What we owe, and do not owe, the past, Part 1 of 2

Reckoning with the history that shapes health in the present.

My recent writing has been centrally concerned with the moment— the daily disruptions caused by the changing political winds in the U.S. and their effect on the work of health. This focus seems appropriate given the challenges we are seeing to the structures that support health in this country, and I will remain engaged with unfolding events as the tides of this sea change continue to shift. However, I have always tried to make The Healthiest Goldfish a place for sometimes stepping back from the immediacy of the moment to reflect on the deeper forces driving events, to pay attention to the important, beyond the urgent. This includes the history that shapes health in the present and that is at the heart of so much of what we see in our daily view. With this in mind, I wanted today to reflect on history, its implications for the present, and what we owe history as we work to build a better future.

These reflections are grounded in my reading, over the past couple of months, of two books. First was Robert Caro’s The Power Broker: Robert Moses and the Fall of New York, and second was Walter Johnson’s The Broken Heart of America: St. Louis and the Violent History of the United States. I was reading both books for different reasons. Last year was the 50th anniversary of Caro’s book, and while I had read much of it when I was working in New York City, now more than a decade ago, I had never read it cover to cover and thought it was high time I did. The second book was recommended by many colleagues ahead of my move to WashU in St. Louis, and the recommendations turned out to be just right — it was a perfect history of the city I am now living in, and of how the city today is shaped by its history over centuries.

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The input problem

The challenge of disagreeing on issues when we cannot agree on facts.

Readers of these essays will know that, as a new administration has made significant changes to the country, I have tried to be open to the spirit of accepting new ideas about the reorganization/rethinking of what should be, mindful that the actions we are seeing reflect the wishes of millions of Americans who chose this course with open eyes in the last election. Our criticisms, then, of the changes we are seeing should not be knee-jerk, but, rather, considered and thoughtful, reflecting an awareness of the complex cultural and political forces driving this moment. However, I did want to comment on this week’s announcements about layoffs at the Department of Health and Human Services, the Centers for Disease Control and Prevention, and other health agencies. I have written before about the underfunding of public health, and how it contributed to the disaster of COVID, among many other diseases. This new disinvestment in health agencies is clearly going to make this worse. Leaving aside — but acknowledging — the cruelty of these moves happening quickly and unexpectedly, the threat that they pose to the country’s health cannot be underestimated. I worry, as do many others, that this is setting us on a path to perdition, to an escalation of public health challenges that are going to manifest in the years to come. And that is a worrisome thought indeed.

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A new global order, for better or worse

Learning from a changing world.

The past two months have brought dizzying changes to many aspects of the world, disrupting much that we may have once believed were largely settled, stable. We have seen changes come to “the post-war global order,” where the US is a core part of NATO, closely aligned in its interests with Europe, forming a unified bloc that pushed back on Russian expansionism. This unity is now in doubt as the US appears—in the rhetoric of President Trump at least, and in that of some members of his administration—to have changed how it thinks about both Russia and about its commitments to long-held European allies. Moving domestically, assumptions about the solidity of federal employment have been upended, as have the country’s investments in, among other areas, global aid, a belief in scientific research as a national asset, and, potentially, an understanding of a social safety net that reflects a shared social compact.

These few sentences do not fully capture the scope of the changes we are seeing or the likely consequences of these shifts in the “order of things.” I have written before that we should aspire to give space for alternative visions of what the country, and the world, might look like even as we have a responsibility to call out the cruelty of intemperate action. But today, I wanted to reflect on the fundamental shift in the global and domestic order, and, centrally, what it means that we are going through such a moment, and how we might respond to it.

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Null (And Void?)

Scientists like good news: positive and significant findings impress the public and funders of the work. As a corollary, science tends to downplay studies with null or negative results — those that fail to confirm a preconceived hypothesis (usually in the form of being unable to find an expected relationship between variables or groups) or that demonstrate a new medication or behavioral intervention does not improve health. Negative or null findings are far less likely to be published than positive results. Unfortunately, this publication bias can mislead other researchers or the public.

Put this into the context of how scientists think of their work: how might one interpret a null finding, the failure in finding a predicted difference between two treatments or proposed causes? There are four possibilities. First, the researchers did not find what they and many others thought they had good reason to find. Second, the researchers did not find what only they thought they had good reason to find. Third, the researchers did not find what they only had a hunch they would find. Or, fourth, the researchers did not find what they had no good reason to expect but hoped they would anyway.

We make these distinctions because they can teach us a lot about science, how science is practiced, and how it can be better.

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On balancing complex, competing ideas

How can we be a constructive influence in the midst of challenge and uncertainty?

We are in a complex, challenging moment. The country remains deeply polarized, with no end in sight to the partisan rancor that has characterized the last decade. Technological changes have deepened these divides, even as they also help connect the world in the digital space. In the case of AI, these approaches have the potential to radically improve the lives of populations, although this potential carries many uncertainties. We continue to argue amongst ourselves about what all this means, about who is to blame for the challenges we face, and about what is to be done to seize the opportunities of this moment and mitigate its risks. There is much about this moment that lends itself to easy outrage, with no shortage of voices reflecting this sentiment in the public debate. In this context, it is worth asking: what is our job in this moment? How can we be a constructive influence in the midst of challenge and complexity?

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Women in Science

Have women had the same opportunities and options to participate in the work of science, either as scientists or as participants, as men? The evidence suggests not. Although inequities may be decreasing over time, men continue to hold about 70 percent of all research positions in science worldwide.

Why is this the case? There are undoubtedly a broad range of reasons. Gender inequities seem to be embedded in the processes that influence the conduct of research, including what is prioritized, as well as who does research, who is promoted, who becomes leaders, and whose contributions are valued. There has been considerable research on sex-based disparities in the health sciences focusing on how explicit or implicit bias differentially affects investigators. Women may also have a harder time getting hired in science than men. In an experiment, when sex was randomly assigned to curricula vitae, a hiring committee was more likely to choose male candidates. Once settled into scientific jobs, mobility and advancement remain uneven. Women have fewer publications, and as research shows, women on scientific teams are significantly less likely than men to be credited with authorship; both of these contribute to slower career trajectories. Women also have fewer collaborators and less research funding. And more than forty percent of female scientists in the United States leave full-time work in science after their first child.

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Health as a private and public responsibility

Government and industry both have a role to play in shaping a healthier world.

Why does health matter? In many ways, answering this question is the central preoccupation of these essays. I have written a number of pieces that attempt to define the meaning of health—why health is something worth pursuing as individuals and collectively. Fundamentally, I see health as mattering because it creates opportunities for us to live rich, full lives. It is a means, not an end, and that end is living a good life, one that is full of time with friends and loved ones, full of the experiences that define what it is to be human. A world where everyone can be healthy is a better world indeed, one worth striving for.

Given the importance of health, given its role in supporting so much of what gives life meaning and value, it makes sense that we should be centrally concerned with asking where the responsibility for promoting health lies. Is it primarily the responsibility of the public sector? Or should the private sector, with its capacity for innovation and scalability, play a larger role? I argue that the achievement of health is both a public and private responsibility, and, as such, we should behave in ways that reflect this. For public health to be most effective in this moment, it should engage with both sectors—finding synergies at the intersection of industry, government, and public health teaching and research—towards shaping approaches that create healthier populations.

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Innovation

Where do new scientific hypotheses come from? Pasteur’s nugget, “Chance favors only the prepared mind,” suggests that scientific breakthroughs—ones that are groundbreaking and impactful—do not occur idiosyncratically. Rather, the scientific mind needs to contain a reserve of information, but also be open to anomaly and surprise, to recognition when something novel comes into view, and to accepting that something new is not impossible. This could happen for an individual scientist long-experienced in her field who remains persistent: one who has assembled enough evidence over time to make a new claim. Or it could happen when a scientist crosses fields and solves a problem far from her home domain, who steps over a line to speak to a new audience. It turns out that breakthroughs in content (papers, methods, concepts, patents) are indeed prodded by new context (input from a faraway technological discipline).

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