Our place in the natural order of things | The Healthiest Goldfish

I have written previously about the aspirations of public health, seeing public health more as a journey, a path on which we should always be traveling, towards creating a better and healthier world, rather than as any specific set of actions, prescribed by narrow strategies. The challenge in that vision is that it risks being too broad, too all-encompassing. It then often falls on us to ask: what matters most? What should we be acting on to best advance our aspirations?

These questions can seem abstract. But the COVID-19 era has made them perhaps sharper in our minds than ever, providing urgent, real-world examples of their relevance. Addressing these questions is an animating force behind why I am writing The Healthiest Goldfish. Chiefly, I am trying to understand, through writing, what matters most to those of us who care about the aspirations of public health. I have, with colleagues, written previously about what matters most from a technical perspective, but in a year when we are (hopefully) emerging from COVID, I find myself asking—what values and aspirations should we be foregrounding, as we look towards creating a healthy future?

I was recently reflecting on this question by thinking about parallel universes, which, in my disciplinary home, epidemiology, we call counterfactuals. These counterfactuals allow us to model how the introduction of a given variable might shape health. We do so by comparing a real world where someone may, say, smoke, with a counterfactual universe where that same person, with everything else held exactly the same, does not smoke. This allows us to compare counterfactual universes where all is the same except for that one variable, whereupon we can then conclude that if the person we are observing gets lung cancer in the universe where she smokes—and avoids it in the universe where she does not—we might say with some confidence that smoking causes lung cancer.

Read the full post on The Healthiest Goldfish.

Health Inequities Beyond Covid-19 | The Turning Point

In 2020, Covid-19 was the third leading cause of death in the US for persons over age 45, and the second leading cause of death for persons over 85. There is no argument that Covid-19 represented a cataclysmic event for health, one from which we are now slowly beginning to see signs of potential recovery.

Taking a step back, since the beginning of Covid-19 more than 4 million people have died from all causes. In any given year, almost 3 million Americans die, with the leading causes of death being heart disease, with about 650,000 deaths, and cancer, with about 600,000 deaths annually. As we begin to move beyond Covid-19, it becomes then important to ensure that we take what we have learned during this past year and apply it to US health going forward.

The disproportionate burden of Covid-19 borne by people of color has brought to a fore the centrality of health inequities, the unfairness that underlies health inequities, and has produced new urgency to address systematic forces like structural racism and underinvestment in ways to improve the social conditions that create health as a means of tackling these inequities. But these same forces are relevant not only to the deaths due to Covid-19. The deep and entrenched racial and socioeconomic inequities that drove Covid-19 influence nearly all other deaths in the US. In a recent analysis, sociologist Elizabeth Wrigley-Field estimated that 400,000 excess white deaths would be needed to raise white mortality to the best ever black mortality; it would take 700,000 excess white deaths to narrow the Black-white life expectancy gap. This analysis of course suggests that the scope of death from Covid-19 is comparable to the scope of the Black-white gap in mortality in general, every year.

Read the full post on The Turning Point.

“One does have joys” | The Healthiest Goldfish

Public health is fundamentally about trying to create a world that is healthier, better. In doing this work, we must, at times, assume the role of commenting, a priori, on how we are falling short on generating health. This can have the effect of making a discipline that is all about health seem chiefly concerned with sickness, so often do we find ourselves discussing it—its causes and its consequences. This conversation is necessary for the work of public health. But it is worth asking: can this have the effect of keeping our attention fixed on challenges at the expense of a focus on the more positive aspects of health—of all the ways health can enable a happy life? It strikes me that it might be worth taking a moment—perhaps informed by the promise of soon summer—to discuss how public health can refine its emphasis, to better communicate the inherent positivity of the work of public health.   

This positivity can, at times, get lost in translation. Our messaging seeks to curb behaviors which can lead to sickness and preventable harm. This messaging tends to involve statements that begin (implicitly), with the words “Thou shalt not.” “Thou shalt not drink.” “Thou shalt not smoke.” “Thou shalt not eat to excess.” What we mean by these statements is to offer a blueprint for behavior which supports a long, healthy life. Yet it is possible to read them as prohibitions against fun, against the pleasure and joy which are core to living that very life to begin with.

Some might dismiss this as a matter of mere tone, secondary to more urgent priorities. Yet the wrong tone can risk alienating the very public we are meant to serve, and, in doing so, weaken the effectiveness of public health. Consider what we have seen during COVID-19. The threat posed by the pandemic has meant that, during the past year, the population has been receptive to the message of public health arguably like never before. Yet, even under these circumstances, there has still been resistance to public health. Such resistance—even in the midst of a pandemic—suggests that, for some, public health is seen primarily as an attempt to curtail freedom and enjoyment and is, as such, to be resisted. The great irony of this is that curtailing freedom and enjoyment is the precise opposite of what public health should aspire to do. Our actual intent is to ensure as many people as possible are free to live long lives full of the activities and interactions that bring happiness and meaning. Such lives are only possible in a context of health, of being free from the disease and preventable harm that can stand between us the pursuit of a happy life.

Read the full post on The Healthiest Goldfish.

Fixing Our Health System After Covid-19 | The Turning Point

The Covid-19 pandemic was the best of times, the worst of times, for our healthcare system. We saw the ceaseless efforts of frontline doctors and nurses, working to contain an unprecedented plague. Yet, we also were reminded of the fragility of our medical system, buckling rapidly under the weight of a new disease, made worse by lack of access to quality care for many, and a population burdened by chronic diseases that have made Covid-19 so much worse.

Our healthcare system matters. How do we protect it?

We argue for three things.

First, we can adopt payment models which encourage health rather than sickness. We currently have a model which incentivizes providing ever-more expensive care for disease. It is a sick care system. We readily attend to people who present for care with symptoms; we are less skilled at improving health across entire populations. Models which shift the focus of market competition to keeping patients well have been explored in shelves’ worth of books and we here deflect away from specific ways to implement. But the fundamental concept: changing incentives from sickness cure to keeping health, seems to us indisputable. Put simply, the medical care system needs to embed public health practices.

Read the full post on The Turning Point.

UFOs, COVID, and the return of radical uncertainty | The Healthiest Goldfish

Imagine it is 2024. For the last few years, it feels as if the world has largely moved past the COVID moment. There is a widely-shared sense that we have successfully dealt with our generation’s big challenge, and can now resume a calmer life. COVID was the worst pandemic in one hundred years, so we allowed ourselves to believe it would be at least another century before we faced anything so disruptive again. Unfortunately, this turns out not to be so. A new pandemic emerges, shutting down the world again, this time for a full two years.

Such a scenario likely seems farfetched. Not because it imagines a global pandemic shutting down the world—while that may have seemed farfetched two years ago, we now know it to be all-too plausible. No, it seems farfetched because imagining another pandemic so soon after the last one violates our bias towards thinking the world is much more predictable than it actually is. Within the framework of this bias, there is room for unprecedented challenges, but only with the unspoken assumption that, the world being predictable, unprecedented challenge will be followed by a long period of relative tranquility, giving us time to collectively regroup. That another global pandemic could conceivably follow COVID in the next three years speaks to a reality of our existence we do not like to acknowledge—that it is deeply uncertain. Regardless of whether or not we see another pandemic in 2024, the possibility that we could is indeed an uncertainty we must each day face.

Earlier this month, The New York Times ran a story with a headline which spoke to the uncertainty with which we live, “U.S. Finds No Evidence of Alien Technology in Flying Objects, but Can’t Rule It Out, Either.” The story concerned an upcoming government report on Unidentified Aerial Phenomena (UAPs), an updated term for what are more commonly referred to as UFOs. The article contained this eye-catching line:

“[S]enior officials briefed on the intelligence conceded that the very ambiguity of the findings meant the government could not definitively rule out theories that the phenomena observed by military pilots might be alien spacecraft.”

Read the full post on The Healthiest Goldfish.

Defining Out Goalposts | The Turning Point

During April of 2020, the in-hospital mortality rate from Covid-19 was at 19.7%. By November, it had declined to 9.3%. That is a remarkable testament to the triumph of clinical medicine in the face of a previously unknown disease. The drop in mortality was due to many factors, including the use of non-pharmacological approaches such as patient proning, the use of pharmacological therapies in hospitals such as remdesivir and steroids, and perhaps also due to lower viral loads seen in hospitalized patients because of more universal embrace of mask wearing. Regardless of the explanation, it is clear that our handling of Covid-19 got better quickly, changing dramatically the risk of what should be the ultimate outcome of concern: death.

But this dramatic improvement in mortality did not do very much to change our broader public narrative of Covid-19. Our impression—legitimate as it was—of a new deadly disease that was to be avoided at all costs was fixed quickly in March of 2020, and it did not budge much when the risk of the disease’s feared outcome changed substantially. We were seeing the same dynamic a year later as the widespread introduction of vaccines provided protection for those most vulnerable—the elderly and those with underlying medical conditions—lowering mortality rates and leaving cases to be driven by younger people who have had much less risk of contracting severe Covid-19. Despite this dramatic change in disease profile due to widening vaccination, the public conversation about the state of the pandemic remained driven, largely, by fluctuating case numbers, and state-by-state decisions were informed primarily by case load, even if these cases were milder and posed less risk.

Read the full post on The Turning Point.

Too far, or not far enough? | The Healthiest Goldfish

The business of creating a healthier world is, fundamentally, the business of pushing for change. This means pushing against a status quo which often does not serve us well. This can require us to oppose systems, and even people, that are invested in entrenching the drivers of poor health. This is all to the good. However, while we are quite familiar with the reasons why this pushing is necessary—an awareness informed by our understanding of the drivers of poor health—less discussed are some of the ways this pursuit of change can, at times, undermine itself, leading in counterproductive directions. This is well-illustrated through a story told by the conservative political theorist Kenneth Minogue, one which he used to critique the development of liberalism:

“The story of liberalism, as liberals tell it, is rather like the legend of St. George and the dragon. After many centuries of hopelessness and superstition, St. George, in the guise of Rationality, appeared in the world somewhere about the sixteenth century. The first dragons upon whom he turned his lance were those of despotic kingship and religious intolerance. These battles won, he rested for a time, until such questions as slavery, or prison conditions, or the state of the poor, began to command his attention. During the nineteenth century, his lance was never still, prodding this way and that against the inert scaliness of privilege, vested interest, or patrician insolence. But, unlike St. George, he did not know when to retire. The more he succeeded, the more he became bewitched with the thought of a world free of dragons, and the less capable he became of ever returning to private life. He needed his dragons. He could only live by fighting for causes—the people, the poor, the exploited, the colonially oppressed, the underprivileged and the underdeveloped. As an ageing warrior, he grew breathless in his pursuit of smaller and smaller dragons—for the big dragons were now harder to come by.”

I acknowledge that this story, excerpted from Minogue’s book, The Liberal Mind, may strike some readers of this newsletter as perhaps unfair. Where Minogue sees “smaller dragons,” a different perspective might see normal-sized dragons to which we are only just now applying the correct measure of attention.

Yet it is hard to deny Minogue’s story raises some necessary, though perhaps uncomfortable, questions: is there a degree to which we, too, need our dragons, even if certain challenges have diminished or changed over time? Can we know progress when we see it, and, if not, what are the forces which may be clouding our vision? In today’s Healthiest Goldfish, some thoughts on these questions, on what form our pushing for a healthier world might take, and on how we can better calibrate our efforts so they will always be in proportion to the “dragons” of the moment.

Read the full post on The Healthiest Goldfish.

Part 2: Recognizing, and moving beyond, our collective grief | The Turning Point

There have been few moments in the country and the world’s recent history when we have collectively grieved for so many. Over the course of the Covid-19 pandemic, nearly . 00,000 Americans have died, and over 3,500,000 people have died around the world. The dead are our family, friends, neighbors, colleagues, and all are mourned. Recent data suggest that 33%of Americans know someone who died during Covid-19; that would be a total of about one hundred million Americans who are, in the moment, grieving personal losses, grief that in and of itself has implications for their health.

As we look past a global pandemic and move to rebuilding, the first step is acknowledging and recognizing the grief of many. This starts with our personal lives, in the opportunities we have to share grief with loved ones, and to acknowledge and make space for the sadness of the moment.

Beyond sadness, the science on the mental health consequences of grief should be sobering. In a study conducted in 2014, it was shown that the bereavement period is linked with greater risk of new onset of multiple psychiatric disorders, regardless of when the grief happens during the life course. We already know that with Covid-19 there has been a dramatic increase in anxiety or depressive disorders, with roughly four in 10 adults in the US reporting symptoms, an increase from one in 10 in January through June of 2019.

Read the full post on The Turning Point.