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January 23, 2024
America Dissected
Has Public Health Lost Its Way? This Public Health Dean Thinks So.

In This Episode

The COVID-19 pandemic was a crucible for America’s public health institutions. It brought out their best — and worst. And many of us didn’t like what we saw. Abdul sits down with Prof. Sandro Galea, Dean of the Boston University School of Public Health to talk about his new book, Within Reason, in which Galea argues that the pandemic uncovered an “illiberal,” even, at times, authoritarian, strain within.

 

TRANSCRIPT

 

[AD BREAK] [music break]. 

 

Dr. Abdul El-Sayed, narrating: For the first time in American history, the majority of Americans with medical debt have health insurance. Overall, cancer mortality is down, but new cases of cancer, particularly among young people, are up. New documents show that Chinese scientists shared the genetic sequences of SARS-CoV-2 earlier than previously known. This is America Dissected. I’m your host, Doctor Abdul El-Sayed. [music break] You know, most of us in public health, and I think I speak for almost all of us, don’t think of ourselves as authoritarians. In fact, most of us probably think of ourselves as just the opposite. Public health, after all, is focused on empowering the communities we serve through the single most foundational ingredient of our lives, our health. We save lives, we tell ourselves. Of course we do good. But then who gets to define what’s good? I’m no motorcycle enthusiast, but I’m told that nothing beats the rush of the wind flowing through your hair when you’re riding the open road on your hog. But that’s actually illegal in many states because you have to wear a helmet. The logic here is clear. Keeping your head in a crash is almost certainly more important than feeling the wind on it, right? Well, at least it is to me. But that’s just it. I don’t know the rush of the wind flowing through my hair on a hog, but people like me have up and made that decision for folks who do and think that it’s worth all the risk. The fact that we think we get to make that decision for people, that’s the essence of Professor Sandro Galea’s new book, Within Reason. He argues that in valuing health as the ultimate good, public health risks stripping people of the individual choices to define what they value for themselves, and that that implies a certain illiberal, even authoritarian bend. According to his book, nowhere were the trade offs more obvious than during the pandemic, when public health officials were making sweeping decisions with major ramifications for people’s lives to stop a virus about which we had slim to no data. We’re still, he argues, even as more evidence became clear about what did and did not spread the virus, as well as the costs of our interventions in everything from the ability to kiss your grandmother’s cheek one last time to learning loss in school. Public health insisted on both its evidence and its priorities. He also critiques public health’s increasingly value laden political tenor, arguing that a politicized public health is by definition, a public health that lacks credibility with broad swaths of the population. Let me put my cards on the table here. Within Reason was a challenging read, not in the least because its author is probably my most impactful mentor and a dear friend. I met Sandro when I was a college senior, and he was junior faculty at the University of Michigan. This is no exaggeration. Sandro is literally the reason I went into public health. He mentored me through grad school and gave me my first job as an epidemiology professor. Needless to say, his past work has had a profound impact on my thinking. But since then, our paths have diverged. I moved from the Academy into public health practice, making hard decisions about how best to leverage resources to shape public health in the communities I served. I ran for office, a crash course in understanding exactly how little of the public narrative you can even shape, and how much of it is shaped by malign forces and algorithmic amplification. All rendering events in the world into substrate for outrage. And I’ve worked in media, trying to push back on those forces and usually losing. Our perspectives differ. And that’s why I disagreed with a lot of what was in the book. In epidemiology, we talk about a, quote, “epidemiologic triad,” agent, host, environment. It’s not just the influenza virus that causes the illness. It’s the virus in a susceptible host, in an environment that brings them together. And one of the most important lessons Sandro taught me is that it’s easy to forget the host in the environment, because they literally fade into the background. Which is why I found the book frustrating. Sandro, a tried and true public health professional, is writing to his own community, beckoning us to look within and ask questions about whether or not we might be selling short foundational values that should undergird our work. Values like reason and individual autonomy. The enlightenment principles that birthed public health in the first place. And I’ll be honest, it’s important for us to take stock of how we responded to the most important public health challenge of our lifetimes, of course. But those weren’t normal times. They still aren’t. And I worry that circumstances played a much bigger role. The advent of the pandemic during the presidency of a true authoritarian, the way that the internet magnifies bad faith, misinformation, and the fact that the way we vetted science was changing quickly with the advent of near real time, non peer reviewed preprints. I worry that in castigating public health, we’re focusing too much on the host and the agent and missing the environment altogether. To be sure, public health as an institution is nowhere near blameless. We made a lot of mistakes, but I think the issue isn’t that we’re illiberal or authoritarian. I think it’s that we didn’t know how to deal with illiberal authoritarians, and we still don’t. We thought we were going swimming in a swimming pool. Instead, we jumped into whitewater rapids. And yet, I think that Within Reason is an important read. However much I may disagree with some of the arguments because whatever its cause, public health is exiting the pandemic with a serious image problem, one that we desperately need to fix. Which is why I’m so grateful Sandro took the time to join us to talk about his book. You’ll notice I really wanted to plumb the spaces where we can agree and the spaces where we don’t. And as always, Sandro was gracious, kind and thoughtful. Here’s my conversation with Professor Sandro Galea. 

 

Dr. Abdul El-Sayed: Okay. Can you introduce yourself for the tape?

 

Sandro Galea: Sandro Galea, I’m the dean of the School of Public Health at Boston University. 

 

Dr. Abdul El-Sayed: And author of a brand new book, which I cannot wait to talk about. Um. So I have to say, this is like, you know, for me, Sandro, uh just for listeners is somebody who’s informed my thinking on public health from before I knew what public health was. So, uh it’s impossible to read everything Sandro’s written, but I’ve read all of the uh, the public facing books Sandro has written and many of the papers and have had the privilege and and honor of of writing some of them with him. Uh. So, Sandro, I want to I want to dig right into your your new book, and you titled it Within Reason, which you know, from the from the jump you start to appreciate that this is uh a critique of an expansive public health. Why did you write this book? 

 

Sandro Galea: You know, the book came out in December of ’23, right? So it was about four years after Covid hit us, and I wrote it, obviously to publish a book in ’23, write it in ’22. But it was, it emerged from my growing sense that Covid was this enormous tragedy, and nothing redeems a tragedy. But certainly we would be doing disservice to the tragedy, to the lives lost to the people living with long Covid if we don’t take time to think and to say what are we learning and what should we learn to do better in the future? And I wanted to publish the book at a time when we’re far enough away from acute Covid that we would be willing to pay attention, to not be so wrapped up in the immediate complexities of the moment, but also not so far in the future that we have forgotten all about it. So the intention was a book to force us to reflect, to force us to say, well how did we do? What could we have done better? And what should we learn looking forward? 

 

Dr. Abdul El-Sayed: As I read the book, you know the the passion you have for really forcing us to look back and ask what went right and really what went wrong, uh is is evident. But it also reflects sort of an overriding like on ennui for, for this Covid moment in a post-Covid moment. And, you know, knowing you rather well, I can imagine you just being like, ugh it’s not quite right. We’re not we’re not quite right here. When did this really crystallize for you? When did it–

 

Sandro Galea: Yeah. 

 

Dr. Abdul El-Sayed: –really hit you that you’re like, no, you know, this is just not what I had wanted for us. 

 

Sandro Galea: Yeah, yeah, yeah. This came I think you’re correct. I like to use the word ennui. I mean, I think some of this comes from a place of sadness. You know, it comes from a place of we should do better. And I think a lot of this crystallized for me in the summer of 2020 when, you know, Covid hits March of 2020, it’s terrifying. We’re all afraid, Italy we’re seeing what’s happening, what’s happening in Iran. It comes to the US. And you’re thinking, this is, you know, we should everything we need to do to mitigate it. And then once we figure out what’s going on, we get our handle, our hands around the epidemiology of it, and then we start doing things. And some of those things make sense, and some of those things don’t make sense. And then I ask myself, are we paying attention to alternatives? Are we keeping our mind open to different perspectives? Is it reasonable that we’re taping off playgrounds for our children, when we know that the respiratory diseases are much less likely to be spread on outside? Is it reasonable to be criticizing young people for being out on the beach, when we know that being outside probably is the best thing they can do? Is it reasonable to deny people the opportunity to be with their dying loved ones, when what all people want is to give their loved ones death with dignity. And then seeing all that happen at the same time as there was a closing of the public health mind where public health decided there was an orthodoxy, there was a way to do things. There was an approach that we should all fall in line behind and not allow other perspectives to battle it out in the court of public opinion. And at that moment, in the summer of 2020, leading into the fall of 2020, I realized that this was not the public health that I believed in. This was not a public health that centered autonomy and dignity of individuals, that based what it did on the notion that we should be empirically driven, not belief driven, and that we should aim to do things building on those beliefs to improve things gradually and without disrupting people’s lives unnecessarily. And I think that’s when, in the summer in fall 2020, I developed this to use your word ennui, which it really were the seeds of then writing this book two years later. 

 

Dr. Abdul El-Sayed: So, you know, I’m going to play a lot of devil’s advocate here. Um. Because I remember that time vividly. I think all of us do. And part of what I feel about the way that the public conversation about public health and what public health ought to do in the pandemic evolved is, is that we would have liked to have this conversation in a sterile testing ground, in a place where everyone was engaged in good faith, where the discussion could be had on its merits, where evidence would be given full engagement and an honest assessment. And instead, the conversation was being waged in the context of a moment where there were bad faith actors almost everywhere, where our conversation had been collapsed via social media and so much else of the nature of the way we discuss and and move ideas these days. Into almost a, you know, philosophical tug of war. You’re either here or you’re there. And any argument that gives a shred of support for bad faith actors is a bad faith argument. And so I guess I wonder, would it have been possible for public health to have a public debate in the context of those times that was as open, fair and free as I think both of us would have wanted in the context–

 

Sandro Galea: Yeah. 

 

Dr. Abdul El-Sayed: –of having to do something. Uh.

 

Sandro Galea: So, yeah yeah. So, I mean, you’ve you’ve captured a lot of thoughts that uh I’ve had that I’ve struggled with. And in the book I’m clear about this, that I write a book that is a critique of public health that is not meant to exonerate the bad faith actors who have plenty of blood on their hands. I want to be very clear about that, but I’m not writing a book about that. That does not mean that having a president who was actively, actively trying to pretend that Covid didn’t exist, actively promoting treatments that we knew were were false and harmful to people, was not enormously harmful and disruptive, and somebody else should write a book about that. So I want to be very clear that I recognize that. I suppose my contention is that public health has a responsibility always, but particularly in a time of public health crisis, to be the adult in the room and being in the adult in the room means that if the those who are acting in bad faith. Those who are acting with bad intent are misbehaving. They’re causing a ruckus. You still have a responsibility to keep a level head about it. You still have a responsibility to base what you do based on the evidence. You still have a responsibility to listen to ideas, even if they may come from suspect sources and to weigh trade offs. And these are things that we did not do. We lost our head in public health. I’m not saying that we didn’t have reason to lose our heads. I’m not saying that, but I am saying that we needed to do better. 

 

Dr. Abdul El-Sayed: I want to, uh I want to I want to really dive in because your central argument is, is that public health at that time, it was a it was a tipping point for us where we we lost the central values of reason and liberal thought that undergirded the founding of our science in the first place. We became, yeah and to use your words, illiberal. I want to ask you, what do you mean by illiberal? How do you think about that? Um. And why do you think that that we tipped into that direction? 

 

Sandro Galea: You know, I mean, liberalism in the classic enlightenment sense of liberalism, I don’t mean it in the context of left or right, Democrat or Republican. I mean liberalism, it meaning that one that centers the autonomy of individuals, that one focuses on, builds opinions on data, one is empirically driven. One separates oneself from belief and religion, and where one is committed to improving the world, improving society through reasoned reform. That’s what I mean by liberalism, which actually, in our current political landscape, there are echoes of that on both the right and the left of the political spectrum. On the left of the political spectrum, a lot of building social programs to reform society based on data come from liberal thinking and on the right a lot of libertarian thinking, which is centering it, individual above all else, come from liberal thinking. So I mean liberal thinking in this classic 19th century enlightenment tradition. Now, why did we deviate from that? Well you answered that question with your last question to me. I think we deviated from that, A, because there was intense provocation. I think there was intense provocation. A lot of it came from very high profile political actors. And I think a lot of responsibility lies at the feet of the person who was president at the time, who pushed public health to feel defensive, to feel like, oh my goodness, there is somebody who is saying that this disease doesn’t exist. Well, therefore our response has to it has to be not only does it exist, the only thing for us to do is to adopt these policies where we keep our children out of school for years at a time, because that shows that the disease exists and our reaction was not unreasonable. But I come back to the point that we incurred harms through an overreaction that was provoked by bad faith actors. 

 

Dr. Abdul El-Sayed: You know, it’s interesting because I keep coming back to the, you know, not to not to um over tork the analogy here. But you know, in epidemiology we’re taught the classic epidemiologic triad. The idea that you have a vector, you have a host, and then you have an environment. And the vector here was the incoming Covid pandemic. The host was us. And then the environment was a moment in which, and I don’t even want to say that we’ve lost uh liberal values in the sense that you’ve defined them and in the ways that I think in local contexts, we we think about and try and try and adjudicate the world around us, but that we have built a method, a mechanism of communication that has traded scale for nuance. And I think in trading scale for nuance, we were in an environment where the nature of our public communication was always going to be seen as absolute. And even if it wasn’t an absolute argument, even if 95% of public health, uh talkers and influencers weren’t saying the absolute thing, that the algorithm was always going to find the most absolute and deduce it into that. And then over time, what would happen is if that’s the most popular argument, right, people start to move to that. And I think what you’re saying is we should have had a clearer anchor. But in the nature of this problem is, is that you almost always get pegged for your most extreme. And so there is there’s like a collective action problem where anyone speaking on behalf of public health who makes the most extreme argument is going to be picked up by the algorithm, amplified, and then that’s going to set the tone for the rest of the conversation. And I, I want to ask you, like, because your, your, your book is, is is almost, you know, you embody the argument, which is to say we need to have a conversation and have reasoned conversation about public health, but that implies that the issue is about the thinking of public health individuals, and less so about the environment in which public health individuals live. And I want to ask you, you know, to as we think about that, what is the role of the individual, you know, public health talker, expert, etc.? You know, in a world where you have this, you know, to use Jia Tolentino’s words a trick mirror of a public conversation. 

 

Sandro Galea: I think the um, a couple of things. Number one, I’m not willing to trade anything for nuance, and I don’t think we should either. I don’t think we ever should, because the world is a complex place, because different people have different values, because different people see the world differently. Any time we start thinking that uh somebody sees that everybody should see the world the way I do, we have embraced the hubris that’s going to be our downfall. So, you know, one of the things that uh, I’ve been uh criticized in the book is to say, well, who’s to say what’s reasonable? You know, the book’s called Within Reason. And my answer is, I don’t know. We should collectively decide what who’s reasonable by through public conversation. So I don’t think we should ever sacrifice nuance and complexity, it’s number one. Now number two, I’m not so naive as not to realize that the tool at our disposal, which largely dominated the public conversation is social media, is what stripped us from that nuance. And the point I make in the book is that this was an example of a new technology that we did not know how to use in the context of a crisis. The analogy was 9/11, where 9/11 was the first crisis we lived through in a time of 24/7 cable news. And a lot of what happened in 9/11 was driven by the technology that we did not know how to use to bring about nuance and complexity. The Patriot Act, which is an example which I, I mention in the book, which at the time, you know, we today we look at the Patriot Act as an enormous, extraordinary infringement of civil liberties. It is something that gives away things that we, that we are not willing to give away. And we forget at the time, 98 senators voted for the Patriot Act. That’s how that’s how it seemed at the time, like this was the right thing to do. There was no discussion, and the one senator who voted against it was essentially excoriated. We made the same mistake in this case mediated by social media. So I come back to and, you know, I think you can reasonably say to me, well, but what can we do? We’re just human and I I I agree. And that’s why the book is not backward looking. There’s no there’s no finger pointing in the book. There’s no name calling in the book. I’m not saying person X or person Y did something wrong, because I’m trying to come at it from a place of recognizing how difficult it was. I’m simply saying, observing what happened, what are the lessons we should extract so we can do better in the future? [music break]. 

 

[AD BREAK]

 

Dr. Abdul El-Sayed: I want to pivot a little bit because one of the implicit assertions, and I really admire it as a faceless bureaucrat uh in my day job. Um. You you you wrote an essay in effect, in defense of the faceless bureaucrat. And–

 

Sandro Galea: I did, I did. 

 

Dr. Abdul El-Sayed: One could argue that your call in that essay and frankly, throughout the book, is that rather than venerating platforms, uh or power, we really ought to bring technical excellence back to the fore in our conversation. You know what is what is technically true and be guided by the evidence and the science. And that obviously I, I fully and wholeheartedly agree with you. I think, though, there is a difference between following evidence and a sort of scientism which limits the bounds of public health to what is technically observable, and then who wields data. And I always come back to the sort of recursion problem, which is to say that, you know, you and I have enough statistical skills between us to make data say almost anything. And so the one who interprets the data, right, who has any ideological perspective whatsoever, will read that in whether they choose to or they don’t. And I think we you know, that’s the reason we do peer review, which is to say, hold me accountable to my interpretation of the evidence. But the worry I have is that that almost seems to be a call for a far more limited public health that is really technically engaged. And, you know, I have as as literally your student and a student of your writing, you know, it wasn’t more than ten years ago where you talked about a consequentialist public health, which, you know, almost–

 

Sandro Galea: Yes. 

 

Dr. Abdul El-Sayed: –seems in in direct opposition to this. Right. Consequentialism, by definition, engages with the outcome in the object oriented approach. And here you’re saying this is a process question. It’s almost a a technical deontology. So I want to I want to, get your sense on how you balance that? 

 

Sandro Galea: Yeah, no no. Yeah I don’t I don’t think that uh, I like your use of this term scientism. And I certainly don’t call for it. In fact, in the book, I make it clear that one of my least favorite movements in the pandemic was the bumper sticker, Follow the Science. I really did not like that, because Follow the Science suggests that there’s a linearity, that science tells us what to do, but science doesn’t tell us what to do. Science is just one input in what we choose to do. You know, I go to an example which I use in the book, which is of people dying. We, people are dying, and we said no one can go near them because they might also get Covid. So, you know, people’s grandmothers are dying in hospitals. Heartbreaking. They can’t go to them, or at least they can go to them through plastic. And that was the science was clear that if you go around these people, you’re more likely to actually get Covid, but people were gladly willing to trade getting Covid for a chance to give their to kiss their grandmother one more time. And that is where the science has to be balanced with the values. Similarly, for example, the issues of what we did around schools when we kept schools open, one of the things which one of the examples I use in the book is the fact that in this country, in the US, we never had a conversation about whether or not Covid vaccines should be mandatory for children. We just said they [?] mandatory if you are going to school. Now in Europe, they actually didn’t vaccinate uh children. And we often look to Western Europe as being ahead of us. Now, why did they not do that? They did not do that because the evidence was clear that children are less likely to get Covid, less likely to transmit it. If they get it, they’re actually uh going to get a weaker form of Covid. Now, I did say in the book that I got my children vaccinated for Covid. Um. But that was a trade off. That was a trade off that I was willing to make. These are societal tradeoffs that we must make that combine empiric inputs and moral inputs. So no, so I’m not I am not elevating the science above all else. I’m simply saying that science has to take precedence over belief. There’s no question about that. But the decisions we make as a society need to balance the science with our other inputs and our other prerogatives that we value as a society. 

 

Dr. Abdul El-Sayed: I really appreciate that. And I guess where I’m headed here is, is that. You know, as, as as we think about where our work is headed. There’s been a big shift in the way we think about what we want to prevent in public health writ large. And I remember when I was in grad school, we wanted to prevent disease, baseline. And that’s an important outcome. But as we started to appreciate and understand the profound inequity in who suffers disease. So much of of how we’ve thought about preventing disease has been about preventing inequitable disease burden. And when you start thinking about equity, then you have to think upstream. And, you know, and everybody who listens to this podcast knows I hate the term social determinants of health because it doesn’t mean anything to anybody for whom they need to understand it. But um, you start to think about those social determinants. The notion that that distribution of disease is about a number of structural features of society. Who gets housing? Who doesn’t? Who gets clean food, clean uh air and and quality food? Who doesn’t? Who gets to walk in their community? Who doesn’t, uh who gets a good high quality job with representation, who doesn’t. And then you start to then ask, okay, well, if those are the structural features that determine disease outcome, then we ought to be advocates around those issues. And I think in some respects, some of what has led us to this moment has been a willingness for our science to engage with the upstream features. And I think someone could could read your book and say, yeah, but like, not that far, right. Once we start getting to the political advocacy around these questions of who gets and who doesn’t get, then then we sort of hit, gone too far. And I, I want to ask you, right, what is the bound? Because there is a trade off between those patterns that become a function of politics and the need to engage the politics that create them, and the technical features in the nuance underneath them, over which we have a lot more control. And I think what’s happened is public health has gotten explicitly political around features of the community that we want to engage for health. And, I think that in some respects, because that’s turned us into political advocates at times, it has led to a lot of the same themes in our politics that have led to this illiberalism that, you know, that we’re talking about. How do we balance? How do you think about balancing the responsibility to advocate for the purposes of health around the unequal distribution of resources in society? Vis-a-vis our need to always be led by the science and not to be seen as explicit advocates. 

 

Sandro Galea: Wow, so many great questions. Um. This is going to take me an hour to answer this. Uh. Let me let me just answer two parts of your many many part question. Number one, our job is to make people healthy so they can live. Our job is not to make people live so they can be healthy, and that is a critical distinction. I talk about this in the book. I talk about the importance of joy. And I use this this metaphor in the book because uh, you know, everybody here has the experience of you go to a public pool, right? And there’s a sign in the public pool that says, don’t run, no drinks, stay away from the wet, from the wet pavement, twenty things. And nowhere in the sign does it say, have fun. The whole point of going to the pool is to have fun. And public health makes that mistake all the time. That we think that people want to live in a human zoo. People want to be healthy at all costs and not allowed to do anything. So the answer to your question is who decides where’s the line? Well, the line is within reason. Let me give you another example. You probably drove your car on a highway today in Michigan, and you probably drove at the speed limit of 55mph. I know you might would have been under the speed limit just 54, let’s say. 

 

Dr. Abdul El-Sayed: Uh you’ve never been in my car Sandro.

 

Sandro Galea: And as you were doing that, Abdul. 

 

Dr. Abdul El-Sayed: I’m sorry about that. [laughter]

 

Sandro Galea: As you were doing that Abdul, you know, because you’re an epidemiologist by training, that actually being in an accident at 55mph makes you twice as likely to die than if you were in an accident at 25mph. So why is the speed limit at 55mph? Why is it that we as a society don’t say no, nobody should drive over 25mph. Well, the reason is that we determined a balance. We find a balance between the bounds that keep us safe and how we want to live as a society. Now, all of that is up for discussion and debate and should be part of the public square. And we should try to allow those discussions as free from undue influence, as free from bad faith inflection of those arguments as much as possible. And I’m not so naive not to realize there are a lot of bad faith action in trying to manipulate those conversations for people’s individual gain. But we should be better than that, and we should be creating space where the inputs of science and public health jostle in the public space with other moral imperatives that we have as a society with other inputs, other desires that we have as a society where we create limits that are reasonable and that are tolerable without overstepping. And that is the public health that I always thought I was a part of until Covid happened, when I realized that Public health forgot that in the context of a crisis, we said, no, no, no. The only thing that matters, the only thing that matters is health. But health to me is useless if I can’t live. And likewise to you, it’s like saying my car works beautifully, but I never take it out of the garage. 

 

Dr. Abdul El-Sayed: And I appreciate that point. And I guess I, I, you know, you and I, um you know, as we think about our beings and doings. We tend to be the kind of end user around which our society is built. And I think part of the challenge of the equity conversation and the social determinants conversation is what about those for whom our society is not built? And is there a kind of beyond explicitly health conversation that public health ought to be a part of? Now look, I’ll be I’ll be honest with you and I’ll be the first to say this, the health framing around a lot of our uh advocacy against racism and our advocacy against poverty is not as effective as we all think it is, right? We commit the the hermeneutical fallacy, the notion that, you know, we assume everybody values health the same way we do because this is what we do for a living. When we say, for the sake of public health, you ought to give people housing. I think you’ve even if you talk to to the people whom you’re advocating for, ostensibly they’ll be like no for the sake of housing, I want housing, right? Not for the sake of my health I want housing. Because I want to reduce my probability of asthma, or I want to reduce my probability of you name the health outcome that we measure. So I I, you know, with the caveat that there’s a limitation here. But I guess the the question I want you to help me reflect on is what is the space for advocacy beyond health from public health? Because the, you know, obviously, you know, I ran for office and a lot of the reason I ran for office is because as I looked at a lot of the challenges that people I was studying or advocating for or serving as a as a public health commissioner, as I looked at the challenges they were facing, I realized actually the public health framing is is missing the point. There are there are broader, bigger issues that we need to engage with. But it was important to me, and it was important to frame on the notion that I am a physician by training, an epidemiologist by training, and a public health practitioner. And I guess my question for you is, you know, what is that balance? Because on the other side of public health advocacy is the risk of patterning that advocacy in the same way that we do politics, which I think you’re implicitly critiquing here. So what is a responsible public health equity advocacy and what are the bounds within which it works? And how do you resist, right, being labeled as a partisan in the setting where 95% of the things that you advocate for end up being advocated for by a one party and not the other. 

 

Sandro Galea: There’s no simple answer to your question. And I think the way I try to deal with it in the book is by looking at the public health community, which is what the book really is about. And what the book says is, it is up to the public health communities, on the public health community to make sure that we listen to a plurality of voices within the community. It is certainly wrong for us to rapidly descend on an orthodoxy of perspectives that closes our mind to different perspectives. There are enough people. It’s a big enough tent that together we can jostle it out for the best idea, which then we push forward. Our job in public health is not to tell society what to do. Our job is to provide the analysis, to guide society, and I think it’s reasonable for us to advocate for those positions. You know, I’ll use a concrete example because I think sometimes these things are easier by analogy. Think about cars. Again, we talked about cars a second ago. Cars are much, much safer now than they were 60 years ago. Why are they safer? Because of seatbelts, shatterproof glass, laws against drunk driving. All of those emerged because of public health efforts to advocate for implementing particular approaches based on empiricism. And I think. We should not be. We should not be ashamed of those. We should be proud of that. But as we’re getting there, we need to make sure that we allow space for the discussion, what level of freedom are we willing to tolerate? Because, by the way, it would be safer when you’re driving your car to be wearing a motorcycle helmet. Why don’t you do that? I mean, you’re you’re you’re a highly prominent, um you know, one of the most articulate spokespeople for ideas of health Abdul. Why is it that you are not advocating for all of us to wear our helmet inside our car? Why aren’t you doing that? 

 

Dr. Abdul El-Sayed: Because my hair looks so good when I’m driving.

 

Sandro Galea: Are you are you [laughter] No, no, but this is exactly the point Abdul. Because actually, because your hair does look good. 

 

Dr. Abdul El-Sayed: Thank you sir. Thank you.

 

Sandro Galea: Let’s be clear. But it, but but it really what you’re saying implicitly is I value the way my hair looks. So therefore, I don’t want to wear a helmet. You know, obviously we’re we’re joking. But but hopefully listeners will recognize there’s truth to that, right? It’s, because we value other things because we, you know, and we in public health under normal circumstances are willing to tolerate that. In the context of Covid, we forgot to tolerate that. For example, one of the things that emerged in public health time and again is like, how could anybody, anybody, not want to wear a mask? It’s such a trivial thing to do. To which, is it trivial? I mean, sort of inconvenient. A lot of people really hated it. A lot of people hated it as much as you wearing a helmet that messes up your hair. I mean, it’s trivial, but these are decisions. These are things that we like or don’t like as a society. So all I’m saying is, yes, we should have the science. We should be clear about what it is. We should we shouldn’t be afraid of advocating for it, but keep our minds open to the fact that there are a reason why many people are disagreeing with us. And now you can say to me, look, Sandro, the data tells us what we should do. Let’s, let’s, let’s stick with the example of the helmet in the car, right? And we know it’s going to save X lives a year. So we should you know, we have a moral imperative to just argue that out and keep hitting, keep hitting it, and hitting it and hitting it until we win. Well, is there a cost to that? Of course there’s a cost to that. The cost of that is that people are going to tune us out, stop listening to us and stop trusting us. And that’s exactly what happened in Covid. When you look at the Pew data that just came out last month, which is from their annual essentially survey around trust in government, trust in science, trust in public health. Public health science is 25 points less trusted now than it was before Covid. Now think about it for a second. It’s extraordinary after this incredible crisis, there was a public health crisis where public health objectively did better than we could have hoped like we saved millions of lives. The rapid vaccines, the rapid testing, screening, mitigation measures saved millions of lives. You’d think that trust in public health should be through the roof, but no, trust in public health is much less than it was before Covid. What are people reacting to? People are reacting to the sense that public health was not willing to listen to different perspectives, because we valued only one particular view. We valued we leaned in to bumper stickers like Follow the Science. We leaned into ideas that the only thing that mattered was a narrow definition of health. 

 

Dr. Abdul El-Sayed: I would say that might be part of it. I would say the other part of it is that there are a lot of really bad actors who have a lot bigger microphones than we do, who highlighted a lot of our missteps and just the fundamental features of the dynamics of this virus, which are that 99% of people who get it survive it. But 1% of people still accounts for millions of lives lost. And I actually think that that number is somewhat paradoxical, because people will say, well, you told me it was so deadly, but like 99% of people survive it. And that makes us look like fools, except for the fact that we can point to the numbers and say, yes, you are correct, except for how many people died of this thing. So I hear you that there was a certain um, there was a certain public health orthodoxy that ended up becoming the loudest voice in most rooms and speaking for public health. That made us seem, you know, particularly absolutist about a particular set of outcomes at the expense of a number of–

 

Sandro Galea: Correct. 

 

Dr. Abdul El-Sayed: –other values that people valued. 

 

Sandro Galea: Correct. Correct. But everything you’re saying is correct. And I agree about the bad faith actors. I want to be very clear about that. I agree. That’s not my that’s not my ecosystem. I’m not writing about that. I’ll let others write about that. I’m not getting letting them off the hook. But if if in public health all we do is say it was other people, then we’re not learning. So I’m acknowledging the bad faith actors. I’m simply saying someone in public health should start a conversation, let’s say recognizing the bad faith actors, how do we get our house in order? 

 

Dr. Abdul El-Sayed: And I, I guess what where where the kernel of our different interpretation of this moment sits is that I actually worry we’re at risk of over indexing on our our own agency here. I think we may learn the lesson that we cannot say anything until we know everything. And then we can say something. Because–

 

Sandro Galea: No not at all. We should we can say, we can say things when we don’t know. We should just say that we don’t know. 

 

Dr. Abdul El-Sayed: And and I val — I appreciate that. I just having had conversations with a lot of folks in public health, as you have. I worry that a lot of folks had this experience of for the first time having to engage in the public debate. And finding it to be an extremely painful experience, and that we’re going to use this moment and we’re going to tuck in. And I worry that we as a community, we have this odd mix of two things. We we value deeply our authority and our expertise. And we don’t like to have it questioned, which is a problem. And I hear you speaking to that in this book. But the other side of it is that we do not relish the bumps and bruises of the public debate. And for that reason, our outcome here will be to tuck in and say less. And I worry that rather than lean in and be a lot better about teaching foundational basics so that we can actually have a coherent conversation with the public, so that when we say, well we’re really not sure here. There aren’t people are not as vulnerable to the con men on the other side who exploit the difference in confidence between what they’re saying and what we’re saying, and that that is my fear here. And I just that is, I think, where I I worry, I worry that we’re going to we’re going to pull out and we’re going to say, well, I don’t know that I’m being reasonable. I don’t know that I’m offering, uh you know, a good faith engagement. And when you engage with somebody who’s engaging with you in bad faith, in good faith, what tends to happen is you come out looking like you don’t know what you’re talking about, and they come out looking right, like they’re obviously correct. And in the grand scheme of the environment in which we live, that what tends to happen is it ends up silencing our voices. And I worry a lot about what that might look like. 

 

Sandro Galea: If that’s what happens, it will be a failure and that shouldn’t be what happens. We should lean in. Look, I, I believe in the mission of creating a world where people can be healthy and people can be healthier, and so they can go about living rich, fulfilled lives. I care enough about the mission that I wrote this book, recognizing that it’s going to ruffle some feathers and some people may have a hard time wrapping their mind around it. So this is a clear, strong encouragement for everybody in public health to, yes, lean in and think about what we’re doing when we’re leaning and think about the lessons we’re learning, because the world needs public health and needs public health more than ever. But um, you know, to use the old aphorism, you know, mistakes were made and we should learn from them. 

 

Dr. Abdul El-Sayed: Yeah. I appreciate that. I want to ask you one more question. And, you know, it comes up in some of the critiques of the book. Uh. And some of your thinking in in in this post Covid moment. Um. And I, I want to I want to take seriously a kernel here because I think there is this way in which we end up going down the thought slide when when we engage with something, it’s like you’re not adequately valuing the health of so-and-so individual. Therefore you want that individual to be hurt. Therefore you want that individual to be dead. Therefore you’re advocating for genocide. You’re genocidal. Like that that actually happens. And I know it sounds nuts, but like that is basically every Twitter thread or now X thread, whatever you wanna call it. But–

 

Sandro Galea: Yeah. [?]

 

Dr. Abdul El-Sayed: I want to I want to engage with this question of collective action, because at core in public health, one of the fundamental arguments that we make is actually foundationally less liberal, if at the core of liberalism is individual autonomy. We are consistently in this presence of of advocating for collective action, which by definition is asking an individual to sacrifice something for the well-being of the collective. And the question then becomes right again, how far should we go here? Because you’ll have folks who will say, well, actually, we should be asking everybody to wear a mask because there are some people for whom the consequences of getting Covid are so bad, right, that we all have to do our part to protect them because they’re more vulnerable. And they’d argue that we should continue to be wearing masks now. Now, I I I predict that your point would be okay. Listen, wearing masks is not without cost and asking folks in the context of this particular risk profile to do that thing might not be within reason, but at some point there there is a question about what is the what is the bounds of our collective action, particularly for a practice that is collectively oriented. Right. And that’s the part that I, I, I find myself struggling with also in the book. Is that okay yes. I I agree with you that at some point folks should have their their own autonomy, but are, we do have a responsibility to protect folks that are more vulnerable to what extent and how do you think about that bounds of, of collective action and what we can reasonably ask folks to do? Because I think part of the response to what folks are frustrated in with public health right now is actually that we ask them to to make collective sacrifices. And I think that’s just a profoundly un-American thing in most people’s minds. And they don’t like to be asked to sacrifice. 

 

Sandro Galea: But the– 

 

Dr. Abdul El-Sayed: So I want to get your thoughts on that. 

 

Sandro Galea: I think the bounds of what is reasonable are defined and redefined and negotiated and renegotiated by society all the time. And let me let’s stick to the car analogy, which has threaded through our conversation. Implicit in our last conversation is that you don’t think it’s reasonable that you should wear a helmet while you’re driving your car, but I’m pretty sure you think it’s reasonable that you should wear a helmet while you’re riding your motorbike on the highway. Now why? Why are you doing why are you saying that? Why do you think that? You’re thinking that because you’re doing a risk calculus, that the risk to riding your motorbike and falling off your motorbike and dying if you’re not wearing a helmet is so much higher than it is than there’s a risk of being in a car because car has other safety features, right? The the line is somewhere in between those two. It’s somewhere between not wearing a helmet when driving a car, but yes, wearing a helmet when you’re riding your motorbike and getting to that place requires our honest engagement based on data and also exercising our powers of persuasion. My argument in the book is that we need to be careful and thoughtful about when we exercise that advocacy, when we ask for that collective action, because our game. We’re in for the long game. And the reason you laughed when I said we should ad– you should advocate, use your platform to advocate for wearing a helmet inside a car is because, you know, I don’t think you had thought it through that quickly, but I bet your sequence of thoughts were, if I do that, then nobody’s going to listen to me and I’m not going to have any impact on anything else, right? And that’s what I’m saying, because we are at a place where people have stopped listening to us. That doesn’t mean we compromise the vision. The vision is to create a healthier world. But it means being thoughtful and smart about it, and recognizing that we need to be seen as reasonable and as engaging of a whole of society, not just some of society. So, you know, to your point about Americans don’t like sacrifice, Americans sacrifice all the time. I actually think, you know, we have restrictions on action all the time. I mean, people in the middle of the night stop at stop signs and traffic lights when there’s no one else around, and millions of people do it every night in this country. That is remarkable, right? We have achieved a place where people recognize that that is right and that is a correct collective action. And I want to make sure that we get as many people as possible to the kind of collective actions that we can all embrace to make us all as healthy as possible. And I’m pretty sure that we don’t do that by saying let’s put all our eggs into arguing for wearing a helmet inside your car. 

 

Dr. Abdul El-Sayed: Yeah. And I I hear your point. I’d be interested in seeing some of those crosstabs in that Pew research about who trusts public health science and who doesn’t. And, you know, to my earlier point about this being more of an environmental feature than a, than an than a, than a host feature. Um. I think a lot of that is a function of a moment that has hyper polarized everything. And then we happen to be substrate for that. I um, I want to finish on a on a final note. You know, you you trace out, um I think beautifully in the book, your argument about an illiberal public health and some of the consequences. And it’s, your argument about where that may lead us has come out a bit in this, in this interview. But I want to ask you, you know, what are the consequences of, uh in your mind, public health’s failure to, to be, um to be more conscious of, uh our need to, to focus on reason and to create and foster a space for debate. 

 

Sandro Galea: You know, I’ll I’ll I’ll end this interview with where I start the book and I start the book at this anecdote where of this bakery close to my house, where I run to on the weekends. And towards the fall of ’21, the baker had a sign on the door which I took a picture of. And I quote in my in the book, which says, the town where we live in has determined that uh you no longer should need to wear a mask. But we disagree, and we insist you wear a mask in our store. Now, in and of itself, that sign is innocuous, and wearing a mask I saw was not any particular hardship. But the reason I pointed out is to ask the reader and the audience, can you imagine a time before Covid when a bakery, which doesn’t have its own medical board or board of advisors would put up a sign on the door that said, the health experts say X, but we don’t believe the health experts we think the answer should be Y. Like it was inconceivable before Covid. And since Covid that’s become commonplace. And that’s a real loss. 

 

Dr. Abdul El-Sayed: Now, I appreciate that. Um. That note and it’s a it’s a poignant example to end on. Our guest today was dean Sandro Galea. He is uh the dean of Boston University schools pub– he is the dean of Boston University’s School of Public Health, author of over a thousand scientific journal articles and 24 books, including his latest, Within Reason. Sandro, we really appreciate you taking the time to uh to join us and uh for a vigorous conversation today. 

 

Sandro Galea: Thank you Abdul. It was always a delight. [music break]

 

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. As of 2022, the majority of Americans with medical debt had health insurance. In a recent analysis, 58% of those with debt had had medical insurance when they took it on. That compares to 2018, when just 11% were insured. What happened? Insurance has gotten less sure. Who’s got my soapbox? Because, you know, your boy’s been saying this for years now. In the past, health insurance used to cover all of our out-of-pocket costs. That’s the whole point, after all, to protect you from the emerging economic consequences of getting sick. That’s why those of us who can afford it, buy insurance. But insurance itself has changed. Rather than negotiate down the price of health care on our behalf. Health insurance corporations have instead figured out ways to pass on those growing costs to us in the form of gimmicks like deductibles and co-pays. Not to mention the fact that premiums, what we pay every two weeks or every month have gone up themselves. The average deductible for a single covered individual in 2022 was nearly $1,800. Think about that. $1,800 out-of-pocket before your insurance even kicks in. And if that $1800 comes all at once. Well, that explains where we are right now. Family deductibles are even higher, often around $4,000 or more. All of that should remind us we don’t have to live like this, at the whims of the greed of both health care companies and health insurers. You know what I’m about to say. Medicare for all? And we probably want to make sure we have health care because, well, the American Cancer Society’s new report is painting a changing picture of the disease. Let me share the good news first. Cancer mortality is down substantially, with over 4 million deaths to cancer prevented since the 1990s. That’s a great news. And it’s a massive win for public health. How did it happen? The biggest reason is that people are smoking less. Accounting for a massive decline in lung and other smoking related cancers. We’re also screening a lot more, identifying cancer early enough to be able to treat it effectively. And finally, we’re just better at treating cancer. But on to the bad news. More young people are getting cancer, particularly colorectal cancer. Whenever you talk about cancer incidence, meaning the number of new cancer cases. It’s important to differentiate between new cancers and new cancer diagnoses. Think about it. Cancer is a biological process of cells dividing uncontrollably and infesting tissue. More of that is unqualifiedly a bad thing. But new cancer diagnosis meaning more people identifying their cancer at a younger age. That’s actually a good thing. It means more people are getting their cancer treated and hopefully beating it. This looks like some of both. Meaning in part that there’s actually just more cancer happening. The rise is particularly pronounced in younger people. And this situation with colorectal cancer, it doesn’t really have a clear explanation. The incidence has been rising about a percent or two every year since the ’90s. In fact, today, colorectal cancer has become the single leading cause of cancer death in men and second in women only to breast cancer. What’s causing it? Well, look, we’re going to have to dissect that together in a later episode. Stay tuned. Finally, as the search to understand the origins of SARS-CoV-2 continues. New documents demonstrate that Chinese scientists had uploaded the virus’s genetic details into a massive American genetic database as early as December of 2019, at least two weeks earlier than it was previously known. While the Chinese government has been anything but forthcoming about what it knew about SARS-CoV-2 in the earliest days of what would come to be an era defining pandemic, Chinese scientists tried to do the right thing. I share this as context for a broader point. As Sandro and I discussed, the pandemic had major impacts on the country’s perception of science and the health officials who try to use it to make decisions. In the whitewater rapids of the pandemic, in the moment in which it hit us, science and public health were politicized and in that rendered suspicious. And while it’s true that governments and politicians may want to bend the truth for their own purposes, it also remains true that the public health community is built of people for whom truth and human welfare really are the main goal, even if that means that they may come to some harm for it. Though scientists who share that data were doing so despite what their government would end up doing to conceal the truth, they took risks in doing that. Risk they probably understood even better than we do. But they did it anyway because it was right. And they wanted to protect lives. And while folks may make mistakes, or the bureaucracies we build and work in may stymie our best efforts, it’s important that we reflect on the fact that there really are good people in the world who care about getting it right. That’s it for today. On your way out today, please don’t forget to rate and review the show. It does go a long way, and if you love the show and want to rep us, drop by the Crooked store for some America Dissected merch. Don’t forget to follow us at @CrookedMedia and me at @AbdulElSayed no dash on IG, TikTok, and the website formerly known as Twitter. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher, our associate producers are Tara Terpstra and Emma Illick-Frank. Charlotte Landes mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice, and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests, and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human, and Veterans Services.