Different People; Same Swamp?

Jumping in the rabbit hole of administration selection.

The 2024 post-election season is shaping up to be quite the game of political fantasy football, isn’t it? 🏈

Trump announces his administration one-by-one, as everyone huddles up on the sidelines playing Monday morning quarterback. If the Heisman trophy goes to one pick (← okay, I know the Heisman doesn’t apply here, but c’mon - some analogies fall short!), there is no doubt who wins:

🏆🏆Robert F. Kennedy, Jr, Secretary of Health and Human Services (HHS) 🏆🏆

RFK Jr. has spent decades exposing and fighting corruption within HHS. Now is his opportunity to drive agency-level reforms that break the patterns of corruption that keep our nation chronically sick.

The first step toward reclaiming the integrity of our federal agencies—and the one receiving the most attention—is leadership restructuring. Both Trump and RFK Jr. have pledged to “drain the swamp” and replace entrenched staff within agencies like HHS as a critical step toward systemic reform.

This has prompted me to jump down the rabbit hole of the complexities of federal agency leadership selection — reflecting on what it truly takes to transform these institutions.

At the heart of the "drain the swamp" strategy lie two implicit assumptions:

1. The problem of corruption and collusion stems from bad leadership, and

2. Replacing these leaders will resolve the problem.

In this Substack, I challenge these assumptions.

While it’s undeniable that certain leaders (ahem, Fauci!) have caused serious harm and should be replaced and held accountable, this article is not about those individual leaders. Instead, the focus is on how genuine transformation requires more than a mere personnel swap. It requires a shift in paradigm.

If we truly want our agencies to function differently—not just to address today’s challenges but to prepare for the future—we must go beyond addressing the “symptoms” of leadership corruption and collusion.

Swapping leaders is a necessary but insufficient condition.

True change requires tackling the systems and structures that allowed these issues to take root in the first place. It’s not enough to simply change the people and hope for a better outcome. To change the trajectory of health in this country, we must redefine how we understand health—and reshape these agencies from the ground up. Without this paradigm shift, meaningful progress will remain out of reach.

Drain The Swamp to Clean the Water?: The Importance of Paradigms

A paradigm for health is the overarching framework that shapes how health is understood, approached, and managed. It’s kind of like the blueprint of a building—dictating the structure, design, and functionality of everything it governs. Paradigms encompass the core beliefs, values, practices, and priorities that define how individuals, organizations, and societies view health and well-being.

As the foundation of a system, a paradigm establishes its guiding principles and drives its actions. They reflect the underlying theory that guides health agencies' decisions and actions, influencing everything from availability of treatment choices to strategies for health promotion.

In healthcare, there two dominant paradigms—allopathic and salutogenic—that underlie completely different conceptualizations and approaches to health.

Examining these paradigms is essential to helping us understand the foundation upon which our health agencies are based— and identify where the cracks in the foundation appeared that gave way to corruption. 

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Complementary Paradigms

Allopathic medicine, often synonymous with Western medicine, focuses on diagnosing and treating disease through a dichotomous model of health—defined by the presence or absence of disease. It targets external causes (e.g., viruses, bacteria) and internal factors (e.g., genetic defects) using specialized interventions such as pharmacology and surgery. Renowned for its effectiveness in managing acute illnesses, infections, and trauma, its disease-centric approach often overlooks holistic well-being (including social, psychological, and environmental determinants of health) and remains more reactive than proactive. Because the focus is on disease, the primary solution is often pharmaceutical in nature. This model forms the foundation of training and practice for most mainstream Medical Doctors (MDs), with the exception of those MDs who focus on root causes of disease and the promotion of true health through lifestyle and environmental optimization.

Salutogenic approaches to health, conversely, view health as a dynamic continuum and emphasize the promotion of well-being, rather the absence of sickness and disease. This model adopts a holistic perspective that integrates physical, mental, emotional, social, and spiritual dimensions of health, focusing on understanding and enhancing factors that support overall well-being. Salutogenesis prioritizes proactive strategies, such as lifestyle modifications, stress management, dietary improvements, and community engagement, to build individual and community resilience against external and internal health challenges. While less suited for managing emergent, acute, or life-threatening conditions, salutogenic care is particularly effective for fostering long-term health and preventing chronic conditions by addressing systemic and social determinants of health.

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Understanding the difference between these paradigms is essential for HHS reform. In theory, public health is grounded in a salutogenic model, where health is viewed as a continuum, with individuals and communities dynamically shifting between states of health and disease. The primary goal of public health, as originally conceived, is to create environmental and societal conditions that promote overall well-being and move individuals toward better health.

Public health is intended to ask, “What keeps people healthy?” rather than “What can we do to keep them from getting sick?”.

However, in practice, this ideal has shifted.

Our public health agencies—especially in recent years—have moved away from their original salutogenic paradigm and adopted an allopathic model, focusing on pathogenesis (the causes of disease) rather than promoting overall health. Rather than focusing on promoting health and well-being, the emphasis has shifted to disease mitigation and responding to immediate crises.

(During the pandemic, we even witnessed public agencies overstep their role into individual medicine, intervening in the doctor-patient relationship by dictating what treatments individual allopathic doctors could prescribe! They began recommending allopathic solutions within a fundamentally salutogenic discipline—it’s no surprise that such an approach failed so dramatically!)

Our public health institutions are facing an identity crisis.

There is a major gap between what public health should be and what it is in practice. This gap exemplifies the problems we face in the U.S. healthcare system and must be fixed.

How did this paradigm drift happen? 

When we discuss public health institutions, we often anthropomorphize the situation, attributing human characteristics to complex systems and act as if the institutions themselves caused the drift (or blame the opposition as if none of this is under our control!).

The simplified truth underlying the complex problem is that institutions are made up people – and it is the underlying belief systems of the people hired will drive the paradigm of the institution. 

If we want to reform an agency to function differently, you must hire people who see the world differently. For public health institutions to function as designed, leaders must be hired who understand and align with the mission of promoting health. They must represent salutogenic paradigms for health.

There is often a tendency to hire individuals with MDs to lead health institutions on the grounds that they hold an advanced degree. Sometimes, depending on the orientation of the individual MD, this is an excellent fit. However, the use of level of educational attainment as justification for leadership position is a fundamental flaw.

Placing a leader with an allopathic mindset into a salutogenic institution will not yield health promotion outcomes, no matter how many degrees they hold.

It's like putting a football player on a pitcher’s mound and expecting him to throw strikes—people perform best when trained in the right context.

Without paradigm alignment between leadership and the core principles of the institution, the ability to fulfill its purpose is severely compromised.

The FDA: A Lesson in Paradigm Shift

Of all the agencies under the umbrella of the HHS, the FDA (U.S. Food and Drug Administration) stands out as one most urgently in need of reform. The overarching mission of the FDA is to protect public health by ensuring the safety, efficacy, and security of drugs, medical devices, food, cosmetics, and tobacco products while advancing innovation and providing science-based information to improve health. In theory, it is an essential agency for protecting the public from harmful substances being introduced to the market.

Unfortunately, the FDA has faced widespread criticism for conflicts of interest, collusion, and corrupt practices that undermine its credibility, hinder its effectiveness, and allow harmful products to enter the market—contradicting its very mission to protect public health. Perhaps the most significant critique centers on the agency’s deep ties to the pharmaceutical industry. With a substantial portion of its funding coming from industry-paid user fees, critics claim this financial dependence creates a troubling conflict of interest, prioritizing corporate profits over public safety and contributing to the approval of drugs and treatments without adequate safeguards. The regular and accepted practice of personnel moving between the FDA and private industry has been a particular point of contention. Critics argue that this “revolving door” leads to a focus on drugs, rather than prevention or non-pharmaceutical approaches, and contributes to a health crisis with unsafe drugs and devices reaching the market.

The FDA is an agency that should be focused on protecting and promoting health; yet their hyperfocus on medications and pharmaceutical solutions stands in the way of any real health promotion.

Stated differently, an agency with a primary salutogenic mission (protecting health) is operating within an allopathic framework, resulting in a disease-centric approach that sidelines its mission of prevention and public health promotion. Under this paradigm, they can never fulfill their primary mission.

This makes perfect sense as to how this happened when you look at the organizational map of the FDA:

Roughly 40% of all leaders maintain an MD, a quintessential allopathic educational background. These individuals, shaped by an allopathic paradigm that emphasizes disease treatment and pharmaceutical intervention, reinforce the industry's grip on the agency. When you populate a staff with individuals who believe that pharmaceuticals are the solution to the absence of disease, you invite the pharmaceutical industry (and all the corruption that it brings!) to the table.

If you ask a builder with a hammer how to build a house, they find the nail.

If you ask a traditional allopathic doctor how to improve public health, they will turn to pharmaceuticals to treat the disease.

No matter how many times you “drain the swamp”, if you leave the door open for the pharmaceutical industry to have a seat at the table, they will find their seat (and probably bring a few friends!) In order to truly close the revolving door and drain the swamp, leaders from more diverse backgrounds — especially those who understand health promotion and salutogenesis — must fill the seats at the table.

Without reforming the underlying structure and policies that allowed these conflicts of interest to thrive, the FDA will never be able to fulfill its mission to protect and promote public health effectively in the long run.

Clearly, closing the “revolving door” at the FDA marks an important step forward. We must remove the individuals with conflicts of interest and kick collusion to the curb. However, simply swapping personnel is not enough. Without addressing the systemic issues that enabled collusion and corporate influence in the first place, we will find ourselves in the same position again in the future.

We mustn’t only replace the individuals; we must replace the paradigms that leaders work within. An organization that is intended to serve a health promotion function, should be filled with leaders that understand salutogenesis, placing social determinants of health and true health as a top priority.

If we continue to fill leadership positions with leaders who think in allopathic and pathogenic ways, then we will continue to leave a door open for the pharmaceutical industry to enter. Again, when you have a hammer, you look for a nail. When you focus on disease, you look to pharmaceuticals.

If we want to shut the revolving door, we must change the paradigms of our institutions. Only then, will the need for reliance on the pharmaceutical industry disappear — and the revolving door close forever.

Action Path Forward

Clearly, the new administration is on the right path. We need to drain the swamp and get rid of existing conflicts of interests. We need to remove the obvious harms.

This is Step 1.

Step 2 is where true organizational transformation must happen. Rehiring under the same principles that created the problem that created the problem in the first place will only perpetuate the same flawed processes.

Here are the essential action steps this administration can take to not only drain the swamp, but to make sure that it is filled with different water. These strategies can help us move beyond a personnel swap to truly transforming paradigms to promote population health:

1. Shift the Leadership Paradigm
   Transform the hiring process to prioritize individuals with expertise in salutogenesis and health promotion, not just those with an allopathic background. Certainly, MDs play a critical role in the health department and the advancement of health. This is not an "either/or” situation. In particularly, in agencies such as the FDA, where there are positions for which an MD is best suited, they should lead the way. But this representation should be balanced with representation from salutogenically-oriented fields — such as naturopathic medicine, chiropractic, nutritionists, health promotion, functional medicine, farmers, and prevention scientists. Actively seeking leaders who are trained to address root causes, rather than just treating disease, will help break the reliance on the pharmaceutical industry, which often fails to address social determinants to health and therefore offers no viable solution to the problem.

2. Revisit the Mission
   Revisit and revise the mission statement and core values of agencies to center on health promotion, prevention, and wellbeing—rather than disease management. This shift would require a long-term commitment to supporting policies, programs, and procedures that focus on the root causes of health issues and address the social determinants of health within each agency. When the underlying mission and paradigm do not align with the profitability of the pharmaceutical industry, there is no need for overreliance on the industry. Every new leader who accepts a position in HHS should be expected to revisit the mission statement on day 1.

3. Increase Funding for Non-Pharmaceutical Solutions
   Rethink how agencies allocate funding, with a larger portion dedicated to promoting alternative and non-pharmaceutical health approaches, such as nutrition, mental health, physical activity, and social-environmental factors. This would help create a more balanced and diversified approach to health with less reliant on drugs. When there is less reliance on drugs, there is less need for reliance on the pharmaceutical industry, thereby closing the door on inevitable collusion. When multiple doors are available, it is easier to shut the revolving door.

4. Foster Transparency and Accountability
   Implement strict transparency standards, particularly regarding financial conflicts of interest as a regular practice in agency functioning. Publicly release data on any relationships with the pharmaceutical industry and ensure that decision-making processes are free from undue influence. The “revolving door” between industry and regulatory bodies needs to be closed to restore public trust in public health agencies.

5. Promote Health Literacy
   Prioritize initiatives that focus on improving public health education, particularly in the areas of nutrition, lifestyle choices, and prevention. By empowering individuals with knowledge, we can reduce reliance on pharmaceutical expertise and instead rely on an educated population.

6. Collaborate Across Sectors
   Promote a systems approach by collaborating with public health agencies, educational institutions, and private sector organizations to align strategies for promoting health. No single agency can promote health in isolation. We must work together better to get to better outcomes. Cross-sector collaboration allow builds the capacity of the full system to identify gaps in performance that give way to colluded practices or conflicts of interests.

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Join me in this rabbit hole of draining the swamp!

I’m curious — what action strategies would you take to ensure sustainability of an ethical system, and not just another swamp? Leave your thoughts in comments below.