Public Health Within Reason
On pausing The Healthiest Goldfish and looking ahead to the new year.
A bit of an opening announcement: This is going to be the last regular weekly Healthiest Goldfish.
When I started The Healthiest Goldfish, my aim was to write a series of reflections about the forces that shape health. These reflections were to be informed by our experience of COVID-19, although hopefully not unduly constrained or defined by the urgencies of the moment, pressing as they were. Indeed, one of the joys of writing is seeing thoughts and ideas evolve and not always knowing the ways in which they will do so. Much of my writing in this space did indeed concern the lessons of COVID-19 and how they point us towards engaging with the foundational drivers of health. From the role of money and resources in shaping health to the dangers of moralism in public health, to the ineluctable importance of complexity, the themes of this newsletter intersected with much that I have written on throughout my career and which have risen to the fore during the crisis of the last two years. It is also true that interwoven with these themes have been a number of detours, touching on subjects as diverse as social media, UFOs, and the importance of good faith argument.
Writing this newsletter was also an occasion to reflect on the core importance of pursuing a healthier world within a small-l liberal framework. This is to say within a context of free inquiry and rigorous debate, guided at the analytic level by the scientific method. These principles of liberalism and modern science are, in large part, inherited from the Enlightenment, a history we would do well to remember in our pursuit of a better world. When this pursuit aligns with these ideals, it is healthy, constructive. When it disregards or undermines them, it imperils progress. This, as much as anything, has emerged as a core theme of this newsletter.
Looking back on these columns it strikes me that they fall into roughly three categories. First, foundations. This is to say reflections on the cores forces that shape health in society—factors like money, politics, power, and technological change. Second, heresies. These are areas of discourse which may be uncomfortable for us to visit, and which are even, at times, critical of public health itself. They include conversations about class, the temptations of power, and the occasional mismatch between academic theorizing and real-world need. Third, hopes. This category reflects an aspirational approach to health, one which expresses the many causes for optimism in our world today. They include the younger generation’s potential to shape a healthier world, emerging technologies that support healthy populations, and the role of joy in promoting health.
Throughout The Healthiest Goldfish, I have tried to engage with a conversation about health that prizes nuance, data, and lack of ideological precommitments (while understanding that they are difficult to avoid entirely). I did so conscious of the fact that this approach, while foundational for a liberal discourse, has been under strain of late. We are living in a moment when narrative often trumps fact, when ideology is all many see, and when the uses and integrity of data have been questioned as never before in recent memory. In this context, it is even more important to hold firm to the principles which have served us so well for so long. They may seem simple, the stuff of basic civics class. But sustaining them is anything but simple—as our present moment has shown. The crisis of a pandemic has only amplified what could fairly be described as illiberal thinking. This phenomenon varies in degrees, but—and this is the point on which we are often myopic—it is to be found across the political spectrum, from antiscientific attitudes promoted by former President Trump to a seeming-insouciance about the deleterious effects of lockdowns and pandemic restrictions which can be found in more progressive circles.
I have often written about how our rush to embrace heavy-handed lockdowns made ample sense at the start of the pandemic, but made less sense as the crisis evolved, our understanding of the disease changed, and, ultimately, we created effective vaccines and therapeutics to mitigate the threat. We now have the tools to dramatically reduce the risk of catching COVID-19, developing a severe case, or dying from it. Yet with the rise of variants like Omicron, I am often asked if I foresee a return to the kind of lockdowns we saw at the start of the pandemic. That this question keeps reoccurring suggests that we still are not thinking enough about the foundational forces that shape health. If we were, we would be thinking not just about the diminished risk of a still dangerous virus, we would also be thinking about the risk to health posed by the disruptions to early education so many children faced over the past two years. We would be thinking about how job loss and lack of resources undermine health and worsen susceptibility to diseases like depression, as we saw during the pandemic. And we would be thinking about how the appearance of a capricious or seemingly arbitrary approach to lockdowns, masking, and school closures can undermine trust in public health.
All this suggests the importance of maintaining a nuanced conversation about health in tandem with renewed respect for the liberal context that allows such conversations to take place at all. No one among us is immune from the temptation toward illiberalism; this is particularly the case among those who feel themselves aligned with the good, which we in public health—it must be said—do. My hope is to focus my efforts in the new year looking to the future—to our tremendous capacity for supporting that good in the coming years—and to the past, to the time-honored liberal principles that can stop our zeal from becoming something counterproductive, or even detrimental to health.
I should note that this is not the end of ideas in The Healthiest Goldfish. While the newsletter will no longer be publishing weekly content, it will still go out intermittently, as events and ideas warrant. And pausing on the regular weekly newsletters will afford me headspace to evolve these ideas into a book. I have much enjoyed engaging with readers here, on e-mail, through our series of Healthiest Goldfish zoom events, and elsewhere, and I look forward to continuing that engagement through future writing. Writing is in many ways its own reward, but it is made infinitely richer by an engaged readership, which challenges and argues as much as it concurs. To all who have read this newsletter, thank you.
The Healthiest Goldfish takes its name from a metaphor. It is a metaphor of a goldfish who died because his water was dirty. His owner tried to give him a good life, with exercise, nutritious food and good goldfish doctors, but she forgot the basic necessity of changing the water in his bowl. In our society, our “water” is our schools, our neighborhoods, our economic circumstances, the people we see each day, our political leadership, the air we breathe, the water we drink, the food we eat, the socioeconomic circumstances into which we are born. It is everything that comprises the context in which we live.
Ensuring our water is clean means ensuring that these circumstances are, at every level, optimized for health. This is an ambitious ask. To achieve it, we need to have the kind of conversations that truly shift paradigms. This cannot be accomplished by any one book or newsletter or social media account. But these platforms can perform the necessary work of helping to inform just such a conversation, like rivulets that coalesce into a stream, which becomes a river before reaching the sea. Ideally, we should conduct all our conversations mindful that they are informing this process, that they are an indispensable piece of a larger whole. This argues for a public debate that is rooted in civility, respect, and the liberal norms that are the cornerstone of much progress. It has been a privilege to work in this space to try to inform just such a conversation. Thank you for joining me.
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In this week’s The Turning Point, Michael Stein and I sunset that regular newsletter too, also paving the way for a book project. I am looking forward to working on these projects in 2022 very much.
We will continue to host conversations about The Contagion Next Time, finding that the lessons from the book continue to be relevant, particularly as we navigate new variants of the coronavirus. I am grateful to all who purchased books, who shared it with others, and who engaged the ideas it proposed.
And finally, thank you to all who have read this column and our other work over the past year. It has been a privilege to think, reflect, and write on the moment. I hope all have a good holiday season ahead, and will look forward to 2022 with hope, optimism, and ambition for what we can accomplish together.
- Sandro Galea is Dean and Robert A. Knox Professor at the Boston University School of Public Health. He has been named an epidemiology innovator by Time, a top voice in healthcare by LinkedIn, and one of the most cited social scientists in the world. His writing and work are featured regularly in national and global public media. A native of Malta, he has served as a field physician for Doctors Without Borders and has held academic positions at Columbia University, University of Michigan, and the New York Academy of Medicine. His upcoming book, The Contagion Next Time, will be published in fall 2021 and is available for pre-order: https://www.sandrogalea.org/the-contagion-next-time.
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