“Cavities are a communicable disease, and if you’re among the 90 percent of Americans who’s ever had one, you probably got them from your mother.”
So begins “The Rise and Impending Fall of the Dental Cavity,” a remarkably engrossing and, for me, genuinely eye-opening survey of the history and science of tooth decay, published last week by the pseudonymous Cremieux Recueil on his Substack. The bacterium Streptococcus mutans might not seem like the likeliest subject for a 7,600-word general-interest deep-dive, but Cremieux takes detours into the immaculate teeth of dinosaurs, the practice of Neolithic dentistry, the agricultural and industrial revolutions and their effect on our diets, and the dental agony of America’s founding fathers.
His essay is a kind of masterpiece of an emergent form of internet argumentation — one with roots in the blogosphere and the message-board culture of an earlier era but which really flowered in the pandemic years: extremely long, exhaustively researched, often compiled by obsessive nonexperts and aimed at a contrarian lesson about public health, say, or educational achievement, or the origins of the pandemic. For me, the archetypal example is probably the 10-part investigation, with nine “interludes,” into the causes of American obesity published in 2021 by a pair of anonymous researchers, calling themselves Slime Mold Time Mold, who proposed environmental contamination of our water table by the runoff of the mood stabilizer lithium as the driver of the country’s skyrocketing body mass index and have since undertaken the staging of a large-scale, self-supervised “community trial” of what they call the “potato diet.”
In this case, the lesson was about what is going on in the bacteria pools we call “mouths” and what we could do to clean them up. Probably, you remember admonitions from childhood that eating candy will rot your teeth, but that story turns out to be a bit simplistic — the problem isn’t that your teeth hate sugar but that Streptococcus mutans loves it. And when it consumes sugar, the byproduct is lactic acid, which is what really starts to eat away at your dental enamel. Not everyone has an oral microbiome dominated by Streptococcus mutans, but chances are if you do, it was passed to you by your parents, very early on — and if you eat any sugar, you’re very likely to suffer tooth decay.
In places like the United States — where drugs are advertised directly to consumers, pharmacies are lined with whitening toothpaste and yuppie dentists hawk Invisalign between fillings — you might have come to see oral health as primarily a cosmetic matter. (Perhaps, given the costs, even a scam.) But probably a quarter of Americans and more than a third of the world have untreated cavities or tooth decay, and there is an awful lot of science linking oral hygiene with overall health and well-being. The connections are both direct (untreated cavities can host infections, which can spread elsewhere in the body, causing cellulitis and osteomyelitis, among other infections, and other forms of oral bacteria have been linked to colon and colorectal cancers) and indirect (Tooth loss is correlated with higher all-cause mortality, with studies of large-scale tooth loss finding large increases in all-cause mortality risk.) That’s one reason, over the past few decades, there have been periodic efforts to develop a vaccine for tooth decay, focused on Streptococcus mutans.
But “Impending Fall” was not prompted by an F.D.A. approval of such a vaccine, a successful large-scale clinical trial or even news of such a trial getting underway. It wasn’t even occasioned by the publication of new academic research or a new book. Instead, it referred to the rollout of a new product called Lumina, conceived by the startup Lantern Bioworks and sold to customers directly as a probiotic supplement — and an opportunity to participate in something more like a health-care version of a beta-test soft launch.
“Lumina does not have F.D.A. approval, the endorsement of major scientific organizations, or any of the other trappings that sound medicine is supposed to have,” acknowledged Richard Hanania — a prominent anti-woke, pro-vaccine Substack provocateur, whose views on race my colleague Jamelle Bouie called “rancid” and whose furious history of social justice was endorsed by Peter Thiel, Tyler Cowen and Vivek Ramaswamy, among others — reflecting on his decision to “let some genetically engineered bacteria colonize my mouth.” So why had he done this?
He wasn’t motivated by the science or even the reputation of the company’s scientists. “The real reason I brushed my teeth with Lumina,” he writes, “was Scott Alexander told me to.”
Alexander, if you don’t know, is the nom-de-plume of one of the tech world’s most prominent public intellectuals — a Bay Area psychiatrist who used to publish a website of Rationalist musings and investigations called Slate Star Codex and now publishes one called Astral Codex Ten — including, recently, a 15,000-word summary of a 15-hour debate about the origins of the pandemic and a persuasive defense of the utilitarian-philanthropic movement Effective Altruism. Like Hanania, Alexander was supportive of vaccines, and was cautious about Covid, though he has been critical of the F.D.A., which he believes could’ve brought us those vaccines much more quickly. In other words, though his worldview can skew “right,” he is not exactly the conventional liberal stereotype of the anti-science crusader but much closer to its sociological opposite. And in December, he published a long FAQ-style interview with the founder of Lantern Bioworks, which amounted to a kind of endorsement, though Alexander was typically careful not to make claims about Lumina’s efficacy, given that it has not endured conventional clinical trials, and to disclose his own conflicts of interests (his friends at the company and the consulting work his wife did for them).
To a lay reader like me, the idea does indeed appear promising: a $250 one-time treatment to crowd out the bacteria that’s in my mouth now, producing lactic acid anytime I eat sugar, with an engineered variety that will not. (The process is a bit like “gene drive” proposals to outbreed disease-carrying mosquitoes with varieties that can’t harbor malaria or dengue or other diseases menacing to humans.) But it is nevertheless disorienting to find myself, reading about Lumina, in the position to decide, on my own, whether it’s worth it, or safe, to give a novel bacterium a permanent home in my microbiome (“once you use it, it’s in your mouth approximately forever,” Alexander writes). And to thereby undertake what is essentially an unproven and untested treatment without any traditional reassuring oversight. (As Ruxandra Teslo puts it, “most of the direct data comes from small studies in rats and well … most humans are not rats.”)
And yet this position is an increasingly common one, at least in certain corners of the internet, especially since Covid upended an awful lot about not just our lives and our health but also the structure of our epistemic faith. Suddenly, groceries weren’t safe, and then they were; parks weren’t, either, and then they were; masks didn’t work, and then they did, and then maybe they didn’t again. Early on, especially, guidance seemed to shift almost by the week, which emboldened certain people to try to sort it all out for themselves, while others languished in sometimes fearful confusion. In 2020, there were those who placed their pandemic bets on ivermectin and hydroxychloroquine, infamously, but also those hawking vitamin D as a Covid fix and those who didn’t want to wait for the conclusion of clinical trials and instead assembled their own versions of the Covid vaccines, administering them in the form of nasal sprays. The pandemic’s rise of at-home test kits was not just about Covid-19 — which, in fact, became widely available only after many months or regulatory and messaging obstacles — but also about Lyme disease, hormone levels, STIs, menopause, vitamin D, DNA sequencing, thyroid function and many other health indicators. By 2021, a majority of states had passed laws restricting public health authorities from taking actions against future pandemics. In the aftermath of the Covid emergency, the country’s biggest pharmaceutical and perhaps biomedical story has been the spectacular rise of Ozempic, which technically hasn’t even gotten F.D.A. approval for weight loss (though its semaglutide cousin Wegovy has).
Off-label use is nothing new, of course; some estimates suggest up to one-third of all prescriptions for common drugs in the United States may be written for purposes other than those originally intended. And skepticism about the American medical establishment didn’t begin with the pandemic, given decades of hostility toward the authorities like the F.D.A. and an even longer national infatuation with quick fixes, “secret knowledge” and quack cures. But in part because no one was happy with how the pandemic went, and because everyone wanted to believe it would have been easy to handle it better, it did help cultivate what my colleague Michelle Goldberg has called “a coalition of the distrustful” — an anarchic sort of D.I.Y. health and wellness counter-establishment, one that mixes disdain for much conventional wisdom with great faith in the ability of smart people on the internet to do better. “Substackism,” Max Read recently called it, on his own Substack.
“The anti-woke wellness corner of Substack is just one portion of a large and loose network of influencers, podcasters, gurus, scientists, pseudoscientists, quacks, dieticians and scammers,” Read wrote earlier this month. “What links all of these diverse content producers together is less a particular level (or absence) of scientific rigor or expertise (sometimes these guys are absolutely correct!) and more an outsider attitude — a mistrust of institutions.”
To most Americans, not just on the right, this all feels not just familiar but intuitive: that the apparent stumbles of our public health establishment through the past few years would produce distrustful backlash against elite authorities. And there were missteps and mistakes: early on, about testing kits and aerosol spread; in the middle of the pandemic about “natural immunity” and breakthrough infections; and in the post-emergency phase about the universal value of Paxlovid, for instance, which, one recent study suggests, may offer little to no clinical benefit for the fully vaccinated.
But it is also the case that those elites, and that establishment, produced in this same period what is not just the great success of the pandemic but probably the most impressive public-health achievement in a generation: the record-time design, production, clinical testing and delivery of an entirely new kind of vaccine, which, when rolled out less than a year after the country’s first publicly identified Covid case, saved the lives of several million Americans and more than 10 million living abroad.
How should we balance those mistakes and those contributions? Or the pandemic wisdom of the establishment against those who promised that Covid would kill only a few thousand Americans, or who believe the pandemic experience was an unequivocal indictment of the scientific establishment? And how far should we take the argument that the F.D.A. could often move faster?
Not everyone who doubts the wisdom of the F.D.A. is calling for its abolition, of course, and not everyone who’s wondering about the wisdom of seasonal Covid booster shots for the young believes that it would be good if parents seeking shots for their kids were reported to children’s services. Not everyone who was skeptical of those shots at the outset believes they have already killed millions. And not everyone who thinks American schools were closed too long believes those closings were a bigger public policy failure than the Iraq War. But for many the pandemic experience does seem to have been a kind of gateway drug, and it isn’t just among anti-vaxxers that Covid cynicism has given way to a new age of medical libertarianism. In certain corners, it has come to look almost like a second mainstream, at least as sure of itself as the first.
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