After 15 years of SBM: Lessons learned and what the future holds

It shocked me to realize this weekend as I sat down with my laptop to compose this post that it will (probably) be my last SBM post of 2022. Dr. Steve Novella’s post last week also reminded me that this blog is fast approaching its 15-year anniversary. That’s right. On January 1, 2008, Steve introduced the blog with a post entitled, simply enough, Announcing the Science-Based Medicine Blog. He then followed up the next day with a post about the false dichotomy between plant-based medicine and pharmaceuticals to address a common trope that somehow “natural” (i.e., plant-based) medicine is better than purified pharmaceuticals. Next up, Dr. Kimball Atwood, now retired from practice and blogging, introduced concepts with which our readers have become familiar, namely how randomized controlled clinical trials (RCTs) of homeopathy reveal the shortcomings of evidence-based medicine (EBM). Indeed, it is an example that we’ve also come back to again and again of modality that is totally implausible if not outright impossible from a basic science standpoint to undergird our our central argument that prior plausibility rooted in basic science and prior scientific evidence must inform clinical data because what happens when that isn’t the case and “pure” EBM is used is “complementary and alternative medicine” (CAM), which was rebranded as “integrative medicine,” and, more recently, “integrative health.” What happens is quackademic medicine, in which ostensibly science-based academic institutions like the Cleveland Clinic and UCSF embrace “integrating” quackery like acupuncture, naturopathy, and homeopathy into medicine and, as Steve put it, the exploitation of EBM to promote a worthless treatment based on unscientific notions. Such were the main concerns of this blog in the early years.

Although I cringed a bit when I reread the post, I first introduced myself on this blog, I chose to riff on a memorable quote from Admiral James Stockdale, Ross Perot’s running mate who famously introduced himself during the first 1992 Vice Presidential debate with, “Who am I? Why am I here?” The reason was that, at the time, I was largely unknown under my real name, although I had built a blog following on my not-so-secret other blog. Fifteen years on, I’m in some ways not much better known and in others too well known, having, like nearly everyone on SBM, endured intermittent attacks from quacks and antivaxxers, including threats of lawsuits and even a couple of lawsuits, one against Steve and one against several editors, including retired ones. Truth be told, I still sometimes feel like that unknown pseudonymous blogger who was invited 15 years ago to join this enterprise. But I’m not. Not anymore. Not after 15 years. After 15 years of dealing with medical misinformation, I sometimes feel like Aragorn at the Black Gate of Mordor in The Lord of the Rings. But I continue, and I hope to rouse the troops, metaphorically.

No, we’re not Aragorn, but we do want to rouse the troops to go into what seems like a hopeless battle.

Now I’m ostensibly the managing editor of SBM. (I say “ostensibly” because in practice I rarely do much actual editing, at least not of any of the regular bloggers (particularly the remaining founders of SBM, such as Drs. Harriet Hall and Steve Novella) and now primarily restrict myself to choosing and editing guest posts. More on that later.) In that role, I’d be lying if I were to claim that the landscape with respect to science and medicine has improved since we first started this quixotic effort in 2008. Now is as good a time as any for me to look back and forward. Steve concentrated mainly on what SBM is, what we’ve accomplished, and what’s next. I’m going to contrast more on lessons learned, particularly from the pandemic, what I view as the single biggest challenge to SBM as a concept and a blog now, and some ideas on what to do next.

Successes in context

In his post last week, Steve outlined some successes of SBM, and I have to agree. First, there’s the sheer volume of what we have produced, with a new post (nearly) every weekday (and some weekends) for 15 years:

…we have published 4,328 articles covering just about every topic in the science of medicine. Hopefully we have at least added a useful voice to the much needed conversation surrounding how best to apply the latest science to the practice of medicine.

Indeed, I like to think of this as perhaps our greatest ongoing contribution and utility. Because a number of our posts have ranked high in Google searches of various topics, such as homeopathy and various antivaccine claims (the latter particularly true since the pandemic hit), SBM is now well-established and has become a resource for journalists looking for a science-based viewpoint for stories about various medical issues. So have our bloggers, whose commentary is featured in various news stories. Before SBM, I had never been contacted by a reporter to comment on a medical story. Now, while I wouldn’t say it’s common I can say that it’s not uncommon. Generally several times a year I’ll be asked to comment, and sometimes my pearls of wisdom even show up extensively in stories.

Still, I also have to agree with Steve when he wrote:

It is, of course, very difficult to assess the impact of SBM. There is no way to know what the world would have been like had we not engaged in this project. There is no controlled experiment. We must make due with anecdotal evidence. We frequently hear from practitioners who find our articles and our perspective useful in their practice, even changing how they practice medicine. We are often a resource for the media who would otherwise have only promotional or gullible voices on topics involving pseudoscience in medicine. And we hear from many health care consumers who were able to make a much more informed decision before turning to “alternative” interventions. I like to think we even influenced the FDA and FTC when they were reconsidering their regulation of homeopathy. We also engaged with the NIH regarding their funding of pseudoscientific research.

When it comes to influencing the FDA and CDC, I believe that Steve is probably correct, although it is important to note that SBM was alone in this effort. At various times, we did team up with the Center for Inquiry to submit comments to the relevant regulatory agencies. Even so, in particular I am proud how, as our only lawyer, routinely used to shine a light on the efforts of naturopaths and other practitioners of unscientific “medicine” to lobby state legislatures to license their pseudoscientific quackery, as well as her warning about “health freedom” bills long before they became a routine feature of the pandemic. For my part, I like to think that frequent posts by Jann and me about “right-to-try” bills (which I first likened to the movie Dallas Buyers’ Club), which emerged nearly nine years ago as a strategy to build momentum by passing “right to try” bills as state laws in order to build momentum to pass a federal law designed to weaken the FDA were prescient, even if ultimately right-to-try largely succeeded and was passed as a federal law, with the help of Sen. Ron Johnson, a name that has become very much synonymous with promoting COVID-19 misinformation and pseudoscience, as well as antivaccine legislation.

If I had to pick the single most important success of SBM it was coining and defining the term “science-based medicine” in the first place (I personally can’t take credit for that part) and introducing it into the discussion and hierarchy of medical evidence to point out how what we call the “blind spot” of EBM (i.e., prior plausibility based on basic science) and how that has been weaponized by quacks to produce not just the appearance that many unscientific, prescientific, and mystical modalities, such as acupuncture, homeopathy, reflexology, energy medicine, and the like, might actually work, but an entire pseudodiscipline of medicine, “integrative medicine.” As Mark Crislip, who this year rejoined the fold to blog for SBM after a prolonged absence, put it 11 years ago:

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

This brings us to the first lesson. The pandemic has taught us that SBM is useful for more than just approaching the claims of alternative and integrative medicine.

Ivermectin: SBM could have prevented this

There’s a line from an old song by The Clash that I now like to quote to the point of sometimes annoying readers. it comes from the 1980 song Something About England and goes:

“You really think it’s all new,””
“You really think about it too,””
The old man scoffed as he spoke to me,
“I’ll tell you a thing or two”

The rest of the song isn’t a perfect fit to the concept that I’m trying to get across about alternative medicine and the antivaccine movement, as the old man then lectures the young man singing about his life after World War I, during World War II, and how, for all the changes that “were to come,” certain things never change at their core. However, those lines describe perfectly how there is nothing new under the sun in antivax pseudoscience or quackery. Sure, there have been superficial changes in quackery and antivax messaging since COVID-19, such as the “clot shot,” mRNA “permanently altering your DNA,” and ivermectin as a cure “they” dont’ want you to know about, but none of these are, at their core, different from old antivax messaging: Vaccine kill, vaccines somehow permanently “alter” your very essence (a message that goes back to the 1800s); and there is a safe “miracle cure” that “they” don’t want you to know about.

Interestingly, Peter Moran, one of our longtime commenters whom I used to lionize for his advocacy against cancer quackery but who over the last decade or so has become very sympathetic to the claims of unscientific medicine, said something that I agreed with:

The HCO/Ivermectin episode was a blow-by-blow replay of all the factors that have given rise to CAM. That has never been a political partisan thing.

True, Peter buried that one gem of truth in a background of denying documented connections between various right-wing astroturf think tanks and the spread of ivermectin conspiracy theories and grift. I’ll discuss that later. First, though, Peter’s comment reminded me of two that I wrote earlier this year, the first in March, when I wrote a post entitled Ivermectin: The acupuncture of COVID-19 treatments, and the second in April and entitled Science-based medicine isn’t just for CAM. The case of ivermectin shows that it never was.

I’m not going to go into a lot of detail; you can read the posts if you want the nitty gritty. The Cliffs Notes version follows, however. The reason why the comparison came to me is because the reaction of those promoting ivermectin as a highly effective treatment—miracle cure, even—for COVID-19 reminded me strongly of the approach to evidence long demonstrated by advocates of “complementary and alternative medicine” (CAM)—or, as it’s now called, “integrative medicine” or “integrative health”—and especially by acupuncture advocates. Specifically, as more and more high-quality evidence from high quality RCTs failed to find a therapeutic effect for ivermectin for COVID-19, increasingly its advocates pointed to positive studies that are less rigorous, such as observational and uncontrolled clinical studies. This is, more or less, exactly what acupuncture advocates have been doing as more and more high-quality studies with appropriate sham acupuncture placebo groups fail to find a detectable benefit for acupuncture for treating anything.

Of course, I had to concede that ivermectin was not as implausible as acupuncture from a scientific standpoint. After all, acupuncture is based on the concept of altering the flow of “qi,” a magical mystical life force “energy,” by sticking needles into “meridians,” magical mystical pathways along which qi flows that have no detectable basis in human anatomy, in order to treat diseases. Ivermectin, on the other hand, is a drug that had demonstrable antiviral activity in cell culture against SARS-CoV-2, the coronavirus that causes COVID-19. So where does the implausibility come in? After all, the drug “worked” in cell culture? Doesn’t that mean that it might actually work in animal models and then in humans?

Yes and no. Here’s the rub. As this review article documents (and I discussed in both of my posts), the the IC50 (the concentration that produces 50{7b6cc35713332e03d34197859d8d439e4802eb556451407ffda280a51e3c41ac} of maximal inhibition of an activity) was in the 6 μM for ivermectin’s inhibition . Given that the molecular weight of ivermectin is 875 g/mol, 6 μM translates into ~5.25 mg/L or ~5.25 μg/ml, a concentration that is roughly 66-fold higher than the upper end of the range of blood levels of ivermectin safely achievable in a human’s bloodstream. Summarizing existing in vitro data, I wrote:

This is almost certainly the reason that ivermectin doesn’t work against COVID-19 in spite of its activity in vitro against SARS-CoV-2. It requires a concentration roughly 66- to 197-fold higher than is safely achievable in the blood. That’s why the review concluded that maybe an ivermectin analogue that is either more active or can achieve a higher concentration safely in the bloodstream is worth investigating. Based on the proposed mechanism in the Australian paper, ivermectin was never a good candidate as a treatment for SARS-CoV-2. As I discussed for the claim that ivermectin should be considered a promising drug for COVID-19 based on its protease inhibitor activity, the situation is just as bad. Again, based on in vitro results, ivermectin was never a promising candidate as an antiviral drug to treat COVID-19.

Or, as I put it more succinctly on Twitter:

Also:

As I elaborated, if ivermectin were to be actually useful against COVID-19, it would almost certainly have to work by a different molecular mechanism than the one described in the in vitro study cited because it’s known to be impossible to safely achieve ivermectin concentrations in human blood that are sufficient even to inhibit viral replication by 50{7b6cc35713332e03d34197859d8d439e4802eb556451407ffda280a51e3c41ac}. While one must always concede that it’s possible that such a previously unknown mechanism is operative, albeit highly unlikely. There is a caveat, however, and Steve stated that caveat well 12 years ago, “When the basic science dictates that a proposed treatment is highly implausible, the bar for clinical evidence should be raised proportionately.” In other words, to overcome a mechanistic bar as high as that of ivermectin in cell culture, you need some really pristine, bullet-proof clinical evidence, even more so for acupuncture. As I like to put it, a highly implausible mechanism of action for a treatment coupled with equivocal clinical studies equals a treatment that doesn’t work.

I like to think that SBM (the concept, not necessarily the blog) could, if invoked properly, prevented the waste of a lot of research money on ever larger RCTs of ivermectin for COVID19 that ended up, as I predicted that they almost certainly would be, negative. Of course, SBM probably would not have helped with another aspect of this problem, conspiracy theories.

Conspiracy theories über alles

Regular readers (and just anyone paying attention) certainly realize that one of the most intractable problems for SBM (or even just EBM) during the pandemic has been conspiracy theories. Indeed, they started early. The very first time I wrote about a COVID-19 conspiracy theory was in February 2020, when James Lyons-Weiler claimed to have “broken the coronavirus code.” (Hint: He had not.) Basically, the conspiracy theory was the same one that has followed every single epidemic of a new pathogen since there have been large labs, namely that Lyons-Weiler claimed to have found evidence that SARS-CoV-2 (which hadn’t even gotten its official “final” name then) had been engineered in a lab. This was a very early version of the same conspiracy theory that persists today, the “lab leak” conspiracy theory.

I bring this up because, if there’s one thing that I think SBM needs to be better eequipped to address and counter, it’s conspiracy theories. I once coined the term “central conspiracy theory of the antivaccine movement” way back in 2014. It’s a very simple conspiracy theory that leads to ever more complex variants. The simple version is that vaccines kill or harm by various means (and don’t work), but “they” don’t want you to know about it and cover it up. This is why I wasn’t too surprised that by May 2020 conspiracy theories about COVID-19 were flourishing. (Does anyone remember Plandemic? To me it now seems like ancient history, over two and a half years ago!) Indeed, ultimately during the pandemic Steve pointed out the threat of conspiratorial thinking to SBM, and I ultimately argued that not just antivaccine beliefs and quackery were largely based in conspiracy theories, but all science denial is a form of conspiracy theory.

What the pandemic has taught us at SBM is the power of conspiracy theories when weaponized against science and medicine, which Steve recognized nearly two years ago:

This phenomenon is nothing less than an existential threat, including to science and therefore SBM. But more broadly this is a threat to any notion of evidence, logic, facts, and reality. We need to take this threat seriously, and devote time and attention to figuring it out and mitigating it.

I’ve also come to the conclusion that we will not successfully mitigate science denial of the sort that has resulted in millions of potentially avoidable deaths from COVID-19 until we are able to understand conspiracy theories and develop effective strategies for countering them because, even if you do not accept the proposition that all science denial is a form of conspiracy theory, it is without a doubt true that all science denial relies at least in part on conspiracy theories to support it. As we’ve seen in the COVID-19 pandemic, the conspiracy theory of science denial can have deadly consequences, consequences that, once the pandemic finally abates, will become apparent as the earth’s climate continues to warm due to human activity.

Ideological misinformation, disinformation, and social media

We at SBM have always noted that there were ideological entities promoting quackery and its “integration” into medicine. One just has to point out our many posts about, for example, the Bravewell Collaborative, the Samueli Institute, and any number of wealthy donors contributing to fund centers and departments of integrative medicine at academic medical centers. Compared to what SBM has to deal with now, these groups seem almost quaint.

I’m referring, of course, to groups such as the American Institute for Economic Research (AIER), which birthed the Great Barrington Declaration, which in October 2020 basically proposed a “let ‘er rip” strategy for the pandemic, with little or no mitigation to the spread of the coronavirus among the “young and healthy” and a poorly defined “focused protection” of those at high risk of severe disease and death (e.g., the elderly and those with chronic health conditions). As I said at the time, it was basically eugenicist in that it proposed sacrificing those at high risk in the name of reopening the economy and profoundly anti-public health.

Later, Jeffrey Tucker left AIER to found the Brownstone Institute, which he declared the “spiritual child of the Great Barrington Declaration.” Unfortunately, the Brownstone Institute rapidly attracted a number of ideologically similar pundits, scientists, and physicians to promote a steady stream of anti-“lockdown” rants and even outright antivaccine misinformation about COVID-19 vaccines. Basically, the Brownstone Institute is opposed to any sort of collective action in the service of public health and portrays public health efforts as, depending on their mood, Nazi or Communist totalitarianism. Increasingly, groups like this take their cue from more well-established antivax propagandists and their organizations, like Robert F. Kennedy, Jr.’s Children’s Health Defense, Joe Mercola’s longtime antivax messaging, and even at times Mike Adams.

As Steve and I (and many others) have noted, the spread of misinformation and conspiracy theories is also facilitated by the algorithms that drive social media. This is not a new phenomenon. For example, various SBM bloggers were discussing research about how antivaxxers were gaming Facebook against vaccine advocates years before the pandemic and how inadequate the efforts of social media companies were to the task, but these days it’s arguably worse than ever.

Worse, unlike past the misinformation and disinformation about vaccines and pandemics (e.g., the H1N1 pandemic 13 years ago), it’s not just ideological entities promoting antivax and COVID-19 misinformation, but what would be considered “mainstream” outlets, such as Fox News, particularly Tucker Carlson, who routinely parrots common antivax lies about vaccines while lamenting the apparent decline of men.

This brings us to an elephant in the room that the role of SBM in promoting the best medical evidence has traditionally made us reluctant to emphasize too much, namely the partisan imbalance among those promoting COVID-19 misinformation.

Political vs. partisan

We at SBM have never claimed to be apolitical. How could we credibly make such a claim when we regularly take what are inherently political positions with respect to, for instance, opposing right-to-try, licensing naturopaths and other quacks, vaccine mandates (prepandemic and now), and how the FDA licenses new medications? Here’s how I like to characterize us. SBM is not apolitical, but we do strive to remain nonpartisan and to promote political policies and regulations that are based in and promote a high standard of scientific evidence for medicine. Indeed, just search for Senator Tom Harkin’s name, given that he was the driving force behind the creation of the National Center for Complementary and Alternative Medicine (NCCAM), which is now known as the National Center for Complementary and Integrative Health (NCCIH) and a Democrat who once famously expressed his disappointment that NCCAM hadn’t “validated” more CAM. Back then, the stereotype was that the antivaccine movement and believers in alternative medicine consisted mainly of crunchy hippie-dippy lefties.

Years ago, I routinely used to point out that survey evidence indicated that support for vaccination and school vaccine mandates was pretty similar on the right and the left. (At least, it was then.) I also used to suggest that, back in Jenny McCarthy‘s heyday as the celebrity face of the antivaccine movement 15 years ago, it was the heavy representation of celebrities among famous antivaxxers that contributed to the public perception that the antivaccine movement was predominantly left wing, Hollywood celebrities like Rob Schneider (admittedly, with him I’m probably being generous in my definition of “celebrity”), Mayim Bialik, Alec Baldwin, and Robert De Niro, among others. It’s also true that areas with a lot of affluent people on the coasts, whose politics tend to lean heavily liberal, used to routinely suffer outbreaks of vaccine-preventable illnesses in recent years leading up the pandemic due to low vaccine uptake. Then, of course, there was (and, alas, still is) Robert F. Kennedy, Jr.

To be sure, there was always such a contingent of a “back to nature” crowd, but in reality that stereotype was never true. For example, there has always been a libertarian right wing component to the antivaccine movement, for example, General Bert Stubblebine III’s Natural Solutions Foundation, far right libertarians, and others with extreme distrust of the government, including government-recommended vaccine schedules. Similarly, the “health freedom” movement has tended to be right wing and also very antivaccine.

The elephant in the room, therefore, is just how much the antivaccine movement has found a home on the far right and how much COVID-19 disinformation comes from the political right as compared to the left. This is not a new phenomenon, but rather a culmination of a drift that began over a decade ago (at least). For instance, as early as 2011, Fox News was airing sympathetic segments on Andrew Wakefield, interviews with Dr. Bob Sears, SafeMinds’ anti-vaccine PSA campaign, and Louise Kuo Habakus (who was virulently anti-vaccine herself and politically active in New Jersey advocating for more easily obtained “philosophical exemption” laws). Let’s also not forget about Rep. Dan Burton (R-IN), who routinely used to hold “hearings” before his committee about the vaccine-autism link back in the 1990s and early 2000s.

Then there was The Canary Party, founded in 2011, which soon started working with Tea Party-affiliated groups in California. Not long after, the Canary Party became known for sucking up to Rep. Darrell Issa (R-CA), with one of its major financial backers Jennifer Larson contributing a lot of money to Issa’s campaign (indirectly, of course) in order to buy influence and win a hearing by his committee examining autism and focused on vaccines as one potential cause. Around the same time, at the right-wing Libertarian FreedomFest in 2012 I was privileged to watch a debate between Julian Whitaker and our very own Steve Novella about vaccines. At the debate, vaccine pseudoscience flowed freely from Whitaker in a most embarrassing fashion, and I couldn’t help but note that FreedomFest that year featured two screenings of Leslie Manookian’s antivaccine propaganda piece, The Greater Good and had featured antivaccine talks in previous years. I was there, too, and amazed at the merchandise and conspiracy theories being touted, although in retrospect, in the era years before the rise of QAnon, conspiracy theories about the gold standard and New World Order now seem almost quaint.

This leads me to something else that Peter Moran said:

Antivax sentiments and mandate resistance have never required political underpinnings.

And:

Perhaps familiarity — sheer repetition in a nurturing tribal environment — alongside a little political bias can give such nonsense a veneer of truth.

The first part is sort of true but not really. What do I mean? Unless you consider politics separate from ideology, it’s hard to claim that antivax sentiments are independent of political underpinnings, because antivax sentiments are very much tied to ideology. The second part is also likely true to some extent, but not in the way Peter intended. He was mocking the idea (“such nonsense”) that a network of right wing groups are supporting the spread of COVID-19 and antivax disinformation, when there is actually good evidence to support this contention. In fact, it’s definitely likely that “sheer repetition in a nurturing tribal environment” can give misinformation, be it antivaccine misinformation or misinformation about COVID-19, or just general quackery, can do just that. We were writing about how this could happen long before the pandemic, such as the story of Jim Laidler as well as the appeal of being a medical “apostate.”

Moreover no one here at SBM is claiming that the left is not capable of promoting medical misinformation. Certainly it is. The problem is, as I like to say, that right here, right now, at the end of 2022, it is inarguable that the primary forces promoting antivaccine, anti-public health, and COVID-19 disinformation are currently right wing, often far right wing, to the point where public health responses to COVID-19, particularly vaccines, have become very partisan, a process that began long before the pandemic, when antivax ideology reared its ugly head during the 2016 Republican primaries and in 2018 when it showed up in the form of a “roundtable” held by the local Republican candidates in my district, and now has Sen. Ron Johnson holding antivaccine “round table” discussions featuring a bunch of quacks and grifters and the governor of a large state not only using his state public health apparatus to promote studies questioning vaccines but openly calling for a mini-“Nuremberg 2.0” (although in fairness he didn’t call it that).

Basically, what this politicization means is that, no matter how much we try to assiduously remain nonpartisan, just by advocating for interventions and policies rooted in science-based medicine, we are no longer going to be able to avoid charges of being partisan, “woke,” or whatever. This is a problem that we struggle to deal with, particularly given that other areas of SBM are similarly becoming partisan in a way that we haven’t had to deal with before, areas such as gender-affirming care for transgender adolescents. The problem, then becomes that our message will be rejected out of hand based solely on the perception that we are somehow far left wing and highly “woke” (whatever that word even means anymore).

I would be lying if I didn’t say that I’m struggling how to deal with this development, mainly because the only way to be seen as non partisan would appear to be to soft peddle our advocacy for SBM-based policies in certain areas, which we will not do. Yet, at the same time we need to reach everyone who is reachable, and the fusion of COVID-19 quacks and antivaxxers with right wing political movements makes it a huge challenge, one that I’ve experienced in my personal life trying to convince conservative acquaintances who, as I like to say, came to COVID contrarianism for the freedom but stayed for the conspiracy theories and pseudoscience. In addition, there is no way of knowing if someday the partisan landscape might change someday (although how it would change any time soon I struggle to envision), which means that we have to be nimble and consistent.

The best solution that I can think of for now is to promote the best science that we can and to pull no punches when criticizing those promoting pseudoscience, quackery, and conspiracy theories, regardless of their ideology or partisan politics. At the same time, we have to try not to alienate those who might be predisposed to embrace the misinformation that is associated mainly with one partisan side of the political spectrum, regardless of the politics of me or any SBM blogger. It’s a balancing act that is at best difficult and that might well be impossible. How do we avoid doing nothing more than “preaching to the choir”? I argue that “preaching to the choir is not in and of itself a bad thing given that it provides science advocates tools to communicate science and counter medical misinformation, but it clearly isn’t enough by itself.

SBM and the future since the pandemic

The quackery and medical misinformation landscape now, compared to when SBM debuted 15 years ago, is very different and yet the same. As I wrote at the dawn of our now fading year, everything old is new again, with the sarcastically added question, “Who could possibly have predicted this?” It’s the same in that there is nothing new under the sun. Misinformation about medicine, quackery, and vaccines follow an old script that dates back decades, if not centuries: “Health freedom,” appeals to the “natural,” the idea that one can will oneself to health, and distrust of medicine and political authorities. I refer to my post a year ago for the details, for those who are interested.

The first step in combatting this threat remains the inculcation of critical thinking skills into the next generation. Obviouslym this is easier said than done, and we need to explore strategies for doing this not just in medical school but much earlier, as it’s not just physicians who need it. I would also argue that SBM as currently constituted needs help. Our hardy band of bloggers have done the best we can and have tried to recruit guest bloggers to fill in the gaps, but gaps remain. Besides COVID-19, we lack high level expertise in women’s health, psychiatry, epidemiology, and a number of medical subspecialties. Guest posts are always welcome in these areas, but we could really use regular contributors to join us.

We also need to emphasize science communication more, in particular “prebunking.” Increasingly, the combination of social and old media result in “firehosing” of misinformation, in which falsehoods and misinformation fly so fast and furious that it’s impossible to counter them all. We need to be more proactive about educating about the forms that misinformation takes, such as the conspiracy theories at the root of nearly all of it, and why it is being promoted, in order—if you will—to inoculate people to be able to recognize new forms of misinformation or claims that are questionable based on the forms that they take, even if the person doesn’t necessarily have the detailed knowledge to know specifically what is not accurate in the claims.

Finally, I’m not getting any younger. As hard as it is for me to believe, I just turned 60 recently. If SBM still exists and I’m still with it 15 years from now, I’ll be 75 when our 30th anniversary rolls around. As much as I’d like to pretend otherwise, I can’t do this forever, and neither can Steve, who is younger than I am but not that much younger. We need to nurture the next generation, so that someday we can hand over the reins to others to continue the mission. The problems of quackery, medical misinformation, and conspiracy theories have long been with us and are not going away any time soon. The mission of SBM will need to continue after Steve and can no longer do this. “You really think it’s all new,” indeed.

In the meantime, sometimes we do feel as though we are trying to rouse the troops, like Aragorn at the Black Gate of Mordor, to fight what seems like a hopeless battle