Public pieces.
RGovernment scientists shape, implement, adjudicate, and enforce public policies of every stripe. Any data-based issue that might require government to act—from gun control to tobacco use to the opioid crisis to the safety of vaccinations to climate change—is a point at which, to some, government could infringe upon business or personal liberty. Disputants turn to rejecting factual evidence on these problems as a way to undermine government action.
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Over the past year or so, these essays have tried to articulate a new practical philosophy of health for this moment, engaging with topics of consequence for how we conceptualize health, towards better understanding what we think about when we think about health. In this sense, they represent a cycle, just as past writings in The Healthiest Goldfish have been a cycle, most recently with the essays which informed my last book, Within Reason. These reflections on shaping a new practical philosophy of health were meant to be useful, to help inform conversations towards building stronger foundations for our pursuit of health going forward. Having engaged with this theme for a while now, it seems a good time to review some of the ideas that have emerged over the course of this writing. I do so today with an eye towards concluding this cycle of essays, as I think about evolving my Goldfish writing and thinking, in a period of personal reflection and reassessment.
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Randomized trials originated in agricultural research in the 1920s where the field conditions of experiments with seeds were nearly perfectly controllable. Trials soon moved to humans, and studies to lower high blood pressure and other conditions using medication have been successfully completed and interpreted thousands of times; randomization of individual patients to individual pills is also reasonably controllable. But there are scientific experiments that are less manageable, more subject to forces that are largely unpredictable. For example, researchers recently set out to study ways to reduce opioid overdoses deaths in towns across America and used a randomized trial design—the scientific method that has historically brought us our most reliable evidence—but applied here to a knottier problem. These researchers entered the messiness of the complex system non-scientists call “the real world.” Such a study raises the question: is it possible to impose city- or community-wide interventions that change health behaviors and outcomes?
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The work of science is generally carried out in institutions that create the conditions for research and scholarship to flourish. Those institutions, principally universities—but also including research institutes, private corporations, and some other entities—have created structures and mechanisms to evaluate the work of scientists. At universities—where in the U.S. most of the work of science is done—scientists are typically professors who advance through the ranks as assistant, associate, and full professors. Institutional review committees evaluate the contribution of the scientist to move them along the path to promotion.
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Taking stock of the present, to shape a healthier future.
I will start this essay by saying something controversial, something which many readers may disagree with, perhaps strongly: there has never been a better, healthier time to be alive than right now. I say this is controversial because we are in the business of improving health. This starts with recognizing the many ways health needs improvement. If we do not spend significant parts of our days deepening our understanding of how health is undermined by forces like racism, inequality, climate change, and hate, we are, in a sense, not doing our job. Doing our job also means communicating to the wider world how these forces harm health. This work of communication means emphasizing where we are falling short on health and, perhaps at times, strategically deemphasizing where we are actually doing well.
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International weapons treaties work from a motto based on an old Russian proverb: trust but verify. Science works from a related point of view: trust and verify. The “and” is important. As scientists, we tend to concentrate on the verification aspect: we like to double- and triple-check our own findings before making them public. But as a scientific community, we move forward based on trust. We accept that knowledge is communal and cumulative, and we depend on the work of our predecessors and contemporaries.
To a great degree we are obliged to trust others. When we perform peer review—the sine qua non of the scientific enterprise—we trust that the data presented is legitimate and that the study proceeded in the way that the scientists who performed it said it did. Scientific methods are a central part of any published paper—the protocol, the population, the analysis—allowing replication by others. Yet we must admit that when we peer review studies, we concentrate on study design and the authors’ data interpretations and have no easy way to judge the authenticity of findings. Groundbreaking work always requires replication, verification.
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We are entering the last few months of a year that has been marked by horrors. Around the world, we have seen conflicts that have injured, killed, and displaced many. It has been nearly a year since the October 7 attacks, when Hamas invaded Israel, killed 1,139 people and kidnapped 251. Israel’s retaliatory actions in Gaza remain ongoing, a conflict which has killed over 40,000. Russia’s war on Ukraine also continues, with more than 500,000 dead and creating global tensions which threaten the world with their potential for nuclear escalation. In Sudan, a civil war has killed some 150,000 people and displaced over 8 million, with no end in sight. These conflicts are devastating for the millions of humans caught up in them. This reality has made for appropriately strong feelings, particularly on college campuses, as we have engaged with the challenge of what to do, as individuals and communities, when faced with atrocities that harm many.
The moment is ripe for turbulence and belligerence. These global conflicts are occurring against a backdrop of mistrust and division, with politics and culture increasingly polarized. In the US, we are facing a federal election in November with the potential to surface much of this division. It seems fair to anticipate that many of us will be engaged in the moment, that none of us will emerge without emotionally tangling with some aspect of what is swirling around us. This engagement will require, of all of us, a clear-eyed commitment to our core aspiration—to build a healthier world by creating the structures that generate health. This means working in the space of ideas in a way that is constructive, humane, and supportive of the kind of world we wish to see.
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In a series of papers we published over the past decade, we explored a question that seemed to us interesting: Why were there dramatically different schools of scientific thought about whether reducing population-level salt intake would result in fewer cardiovascular complications?
The science has long been settled that for people with high blood pressure, salt reduction can be part of the risk reduction armamentarium. However, two competing National Academies of Science, Engineering, and Medicine reports came to rather different conclusions, highlighting the lack of consensus in the field about the utility of reducing salt for everyone. While one report noted that this was an open question for decades, the other report said that “For 40 years we have known about the relationship between sodium and the development of…life threatening diseases.” This leaves consumers confused and policymakers without direction.
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This is the personal website of Sandro Galea. All photos are taken by Sandro Galea.
