wonder that both practicing clinicians and the public are confused, and that there are thriving communities of alternative practitioners.

Finally, Makary is tough on the medical profession. He divides his views into right and wrong, and gives many examples of wonderful, innovative treatments—starting with the finding that citrus fruits treat scurvy and ending with mRNA vaccines—that were met with anger and scorn. These things are easier to see in retrospect once we have conclusive answers, yet there are many new ideas that are proposed. It is not possible to research every new idea nor every old assumption we have taken for granted. Still, we are not doing it all wrong, people are living longer and healthier lives, and I am not sure a reader would know this from reading Blind Spots.

The book had me thinking about the assumptions we make in psychiatry. Makary mentions the debate around gender affirming care and the consequences to researchers who have reported unpopular findings. There are many other areas of psychiatry where these issues are salient. Antidepressants and psychotherapy are more available than they ever were, and yet our suicide rates have steadily climbed, as have our rates of depression. Are black box warnings helpful, or do they deter clinicians from prescribing helpful treatments? Is psychedelic medicine a new hope for sustained treatment without the risks of on-going medications? Is there any way to do unbiased, placebo-controlled studies to get definitive answers about their utility? And why do individuals with serious mental disorders have shorter life spans? Is it the ravages of untreated disease or are our treatments leaving patients more susceptible to early deaths (or some combination)? What is causing the surge in autism spectrum disorders and are we doing enough to uncover the etiology? There are more questions for psychiatry, but this is my start.

Despite my skepticism, Blind Spots gets 5 stars from me—I learned a great deal and at moments I felt like I had just crawled out of a cave. The behind-the-scenes revelations about health recommendations that have changed our way of life is astounding. The take home messages are excellent: question our assumptions, look at the raw data, open our minds and our funding to innovation. It is quick, compelling, and something all clinicians will want to read. Blind Spots makes a strong argument for holding off on medical recommendations and owning up to what we just do not know. Medicine does not like to do this.

References

1. Makary M. Blind Spots: When Medicine Gets It Wrong and What it Means for Our Health. Bloomsbury Publishing; 2024.

2. Manson JE, Crandall CJ, Rossouw JE, et al. The women’s health initiative randomized trials and clinical practice. JAMA. Published online May 1, 2024.