The ineluctable role of the faceless bureaucrat | The Healthiest Goldfish

When I was in New York City I was talking to a colleague and happened to make a comment about how much of the work of public health is about establishing bureaucratic norms. My comment reflected how a core focus of our work is creating effective processes within institutions that support health—which is indeed the work of bureaucracy. My colleague responded by saying, “Wait till they call you a faceless bureaucrat.” This remark—which, perhaps, I should have seen coming—captures the disregard many have, intrinsically, for bureaucracy. The very word conjures blandness, redundancy, and red tape. This is reflected in representations of bureaucracy in film and literature, in the novels of V. S. Naipaul and Franz Kafka, and in movies like Office Space and the television show The Office.

So, bureaucracy is easily lampooned. But what, exactly, are we lampooning? Is it the reality of what bureaucracy does, or merely the reputation of bureaucracy—the outward trappings of what is, in fact, a complex and essential sector?

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The aesthetics of a healthier world | The Healthiest Goldfish

As we enter the Sunday of Summer, I wanted today to muse on a somewhat lighter topic than ones I have taken on of late—namely the aesthetics of a healthier world.  Public health is an aspiration as much as it is a technical set of skills, tasks, and methodologies. It is, at core, the pursuit of a vision—a vision of a healthier world. This pursuit is more than a technical process. It is an imaginative, creative endeavor. It requires us to radically rethink what the world could be, so that our aspirations might support a future which is far better than our past. To imagine a radically healthier world is to imagine a world unlike one we have yet seen. Lacking this frame of reference means we need to draw on our creative capacities in envisioning this future. Doing so takes us beyond the realm of purely technical considerations, and into that of art and metaphor. I recently wrote the introduction to an “Arts and Public Health” supplement for the journal Health Promotion Practice.  I am grateful to the editors for affording me a chance to think more about how art reflects and informs the forces that shape health. This Healthiest Goldfish is, in part, inspired by these prior reflections on the interplay of art and health and the work of many who have written on this topic. Leaning for a moment on the work of Leonard Bernstein who once said:

“Any great work of art…revives and readapts time and space, and the measure of its success is the extent to which it makes you an inhabitant of that world, the extent to which it invites you in and lets you breathe its strange, special air.”

This speaks to how art, through its aesthetic power, can shape a vision of a different world, one which invites the public to engage with new possibilities for how life could be. Is there any reason why the pursuit of health should be less visionary? Bernstein was a master of working within the medium of music to transport listeners to another place. His music for West Side Story, for example (with lyrics by Stephen Sondheim), takes those who hear it to an impressionistic, almost dreamlike version of New York City, which serves as the canvas for a tale of tragedy and young love. If such care can be taken to craft a fictional world for audiences to enjoy, public health, which seeks to create a new world in a literal sense, should be just as comfortable working within aesthetic domains as it is engaging with the more tangible aspects of our field.

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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.

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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. 

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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.

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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.

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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.

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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.

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