The Irreplaceable Public Sector | The Turning Point

Much has justifiably been made of the embrace by the Biden administration of the levers at its disposal to bring about a latter day version of FDR’s New Deal. President Biden in his first 100 days launched unprecedented, large-scale efforts to rebuild national infrastructure and to implement programs to support those most affected by the Covid-19 pandemic. This comes as a dramatic contrast with his predecessor whose efforts were much more in line with Republican administrations dating back to President Reagan, aiming to reduce the size of government and to limit the scope of the public sector as much as possible.

In the wake of a global pandemic that froze the world in its tracks for more than a year and resulted in nearly 600,000 American lives lost, the return to an engaged, muscular public sector is a welcome shift indeed. From the point of view of the decision-making that is needed to create health, we think that greater engagement of the public sector is not only welcome but essential, both to mitigate the current pandemic and to help us prevent a future one.

In March 2021, President Biden introduced his “Build Back Better” proposal, a $2.3 trillion once-in-a-generation investment, the largest government intervention since the 1960’s. To be spread over eight years, this proposal overtly tackles “infrastructure”—roads, bridges, utilities—and was not framed as an effort to address the nation’s health. But to our minds, this bill addresses many of the drivers of health that shape the world where Covid-19 emerged. By attending to child care ($25 billion), affordable housing ($213 billion), home care for seniors ($400 billion), public transportation, and even the removal of all lead water pipes in the country, the legislation takes on the conditions and structures that create poor health. All these efforts can improve the situations of millions and address the vulnerabilities that Covid-19 exposed.

Read the full piece on The Turning Point.

The false choice between diversity, inclusion, and the pursuit of excellence | The Healthiest Goldfish

In April, United Airlines pledged to train 5,000 new pilots by 2030 with the intention of no less than half of these new students being women or people of color. With this announcement came pushback, informed by a common objection to diversity and inclusion efforts, one which extends all the way back to the start of debate around initiatives like affirmative action. The objection is that, in seeking to make greater room for historically underrepresented groups, we risk elevating concerns about identity over a commitment to excellence, to bringing in the best people regardless of skin color, sex/gender identity, or other characteristic which has led to past marginalization. These concerns were particularly potent with regard to the airline industry, where anything less than excellence in the cockpit could put lives at risk.    

United’s pledge aligned with ongoing, and welcome, efforts to promote greater diversity and inclusion within organizations. This has been a long time coming, and is something that I have cared about throughout my career. When I first started my time at BU School of Public Health, working with Dean Yvette Cozier we articulated an 11-point agenda for diversity and inclusion at the school. The idea that we should be centering some of these concepts was unusual enough at the time that it was often parodied in right-leaning media. Today, the ideas in the original 11-point plan, since updated regularly are uncontroversial and in fact entirely of a piece with many such plans in institutions throughout the country.

Yet, as the elevation of diversity and inclusion have become a part of the fabric of more and more institutions, we are hearing more frequently the objection that diversity and inclusion are in conflict with excellence, undermining the meritocracy which sustains effective organizations. This has implications for health. Building a healthier world depends on the pursuit of excellence within a range of organizations, from academia, to government, to the public health infrastructure.  As this necessity intersects with the growing embrace of diversity and inclusion within these bodies, it is important not to shy away from engaging with objections to this focus. For our institutions to be strong enough to support health, those working within them must be able to respond to this contention.  With that in mind, I share a few thoughts about the supposed conflict between excellence and our pursuit of diversity, and this pursuit’s broader implications for health.

Read the full piece on The Healthiest Goldfish.

Pandemics and Prisons | The Turning Point

The incarceration rate in the U.S. is higher than any other country in the world, and about five times higher than the median worldwide. The health consequences of incarceration are legion. Disability Adjusted Life Year (DALY) rates linked to incarceration are more than double that attributed to other conditions commonly experienced in the general population. Death rates are high and are the result of overcrowding, inadequate mental health care, lousy sanitation, freezing temperatures and delayed medical treatments. Half of prison suicides result from solitary confinement.

Further compounding the horrors of the American incarceration system, its burdens are deeply and unevenly felt. African Americans are incarcerated at five times the rate of whites. Nearly half of all Black women have a family member in prison. One in three Black males born today will end up in the correctional system at some point. The bias against people of color is operationalized at many levels: through police arresting minorities at higher rates than whites, prosecutors charging them more often and more severely, leading to longer sentences. The “justice system” is notably unjust.

Read the full article on The Turning Point.

Who Decides? | The Turning Point

The Covid-19 moment has been fraught in countless ways, but perhaps most so when concerned with arguments about the trade-offs between strict measures to control viral contagion, and the economic consequences of those trade-offs. At the heart of these arguments has been one—often unspoken—question: who gets to decide what is right for societies? Who decides how to evaluate the trade-offs?

Perhaps this question is illuminated by analogy.

Increases in speed limits across the country have been associated with 37,000 deaths during the past 25 years. In 1993, 41 states had a maximum speed limit of 65 mph; the other nine states had a speed limit of 55 mph. Today, by contrast, 41 states have maximum speed limits of 70 mph or higher; six have 80 mph speed limits. The change has happened slowly as advocacy groups have argued for higher speed limits to reflect reality—many drivers exceed the speed limit anyway.

Read the full article on The Turning Point.

Mercy and our present moment | The Healthiest Goldfish

In his play, The Merchant of Venice, William Shakespeare created a character who is entirely justified in seeking revenge. Shylock, a Jewish moneylender, has lived his life as the subject of constant anti-Semitic attacks, with one of his main antagonists being Antonio, the merchant of the play’s title. Antonio has called Shylock terrible names, assaulted, and spit on him. So, when Antonio defaults on a loan from Shylock, one for which the merchant offered a pound of his own flesh as security, Shylock is eager to collect, and the audience—having witnessed the many injustices suffered by Shylock throughout the play—can find it hard to blame him. Yet something unexpected happens in the famous scene when Shylock demands what he is owed. It is there one of the characters, Portia, begs Shylock to consider mercy:

“The quality of mercy is not strain'd,
It droppeth as the gentle rain from heaven
Upon the place beneath: it is twice blest;
It blesseth him that gives and him that takes:
'Tis mightiest in the mightiest: it becomes
The throned monarch better than his crown;
His sceptre shows the force of temporal power,
The attribute to awe and majesty,
Wherein doth sit the dread and fear of kings;
But mercy is above this sceptred sway;
It is enthroned in the hearts of kings,
It is an attribute to God himself;
And earthly power doth then show likest God's
When mercy seasons justice.”

It is worth hearing the entire speech, well-performed here by Laura Carmichael. These words in defense of mercy complicate the scene of perhaps would-be vengeance. As anyone familiar with The Merchant of Venice knows, Shylock is justified in his anger. The play is rife with examples of anti-Semitism, including Shylock’s eventual fate (he is ultimately thwarted in his pursuit of revenge and forced to convert to Christianity). This anti-Semitism should be deeply troubling to all readers and playgoers today, especially given the events of the last century, and recent resurfacing of anti-Semitic animus in the US and globally. Yet—and perhaps because of—the context of Shylock’s justified anger, mercy’s appeal still resonates. It is an appeal worth thinking about, in our present-day context, and particularly in the context of health.

Read the full piece on The Healthiest Goldfish.

The radical importance of acknowledging progress | The Healthiest Goldfish

I tend to be asked to speak about problems, about challenges to health, and about the steps we can take to fix them. There is always much to talk about. As a society, we face many obstacles to health—from health inequities, to racial injustice, to obesity and gun violence, to climate change. These problems can seem overwhelming, and it is true that solving them is no simple matter. I have written and presented often on these challenges, their scope, and the difficulty of addressing them. A core takeaway of this work is that it will take years of patient engagement to advance the structural changes necessary to shape a world free from the fundamental challenges we face.

But it is also true that we have made tremendous progress in creating a healthier world, to such an extent that, if given the option of being born at any time in human history, most of us would likely choose now. The world is less violent, people are living longer, healthier lives, more children are being educated, poverty has fallen, as has maternal mortality, and living standards have dramatically improved since the start of the Industrial Revolution. These improvements are fundamental to how we now live, and served as the opening chapter of my forthcoming book, The Contagion Next Time. For much of human history, life was a brutal daily struggle for all but the most privileged. While many still live lives of desperate struggle, were someone from the medieval era to travel to the 21st century and see how the world has improved, she would likely feel she had arrived in a different planet.

Read the full piece on The Healthiest Goldfish.

Covid-19, Climate, and the Return to "Normal" | The Turning Point

We have no climate vaccine. Covid-19 is our first truly global crisis—changing the way people around the world work and wed, travel and shop, at the same time—but another is coming. And while we expect that we will (mostly) return to the world we knew pre-Covid-19, we should have no such illusion that we can avoid the other challenges that were looming pre-Covid-19. In slow motion, with every day of inaction counting against us, the expense and suffering of Covid-19 escalated; the health effects of climate change will only be worse in due course.

The earth is one degree hotter than it was during the Industrial Revolution. This may not seem like much, but it has been enough to lengthen our fire season and burn 20% of Australia’s forests in one summer, to make our days the hottest in recorded history with worsening crop failures, and to have bleached 90% of the Great Barrier Reef. Climate change has expanded the range and prevalence of some infectious diseases, including Lyme disease and West Nile virus in the US. Deforestation, deleterious for our atmosphere, has brought more wild animals (and zoonotic illness) into contact with humans.

Read the full article on The Turning Point.

What do we want from our political system? | The Healthiest Goldfish

It is one of the most-used aphorisms in public health: “[P]olitics [is] nothing but medicine at a larger scale.” That was written by Rudolf Virchow, one of the founders of modern pathology, who also played a key role in the development of social medicine. Virchow became convinced that the underlying reasons for health gaps were social and economic inequities, leading to his participation in the Revolutions of 1848, among other progressive efforts of his time. In articulating a central role for politics in the health conversation, Virchow was, in many respects, decades ahead of his time and led directly to much of the modern discussion about the role that politics plays in shaping health.  

Politics, defined perhaps most easily as the art and science of governance that allows us to live together, unquestionably shapes health. And, in my assessment, we in public health have been—correctly—increasingly vocal about the role that politics plays in shaping health. Perhaps in direct reaction to the Trump administration, which was responsible for a set of policies that were, in the main, detrimental to health, we have had a growing chorus of voices arguing for the importance of thinking about politics when we think about health. There are now dozens of articles on what the new administration can do for health. And given the more visible role of public health in the public arena due to a world-stopping pandemic, it is possible that these voices will have more weight. But as we engage more in urging politics to consider health as part of its core mission, we could also benefit from clarity about what we are trying to achieve through politics. It is too easy to argue against, say, neoliberal ideas which we sense, reflexively, will cause us to underinvest in health—even if I would suggest that the evidence here is not clear at all—but it is harder to think about what we are trying to achieve through our political systems. Perhaps having some clarity on that may help focus our advocacy efforts, as well as the scholarship that can inform how we engage with politics to begin with.

Read the full piece on The Healthiest Goldfish.