Story time (related to public health, but not necessarily to this post): a child vomited in my 9-year-old daughter's class yesterday. For whatever reasons I don't understand (and I assume they are valid), the child stayed in the classroom. My daughter chose to go to the nurse and request a mask, then decided to bring the whole box of masks back to share with the class. Many of the children accepted her offer. This blew my mind- she clearly learned something about the value of public health and that we don't just have to accept catching a nasty virus for no good reason. While her greatest strengths are in writing and communication, this morning she suggested that maybe someday she will study virology (my grad school field and forever passion) to "work on vaccines for noroviruses" (her words). While many were digging in their heels, crumbling, caving, and letting fear and politics guide their choices or obstruct their better judgment in the height of the COVID-19 pandemic, some were learning, growing, and being inspired to do well by others.
One of the biggest problems with public-health messaging in the US is that it speaks to the lowest-common denominator. We saw this with masks/COVID: we were initially told masks didn't work not because the experts thought they didn't but because they didn't want people to run out and buy up all the PPE. We also see this with things like vaccine timing: "Get your flu shot whenever you can" rather than "Get your flu shot in mid-to-late-October." "Get your COVID booster anytime" rather than "Waiting at least 6 months to get a booster after an infection will improve efficacy."
Until public-health experts tell the nuanced truth regardless of how they think it will impact action, including admitting when the answer is "we don't know," nothing will change.
The politicians railing against public health workers, such as Trump and Desantis, are not leaders. They are nothing but narcissistic stooges interested in their own standing. Problem is, too many Americans are willfully ignorant and follow these types to their own detriment. And too many Americans are whiners about not having enough information to make rational decisions. Bull. Many are just too damn lazy or stupid.
I think it's worth mentioning that the brief of public health officialdom is to protect the society as a whole and not to serve as a bastion of individual liberties. During a health emergency, individual rights have to take a temporary back seat. Consider firefighters battling a blaze in a crowded urban area. Whole blocks might be cordoned off, denying entrance even to rightful homeowners in the affected area until the fire is brought under control. More broadly, the imposition of martial law--which hugely limits individual rights--has been deemed essential to the maintenance of civil order during emergencies (such as insurrections, foreign invasion or other circumstances when regular order breaks down and civil society itself is menaced). So too is the imposition of military conscription in times of war. Just ask anyone who has been inducted just how much their individual liberties were infringed. To me, the outbreak of a deadly, highly contagious virus is on par with a foreign invasion, and warrants all reasonable steps (including even severe restraints on movement and social contact) to contain it until less draconian steps are viable alternatives. These measures are not the the thin edge of the wedge of dictatorship. These measures are temporary and specific to the emergency at hand. We have used them many times before and lo, we are not in the gulag. If your society has not taught you the b=value of its own survival, so much the worse for your society.
If the public health field starts to cater to science-deniers, it will unravel entirely. Consider that there is little-to-nothing experts can do to persuade many science-deniers, but much distrust that could follow from those who embrace science and expertise if the field goes out of its way to coddle those who don't want it in the first place.
We have to remember CDC was the preeminent health agency we could count on. It was gutted by the GOP administration that had as their advisers, people without infectious disease experience. Their criteria was destroy science, make money. Healthcare, science, environmental sciences, social services, women’s rights have been eroded by those who would divide this country. We all used what we knew as best practices of the time and we learned over time what worked and didn’t work. We tried to save lives. We’ve lived some privileged lives here. The reason many of us are alive, is people believed in science and taking care of each other. Now we complain about it.
I am just a lay person, but I believe in science and was counting on our government and the CDC to guide us through the pandemic. Here in Minnesota we had a strong governor (Tim Walz) and public health team that kept us updated with regular televised briefings. We followed their guidance and did our part (social distancing, masks, and vaccines). Switching the channel to the national briefing was like watching a clown car (with the exception of Dr. Fauci when he wasn’t muzzled). “Bleach” from the mouth of a President? I agree that we have a long way to go to create a robust Public Health infrastructure in this country. Reading “The Premonition” by Michael Lewis gave me a good peek into our fragmented system and where we could be. I started following Dr. Osterholm (U of MN) for science based information as the pandemic spread. I found your SubStack and became a paid subscriber. The other day I went to my appointment at Walgreens to get my next Covid booster. I told the tech I had waited 4 months after having a bout of Covid in August. The tech said “good for you” after I mentioned following your guidance as an epidemiologist. She mentioned they follow Mayo and the Cleveland Clinic (rather than the CDC since they apparently follow “more than just the science”). I appreciate your insights and hope you stay focused on creating the national public health system that we all deserve.
P.S. I’m putting that in my letter to Santa this year, too, so get busy. Crooked grin.
Public health policy is supposed to be based on reality. On actual data. We can negotiate on how to promote vaccine use based on differences in political view. We cannot and should never be debating about whether or not they work when all available emperical data says that they do. The Republicans left the public health arena when they decided to claim vaccines were causing deaths and not COVID. They pushed their supporters to do the same. That is where this divide mainly exists.
Galea appears to be ignoring a glaring problem, today's conservatives don't believe in the common good and therefore do not want there to be a successful public health program. There is never going to be a successful public health program that will appeal to them and we should not be compromising everyone else health to appease those that will never be appeased.
I will read the book, and perhaps come back with some thoughts. But re your comment about dismissing new information: one should *never* view anything through a lens even remotely tainted by politics. My goal -- only occasionally attained -- is to take "the view from nowhere," a view of total detachment. And often it helps. The philosopher Thomas Nagel's book of the same name set me down this path... it's worth a read.
the politicization of science will take a long time to come back from. No more mandates (lockdown, masks, vaccine) that infringe on liberties and freedoms, that aren't backed by scientific evidence, and for which no cost-benefit analysis has been done. And no more calling people "science-deniers" for questioning things. "Science" by definition is about asking questions and testing hypotheses.
Thanks for bringing this book to our attention and for summarizing its topics.
In terms of what future Public Health should look like, two thoughts come to mind:
1) Under what circumstances is it morally permissible for government to take away civil liberties and essentially force people to do things (ie, lockdowns, mask mandates, vaccine mandates)?
2) What is the appropriate philosophical mindset for Public Health regarding an individual’s capability to make decisions that are in their own best interest? Essentially, how dumb is the public? Are some groups dumber than others? Is it enough for Public Health to provide accurate and scientific data to the public (Covid mortality risk factors by group, efficacy by vaccine manufacturer, etc) and trust individuals to make decisions that are best for them and their families? When it comes to providing actionable data, is it ever appropriate for Public Health to “stack the deck” and “encourage” certain behaviors?
Regarding #1, at the very beginning, I believe it was morally permissible to temporarily lock down the public to prevent hospitals from collapsing and to study the virus and understand what we were dealing with. But lockdown went on waaay too long, and it’s harder to defend the rest of the mandates. One could even argue that at the time the vaccine mandates were put in place, officials already knew that vaccines didn’t stop infection or transmission, even though the public was being told otherwise. Maybe if the vaccines had been much better and herd immunity was possible this would have been morally acceptable, but knowing what we know now, this never should have happened. Which makes me question just how good vaccines and boosters are at preventing severe disease, hospitalization and death - though I do get an annual jab as a hedge.
When it comes to making tradeoffs between different groups, children should always be prioritized.
County level Public Health Departments have a substantial impact on health policies in California.
In the Bay Area, we have many professional & capable department heads that still connect monthly since the Aids Era. Early adoption of CV 19 airborne risk factor (March 2020) was spot-on.
(1) In order to improve Public Health we also need to include the PSYCHIATRIC ISSUES of those politicians & their minions of morons... who, somehow, overnight transformed masks into a "tool of oppression" instead of a "tool of prevention" to stop spreading a deadly virus that turned the world upside down. That's NOT "Leadership"... That's "Indoctrination" -- aka PSYCHIATRIC WARFARE... (or perhaps "Mass Psychotic Delusional Disorder/DSM-V) -- (2) PR needs to use more Humor & Sarcasm (yes Sarcasm) to get health care "F-A-C-T-S" (remember those?) across to the masses lest they become hijacked (once again) by the toxic, Sociopathic Politicians --esp. those who never passed Basic Hygiene in High School Health Class. [Insert Vomit Emoji Here] -- HUMOR breaks down/thru psychological barriers to reach those who are not easy to reach... I thank God for experts like yourself still fighting for Humanity on this battlefield called Earth! Keep going!
I think "Within Reason" makes the wrong diagnosis. Public health did not become illiberal; it strove to preserve society's "Moral Sentiments" (Adam Smith's phrase), in the face of a virulent, irrational, hostile assault from the highest levels of official government which was craven, selfish and immoral. Unfortunately, time is out of joint and these sentiments have taken hold in a significant segment of American culture, the part dominated by the Republican Party. Public health, that is the protection of the common welfare from environmental and infectious threat by systemic and preventive means, inherently requires the best scientific information available, dealing with uncertainty, having values, expressing paternalism, making hard judgements, and the exertion of (unpleasant) authority. Public health is not liberal or illiberal; it is a functionality to protect communal living.
A worldwide examination of COVID outcomes (Pandemic preparedness and COVID-19: an exploratory
analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021, www.thelancet.com, published online February 1, 2022 https://doi.org/10.1016/S0140-6736(22)00172-6) examined many parameters and found that the best outcomes were correlated with trust in government and in neighbors. In a society where trust has atrophied, the problem is way beyond the traditional means of public health, which should not change.
Dr. Jetelina, I want to thank you and all of those who did for pushing back hard on the Great Barrington Declaration. I remember so well, as an older person, reading about that with such dismay, as if older people are not human, but something like canned goods on a shelf that can be moved around at will. Here’s a personal anecdote that relates. When the pandemic began, we sought out the best advice available and, recognizing we were at greater risk, we did of course isolate. Having done that, one thing we knew would be paramount for preserving both our mental and physical health would be to get exercise and fresh air daily. In the area of the Hudson Valley, NY, where we lived at the time, there are few suitable walking trails, but we do have a wonderful rail trail. Our county, however, during the early part of the pandemic, put up signs advising that anyone over 70 could not use them. (Needless to say, I did contact the county, who, in typical pass-the-buck fashion, blamed the state. We walked anyway, but we were glad when the signs were finally removed.) I can only imagine how much worse it would have been for us had you, Dr. Jetelina, and others not protested.
Story time (related to public health, but not necessarily to this post): a child vomited in my 9-year-old daughter's class yesterday. For whatever reasons I don't understand (and I assume they are valid), the child stayed in the classroom. My daughter chose to go to the nurse and request a mask, then decided to bring the whole box of masks back to share with the class. Many of the children accepted her offer. This blew my mind- she clearly learned something about the value of public health and that we don't just have to accept catching a nasty virus for no good reason. While her greatest strengths are in writing and communication, this morning she suggested that maybe someday she will study virology (my grad school field and forever passion) to "work on vaccines for noroviruses" (her words). While many were digging in their heels, crumbling, caving, and letting fear and politics guide their choices or obstruct their better judgment in the height of the COVID-19 pandemic, some were learning, growing, and being inspired to do well by others.
One of the biggest problems with public-health messaging in the US is that it speaks to the lowest-common denominator. We saw this with masks/COVID: we were initially told masks didn't work not because the experts thought they didn't but because they didn't want people to run out and buy up all the PPE. We also see this with things like vaccine timing: "Get your flu shot whenever you can" rather than "Get your flu shot in mid-to-late-October." "Get your COVID booster anytime" rather than "Waiting at least 6 months to get a booster after an infection will improve efficacy."
Until public-health experts tell the nuanced truth regardless of how they think it will impact action, including admitting when the answer is "we don't know," nothing will change.
The politicians railing against public health workers, such as Trump and Desantis, are not leaders. They are nothing but narcissistic stooges interested in their own standing. Problem is, too many Americans are willfully ignorant and follow these types to their own detriment. And too many Americans are whiners about not having enough information to make rational decisions. Bull. Many are just too damn lazy or stupid.
I think it's worth mentioning that the brief of public health officialdom is to protect the society as a whole and not to serve as a bastion of individual liberties. During a health emergency, individual rights have to take a temporary back seat. Consider firefighters battling a blaze in a crowded urban area. Whole blocks might be cordoned off, denying entrance even to rightful homeowners in the affected area until the fire is brought under control. More broadly, the imposition of martial law--which hugely limits individual rights--has been deemed essential to the maintenance of civil order during emergencies (such as insurrections, foreign invasion or other circumstances when regular order breaks down and civil society itself is menaced). So too is the imposition of military conscription in times of war. Just ask anyone who has been inducted just how much their individual liberties were infringed. To me, the outbreak of a deadly, highly contagious virus is on par with a foreign invasion, and warrants all reasonable steps (including even severe restraints on movement and social contact) to contain it until less draconian steps are viable alternatives. These measures are not the the thin edge of the wedge of dictatorship. These measures are temporary and specific to the emergency at hand. We have used them many times before and lo, we are not in the gulag. If your society has not taught you the b=value of its own survival, so much the worse for your society.
If the public health field starts to cater to science-deniers, it will unravel entirely. Consider that there is little-to-nothing experts can do to persuade many science-deniers, but much distrust that could follow from those who embrace science and expertise if the field goes out of its way to coddle those who don't want it in the first place.
We have to remember CDC was the preeminent health agency we could count on. It was gutted by the GOP administration that had as their advisers, people without infectious disease experience. Their criteria was destroy science, make money. Healthcare, science, environmental sciences, social services, women’s rights have been eroded by those who would divide this country. We all used what we knew as best practices of the time and we learned over time what worked and didn’t work. We tried to save lives. We’ve lived some privileged lives here. The reason many of us are alive, is people believed in science and taking care of each other. Now we complain about it.
I am just a lay person, but I believe in science and was counting on our government and the CDC to guide us through the pandemic. Here in Minnesota we had a strong governor (Tim Walz) and public health team that kept us updated with regular televised briefings. We followed their guidance and did our part (social distancing, masks, and vaccines). Switching the channel to the national briefing was like watching a clown car (with the exception of Dr. Fauci when he wasn’t muzzled). “Bleach” from the mouth of a President? I agree that we have a long way to go to create a robust Public Health infrastructure in this country. Reading “The Premonition” by Michael Lewis gave me a good peek into our fragmented system and where we could be. I started following Dr. Osterholm (U of MN) for science based information as the pandemic spread. I found your SubStack and became a paid subscriber. The other day I went to my appointment at Walgreens to get my next Covid booster. I told the tech I had waited 4 months after having a bout of Covid in August. The tech said “good for you” after I mentioned following your guidance as an epidemiologist. She mentioned they follow Mayo and the Cleveland Clinic (rather than the CDC since they apparently follow “more than just the science”). I appreciate your insights and hope you stay focused on creating the national public health system that we all deserve.
P.S. I’m putting that in my letter to Santa this year, too, so get busy. Crooked grin.
Public health policy is supposed to be based on reality. On actual data. We can negotiate on how to promote vaccine use based on differences in political view. We cannot and should never be debating about whether or not they work when all available emperical data says that they do. The Republicans left the public health arena when they decided to claim vaccines were causing deaths and not COVID. They pushed their supporters to do the same. That is where this divide mainly exists.
Galea appears to be ignoring a glaring problem, today's conservatives don't believe in the common good and therefore do not want there to be a successful public health program. There is never going to be a successful public health program that will appeal to them and we should not be compromising everyone else health to appease those that will never be appeased.
I will read the book, and perhaps come back with some thoughts. But re your comment about dismissing new information: one should *never* view anything through a lens even remotely tainted by politics. My goal -- only occasionally attained -- is to take "the view from nowhere," a view of total detachment. And often it helps. The philosopher Thomas Nagel's book of the same name set me down this path... it's worth a read.
the politicization of science will take a long time to come back from. No more mandates (lockdown, masks, vaccine) that infringe on liberties and freedoms, that aren't backed by scientific evidence, and for which no cost-benefit analysis has been done. And no more calling people "science-deniers" for questioning things. "Science" by definition is about asking questions and testing hypotheses.
Thanks for bringing this book to our attention and for summarizing its topics.
In terms of what future Public Health should look like, two thoughts come to mind:
1) Under what circumstances is it morally permissible for government to take away civil liberties and essentially force people to do things (ie, lockdowns, mask mandates, vaccine mandates)?
2) What is the appropriate philosophical mindset for Public Health regarding an individual’s capability to make decisions that are in their own best interest? Essentially, how dumb is the public? Are some groups dumber than others? Is it enough for Public Health to provide accurate and scientific data to the public (Covid mortality risk factors by group, efficacy by vaccine manufacturer, etc) and trust individuals to make decisions that are best for them and their families? When it comes to providing actionable data, is it ever appropriate for Public Health to “stack the deck” and “encourage” certain behaviors?
Regarding #1, at the very beginning, I believe it was morally permissible to temporarily lock down the public to prevent hospitals from collapsing and to study the virus and understand what we were dealing with. But lockdown went on waaay too long, and it’s harder to defend the rest of the mandates. One could even argue that at the time the vaccine mandates were put in place, officials already knew that vaccines didn’t stop infection or transmission, even though the public was being told otherwise. Maybe if the vaccines had been much better and herd immunity was possible this would have been morally acceptable, but knowing what we know now, this never should have happened. Which makes me question just how good vaccines and boosters are at preventing severe disease, hospitalization and death - though I do get an annual jab as a hedge.
When it comes to making tradeoffs between different groups, children should always be prioritized.
County level Public Health Departments have a substantial impact on health policies in California.
In the Bay Area, we have many professional & capable department heads that still connect monthly since the Aids Era. Early adoption of CV 19 airborne risk factor (March 2020) was spot-on.
(1) In order to improve Public Health we also need to include the PSYCHIATRIC ISSUES of those politicians & their minions of morons... who, somehow, overnight transformed masks into a "tool of oppression" instead of a "tool of prevention" to stop spreading a deadly virus that turned the world upside down. That's NOT "Leadership"... That's "Indoctrination" -- aka PSYCHIATRIC WARFARE... (or perhaps "Mass Psychotic Delusional Disorder/DSM-V) -- (2) PR needs to use more Humor & Sarcasm (yes Sarcasm) to get health care "F-A-C-T-S" (remember those?) across to the masses lest they become hijacked (once again) by the toxic, Sociopathic Politicians --esp. those who never passed Basic Hygiene in High School Health Class. [Insert Vomit Emoji Here] -- HUMOR breaks down/thru psychological barriers to reach those who are not easy to reach... I thank God for experts like yourself still fighting for Humanity on this battlefield called Earth! Keep going!
I just met Dr. Galea this year and saw him yesterday. Very wise and measured man! Thanks for the rec.
I think "Within Reason" makes the wrong diagnosis. Public health did not become illiberal; it strove to preserve society's "Moral Sentiments" (Adam Smith's phrase), in the face of a virulent, irrational, hostile assault from the highest levels of official government which was craven, selfish and immoral. Unfortunately, time is out of joint and these sentiments have taken hold in a significant segment of American culture, the part dominated by the Republican Party. Public health, that is the protection of the common welfare from environmental and infectious threat by systemic and preventive means, inherently requires the best scientific information available, dealing with uncertainty, having values, expressing paternalism, making hard judgements, and the exertion of (unpleasant) authority. Public health is not liberal or illiberal; it is a functionality to protect communal living.
A worldwide examination of COVID outcomes (Pandemic preparedness and COVID-19: an exploratory
analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021, www.thelancet.com, published online February 1, 2022 https://doi.org/10.1016/S0140-6736(22)00172-6) examined many parameters and found that the best outcomes were correlated with trust in government and in neighbors. In a society where trust has atrophied, the problem is way beyond the traditional means of public health, which should not change.
Dr. Jetelina, I want to thank you and all of those who did for pushing back hard on the Great Barrington Declaration. I remember so well, as an older person, reading about that with such dismay, as if older people are not human, but something like canned goods on a shelf that can be moved around at will. Here’s a personal anecdote that relates. When the pandemic began, we sought out the best advice available and, recognizing we were at greater risk, we did of course isolate. Having done that, one thing we knew would be paramount for preserving both our mental and physical health would be to get exercise and fresh air daily. In the area of the Hudson Valley, NY, where we lived at the time, there are few suitable walking trails, but we do have a wonderful rail trail. Our county, however, during the early part of the pandemic, put up signs advising that anyone over 70 could not use them. (Needless to say, I did contact the county, who, in typical pass-the-buck fashion, blamed the state. We walked anyway, but we were glad when the signs were finally removed.) I can only imagine how much worse it would have been for us had you, Dr. Jetelina, and others not protested.