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.

Read the full post on The Turning Point.

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.

Read the full post on The Healthiest Goldfish.

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.

Thinking in groups, thinking for ourselves (or: in praise of iconoclasm) | The Healthiest Goldfish

Americans trust scientists. This may seem, to some, like surprising news, given the extent to which attitudes towards science were politicized during the COVID-19 pandemic. But the data bear it out—the scientific community has long enjoyed public trust. Data show that 44 percent of U.S. adults say they have a great deal of confidence in the scientific community. This trust has remained fairly stable for decades.

Underlying this trust is likely the assumption that science will do what it has historically done ever since it developed its core methodologies—pursue truth through empirical means, guided by data rather than by other incentives, be they financial or partisan. It is then worth asking—do we, in the scientific community, do this? On one level, the answer is obviously yes, we do, though perhaps imperfectly. But what if we modify the question, to ask: do we do this all the time, or at least enough to fully justify the public’s trust in us? How often do we think for ourselves, guided principally by data, and how often are our thoughts shaped by other factors? I would argue that we are susceptible to other factors, though not necessarily in the sense of being unduly partisan or subject to financial incentives. Instead, science, it seems to me, has a weakness for groupthink, for being swayed by the consensus simply because it is the consensus. If this is so, then we have a responsibility not just to be on guard against this tendency, but also to maintain a healthy level of iconoclasm, an instinct for pushing against the consensus as a means of testing our assumptions and ensuring that we are indeed thinking for ourselves.

The integrity of the scientific discipline is a key inheritance of the Enlightenment, a period which did much to support an empirical approach to problems. Such integrity, then, is kin to the principles of small-l liberalism which also emerged from the period, and which are based, in part, on empirical observations about society and human nature. Keeping science “honest”—rooted in empiricism, and as free as possible from groupthink—is therefore core to supporting the liberalism that informs a healthier world.

Read the full post on The Healthiest Goldfish.

Balancing Individual Autonomy and Collective Responsibility | The Turning Point

A Ghanaian colleague reminded us recently of a Ghanaian proverb, “You cannot cry harder than the bereaved.” The proverb suggests that what any of us can do to help ease the suffering of others is limited, and a reminder that it behooves us to have the humility to recognize that. In this second Covid-19 year, we have found this proverb useful, as we attempted to navigate the complicated balance of individual autonomy—what we need to do for ourselves— and collective responsibility—what we can do for each other.

The tug of war around the use of face masks was the first and most visible example of this balance. Although the issue has been cynically exploited for political ends, at heart it is a classic push-pull between those who wish for maximum individual autonomy—I can choose to wear a mask or not depending on my risk tolerance—and those who advocate for collective responsibility—you wearing a mask decreases my risk of getting Covid-19. A classic public health approach in this case suggests that the latter readily outweighs the former.  Mask wearing is an inconvenience, but a relatively minor one, and the case that wearing a mask protects others is strong. We have as a society long decided that we are willing to limit some individual autonomy for a readily apparent public good. For example, worries about the risk of second-hand smoke were critical in the adoption of indoor smoking bans, as we collectively accepted that it was worth limiting the freedom of some to smoke anywhere, to preserve the freedom of many from unwanted cancer risk. In keeping with this logic, the majority of US states put in place mask mandates or other forms of masking requirements during the pandemic.

But as the pandemic evolved, the balance of individual freedoms and collective responsibilities became more complicated, particularly around the issue of vaccination.  Early in the vaccination effort it was clear that many did not have ready access to vaccines, and as such we had a collective responsibility to continue preserving limits on our individual freedoms—physical distancing, masking, restricted availability of entertainment venues—until everyone had the opportunity to be vaccinated, to ensure we could all be protected.

Read the full post on The Turning Point.

The consent of the governed | The Healthiest Goldfish

Over the last year or so there has been much criticism of leadership in the U.S. for the state of affairs in this country. Government at the local and national level has been criticized for failures in mitigating COVID-19 and for challenges in addressing any number of the problems we collectively face. Such criticism is often warranted, helpful even. Power needs accountability, so that it can be used most effectively to support the common good (see prior thoughts on how accountability can help ensure effective functioning within bureaucracies). However, it strikes me that in much of this criticism there is an implicit belief that people in positions of leadership have more power than they actually do to sway events. We seem to believe that there is somewhere a magic wand which can be waved to solve our problems, and that it is only some kind of obstinacy which stops those in power from waving it.

This belief reflects a lack of understanding, on our part, of the extent to which the capacity of leadership to do, well, anything, depends on us—on the consent of the governed. In my writing, including in my upcoming book, The Contagion Next Time, I have found myself returning to a telling quote from Abraham Lincoln, “[P]ublic sentiment is everything. With public sentiment, nothing can fail; without it, nothing can succeed.” The power of public opinion is such that even a relatively low level of public engagement can be enough to reshape society. Research has suggested that it takes about 3.5 percent of a population actively engaging in political protests to bring about real political change.

Given this power, if the public withholds its consent from a given measure, governments face a steep uphill climb towards the measure’s successful implementation. It does not matter how much good the measure might do; without the consent of the governed, it cannot take effect to any significant degree. When this ineffectiveness occurs, it can look like it is solely the fault of incompetent leadership, when, in fact, leadership may be doing all it can within the confines of withheld public consent.

Read the full post on The Healthiest Goldfish.

How Our Expectations Shape Our Perception of Reality | The Turning Point

Japan hosted the 2020 summer Olympics, staged in the summer of 2021 due to a year-long Covid-19 delay. Japan, by any number of metrics did extraordinarily well at the games, coming in third in the gold medal haul, handily outperforming other traditional Olympic powers. And yet, despite this success, many Japanese athletes felt compelled to deliver tearful apologies at their ‘failures’ on winning silver medals.

The curious case of Japanese regret in a moment of triumph can only be explained when we remember that data (in this case, the medal type and count) are simply one input that drives our construction of meaning and truth.  The Olympics were held amidst substantial local controversy as Japan was facing a surge in its Covid-19 cases. This made for added pressure on the host country to do well, so much so that anything short of gold was seen as a failure. This was a dramatic reminder of the powerful role that our expectation of success plays in our perception of that very success.

Take the Covid-19 summer of 2021 in the United States. What started as a season of optimism, with President Biden declaring a summer of freedom with the Covid-19 vaccine, quickly turned sour when, less than a month later, a majority of Americans again thought that the worst of the pandemic was ahead of them, rather than behind them. The rise of the delta variant fueled the dramatic change in American public perception as the US started seeing an increase in Covid-19 cases which had been waning over the earlier months of summer. But the delta variant was not doing anything that was unanticipated. The delta variant was driving viral spread among those who were unvaccinated, with a clear inverse correlation between state-level vaccination rates and new Covid-19 infections. Critically, those who had received the vaccine had a very low risk of re-acquiring Covid-19, and were at even lower risk of being hospitalized or dying from Covid-19. In addition, we had a precedent for how we were going to do with the delta variant as the UK preceded the US by about a month in its epidemic curve and readily showed that we could expect a waxing—and then a waning—of new infections principally among the unvaccinated in the US.

Read the full post on The Turning Point.

Resisting our suburban impulses | The Healthiest Goldfish

Suburbs can be terrific places. I live in a suburb, and I can think of few better places to live, to raise a happy, healthy family. Suburbs represent stability, and the ascent of the middle class, a trend which significantly broadens access to the material resources that support health. Indeed, when we speak about creating a world that generates health by expanding access to these resources, the ideal would be for everyone to be able to enjoy the level of wellbeing reflected by suburban life. 

However, this is not yet the case—far from it. This unfairness is enforced by policies that benefit those with more at the expense of those with less. It is also enforced by habits of thought that allow us, even if we consider ourselves progressive-minded, to oppose measures which would share some of our advantage with others. Sadly, perhaps inevitably, there is a racial element to this, just as there is to the broader gap between the rich and the poor, and addressing this challenge means speaking honestly about the full dynamics of the issue, including its intersection with race. I was struck by an article written last summer by former Minneapolis Mayor Betsy Hodges, where she tackled this uncomfortable truth, saying, “White liberals, despite believing we are saying and doing the right things, have resisted the systemic changes our cities have needed for decades. We have mostly settled for illusions of change, like testing pilot programs and funding volunteer opportunities.”  

Such observations are, I think, bracing and necessary. It is easy to see how ideological opponents can block progressive change; it is perhaps more difficult to see how our own blind spots can help stymie progress. Today’s column, then, will address the suburban impulses that can sway those of us who are committed to the pursuit of justice off the path that leads to better health for all, and how we can resist these impulses, to create a healthier world. 

What do I mean by suburban impulses? Fundamentally, they are captured by an acronym: NIMBY or “not in my backyard.” NIMBYism is when people living in a community oppose measures which would support the public good in that community when these measures would in some real or imagined way encroach on their own personal convenience (I have written previously about NIMBYism here). A corollary is that this opposition can come from people who would otherwise support such measures, as long as they happen somewhere else.

Read the full post on The Healthiest Goldfish.