How bad ideas can make good ones better | The Healthiest Goldfish

In public health, we talk a fair bit about diversity. This conversation is consistent with the broader goals of our field. Our mission is to serve populations with many different backgrounds and perspectives. Engaging with a range of groups—with all of us as different people united in our shared humanity—means celebrating the diversity we reflect, and working to ensure this engagement is fully inclusive. I have written previously about diversity, including in The Healthiest Goldfish. At perhaps the most basic level, a commitment to diversity calls on us to ensure that the public health community is a welcoming space for people of many races, religions, nationalities, and expressions of gender/sexual identity. This strikes me as a necessary condition for our efforts, worth pursuing, always, as a key priority.

But diversity does not just mean diversity of identity. It also means diversity of opinion. A benefit to having communities of people with different backgrounds and identities is that each person has a unique perspective they can bring to bear on the conversations that happen in these spaces. These perspectives can sharpen our collective thinking, helping us to do what we do better. It is important to note that diversity of identity is often closely linked to diversity of opinion, but one does not invariably follow the other. The deciding factor is whether or not we value viewpoint diversity enough to encourage it the same way we encourage diversity of identity.

Read the full post on The Healthiest Goldfish.

Borders in an age of pandemics | The Healthiest Goldfish

Readers of this blog will recognize several familiar themes. One of them is that the world is not straightforward, and interesting answers are seldom simple. I have written previously about how core to our thinking about health should be a capacity to engage with ambiguity and issues which do not always neatly resolve. This has never been truer than when it comes to the issue of national borders in the context of pandemics. Borders and migration have long been some of the most fraught terrain in our current political debate. The issues elicit strong feelings on all sides—whether one favors maximally exclusive national boundaries or something akin to open borders. The conversation about borders becomes even more complicated in the context of infectious disease outbreaks. 

At the core of the issue are two contradictory, yet equally true, realities. 

First, pandemics expose the fundamental interconnectedness of health. It is the case that outbreaks will spread without heed to the artificial lines on maps we call “borders.” With that in mind, borders can play a role in containing outbreaks and closing national borders as early and tightly as possible during an outbreak can, combined with aggressive in-country testing and tracing, help to protect populations from emergent world-wide contagion. The figure below reflects the world’s dawning appreciation of this, showing the state of border restrictions early in the COVID-19 pandemic. 

Read the full post on The Healthiest Goldfish.

HIV and Covid-19: Improving Health Care and Health | The Turning Point

Two pandemics bookend the last forty years—HIV and Covid-19. The first changed our view of health care and its delivery in dramatic ways. Perhaps the second will change our view of health and who has access to it.

Three years past the initial 1981 report of persons with a new infectious syndrome was published, the activist Larry Kramer wrote an article “1112 and Counting” in which he berated every government official connected with health care—from CDC and NIH administrators to local politicians—for refusing to acknowledge the widening AIDS epidemic. (President Reagan had not yet said the word HIV publicly and wouldn’t for four more years). The burden of HIV fell on certain marginalized groups. As the HIV epidemic surged, gay men demanded vigorous federal intervention on their behalf. They wanted the benefits, protections, and resources that only Washington could provide. Cohesive activism slowly developed, taking years to organize, but what the reshaping of public opinion around HIV and biomedical activities produced was dramatic. The average FDA approval time of new drugs went from a decade to a year. Patient groups had to be consulted when new drugs were being reviewed by federal agencies. The purity of the placebo-controlled trial was re-imagined. Consumers started to demand to know treatment options and success rates and to be able to shop for the best care. It was a new era in biomedicine and in being a patient in the health care system.

We jump ahead 40 years. The political response to Covid-19’s arrival was actually worse than Reagan’s choice to ignore AIDS. On January 2, 2020, the director of the CDC contacted the National Security Council to warn about early cases of the coronavirus in China and the potential that it could spread to the United States. Yet when President Trump’s first televised remarks came 3 weeks later, he said, “We have it totally under control. It’s one person coming in from China, and we have it under control. It’s going to be just fine.” Warnings by scientists were soon termed a “hoax.” The disinformation campaign that followed mattered gravely because Covid-19, a respiratory illness, was a broader threat to the general public than HIV ever was.

Read the full post on The Turning Point.

The history of soccer, the butterfly, and public health | The Healthiest Goldfish

My favorite game by some distance is soccer. The game has been in the news lately, most recently with the arrival of the US Women’s National Team—who have done so much to bring attention and energy to the sport of soccer—at the Tokyo Olympics. In the spirit of the moment, I wanted to start with a story about women’s soccer, one that illustrates a key feature of the dynamics that shape our world—and our health.

A key issue in the soccer world, which has belatedly risen to the fore in recent years, is the pay gap between women’s soccer and men’s soccer. One often hears, as justification for a status quo where women players make less than men, that the pay gap simply reflects the fact that women’s soccer has a consistently smaller audience than men’s soccer. While it is true that the audience for women’s soccer is smaller, this begs the questions: did this disparity simply “happen”? Or were there discrete events in the past, choices made, which, over time, led to the present outcome? The answers lie in the history of organized women’s soccer, which dates back to the 19th century.

In the 1890s, there were several women’s soccer clubs in England. In the early 1900s, some of their matches attracted thousands of spectators. This progression, building in parallel with men’s soccer, came to an abrupt halt in 1921, when the Football Association banned women’s soccer from the grounds of its clubs, out of a belief that the game was “unsuitable” for women. It was more than 45 years later, in 1969, when the Women’s Football Association was formed.

Read the full post on The Healthiest Goldfish.

The Problem with Health Behavior | The Turning Point

The conditions of where we live, work, and play, our wealth and resources, inexorably shape our health. But how do these social forces become health?  Through a variety of mechanisms, one of which is, unquestionably, our behavior. 

If I am living in a dangerous unwalkable neighborhood I am less likely to exercise, and more likely to suffer from obesity and attendant heart disease. So, behavior is integrally linked to the world around us, but also itself central to our efforts to improve the health of populations.

This has never been clearer than during Covid-19. Differential early burden of Covid-19 was driven in no small part by changes in behavior. As those with resources were able to shift rapidly to working from home, they had lower risk of acquiring Covid-19, and subsequent lower burden of infection and death from the pandemic. Yet as Covid-19 progressed, prolonged social isolation became associated with harmful behaviors including use of substances, leading to a surge of poor health we will be dealing with long after the worst days of Covid-19 have passed.

Read the full post on The Turning Point.

A playbook for balancing the moral and empirical case for health | The Healthiest Goldfish

At core, public health aspires to strike a balance between the moral and the empirical case for health. I have long thought that at times public health arguably did not go far enough in advancing the moral case. This is what motivated me to argue in the past for an epidemiology of consequence.  In that, and subsequent writing with Katherine Keyes, I argued for an approach to public health which, at its core—guided by the moral imperative of generating health for the greatest number of people—aims to apply its empirical knowledge to the pursuit of a healthier world. This means prioritizing, on moral and empiric grounds, engagement with the issues that matter most for health, our research guided first and foremost by the demands of human need, with an eye towards doing the most practical good.

In recent years, the pendulum has indeed swung in this direction, towards a consequentialist public health guided by the moral case for health. Our collective balance, our effort to find the right mix of moral and empiric motivation has been tested perhaps like never before during COVID-19. This is understandable. Issues of consequence for health are, by definition, matters of life and death, which concern the wellbeing of everyone—both present and future generations—and matter with particular urgency when we are all, or some of us are, vulnerable. COVID-19 has been particularly troubling as we often found ourselves needing to make a moral case faster than empiric evidence was readily available. And yet, despite this challenge, it continues to seem to me important to make sure that for our arguments to most successfully support health, they should aspire to strike a balance between the moral and the empirical. And that this is perhaps even more the case in a time of crisis. Today’s Healthiest Goldfish reflects some thoughts on how we can regain, and maintain, this balance.

The below grid is meant to help visualize how we might approach this. It was inspired by Donald Stokes and his book, Pasteur’s Quadrant: Basic Science and Technological Innovation. Each of the grid’s quadrants contains an action which could arguably help create a healthier world. The quadrant at the top left is for steps for which the empirical case is strong, but the moral case needs development. The bottom left is for steps for which both the empirical and moral case need development. The bottom right is for steps for which the moral case is strong, but the empirical case needs development. The top right is for steps for which both the empirical and moral cases are strong—this is where all our arguments should aspire to live.

Read the full post on The Healthiest Goldfish.

The Limits of Our Science | The Turning Point

The Covid-19 pandemic has been characterized in the public space by enormous fractures, mirroring societal divisions, that have often pitted the science that could inform better response to the pandemic against ideas driven by little more than ideology. This was immensely complicated by President Trump’s assumption of strong positions—for example, on the purported utility of hydroxychloroquine as a treatment for Covid-19—that had no basis in scientific fact. Such highly visible support for ideas that were simply wrong, at a time when the world needed clarity without false hope, pushed science to the fore to an unprecedented degree. “Follow the science” became a rallying cry and was part of then-candidate Biden’s appeal to voters. He promised that he would take a still-evolving Covid-19 science seriously if elected president, in stark contrast to the then-incumbent.

Few would argue that science should not be at the heart of decision-making during a pandemic. There is, however, and appropriately, a growing body of work that discusses what science can, and cannot do. As we look to learn from the Covid-19 moment, it seems worth asking—what are the conditions under which we may be suitably cautious about the science? Three principal conditions come to our mind.

First, we should be cautious about science informing decisions about particularly complex systems, where science can inform our understanding of particular aspects, but where these narrow aspects are only part of a larger and more intertwined whole. This was perhaps most clearly borne out during the pandemic when it came to decisions around keeping K-12 schools open. The science showed relatively quickly that children were at low risk from the virus, and did not much influence transmission of Covid-19 in the general populations. However, the issue of school opening went beyond a single scientific question. Certainly, there were inputs related to the estimated risks of viral transmission, but there were also risk perceptions and issues around the protection of teachers that transcended ready scientific solutions. Scientific engagement on issues that involve different groups with diverse interests need to be focused on particular questions (e.g., how much do children transmit the virus?) but embedded in larger and more complex societal decision-making.

Read the full post on The Turning Point.

Why will we remember what we remember about COVID-19? | The Healthiest Goldfish

Last week, I suggested that, while the COVID moment is far from over, it is possible to see the outlines of what well may become the dominant narratives of this historical period, the key stories we will tell when we look back on the pandemic. The stories that, to my thinking, could rise to the surface are: the story of scientific excellence (reflected centrally in the rapid development of mRNA vaccines), the story of the presence of inequities in both morbidity and mortality from COVID and in populations that faced the brunt of the economic costs of the steps we took to mitigate the pandemic, the story of widespread loss of trust in institutions as a consequence of partisanship and the spread of misinformation, and the fact that, for all the suffering caused by COVID, it could have been far worse, had we faced a more lethal contagion.

Fundamentally, these stories inform a core narrative of why we believed what we believed during COVID—why we came to regard the virus as a threat worth shutting down the world over, worth the pursuit of novel vaccines, worth better understanding inequities, worth trying to convey accurate information in a climate of institutional mistrust, and worth recognizing that the next contagion could be worse. Today’s Healthiest Goldfish will consider why we will remember what we remember about COVID—why certain narratives may “stick” while others may not. Such a consideration is useful, I think, because it reflects why opinions cohere among groups, and the values and habits of thought that underlie the choice to embrace, or not embrace, the narratives that inform health. How we prepare for the next pandemic will depend, in large part, on the story we tell about this one. The better we understand the forces that shape our narratives about health, the healthier we can be, and the better we can prepare for the next pandemic.  

It strikes me that certain narratives are likelier to stick when they meet the following three criteria: they seem to fulfill our pre-existing biases, they fulfill an aesthetic need for coherence (i.e., they seem to “connect the dots,” reflecting some measure of order in a chaotic world), and—yes—they are told by dominant groups, promoted by those in power, by “winners.”

Read the full post on The Healthiest Goldfish.