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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The Limits of Our Science | The Turning Point

The Covid-19 pandemic has been characterized in the public space by enormous fractures, mirroring societal divisions, that have often pitted the science that could inform better response to the pandemic against ideas driven by little more than ideology. This was immensely complicated by President Trump’s assumption of strong positions—for example, on the purported utility of hydroxychloroquine as a treatment for Covid-19—that had no basis in scientific fact. Such highly visible support for ideas that were simply wrong, at a time when the world needed clarity without false hope, pushed science to the fore to an unprecedented degree. “Follow the science” became a rallying cry and was part of then-candidate Biden’s appeal to voters. He promised that he would take a still-evolving Covid-19 science seriously if elected president, in stark contrast to the then-incumbent.

Few would argue that science should not be at the heart of decision-making during a pandemic. There is, however, and appropriately, a growing body of work that discusses what science can, and cannot do. As we look to learn from the Covid-19 moment, it seems worth asking—what are the conditions under which we may be suitably cautious about the science? Three principal conditions come to our mind.

First, we should be cautious about science informing decisions about particularly complex systems, where science can inform our understanding of particular aspects, but where these narrow aspects are only part of a larger and more intertwined whole. This was perhaps most clearly borne out during the pandemic when it came to decisions around keeping K-12 schools open. The science showed relatively quickly that children were at low risk from the virus, and did not much influence transmission of Covid-19 in the general populations. However, the issue of school opening went beyond a single scientific question. Certainly, there were inputs related to the estimated risks of viral transmission, but there were also risk perceptions and issues around the protection of teachers that transcended ready scientific solutions. Scientific engagement on issues that involve different groups with diverse interests need to be focused on particular questions (e.g., how much do children transmit the virus?) but embedded in larger and more complex societal decision-making.

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Why will we remember what we remember about COVID-19? | The Healthiest Goldfish

Last week, I suggested that, while the COVID moment is far from over, it is possible to see the outlines of what well may become the dominant narratives of this historical period, the key stories we will tell when we look back on the pandemic. The stories that, to my thinking, could rise to the surface are: the story of scientific excellence (reflected centrally in the rapid development of mRNA vaccines), the story of the presence of inequities in both morbidity and mortality from COVID and in populations that faced the brunt of the economic costs of the steps we took to mitigate the pandemic, the story of widespread loss of trust in institutions as a consequence of partisanship and the spread of misinformation, and the fact that, for all the suffering caused by COVID, it could have been far worse, had we faced a more lethal contagion.

Fundamentally, these stories inform a core narrative of why we believed what we believed during COVID—why we came to regard the virus as a threat worth shutting down the world over, worth the pursuit of novel vaccines, worth better understanding inequities, worth trying to convey accurate information in a climate of institutional mistrust, and worth recognizing that the next contagion could be worse. Today’s Healthiest Goldfish will consider why we will remember what we remember about COVID—why certain narratives may “stick” while others may not. Such a consideration is useful, I think, because it reflects why opinions cohere among groups, and the values and habits of thought that underlie the choice to embrace, or not embrace, the narratives that inform health. How we prepare for the next pandemic will depend, in large part, on the story we tell about this one. The better we understand the forces that shape our narratives about health, the healthier we can be, and the better we can prepare for the next pandemic.  

It strikes me that certain narratives are likelier to stick when they meet the following three criteria: they seem to fulfill our pre-existing biases, they fulfill an aesthetic need for coherence (i.e., they seem to “connect the dots,” reflecting some measure of order in a chaotic world), and—yes—they are told by dominant groups, promoted by those in power, by “winners.”

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Epistemic Humility During a Global Pandemic | The Turning Point

We often talk about how challenging the Covid-19 year has been for so many people. And yet when we look beyond the individual sorrows and losses, the Covid-19 moment has been good for public health as a discipline generally, and for some of its fields specifically. Public health has had visibility like never before, its central concerns in the headlines for more than a year. Prospective students are applying to public health programs in record numbers. Epidemiologists have been declared “the new rock stars” by The New York Times and reporters fill columns asking epidemiologists what they’re personally doing, for example, on Thanksgiving and other holidays, holding the discipline up as a bellwether of data-informed good sense.

We are delighted with this attention. Public health has long been overlooked in the public conversation, and having more graduate interest in the profession is long overdue. It is likely that there will be more public health jobs created post-pandemic than ever before, establishing a moment of opportunity for us to welcome a new generation to the field that will lead in decades to come.

It is, of course, also true that this heady moment holds peril in that we risk overstating what we know and the confidence with which we know it, to the detriment of the world and our own field and reputation. We have no particular desire to be skunks at the public health garden party. But it does seem to us worth reflecting on the main challenges that public health faces in this moment that suggest a need for a thoughtful pause.

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What stories will we tell about COVID-19? | The Healthiest Goldfish

Throughout the COVID lockdown, I often found myself listening to podcasts. In particular, I gravitated towards podcasts that helped ground the pandemic in historical and political context, providing perspective on an uncertain moment. As I listened, it struck me that, no matter what happened in the past—no matter how tumultuous an era, how disruptive a war or plague, how shocking a sudden turn of events—everything that has ever occurred, the immense variety of historical incident, ultimately becomes the same. Everything becomes a story.

This begs the question: what story will we tell about COVID-19? The events of the past year and a half were more than just a story of the emergence and behavior of a virus. It was also a story of the social, economic, scientific, and political context into which the virus emerged, and the intersection of these forces within complex, dynamic systems. Given this complexity, it can be difficult to predict which stories will rise to the surface of the overarching story of the pandemic. Yet it is important for us to try. The stories we tell about health shape how we engage with the present moment to support a better future—or how we fail to do so.

Consider the issue of race in America. For a long time, the story we told about race was distorted, incomplete, often serving to entrench systems of injustice in the present as we failed to come to grips with our history. This had consequences for the COVID moment, as racial health gaps, informed by this history, worsened the crisis. This reflects why the issue of stories is not merely an issue of how we curate our collective memory. It has deeply-felt implications for the present, shaping our capacity to build a healthier world.

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Air, Water, and Words | The Turning Point

Public health surveillance is absolutely essential to protect and sustain community health. Health departments monitor community health status and investigate new health hazards all the time. They perform health surveys, and investigate clusters of mysteriously ill citizens. Covid-19 brought the functions of testing, tracing and surveillance through state and local health departments to an unprecedented scale. With Covid-19, early on we turned away from a narrow clinical health care approach, focusing on those who were sick, to a broader public health, population-based strategy. Public health authorities tested not only those with symptoms, but also a sample of those who were asymptomatic. Surveillance was and is our warning system.

Covid-19 has introduced us to many bold new approaches to surveillance. We can now monitor our water and air and words. Using technologies that were in development before Covid-19, health surveillance will continue to expand in three ways as we see it.

Using wastewater epidemiology--the study of sewage--we are increasingly tracking the spread of diseases. The sewer system is analogous to the human gastrointestinal system. Just as clinicians can make medical judgements about a patient’s health based on a stool sample, we now learn about a community’s disease state by sampling wastewater that comes from sinks and toilets. It turns out that when Covid-19 levels rise in wastewater, daily cases rise soon after. Testing for Covid-19 (or its future viral version) in a city—are rates rising or falling?—can help make decisions about whether schools should stay open, for instance. Over the past few years, the same testing technology has been telling us whether there is an unexpected amount of opioid use in a town, and in the future might monitor stress hormone levels or nutritional deficiencies among citizens.

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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.

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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.

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