The problem of positional bias | The Healthiest Goldfish

In last week’s Healthiest Goldfish, I discussed how our individualist bias can stop us from seeing the full picture of what matters most for health. Today, I would like to talk a bit about how our positional bias can do the same. I do so as part of a series of columns leading up to the November 1 release of my new book, The Contagion Next Time, which aims to help us look past our biases to see the true causes of health during the pandemic, so we can prevent the next one.  

Positional bias is, broadly speaking, when our vision of health is blinkered by our socioeconomic status—when we cannot see past the confines of our own immediate circumstances, to recognize the true drivers of health. I recently wrote about a form of positional bias when I touched on the suburban impulses that helped shape attitudes towards COVID policies, as stricter lockdowns were more widely embraced by the populations most able to easily navigate them.

For today, I will use a different example, that of vaccine hesitancy and the challenge of understanding it. As I write this, the US is currently undergoing the delta wave of COVID-19. What is distinct about this wave is that nearly all COVID deaths are among the unvaccinated. While the vaccinated can still be infected—although this is rare—we have seen a dramatic decoupling of infection rates from death rates. This speaks to the effectiveness of vaccines and the danger posed by vaccine refusal. On April 19, 2021, the date by which President Biden said all adult Americans would be eligible for the COVID-19 vaccine, there were 567,314 total COVID deaths in the US. On October 15, there were 742,008 total deaths. While the 174,694 deaths which occurred between these two dates cannot be laid entirely at the feet of vaccine hesitancy, it is undeniable that mistrust of vaccines informed the conditions that made these deaths likelier.

Read the full post at The Healthiest Goldfish.

Why did we Keep our Schools Closed? | The Turning Point

By March 2020 the Covid-19 pandemic had taken hold in America, and within a few days the country had moved to an unprecedented slowdown of civic and professional life in an effort to limit the spread of the virus.  As part of this general shutdown we closed K-12 schools. In spring of 2020, 48 states required or recommended the closure of public schools; more than 50 million children and their teachers stayed home. In the face of a new, poorly understood virus, our collective shut down was entirely reasonable, and to a large extent remarkably successful.  

And yet, by the summer of 2020, data were emerging that showed that children were less likely to contract Covid-19, and if they did, their disease was mild, and they had a low probability of transmitting it. Data quickly accumulatedshowing that children were unlikely to be an important cause of viral transmission. This, coupled with other data showing the educational and social developmental losses that were being incurred due to persistent school closure—often affecting marginalized children more than others—made a strong argument for re-opening schools in the fall of 2020.  

And yet, schools continued to remain closed, affecting as many as half of allchildren in the US in the fall of 2020 with only about a quarter of schools remaining fully open for in-person learning. Why did schools stay closed when we knew that the risk of them staying closed probably outweighed the risk of them re-opening?  Of course, societally, we are always particularly tentative if we can imagine even the smallest risk of children dying. But we suggest that there were three additional reasons, and that we might do well to learn from each of them.

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Looking beyond our biases | The Healthiest Goldfish

The 1999 film, The Matrix, is about a man who discovers the world as we know it is actually an elaborate simulation created by intelligent machines who use it to control humanity in the “real” world—a dystopian future where the machines have taken over. In the decades since its release, the premise of the film has become an established metaphor for realizing that the world as it is can sometimes be radically at odds with the world as we perceive it. As one close-to-home example of this, I can recall the moment when I realized that health is more than doctors and medicines; that health is, in fact, an emergent property of the world around us, and that working to improve health means working to improve the context in which we live, and that it is that world that we should be focusing on to improve health.

Much of my career in public health has been an effort to make this very case—a vision of health that only sees health care is incomplete, that we need to talk about far more when we talk about health than treatment alone. In the post-COVID era, this strikes me as more important than ever. The dominant sense of the last 20 months is that what we just lived through was fundamentally a story about a virus. This, I would argue, is wrong, or at least incomplete. True, a coronavirus was the precipitating factor in what we experienced. But the nature of that experience was deeply, decisively shaped by the same factors that always shape health—politics, culture, the economy, the places where we live, work, and play, our social networks, and other structural forces that shape our world. Preventing the next pandemic means engaging with these forces, to shape a healthier society. To do that, we must first be able to see them clearly, to take the measure of their influence on health. Helping us do so is the aim of my forthcoming book, The Contagion Next Time, which will be released on November 1. The book argues that the pandemic was, at core, a story about how structural forces in our society left us vulnerable to the virus. The title is a tribute to James Baldwin’s book, The Fire Next Time, which helped readers better see the challenge of racism, and to insist this challenge must be faced in order to avoid future catastrophe. Contagion aims to shine a spotlight on forces in our society that shape health by examining them through the lens of the COVID moment, and in so doing cast light on the world as we should perceive it, rather than the world that dominates in the public narrative.

Recognizing then that we need to see the world somewhat differently has me asking often, what is it that keeps us from seeing the right world? It seems to me that we see the world the way we do through our biases. 

Read the full post at The Healthiest Goldfish.

Does Today Matter more than Tomorrow? | The Turning Point

Covid-19 has shown us that the present—the today—can be, at times, overwhelming in its salience, and there is little that we can do, or indeed should do, that does not focus on the needs of the moment. At the beginning of the Covid-19 pandemic, in the first terrifying few months of a disease that we did not understand, it was appropriate that we invest every bit of our effort in mitigating the immediate threat we faced. But at what point does tomorrow matter more than today?

There are multiple ways in which one can approach this question. Economists approach it through time discounting, the study of how the value of rewards is shaped by their temporal proximity. Benefits that accrue in the present tend to matter more than those that may accrue in the future, losing value the more distant they become from the present moment, simply because, all things being equal, we put more value on the bird in the hand. There are, of course, alternative perspectives. If we prioritize the needs of future generations-- any parent who invests their money into college funds for their children rather than buying a new car does this—we are valuing the future more than the present.

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Inefficiency in the pursuit of excellence | The Healthiest Goldfish

Among the lessons I am trying to learn, as we navigate the COVID-19 pandemic, is how best to learn from inefficiency. Let me explain. It seems to me that at our best, as a society, we aspire to efficiency in pursuit of excellence. This pursuit entails looking for ways to maximize our time and resources; a focus on improving skill sets and finding ways to enhance productivity. In public health, we pursue efficiency towards the aim of shaping a healthier world. This lends itself to a particular worldview in which we tend to see events through the lens of the conditions that shape health and our commitment to improving these conditions.

This perspective informed our response during COVID, yielding both success and some shortcomings. It allowed us to get much right, helping us provide the public with effective recommendations as we navigated the pandemic. But a fair assessment of our performance during COVID would have to concede that we also had some blind spots, areas which fell outside our perspective, exposing the limits of our collective focus. We did not always account for the degree to which partisan politics mediated how populations engaged with public health recommendations, nor were we always effective at seeing our own biases and how they informed mistrust among the populations we serve. Instead, we did what we do—focused on the core aims of our field, worked to refine our methods, and proceeded from there.

This suggests that there is more to getting better at our mission of supporting health than the efficient pursuit of our core focus to the exclusion of all else. There is also the richness that comes from the interstices, from seeming inefficiencies, from the detours which ultimately take us to a different, perhaps better, destination then where we thought we were going.

Read the full post on The Healthiest Goldfish.

The Caring Infrastructure | The Turning Point

Covid-19 has exposed social problems that existed long before the pandemic. For one, Covid-19 has exacerbated long-ignored challenges we face in caring for the elderly, the disabled, and younger children. Nursing homes became foci of infection and death during the past 18 months. Group homes, day-care, and home-care services for the disabled and elderly disappeared. Schools closed. Caregivers clearly rose to the top of the list of our most essential workers. And this essential workforce, itself sickened, further reduced the substructure holding up our infection-shaken economy.

Backlogs for home and community-based care were already impossibly long for hundreds of thousands of people before Covid-19. Back then, inadequate services challenged predominantly low-income Americans who had to rely on government subsidized caregiving. During Covid-19 the shortage became an issue for everyone. Fifty-three million family members were already providing most of the care for vulnerable seniors and people with disabilities before Covid-19. As caregiving shortages became rampant, the burden of caregiving fell to all, making it next to impossible for families with two working adults to also juggle caregiving responsibilities. Without care options, many adults, most often women, left the workforce.

Essential work, as is now abundantly understood, has historically been underpaid. Covid-19 has exposed a caregiver workforce earning substandard salaries. Caregivers, such as nursing assistants and home health and personal care aides, earn on average, $12 an hour. Most are women of color; about one-third of those working for agencies do not receive health insurance from their employers. By the end of this decade, an extra one million workers will be needed for home-based care.

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Health in an era of resurgent great power conflict | The Healthiest Goldfish

This summer, the journal Nature Food published a study which is, in many ways, a microcosm of a key force shaping the future of global health: the US-China relationship. Notably, the study did not concern COVID-19. It was about soybeans. The study found that China’s retaliatory tariffs on US agriculture could “cause unintended increases in nitrogen and phosphorus pollution and blue water extraction in the United States as farmers shift from soybeans to more pollution-causing crops.” The study also looked at the potential global ripple effects of the trade dispute, suggesting that, if China’s soybean demands were diverted to Brazil, meeting them “may add additional pressures on phosphorus pollution and deforestation.” Given the extent to which our health depends on the condition of the natural world, these environmental consequences pose, in themselves, a threat to public health. More broadly, however, the force underlying them—simmering conflict between global superpowers—reflects an even deeper challenge to health in both the near- and long-term.

In many ways, these tensions are part of a larger story—that of globalization. Public health has long been engaged with this story, as globalization has increasingly helped shape the macrosocial determinants of health. As countries become more interconnected, their relations with each other have ever-greater influence on the determinants of health, both within and without their borders. Rising tensions between the US and China—fueled by a range of economic, cultural, and historical forces—have long been part of the conversation about globalization. But they have only recently factored into the conversation about health in a significant way. The emergence and spread of the pandemic are inseparable from the geopolitical concerns of the moment. There is an ongoing debate about the origins of the virus—whether it leaked from a lab in China or was zoonotic in origin. Tensions between the US and China are a key reason why this debate remains unresolved. From the start of the pandemic, the Chinese government has been reluctant to share information about the virus, and the hostile posture of the superpowers has helped maintain this status quo. This has had consequences for our ability to address the pandemic as it unfolds, and to prevent future contagions. It also has implications for how we think about globalization and health more broadly, in a “shrinking” world. Great power conflict reminds us that health does not occur in a vacuum, that it is shaped by global forces which are now coming to the fore in the actions of great powers.

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A Tale of Volition | The Turning Point

Groups long marginalized by health systems continue to have limited access to vaccines and this is heartbreaking. But what about those—as many as a third of the US population—who can be vaccinated easily, but simply do not want to. How do we understand their vaccine refusal?

Herman Melville’s 1853 short story “Bartleby the Scrivener” reckons with the possibility that freedom can be realized through a refusal to submit. Bartleby is the hard-working, dutiful scribe of a Wall Street lawyer, who, at a certain point, refuses to do the tasks that his life demands. When he is asked to do his job, he responds, “I would prefer not to.” Thereafter, he refuses everything, eventually food and water, until he dies of starvation.

“I would prefer not to” haunts the story because Bartleby (and Melville) offers no reason for his refusal. We want to know why we would prefer not to, but there’s no reason. He doesn’t need to give a reason.

In addition to the 15% of Americans who avoid all immunization, Covid-19 refusers continue to claim there is not yet enough real-world experience (despite hundred of millions of doses administered), or that any new vaccine could produce late side effects we don’t know about, or that Covid-19 is mostly a mild disease, or that they will be fortunate or careful enough to avoid infection. But none of these reasons are in and of themselves sufficient explanation.

Read the full post on The Turning Point.