I strongly agree it is time for public health to do some self-reflection, though I would argue it is to counter libertarian (individual responsibility for health) influences rather than illiberal influences. We live in an increasingly urbanized society and the challenges of the 21st century (from climate change on down) will not be able to be met by individual actions or disregard for how much our individual choices impact the well-being of society as a whole.
After reading this piece, here are the changes I would point up for self-reflection in the field:
1. Social media is chaos with potentialAs someone who has managed the peer review process of two health science journals and attended numbered research presentations/symposia/conferences watching peer review play out on social media has been electrifying. Watching debates about study design, methods, pathways, causal inference, etc play out in a public forum highlighted which arguments had evidence-based merit and which leaned more to the theoretical. There was also a democratization of participation where junior researchers could easily contribute and cross-disciplinary expertise chime in. I think about how my own science could be improved if I had the chance to consider both a published article and the commentary upon it as I was citing it as evidence. There are serious moderation hurdles to overcome, but academic journals should absolutely examine how they can apply the best parts of social media dialogue to the publication of scientific research.
2. It's time for a paradigm shift on indoor air qualityThere is a tacit admission from public health that infectious disease can spread through air - we have lingo about "hospital-grade" air filters and biosafety levels for labs and graded PPE. Indeed, a core component of reopening NYC schools in the 2020-2021 school year was verifying ventilation systems in every building were upgraded and fully operational, with an assist from air cleaners in every classroom. However guidance still relies largely on "wash hands" and "stay home when sick." There is push back that air cleaning is "too expensive," but corsi-rosenthal boxes, filter upgrades in existing systems, opening windows, and even "scarlet letter" masks have shown us otherwise.There is strong public appetite for purifying anything we take into our bodies, from clean water, to organic produce, to concerns about microplastics and gas stoves, and even a surprising amount of support for public smoking bans. We also increasingly have to deal with wildfire smoke as an indoor air quality issue. There is powerful work to be done with simple public health education campaigns from public health about how disease spreads through the air and how cleaning air can lead to better health overall.
3. The emergency response playbooks and infection control practices have been devaluedAfter 9/11 millions of dollars and thousands of hours were poured into public health emergency preparedness. However, given our leadership when the pandemic occurred, the powerful playbook built to guide us through such a trial was only reluctantly consulted. There were also major public health missteps right at the outset (eg, "masks only work for doctors" and "you can only use CDC tests, but those don't work") that undermined public trust. Those, along with the discomfort we all felt during the response that was mustered have made emergency preparedness along with infection control almost an embarrassing topic to raise in public health conversations. For example, to return to air quality for a moment, NYC City Council had hearings this fall about air quality in schools, and the DOHMH representatives were dismissive and annoyed with the Council Member's queries about monitoring air quality in schools. Funding for air filtration is ending as well, so general improvements that the pandemic brought about will soon be lost to time, disinterest, and even distaste.
4. To earn back public trust, we need to trust the public The missteps at the onset of the pandemic mentioned in the point above were only the first in a series of ongoing injuries to public trust in public health leadership. For example, there were messages from leadership that vaccines would end the pandemic, vaccinated individuals could not get covid, and that testing, vaccination, and treatment would be reliable, available, affordable, and effective ("we have the tools"). Four years in, individuals continue to be unpleasantly surprised by the various serious effects of the virus can have on long term health, even in the vaccinated. The popularity of dashboards like the one that was run by the New York Times show that people are interested in more knowledge, not less, and they are savvy to when those information sources are not trustworthy. It is time for public health to be radically transparent with our data and decision making and not keep it locked in the ivory tower or obfuscated with strange metrics like the CDC's old (c. 2022) community health map/levels. If scientists can debate in a public forum transparently and productively, it leaves less room for misinformation peddlers to take advantage of the cognitive dissonance that can abound in health advice, especially during the pandemic (eg, you must wear a mask indoors and outdoors, but it's ok to take it off and eat in a group setting indoors) to leap in with more palatable claims.
5. To earn back public trust, we must advocate for the publicWe have added a highly transmissible infectious disease with what looks like two peak seasons a year to our array of what makes us sick. However, there have been no supportive policies implemented - eg, paid sick leave, long covid treatment, etc - for what can for some be a truly debilitating infection of several weeks or more. This severely impacts people's ability to work and pay their bills. Children and families are also suffering repercussions from missed days of school, both through learning loss and through punitive attendance policies. Further, moving testing, vaccination and treatment to the private sector payment model has left millions without access to these tools. Where is public health's voice - full-throated and unceasing - in advocating for policies that improve everyone's lives regardless of what illness they happen to contract? Demonstrate commitment to ideals supported by clear data and metrics (truly our fundamental role), and renewed trust can be won.
I also have some questions about points you made.
1. Public health science has been politicized?The example you gave was teacher unions having discussion with the CDC Director. In the article you linked, there were no indications in the FOIA'd exchanges that any of the science was being undermined by these conversations. I am open to the idea that the science is influenced, and I would suggest that economists and consultants outside the public health field are doing so, but I don't find this example compelling. This looks like a stakeholder being involved in the implementation roll out of a pretty significant policy, which seems appropriate.
2. Public health has forgotten its philosophical roots?You cite an article critiquing the GBD as shutting down debate on the issue, but I strongly disagree. This is exactly the kind of response that the GBD authors must give scientific-based responses to in order for their proposal to be considered. Also, their declaration was an open letter, not a lengthy, modeled, fully cited treatise. It is appropriate for them to need to argue and support their claims, especially in terms of the philosophical underpinnings to our field. They also must show flexibility and adaptability if portions of their proposal (eg, herd immunity) do not seem to be proceeding as originally imagined.
(P.S. Similar to another commenter, I also returned to your substack because of Dr Jetelina's review of your book. Wanted to give credit where it's due!)
Thank you for these comments. There is much here to reflect on, and it is exactly the kind of conversation (in agreement and in disagreement) that I hoped to seed with the book. Thank you for engaging so.
Thank you for sharing your process and purpose in writing your latest book. Public health is inherently political and the relative health of public health practice must always include critical reflection and openness to dialogue and holding multiple and sometimes paradoxical viewpoints. I appreciate your leadership.
I strongly agree it is time for public health to do some self-reflection, though I would argue it is to counter libertarian (individual responsibility for health) influences rather than illiberal influences. We live in an increasingly urbanized society and the challenges of the 21st century (from climate change on down) will not be able to be met by individual actions or disregard for how much our individual choices impact the well-being of society as a whole.
After reading this piece, here are the changes I would point up for self-reflection in the field:
1. Social media is chaos with potentialAs someone who has managed the peer review process of two health science journals and attended numbered research presentations/symposia/conferences watching peer review play out on social media has been electrifying. Watching debates about study design, methods, pathways, causal inference, etc play out in a public forum highlighted which arguments had evidence-based merit and which leaned more to the theoretical. There was also a democratization of participation where junior researchers could easily contribute and cross-disciplinary expertise chime in. I think about how my own science could be improved if I had the chance to consider both a published article and the commentary upon it as I was citing it as evidence. There are serious moderation hurdles to overcome, but academic journals should absolutely examine how they can apply the best parts of social media dialogue to the publication of scientific research.
2. It's time for a paradigm shift on indoor air qualityThere is a tacit admission from public health that infectious disease can spread through air - we have lingo about "hospital-grade" air filters and biosafety levels for labs and graded PPE. Indeed, a core component of reopening NYC schools in the 2020-2021 school year was verifying ventilation systems in every building were upgraded and fully operational, with an assist from air cleaners in every classroom. However guidance still relies largely on "wash hands" and "stay home when sick." There is push back that air cleaning is "too expensive," but corsi-rosenthal boxes, filter upgrades in existing systems, opening windows, and even "scarlet letter" masks have shown us otherwise.There is strong public appetite for purifying anything we take into our bodies, from clean water, to organic produce, to concerns about microplastics and gas stoves, and even a surprising amount of support for public smoking bans. We also increasingly have to deal with wildfire smoke as an indoor air quality issue. There is powerful work to be done with simple public health education campaigns from public health about how disease spreads through the air and how cleaning air can lead to better health overall.
3. The emergency response playbooks and infection control practices have been devaluedAfter 9/11 millions of dollars and thousands of hours were poured into public health emergency preparedness. However, given our leadership when the pandemic occurred, the powerful playbook built to guide us through such a trial was only reluctantly consulted. There were also major public health missteps right at the outset (eg, "masks only work for doctors" and "you can only use CDC tests, but those don't work") that undermined public trust. Those, along with the discomfort we all felt during the response that was mustered have made emergency preparedness along with infection control almost an embarrassing topic to raise in public health conversations. For example, to return to air quality for a moment, NYC City Council had hearings this fall about air quality in schools, and the DOHMH representatives were dismissive and annoyed with the Council Member's queries about monitoring air quality in schools. Funding for air filtration is ending as well, so general improvements that the pandemic brought about will soon be lost to time, disinterest, and even distaste.
4. To earn back public trust, we need to trust the public The missteps at the onset of the pandemic mentioned in the point above were only the first in a series of ongoing injuries to public trust in public health leadership. For example, there were messages from leadership that vaccines would end the pandemic, vaccinated individuals could not get covid, and that testing, vaccination, and treatment would be reliable, available, affordable, and effective ("we have the tools"). Four years in, individuals continue to be unpleasantly surprised by the various serious effects of the virus can have on long term health, even in the vaccinated. The popularity of dashboards like the one that was run by the New York Times show that people are interested in more knowledge, not less, and they are savvy to when those information sources are not trustworthy. It is time for public health to be radically transparent with our data and decision making and not keep it locked in the ivory tower or obfuscated with strange metrics like the CDC's old (c. 2022) community health map/levels. If scientists can debate in a public forum transparently and productively, it leaves less room for misinformation peddlers to take advantage of the cognitive dissonance that can abound in health advice, especially during the pandemic (eg, you must wear a mask indoors and outdoors, but it's ok to take it off and eat in a group setting indoors) to leap in with more palatable claims.
5. To earn back public trust, we must advocate for the publicWe have added a highly transmissible infectious disease with what looks like two peak seasons a year to our array of what makes us sick. However, there have been no supportive policies implemented - eg, paid sick leave, long covid treatment, etc - for what can for some be a truly debilitating infection of several weeks or more. This severely impacts people's ability to work and pay their bills. Children and families are also suffering repercussions from missed days of school, both through learning loss and through punitive attendance policies. Further, moving testing, vaccination and treatment to the private sector payment model has left millions without access to these tools. Where is public health's voice - full-throated and unceasing - in advocating for policies that improve everyone's lives regardless of what illness they happen to contract? Demonstrate commitment to ideals supported by clear data and metrics (truly our fundamental role), and renewed trust can be won.
I also have some questions about points you made.
1. Public health science has been politicized?The example you gave was teacher unions having discussion with the CDC Director. In the article you linked, there were no indications in the FOIA'd exchanges that any of the science was being undermined by these conversations. I am open to the idea that the science is influenced, and I would suggest that economists and consultants outside the public health field are doing so, but I don't find this example compelling. This looks like a stakeholder being involved in the implementation roll out of a pretty significant policy, which seems appropriate.
2. Public health has forgotten its philosophical roots?You cite an article critiquing the GBD as shutting down debate on the issue, but I strongly disagree. This is exactly the kind of response that the GBD authors must give scientific-based responses to in order for their proposal to be considered. Also, their declaration was an open letter, not a lengthy, modeled, fully cited treatise. It is appropriate for them to need to argue and support their claims, especially in terms of the philosophical underpinnings to our field. They also must show flexibility and adaptability if portions of their proposal (eg, herd immunity) do not seem to be proceeding as originally imagined.
(P.S. Similar to another commenter, I also returned to your substack because of Dr Jetelina's review of your book. Wanted to give credit where it's due!)
Thank you for these comments. There is much here to reflect on, and it is exactly the kind of conversation (in agreement and in disagreement) that I hoped to seed with the book. Thank you for engaging so.
Just started, after reading Katelyn Jetelina “Your Local Epidemiologist” post about it last week.
Thank you for sharing your process and purpose in writing your latest book. Public health is inherently political and the relative health of public health practice must always include critical reflection and openness to dialogue and holding multiple and sometimes paradoxical viewpoints. I appreciate your leadership.
Well written Dean Galea.