The consent of the governed | The Healthiest Goldfish

Over the last year or so there has been much criticism of leadership in the U.S. for the state of affairs in this country. Government at the local and national level has been criticized for failures in mitigating COVID-19 and for challenges in addressing any number of the problems we collectively face. Such criticism is often warranted, helpful even. Power needs accountability, so that it can be used most effectively to support the common good (see prior thoughts on how accountability can help ensure effective functioning within bureaucracies). However, it strikes me that in much of this criticism there is an implicit belief that people in positions of leadership have more power than they actually do to sway events. We seem to believe that there is somewhere a magic wand which can be waved to solve our problems, and that it is only some kind of obstinacy which stops those in power from waving it.

This belief reflects a lack of understanding, on our part, of the extent to which the capacity of leadership to do, well, anything, depends on us—on the consent of the governed. In my writing, including in my upcoming book, The Contagion Next Time, I have found myself returning to a telling quote from Abraham Lincoln, “[P]ublic sentiment is everything. With public sentiment, nothing can fail; without it, nothing can succeed.” The power of public opinion is such that even a relatively low level of public engagement can be enough to reshape society. Research has suggested that it takes about 3.5 percent of a population actively engaging in political protests to bring about real political change.

Given this power, if the public withholds its consent from a given measure, governments face a steep uphill climb towards the measure’s successful implementation. It does not matter how much good the measure might do; without the consent of the governed, it cannot take effect to any significant degree. When this ineffectiveness occurs, it can look like it is solely the fault of incompetent leadership, when, in fact, leadership may be doing all it can within the confines of withheld public consent.

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How Our Expectations Shape Our Perception of Reality | The Turning Point

Japan hosted the 2020 summer Olympics, staged in the summer of 2021 due to a year-long Covid-19 delay. Japan, by any number of metrics did extraordinarily well at the games, coming in third in the gold medal haul, handily outperforming other traditional Olympic powers. And yet, despite this success, many Japanese athletes felt compelled to deliver tearful apologies at their ‘failures’ on winning silver medals.

The curious case of Japanese regret in a moment of triumph can only be explained when we remember that data (in this case, the medal type and count) are simply one input that drives our construction of meaning and truth.  The Olympics were held amidst substantial local controversy as Japan was facing a surge in its Covid-19 cases. This made for added pressure on the host country to do well, so much so that anything short of gold was seen as a failure. This was a dramatic reminder of the powerful role that our expectation of success plays in our perception of that very success.

Take the Covid-19 summer of 2021 in the United States. What started as a season of optimism, with President Biden declaring a summer of freedom with the Covid-19 vaccine, quickly turned sour when, less than a month later, a majority of Americans again thought that the worst of the pandemic was ahead of them, rather than behind them. The rise of the delta variant fueled the dramatic change in American public perception as the US started seeing an increase in Covid-19 cases which had been waning over the earlier months of summer. But the delta variant was not doing anything that was unanticipated. The delta variant was driving viral spread among those who were unvaccinated, with a clear inverse correlation between state-level vaccination rates and new Covid-19 infections. Critically, those who had received the vaccine had a very low risk of re-acquiring Covid-19, and were at even lower risk of being hospitalized or dying from Covid-19. In addition, we had a precedent for how we were going to do with the delta variant as the UK preceded the US by about a month in its epidemic curve and readily showed that we could expect a waxing—and then a waning—of new infections principally among the unvaccinated in the US.

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Resisting our suburban impulses | The Healthiest Goldfish

Suburbs can be terrific places. I live in a suburb, and I can think of few better places to live, to raise a happy, healthy family. Suburbs represent stability, and the ascent of the middle class, a trend which significantly broadens access to the material resources that support health. Indeed, when we speak about creating a world that generates health by expanding access to these resources, the ideal would be for everyone to be able to enjoy the level of wellbeing reflected by suburban life. 

However, this is not yet the case—far from it. This unfairness is enforced by policies that benefit those with more at the expense of those with less. It is also enforced by habits of thought that allow us, even if we consider ourselves progressive-minded, to oppose measures which would share some of our advantage with others. Sadly, perhaps inevitably, there is a racial element to this, just as there is to the broader gap between the rich and the poor, and addressing this challenge means speaking honestly about the full dynamics of the issue, including its intersection with race. I was struck by an article written last summer by former Minneapolis Mayor Betsy Hodges, where she tackled this uncomfortable truth, saying, “White liberals, despite believing we are saying and doing the right things, have resisted the systemic changes our cities have needed for decades. We have mostly settled for illusions of change, like testing pilot programs and funding volunteer opportunities.”  

Such observations are, I think, bracing and necessary. It is easy to see how ideological opponents can block progressive change; it is perhaps more difficult to see how our own blind spots can help stymie progress. Today’s column, then, will address the suburban impulses that can sway those of us who are committed to the pursuit of justice off the path that leads to better health for all, and how we can resist these impulses, to create a healthier world. 

What do I mean by suburban impulses? Fundamentally, they are captured by an acronym: NIMBY or “not in my backyard.” NIMBYism is when people living in a community oppose measures which would support the public good in that community when these measures would in some real or imagined way encroach on their own personal convenience (I have written previously about NIMBYism here). A corollary is that this opposition can come from people who would otherwise support such measures, as long as they happen somewhere else.

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Telling Different Stories with the Same Data | The Turning Point

Which country did the best at the Tokyo 2020 summer Olympics?  The United States led the way with the most medals: 113.  China had nearly as many gold medals: 38 to the US’s 39.  But are either total number of medals or total number of gold medals the best way to assess Olympic success?  Both the US and China are, after all, large countries. As pointed out by The Guardian, San Marino, a country with a population of about 35,000, won three medals or, effectively, eight medals per million people, readily dwarfing the US and China which won 0.3 and 0.06 medals per million respectively. So, who did the best at the Olympics? 

All of this is to say that the stories we tell ourselves about our success and failure can be quite different, even in the face of seemingly objective data—in the case of the Olympics, number of medals. This is always also the case in health, as much as in sports. And the same data can lend itself to quite different stories about our health achievement. The US spends far more on healthcare than any of its peer high-income countries.  And yet, we have lower life expectancy at birth than our peers. One story of our health that these data tell is that we spend far too much and have less health dividend than we should. But, we also perform better than almost all of these countries for persons over age 75—when healthcare becomes most important.  A story can then be told that we value our health throughout the life course, and that we spend accordingly, prolonging life, aligned with our national values.

That data are only part of any story we tell ourselves about our health has perhaps never been more evident than during the Covid-19 pandemic.  We struggled initially with what our goalposts should be, whether we considered success primarily a matter of having lower cases or fewer deaths.  Our data also told conflicting stories depending on the premium we placed on health equity.  Early rapid success in vaccination—the single most effective means to mitigate viral spread—was also accompanied by racial/ethnic gaps in vaccination. In most states, white people received a higher share of vaccinations compared to their share of cases, leading to widening racial gaps in risk of Covid-19. Was that early vaccination achievement then a success, or was it a failure? And the vaccines themselves remained extraordinarily effective even as the more transmissible delta variant swept the country. Among fully vaccinated people, re-infection rate was less than 1%, fewer than 0.004% needed hospitalization, and fewer than 0.001% died from the disease. And yet, concern about the delta variant dramatically changed the public perception of our success in mitigating Covid-19 in the summer of 2021.

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Resisting the allure of moral grandstanding | The Healthiest Goldfish

We are living in an age of the visible moral gesture. It seems that all events of some note in our cultural or political life are accompanied by statements of support or opprobrium from anyone with a Twitter account. Social media has democratized the opportunity to weigh in. It allows us to instantly speak in support of, or against, causes we feel are worthy of attention, with hashtags amplifying our words.

These gestures are often made with the best of intentions, and the sentiment they reflect—the wish to engage in the act of building a better world through praising the praiseworthy, or the converse—is admirable. There seems to me no question that some of this social media statement-ing has brought attention to important issues, elevating necessary conversations. But it also seems worth wondering if our focus on these gestures is really helping advance the cause of creating a better world. Could our outpouring of moral gestures on the occasion of, well, everything, be less effective than we think it to be? Could it even be a distraction from what we should be doing to shape a better future?

These questions raise the uncomfortable issue of moral grandstanding. By moral grandstanding, a term originating in psychology, I mean acting and speaking in ways which project the appearance of morality not for the sake of issues themselves, but as a means of reaping the social benefits of being seen to be a good person. It is similar to a term many of us have heard, “virtue signaling.” Such behavior has long been with us. History and literature are full of examples of people who have achieved status by broadcasting a virtue which they may or may not actually possess. Moral grandstanding, and the tendency towards hypocrisy, is also warned against in some of the major religions, as in this passage from the Gospel of Matthew, a tenet of Christianity.

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The Limits of Our Tolerance | The Turning Point

On May 28, 2021, the Centers for Disease Control and Prevention (CDC) issued new Interim Public Health Recommendations for Vaccinated People,essentially giving a green light to fully vaccinated people to resume activities without wearing a mask or physically distancing. This guidance surprised nearly everyone, coming just a few weeks after the CDC director had noted that she had a sense of “impending doom” as she was watching the pandemic unfold. It reflected a dramatic pivot point in the US handling of the pandemic, an implicit shift away from community responsibility for Covid-19 transmission, towards individual responsibility. It suggested, essentially, that the onus was on those who remained unvaccinated to take precautions because the vaccinated could drop their effort to protect others.

Leaving aside arguments over whether this was the correct move based on the science, we saw this as an expression of the CDC’s appraisal of what regulation the country could—and could not—bear, and an acknowledgement that after a year of Covid-19 restrictions, the country was at the end of its pandemic tolerance.

The last 18 months of Covid-19 has tested us all. The hardships experienced were, of course, quite variable in scale; nothing compares to the pain and grief of losing loved ones.   And yet, it was the sum total of all the pandemic-era experiences and losses that shaped the landscape of population behavior during Covid-19, and directly or indirectly, set the stage for what we collectively were willing to do to mitigate the spread of the virus.

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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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