Defining Out Goalposts | The Turning Point

During April of 2020, the in-hospital mortality rate from Covid-19 was at 19.7%. By November, it had declined to 9.3%. That is a remarkable testament to the triumph of clinical medicine in the face of a previously unknown disease. The drop in mortality was due to many factors, including the use of non-pharmacological approaches such as patient proning, the use of pharmacological therapies in hospitals such as remdesivir and steroids, and perhaps also due to lower viral loads seen in hospitalized patients because of more universal embrace of mask wearing. Regardless of the explanation, it is clear that our handling of Covid-19 got better quickly, changing dramatically the risk of what should be the ultimate outcome of concern: death.

But this dramatic improvement in mortality did not do very much to change our broader public narrative of Covid-19. Our impression—legitimate as it was—of a new deadly disease that was to be avoided at all costs was fixed quickly in March of 2020, and it did not budge much when the risk of the disease’s feared outcome changed substantially. We were seeing the same dynamic a year later as the widespread introduction of vaccines provided protection for those most vulnerable—the elderly and those with underlying medical conditions—lowering mortality rates and leaving cases to be driven by younger people who have had much less risk of contracting severe Covid-19. Despite this dramatic change in disease profile due to widening vaccination, the public conversation about the state of the pandemic remained driven, largely, by fluctuating case numbers, and state-by-state decisions were informed primarily by case load, even if these cases were milder and posed less risk.

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Too far, or not far enough? | The Healthiest Goldfish

The business of creating a healthier world is, fundamentally, the business of pushing for change. This means pushing against a status quo which often does not serve us well. This can require us to oppose systems, and even people, that are invested in entrenching the drivers of poor health. This is all to the good. However, while we are quite familiar with the reasons why this pushing is necessary—an awareness informed by our understanding of the drivers of poor health—less discussed are some of the ways this pursuit of change can, at times, undermine itself, leading in counterproductive directions. This is well-illustrated through a story told by the conservative political theorist Kenneth Minogue, one which he used to critique the development of liberalism:

“The story of liberalism, as liberals tell it, is rather like the legend of St. George and the dragon. After many centuries of hopelessness and superstition, St. George, in the guise of Rationality, appeared in the world somewhere about the sixteenth century. The first dragons upon whom he turned his lance were those of despotic kingship and religious intolerance. These battles won, he rested for a time, until such questions as slavery, or prison conditions, or the state of the poor, began to command his attention. During the nineteenth century, his lance was never still, prodding this way and that against the inert scaliness of privilege, vested interest, or patrician insolence. But, unlike St. George, he did not know when to retire. The more he succeeded, the more he became bewitched with the thought of a world free of dragons, and the less capable he became of ever returning to private life. He needed his dragons. He could only live by fighting for causes—the people, the poor, the exploited, the colonially oppressed, the underprivileged and the underdeveloped. As an ageing warrior, he grew breathless in his pursuit of smaller and smaller dragons—for the big dragons were now harder to come by.”

I acknowledge that this story, excerpted from Minogue’s book, The Liberal Mind, may strike some readers of this newsletter as perhaps unfair. Where Minogue sees “smaller dragons,” a different perspective might see normal-sized dragons to which we are only just now applying the correct measure of attention.

Yet it is hard to deny Minogue’s story raises some necessary, though perhaps uncomfortable, questions: is there a degree to which we, too, need our dragons, even if certain challenges have diminished or changed over time? Can we know progress when we see it, and, if not, what are the forces which may be clouding our vision? In today’s Healthiest Goldfish, some thoughts on these questions, on what form our pushing for a healthier world might take, and on how we can better calibrate our efforts so they will always be in proportion to the “dragons” of the moment.

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Part 2: Recognizing, and moving beyond, our collective grief | The Turning Point

There have been few moments in the country and the world’s recent history when we have collectively grieved for so many. Over the course of the Covid-19 pandemic, nearly . 00,000 Americans have died, and over 3,500,000 people have died around the world. The dead are our family, friends, neighbors, colleagues, and all are mourned. Recent data suggest that 33%of Americans know someone who died during Covid-19; that would be a total of about one hundred million Americans who are, in the moment, grieving personal losses, grief that in and of itself has implications for their health.

As we look past a global pandemic and move to rebuilding, the first step is acknowledging and recognizing the grief of many. This starts with our personal lives, in the opportunities we have to share grief with loved ones, and to acknowledge and make space for the sadness of the moment.

Beyond sadness, the science on the mental health consequences of grief should be sobering. In a study conducted in 2014, it was shown that the bereavement period is linked with greater risk of new onset of multiple psychiatric disorders, regardless of when the grief happens during the life course. We already know that with Covid-19 there has been a dramatic increase in anxiety or depressive disorders, with roughly four in 10 adults in the US reporting symptoms, an increase from one in 10 in January through June of 2019.

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A case for good faith argument | The Healthiest Goldfish

A healthy world is a world founded on good ideas, and good ideas are founded on a process of open, rigorous, even heated, debate. Yet such a debate is not always what we see in our public discourse. Polarization has informed a public conversation which does not always support a healthier world. Conducting a better public debate, it seems to me, is trading the cynicism that often informs bad faith arguments for the healthy skepticism which informs the generative conflict of ideas that truly advances progress. Some thoughts on how we can support such a conversation, towards the goal of a healthier world.

The last several years have been a contentious time. Polarization, informed by political divides, has come to characterize much of the public debate. The below graph reflects this, showing how opinion has migrated away from the center and towards extremes on the left and right.

Source: Pew Research Center. October 5, 2017. The Partisan Divide on Political Values Grows Even Wider. From: https://www.pewresearch.org/politics/2017/10/05/the-partisan-divide-on-political-values-grows-even-wider/. Accessed May 18, 2021.

The time of COVID was no exception—it was, if anything, an intensification of the division we have seen. It did not take long after the emergence of a novel coronavirus for the existential stakes of the political debate to migrate to conversations about masking, lockdowns, social distancing, the origins of the virus itself, the means of treating the disease, and, eventually, vaccines.

These divides have done much to undermine our response to the pandemic, just as they have done much to add dysfunction to our political process and fray our social fabric. Having said this, I would also add that I do not regard emotional, deeply felt, debate to be a uniformly negative influence. I have long argued for the importance of a diversity of perspectives and for creating space for these perspectives to be aired and debated, even when such debates are uncomfortable and contentious. This discourse, when it is conducted civilly and respectfully, is necessary for advancing the ideas that support a healthier world, and, ultimately, a culture and politics capable of meeting the needs of the moment.       

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Part 1: Grief and Loss | The Turning Point

Covid-19 has brought 18 months of grief. More than half a million have died from the virus in the United States, day after day, relentlessly; although we can almost see to the end, this dark moment has not seemed temporary. So much has been precarious for so long. But the grief we’ve felt has come from more than death. Grief has swept through us. All around, there is tremendous suffering.

Grief is always individual. Multiplied across a country, these individual griefs leave a great sadness. Grief is loss—what have we sadly lost, collectively? Years of life, years of health; our actuarial tables have shifted. Prolonged grief has had the expected effects: depression, anxiety, cardiovascular decline. Also countable and fallen: jobs and income.

But we’ve also lost confidence. We couldn’t quite control or command Covid-19. We looked for solace in uncertain science. We clung to changes in graphs and curves. With our data and models, we believed we could control and predict Covid-19. But viruses do not obey. We continue to reset and retime our goals. We have lived in uncertainty. Suffering causes humility.

We lost, for a time, our habits. We withdrew. We stayed still, indoors. We have, many of us, been emotionally paralyzed, fearful. We’ve been busy trying to survive. We’ve been consumed by this effort, while pretending to do the work we have, and caring for our children. We have said goodbye on video cameras. We have watched funerals rather than attend them. Our rituals have been interrupted.

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Why health? | The Healthiest Goldfish

Earlier this month, the CDC announced that fully vaccinated people need no longer wear a mask or physically distance to prevent the spread of COVID-19 (with the exception of places where such measures remain required by law). There are undoubtedly a large number of factors—from the political to the scientific—that informed and influenced this decision. But, leaving aside etiology for the moment, the unexpected announcement does present an opportunity to interrogate why we have done what we have done during the pandemic, and what we want, or perhaps should want, to guide our decision-making during these times.

There seems little question that implicit in the CDC announcement is a greater tolerance of some risk; a move away from saying that we are doing everything possible to reduce all risk, to accepting that some risk is acceptable—maybe desirable—as we move to more freely engage with those we have missed this past year. At the same time, I am also aware that the trauma of the pandemic has made it difficult for some to immediately embrace a future without the protective measures we have all become used to, with some amount of risk, even as these measures become less necessary. This is understandable, and those who are processing these feelings deserve compassion and time to adjust. It is clear that returning to something like “normal” will be a journey rather than a single step. So, as we embark, collectively, on this path, I wanted to reflect today on a first principle that informs much about what we have done this past year and will do going forward: why health? Why does it matter that we spend so much time working to generate health? Come to think of it, what is health anyways, at its core? What is it for? Perhaps in better understanding these questions we can better think how to factor in the risks we are, or are not, willing to take, to better address the steps necessary for getting to health; and to think better about the tradeoffs inherent in any decision about the health of populations—now and in the post-COVID future.

Read the full article on The Healthiest Goldfish.

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.

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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.