Reflecting on the themes of the COVID moment

Four learnings from the past year.

This piece was first posted on Substack. To comment, please go there.

Because much of the COVID crisis has been about dealing with the pandemic in real time as it has unfolded, there has been little time to reflect on the broader themes of what we have been through. We are now in a moment when we have been living with this challenge for over a year, a year which has taught many lessons about the nature of the virus and the society into which it emerged. It strikes me that this is a good time, then, to look back, to reflect, and to discuss key themes which emerged during the pandemic. That is why last week, in conjunction with National Public Health Week, we hosted a series of Healthiest Goldfish Conversations. At these conversations, we connected (virtually) with readers from across the world, to discuss the issues addressed in this newsletter, and to express a vision for what the pursuit of health could look like in a post-COVID future. Thank you to all who joined us for these conversations; it was a pleasure to connect with you, to learn from your perspectives. At these conversations, certain points emerged, points which have come to define our experience of the pandemic. In today’s essay, I will aim to address these themes, with the goal of informing broader reflections about the overarching narrative of the pandemic.

A quick “housekeeping” note before I do. The many new faces present at these conversations caused me to reflect that it might be worth reintroducing myself to those who have only recently subscribed to The Healthiest Goldfish. I am a physician, epidemiologist, and Dean of the Boston University School of Public Health. I started my career as a doctor, and most of my academic career has been in population health. Much of that has been concerned with a focus on mitigating the factors which generate sickness, moving beyond addressing downstream effects (more on this here). I have since pursued a focus on the social, economic, and political influences that shape health, with an emphasis on trying to inform a scholarship of consequence, to maximize health for the greatest number of people. 

It is from this professional vantage point that I have observed and engaged with what has been, by any measure, an impossible year. There have been over 31 million COVID cases in the US, and more than 560,000 people in the country have died. This has made public health, and the conversations that inform it, more relevant than ever. Our response to COVID has been guided by this public health focus, from efforts to test and trace, to the development of vaccines. This approach has, by and large, served us well. But the story of our engagement with the virus is complicated, and, along with our successes, we have had moments when we have lost sight of what matters most in our pursuit of health. This newsletter is an effort to bring these overlooked factors to the forefront. Last week’s conversations provided additional space to address these points, with reader perspectives doing much to sharpen my thinking about these issues. During the course of those conversations, four broad points emerged which, I think, are worth revisiting, in this time of realignment towards a post-COVID future. 

Tradeoffs

The first point is the central role of tradeoffs in shaping COVID response. An enormous part of the pandemic moment has been tradeoffs—such as the choice between reducing risk and shutting down economies. These are of a piece with the tradeoffs inherent in any decision affecting the health of populations. What is, I would argue, unique to this moment is the extent to which the conversation about these tradeoffs has been politicized, making it difficult to have this discussion at all. This is perhaps because to acknowledge tradeoffs is to acknowledge there may be some measure of truth to both sides of a given issue, an increasingly uncommon perspective in the context of our current tribalized moment. It also means not making the perfect the enemy of the good, with the understanding that choices—especially choices made during a crisis—often entail picking from least-worst options. To know this is to also think twice about vilifying those in positions of leadership during such crises, mindful that there is no path through a disaster like a pandemic which is entirely without pitfalls and imperfect choices made on the basis of incomplete information. 

Uneven burden

Much of why the conversation about tradeoffs has been so dysfunctional is that the groups most actively engaged in it—political leaders and media figures—are largely exempt from the consequences of pandemic decision-making. This reflects my second key point: the effects of the pandemic have been most heavily felt by populations which were already socioeconomically vulnerable when COVID struck, and most lightly felt by those which were not. If you are a politician whose wellbeing is not tied to the need to sell goods or attend school, if you are an online opinion-writer who can easily write and broadcast from home, or if you just happen to be reasonably well-off, it will not matter very much to your wellbeing whether, say, a lockdown order stays in place indefinitely or schools remain closed until COVID rates are down to zero. On the other hand, if you live in a low-income community where you and many of your neighbors work in the service industry, or if you are a child who has not been in a classroom in a year, choices about lockdowns have a direct effect on your health every day. The disconnect between those who make high-level decisions and those who most feel their effects has kept the pandemic unequal, and the conversation about it polarized.  

Challenged decision-making

Third, decision-making has also been challenged by the rapidity of the moment; in particular by the real-time incentives of social media. COVID is not the first pandemic in human history, but it is the first pandemic to strike during a time when digital technologies have incentivized the expression of feeling over facts, have reinforced partisan echo chambers, and have enabled the instant spread of misinformation and rumor. This has distorted our perception of the pandemic and many of the choices we have made—as individuals and collectively—in response to the virus. Historically, pandemics have provided many examples of the proliferation of quack “cures,” the unsettling of institutions, and the scapegoating of groups perceived as responsible for the contagion, but only our present age has supplied the means to amplify and spread these currents of thought and speech across the world at dizzying speed. This has created a context where the integrity of ideas is often sacrificed to the emotion of the moment.

Underlying divides

Fourth, partisan divisions are undermining the sense of common purpose necessary for working towards a healthier world. One of the pillars of my thinking and writing about health has long been that health is a public good, sustained by our collective investment. COVID was a reminder that we cannot be healthy unless we are all healthy; my health depends on yours and yours on mine. Just as we invest in resources like parks, roads, education, and national defense as public goods, we should also invest in health, with the understanding that this investment is ultimately good for everyone. We all want to be healthy, and to live in a world where our children can be healthy. This desire is not mediated by partisan affiliation—it is universal. However, partisan status has strongly shaped how we talk about getting to such a world, and the steps we take in its direction. As a result, partisan division is preventing us from getting what we all want, creating gridlock and diluting our sense of engagement with the common project of working towards a healthier world.

There are many reasons for the rise of this division, and no simple way to reverse it. But one solution I would suggest—a solution we can all begin to implement as individuals—is to try not to assume bad faith on the part of those with whom we disagree. This can be difficult, perhaps, at times, impossible. However, it is necessary to make the effort, if we are to advance a common vision of health. A healthy world depends on a robust, honest discussion of the factors that shape health, and such a conversation can only unfold when we regard ideological opponents as people, just like us, with a mix of motivations, hopes and fears, whose ideas are worth hearing even when they challenge and upset us.    

Providing a societal framework for such a conversation is, to my thinking, a core achievement of the small-“l” liberal project, an inheritance of the Enlightenment which allows us to develop the ideas which shape a better, healthier world. In this sense, public health is fundamentally an Enlightenment project, characterized by reasoned thinking, aimed at gradual reform. By embracing the tenets of liberal thought—the scientific method, pluralist values, and the pursuit of progress as a common goal worth striving toward—we can rebalance the public conversation towards a healthier mode of expression. This reflects what is, I think, the core aim of The Healthiest Goldfish: to see beyond the urgent of the moment, to the important, towards maximizing a reasoned approach to health in the long-term. Last week’s discussions did much to inform this approach. Thank you to all who joined. I look forward to continuing the conversation.

Sandro Galea, MD, DrPH, is Professor and Dean at the Boston University School of Public Health. His upcoming book, The Contagion Next Time, will be published in fall 2021. Subscribe to his weekly newsletter, The Healthiest Goldfish, or follow him on Twitter: @sandrogalea