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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How bad ideas can make good ones better | The Healthiest Goldfish

In public health, we talk a fair bit about diversity. This conversation is consistent with the broader goals of our field. Our mission is to serve populations with many different backgrounds and perspectives. Engaging with a range of groups—with all of us as different people united in our shared humanity—means celebrating the diversity we reflect, and working to ensure this engagement is fully inclusive. I have written previously about diversity, including in The Healthiest Goldfish. At perhaps the most basic level, a commitment to diversity calls on us to ensure that the public health community is a welcoming space for people of many races, religions, nationalities, and expressions of gender/sexual identity. This strikes me as a necessary condition for our efforts, worth pursuing, always, as a key priority.

But diversity does not just mean diversity of identity. It also means diversity of opinion. A benefit to having communities of people with different backgrounds and identities is that each person has a unique perspective they can bring to bear on the conversations that happen in these spaces. These perspectives can sharpen our collective thinking, helping us to do what we do better. It is important to note that diversity of identity is often closely linked to diversity of opinion, but one does not invariably follow the other. The deciding factor is whether or not we value viewpoint diversity enough to encourage it the same way we encourage diversity of identity.

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Borders in an age of pandemics | The Healthiest Goldfish

Readers of this blog will recognize several familiar themes. One of them is that the world is not straightforward, and interesting answers are seldom simple. I have written previously about how core to our thinking about health should be a capacity to engage with ambiguity and issues which do not always neatly resolve. This has never been truer than when it comes to the issue of national borders in the context of pandemics. Borders and migration have long been some of the most fraught terrain in our current political debate. The issues elicit strong feelings on all sides—whether one favors maximally exclusive national boundaries or something akin to open borders. The conversation about borders becomes even more complicated in the context of infectious disease outbreaks. 

At the core of the issue are two contradictory, yet equally true, realities. 

First, pandemics expose the fundamental interconnectedness of health. It is the case that outbreaks will spread without heed to the artificial lines on maps we call “borders.” With that in mind, borders can play a role in containing outbreaks and closing national borders as early and tightly as possible during an outbreak can, combined with aggressive in-country testing and tracing, help to protect populations from emergent world-wide contagion. The figure below reflects the world’s dawning appreciation of this, showing the state of border restrictions early in the COVID-19 pandemic. 

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HIV and Covid-19: Improving Health Care and Health | The Turning Point

Two pandemics bookend the last forty years—HIV and Covid-19. The first changed our view of health care and its delivery in dramatic ways. Perhaps the second will change our view of health and who has access to it.

Three years past the initial 1981 report of persons with a new infectious syndrome was published, the activist Larry Kramer wrote an article “1112 and Counting” in which he berated every government official connected with health care—from CDC and NIH administrators to local politicians—for refusing to acknowledge the widening AIDS epidemic. (President Reagan had not yet said the word HIV publicly and wouldn’t for four more years). The burden of HIV fell on certain marginalized groups. As the HIV epidemic surged, gay men demanded vigorous federal intervention on their behalf. They wanted the benefits, protections, and resources that only Washington could provide. Cohesive activism slowly developed, taking years to organize, but what the reshaping of public opinion around HIV and biomedical activities produced was dramatic. The average FDA approval time of new drugs went from a decade to a year. Patient groups had to be consulted when new drugs were being reviewed by federal agencies. The purity of the placebo-controlled trial was re-imagined. Consumers started to demand to know treatment options and success rates and to be able to shop for the best care. It was a new era in biomedicine and in being a patient in the health care system.

We jump ahead 40 years. The political response to Covid-19’s arrival was actually worse than Reagan’s choice to ignore AIDS. On January 2, 2020, the director of the CDC contacted the National Security Council to warn about early cases of the coronavirus in China and the potential that it could spread to the United States. Yet when President Trump’s first televised remarks came 3 weeks later, he said, “We have it totally under control. It’s one person coming in from China, and we have it under control. It’s going to be just fine.” Warnings by scientists were soon termed a “hoax.” The disinformation campaign that followed mattered gravely because Covid-19, a respiratory illness, was a broader threat to the general public than HIV ever was.

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