Epistemic Humility During a Global Pandemic | The Turning Point

We often talk about how challenging the Covid-19 year has been for so many people. And yet when we look beyond the individual sorrows and losses, the Covid-19 moment has been good for public health as a discipline generally, and for some of its fields specifically. Public health has had visibility like never before, its central concerns in the headlines for more than a year. Prospective students are applying to public health programs in record numbers. Epidemiologists have been declared “the new rock stars” by The New York Times and reporters fill columns asking epidemiologists what they’re personally doing, for example, on Thanksgiving and other holidays, holding the discipline up as a bellwether of data-informed good sense.

We are delighted with this attention. Public health has long been overlooked in the public conversation, and having more graduate interest in the profession is long overdue. It is likely that there will be more public health jobs created post-pandemic than ever before, establishing a moment of opportunity for us to welcome a new generation to the field that will lead in decades to come.

It is, of course, also true that this heady moment holds peril in that we risk overstating what we know and the confidence with which we know it, to the detriment of the world and our own field and reputation. We have no particular desire to be skunks at the public health garden party. But it does seem to us worth reflecting on the main challenges that public health faces in this moment that suggest a need for a thoughtful pause.

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What stories will we tell about COVID-19? | The Healthiest Goldfish

Throughout the COVID lockdown, I often found myself listening to podcasts. In particular, I gravitated towards podcasts that helped ground the pandemic in historical and political context, providing perspective on an uncertain moment. As I listened, it struck me that, no matter what happened in the past—no matter how tumultuous an era, how disruptive a war or plague, how shocking a sudden turn of events—everything that has ever occurred, the immense variety of historical incident, ultimately becomes the same. Everything becomes a story.

This begs the question: what story will we tell about COVID-19? The events of the past year and a half were more than just a story of the emergence and behavior of a virus. It was also a story of the social, economic, scientific, and political context into which the virus emerged, and the intersection of these forces within complex, dynamic systems. Given this complexity, it can be difficult to predict which stories will rise to the surface of the overarching story of the pandemic. Yet it is important for us to try. The stories we tell about health shape how we engage with the present moment to support a better future—or how we fail to do so.

Consider the issue of race in America. For a long time, the story we told about race was distorted, incomplete, often serving to entrench systems of injustice in the present as we failed to come to grips with our history. This had consequences for the COVID moment, as racial health gaps, informed by this history, worsened the crisis. This reflects why the issue of stories is not merely an issue of how we curate our collective memory. It has deeply-felt implications for the present, shaping our capacity to build a healthier world.

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Air, Water, and Words | The Turning Point

Public health surveillance is absolutely essential to protect and sustain community health. Health departments monitor community health status and investigate new health hazards all the time. They perform health surveys, and investigate clusters of mysteriously ill citizens. Covid-19 brought the functions of testing, tracing and surveillance through state and local health departments to an unprecedented scale. With Covid-19, early on we turned away from a narrow clinical health care approach, focusing on those who were sick, to a broader public health, population-based strategy. Public health authorities tested not only those with symptoms, but also a sample of those who were asymptomatic. Surveillance was and is our warning system.

Covid-19 has introduced us to many bold new approaches to surveillance. We can now monitor our water and air and words. Using technologies that were in development before Covid-19, health surveillance will continue to expand in three ways as we see it.

Using wastewater epidemiology--the study of sewage--we are increasingly tracking the spread of diseases. The sewer system is analogous to the human gastrointestinal system. Just as clinicians can make medical judgements about a patient’s health based on a stool sample, we now learn about a community’s disease state by sampling wastewater that comes from sinks and toilets. It turns out that when Covid-19 levels rise in wastewater, daily cases rise soon after. Testing for Covid-19 (or its future viral version) in a city—are rates rising or falling?—can help make decisions about whether schools should stay open, for instance. Over the past few years, the same testing technology has been telling us whether there is an unexpected amount of opioid use in a town, and in the future might monitor stress hormone levels or nutritional deficiencies among citizens.

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Our place in the natural order of things | The Healthiest Goldfish

I have written previously about the aspirations of public health, seeing public health more as a journey, a path on which we should always be traveling, towards creating a better and healthier world, rather than as any specific set of actions, prescribed by narrow strategies. The challenge in that vision is that it risks being too broad, too all-encompassing. It then often falls on us to ask: what matters most? What should we be acting on to best advance our aspirations?

These questions can seem abstract. But the COVID-19 era has made them perhaps sharper in our minds than ever, providing urgent, real-world examples of their relevance. Addressing these questions is an animating force behind why I am writing The Healthiest Goldfish. Chiefly, I am trying to understand, through writing, what matters most to those of us who care about the aspirations of public health. I have, with colleagues, written previously about what matters most from a technical perspective, but in a year when we are (hopefully) emerging from COVID, I find myself asking—what values and aspirations should we be foregrounding, as we look towards creating a healthy future?

I was recently reflecting on this question by thinking about parallel universes, which, in my disciplinary home, epidemiology, we call counterfactuals. These counterfactuals allow us to model how the introduction of a given variable might shape health. We do so by comparing a real world where someone may, say, smoke, with a counterfactual universe where that same person, with everything else held exactly the same, does not smoke. This allows us to compare counterfactual universes where all is the same except for that one variable, whereupon we can then conclude that if the person we are observing gets lung cancer in the universe where she smokes—and avoids it in the universe where she does not—we might say with some confidence that smoking causes lung cancer.

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Health Inequities Beyond Covid-19 | The Turning Point

In 2020, Covid-19 was the third leading cause of death in the US for persons over age 45, and the second leading cause of death for persons over 85. There is no argument that Covid-19 represented a cataclysmic event for health, one from which we are now slowly beginning to see signs of potential recovery.

Taking a step back, since the beginning of Covid-19 more than 4 million people have died from all causes. In any given year, almost 3 million Americans die, with the leading causes of death being heart disease, with about 650,000 deaths, and cancer, with about 600,000 deaths annually. As we begin to move beyond Covid-19, it becomes then important to ensure that we take what we have learned during this past year and apply it to US health going forward.

The disproportionate burden of Covid-19 borne by people of color has brought to a fore the centrality of health inequities, the unfairness that underlies health inequities, and has produced new urgency to address systematic forces like structural racism and underinvestment in ways to improve the social conditions that create health as a means of tackling these inequities. But these same forces are relevant not only to the deaths due to Covid-19. The deep and entrenched racial and socioeconomic inequities that drove Covid-19 influence nearly all other deaths in the US. In a recent analysis, sociologist Elizabeth Wrigley-Field estimated that 400,000 excess white deaths would be needed to raise white mortality to the best ever black mortality; it would take 700,000 excess white deaths to narrow the Black-white life expectancy gap. This analysis of course suggests that the scope of death from Covid-19 is comparable to the scope of the Black-white gap in mortality in general, every year.

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“One does have joys” | The Healthiest Goldfish

Public health is fundamentally about trying to create a world that is healthier, better. In doing this work, we must, at times, assume the role of commenting, a priori, on how we are falling short on generating health. This can have the effect of making a discipline that is all about health seem chiefly concerned with sickness, so often do we find ourselves discussing it—its causes and its consequences. This conversation is necessary for the work of public health. But it is worth asking: can this have the effect of keeping our attention fixed on challenges at the expense of a focus on the more positive aspects of health—of all the ways health can enable a happy life? It strikes me that it might be worth taking a moment—perhaps informed by the promise of soon summer—to discuss how public health can refine its emphasis, to better communicate the inherent positivity of the work of public health.   

This positivity can, at times, get lost in translation. Our messaging seeks to curb behaviors which can lead to sickness and preventable harm. This messaging tends to involve statements that begin (implicitly), with the words “Thou shalt not.” “Thou shalt not drink.” “Thou shalt not smoke.” “Thou shalt not eat to excess.” What we mean by these statements is to offer a blueprint for behavior which supports a long, healthy life. Yet it is possible to read them as prohibitions against fun, against the pleasure and joy which are core to living that very life to begin with.

Some might dismiss this as a matter of mere tone, secondary to more urgent priorities. Yet the wrong tone can risk alienating the very public we are meant to serve, and, in doing so, weaken the effectiveness of public health. Consider what we have seen during COVID-19. The threat posed by the pandemic has meant that, during the past year, the population has been receptive to the message of public health arguably like never before. Yet, even under these circumstances, there has still been resistance to public health. Such resistance—even in the midst of a pandemic—suggests that, for some, public health is seen primarily as an attempt to curtail freedom and enjoyment and is, as such, to be resisted. The great irony of this is that curtailing freedom and enjoyment is the precise opposite of what public health should aspire to do. Our actual intent is to ensure as many people as possible are free to live long lives full of the activities and interactions that bring happiness and meaning. Such lives are only possible in a context of health, of being free from the disease and preventable harm that can stand between us the pursuit of a happy life.

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Fixing Our Health System After Covid-19 | The Turning Point

The Covid-19 pandemic was the best of times, the worst of times, for our healthcare system. We saw the ceaseless efforts of frontline doctors and nurses, working to contain an unprecedented plague. Yet, we also were reminded of the fragility of our medical system, buckling rapidly under the weight of a new disease, made worse by lack of access to quality care for many, and a population burdened by chronic diseases that have made Covid-19 so much worse.

Our healthcare system matters. How do we protect it?

We argue for three things.

First, we can adopt payment models which encourage health rather than sickness. We currently have a model which incentivizes providing ever-more expensive care for disease. It is a sick care system. We readily attend to people who present for care with symptoms; we are less skilled at improving health across entire populations. Models which shift the focus of market competition to keeping patients well have been explored in shelves’ worth of books and we here deflect away from specific ways to implement. But the fundamental concept: changing incentives from sickness cure to keeping health, seems to us indisputable. Put simply, the medical care system needs to embed public health practices.

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UFOs, COVID, and the return of radical uncertainty | The Healthiest Goldfish

Imagine it is 2024. For the last few years, it feels as if the world has largely moved past the COVID moment. There is a widely-shared sense that we have successfully dealt with our generation’s big challenge, and can now resume a calmer life. COVID was the worst pandemic in one hundred years, so we allowed ourselves to believe it would be at least another century before we faced anything so disruptive again. Unfortunately, this turns out not to be so. A new pandemic emerges, shutting down the world again, this time for a full two years.

Such a scenario likely seems farfetched. Not because it imagines a global pandemic shutting down the world—while that may have seemed farfetched two years ago, we now know it to be all-too plausible. No, it seems farfetched because imagining another pandemic so soon after the last one violates our bias towards thinking the world is much more predictable than it actually is. Within the framework of this bias, there is room for unprecedented challenges, but only with the unspoken assumption that, the world being predictable, unprecedented challenge will be followed by a long period of relative tranquility, giving us time to collectively regroup. That another global pandemic could conceivably follow COVID in the next three years speaks to a reality of our existence we do not like to acknowledge—that it is deeply uncertain. Regardless of whether or not we see another pandemic in 2024, the possibility that we could is indeed an uncertainty we must each day face.

Earlier this month, The New York Times ran a story with a headline which spoke to the uncertainty with which we live, “U.S. Finds No Evidence of Alien Technology in Flying Objects, but Can’t Rule It Out, Either.” The story concerned an upcoming government report on Unidentified Aerial Phenomena (UAPs), an updated term for what are more commonly referred to as UFOs. The article contained this eye-catching line:

“[S]enior officials briefed on the intelligence conceded that the very ambiguity of the findings meant the government could not definitively rule out theories that the phenomena observed by military pilots might be alien spacecraft.”

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