Rebuilding Far Beyond Just Public Health
As the number of deaths from the COVID-19 pandemic exceeds 186,000 in the US and tops 868,000 worldwide [ 1 ], here is a profoundly disturbing fact:
Researchers estimate that birds and mammals harbor anywhere from 631,000 to 827,000 unknown viruses that could potentially leap into humans. [ 2 ]
Keep in mind that any one of those viruses could be less infectious and less lethal that COVID-19 –or far more so. In other words, in the midst of the current crisis, we could experience another, equally or even more severely crippling, infectious disease outbreak. Or two. Or three. Or….
And the truth is, we (both the US and the world) are not ready. While there have been calls –some quite long-standing and many more quite recently– to reform both public health’s and medicine’s ability to respond to serious outbreaks, the rebuilding challenges extend far, far beyond just these two disciplines. [ 3 ]
The rebuilding we must do is not simply to reverse the failed and all too painful response of the current administration or even to restore public health and medical care to their previous states prior to Trump’s election, but to reshape and enhance them to levels of functionality they have never known before. And –and this is critical– at the same time we must fortify our entire social fabric, in which public health and medicine play only a part.
At a minimum, we should strive to:
· Rehabilitate and politically insulate the Centers for Disease Control and Prevention (CDC)
· Depoliticize science
· Promote greater science literacy
· Recognize environment’s role in debilitating health and triggering epidemics
· Develop public understanding of and support for public health
· Expand disease surveillance and tracing capacity
· Encourage self-reporting of outbreaks
· Insure as many people as possible
· Use science as the basis for decisions and policy
· Create centralized, coordinated response authority
· Re-establish international cooperation (e.g., with WHO, Gavi, etc.)
· Build a robust response infrastructure
This ‘simple’ diagram –believe me, it could easily have been far more complex!– illustrates only some nodes of the intricate social web of institutions, practices, and mindsets that together affect our health. You can trace chains of dependencies between these nodes almost endlessly.
For example, take the box on the lower left, “Develop Public Understanding of and Support for Public Health.” That seems simple enough, and in an earlier time we might have addressed that with a series of Public Service Announcements (PSAs) from the Ad Council. But if we’re honest, we know that getting people to support public health today will require (follow the arrow) greater science literacy, which (follow another arrow) won’t occur unless we depoliticize science, which in turn won’t occur (follow the arrow) until we’re able to use science as the basis for governmental decision-making and policy implementation, and so on. And because a number of such chains can end up being circular (meaning there’s no single or obvious starting point), we’d be better off if we could somehow attack all of these challenges simultaneously.
This would be nothing less than a rebuilding of the entire US social fabric.
What’s also not shown in this diagram (remember, I’m trying to keep it fairly simple) are the collection of actors that can make all of this happen and whose cooperation and coordination will be essential to any long-term reforms. Imagine a nebulous ‘cloud of actors’ surrounding the diagram, including, at a minimum, the following: the president and the executive branch, the Congress, political parties, schools from elementary to graduate level, the news media, hospitals, insurance companies, and the host of people and institutions who might promote, lobby, or oppose any of these measures, including PACs, public interest groups, unions, corporations, lobbyists, influencers in general and celebrities in particular.
You will not be alone if you find it difficult to think of anything on which all of these actors have agreed. And if they were to continue to support narrowly-focused self-interests, that will almost ensure that no common ground can be found in the future either. So how do we build, or at least start to build, a smarter, more prepared, and more resilient society, capable of surviving the next pandemic?
A Few Suggestions
Look to Distributed Leadership
Achieving all of these goals is beyond the capability of any single leader including the president of the United States. The demands of the presidency have grown exponentially at the same time that the office has become more politicized and its occupants more polarizing. Even in the most generous of societies, looking to one person to lead a transformative effort of this scope is simply not reasonable. It’s just too heavy a lift for one person. Instead, and to some extent as we often have in the past, we must rely upon many different leaders, each pursuing goals in their narrower areas of interest, like educational, Congressional, or public health reform. The difference now is that these leaders must act in concert, keeping an eye out for and lending support to each other. Recognizing that achievement in any one of these areas depends on everyone else simultaneously achieving their goals, may soften absolutist stances and provide the space for shared advancement.
Find Common Goals
As fast as you can name an issue you’ll discover people with diametrically opposed views on what to do about it. For example, take the matter of abortion; how could partisans like Planned Parenthood and the U. S. Conference of Catholic Bishops possibly ever agree? One approach might be for each side to incrementally abstract or generalize their position until they find common ground. Imagine a step pyramid with “Right to Life” at one corner of the base and “Right to Choose” at the other. Through successive generalizations of their positions (i.e., steps up the pyramid) these two groups could reach the pyramid’s apex in agreement that “Every woman deserves quality health care.” Imagine the impact of these organizations issuing a joint statement and shared commitment to this apex statement. It might lead, for example, to their joint support for universal health insurance. Yes, they would certainly disagree about particulars for such an insurance plan, but their combined influence might in the end lead to expanded coverage and better care for all women.
Finding shared goals and working together to achieve them may exercise the capacity to engage constructively and respectfully and lead to the discovery of even more common ground between those who had previously considered themselves stark opponents. It would also be a dramatic example of what could be done by others who find themselves locked in opposition.
De-stack Identities
In his book, Why We’re Polarized [ 4 ], Ezra Klein observes that our identities have increasingly become ‘stacked.’ He points to the many identities we all inhabit (national, political, racial, cultural, geographic, religious, economic, and many more) and to the fact for many of us those identities have become stacked one upon another to the point that any one of them acts as a proxy for all the others. Someone living in a rural part of the country, for example, is more likely Republican, white, Christian, conservative, etc. Someone with strong environmental concerns is more likely urban, Democratic, liberal, non-white, etc. Klein urges readers to be more aware of this stacking and more aware of the well-funded, almost tidal forces that benefit from reinforcing our stacked identities.
I would go a step further, though, and urge that our institutions should try to de-stack themselves, to not let themselves be defined by others, to broaden their appeal without diminishing their focus. If you want a society with greater science literacy, you could spend all day talking to STEM and educational advocates, or you could also reach out to religious institutions as well. You might be surprised at the number of scientists who are deeply religious and find no conflict between their profession and their faith. I think this is the kind of board-based coalition building that will be needed to achieve the goals listed above. [ 5 ]
Work Intently but Patiently
Change (and its sometimes partners, progress and a better life) is unpredictable. It can happen unexpectedly, almost miraculously, overnight, taking everyone by surprise or it can take years of painfully incremental work, a determined slog that one day, finally, reaches a goal. And even what may seem on the surface as sudden change, is likely the result of many years of diligent work. Fundamental, societal change rarely happens on the quick; it’s more likely to be generational, inextricably tied to slow moving currents of politics, economics, demographics, and increasingly, the environment. And when such change does occur, it’s rarely what one imagined it would be. That’s just the nature of evolving societies. The metaphor that comes to mind is the tension and stress built up over time along a fault line, released suddenly and often without warning, as tectonic plates slip past each other and the earth quakes and the landscape is changed.
So the most reasonable course for affecting change, and the one most likely to yield results, is probably something like head-down/head-up. Head-down means working intently, consistently, on a focused goal. Head-up means keeping an eye out for, and actively extending a hand to, others who might be helpful. All the while, understanding that progress is made and change realized one day at a time, one person at a time.
In Conclusion
Our vulnerability to future pandemics is not just defined by the quality of our systems of public health and medical care. It is, fact, embedded in a web of attitudes and institutions, each with their own frailties and each tightly connected to the others.
As we’ve seen all too plainly this year, strengthening any one aspect of our response simply isn’t enough. For instance, even if the U. S. had on hand and quickly distributed enough personal protective equipment to every medical and elder care facility in the country, infection rates and death tolls would still have been unacceptably high if we had not at the same time had
· Leadership that urged science-based preventive measures
· A population that believed and trusted in science
· Social media that stopped the spread of lies, hoaxes, and misinformation
· Universal health insurance, so those at risk were quicker to seek help
· An infrastructure to expeditiously develop, distribute, administer, and track tests
· Critical agencies like the CDC operating out of reach of political influence
…and so much more.
We can do all of these, and more. We must recognize what needs to be done, not be cowed by the scope of what we want to achieve, and not rest until we are a dramatically stronger and more resilient society.
Please leave your comments below.
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A word on the Biohazard Symbol
In 1966, Charles Baldwin led a team at Dow Chemical Company to create what they hoped would become a universally-adopted biohazard symbol. Baldwin laid out a number of criteria for the symbol: It must be: “1. Striking in form in order to draw immediate attention, 2. Unique and unambiguous, in order not to be confused with symbols used for other purposes, 3. Quickly recognizable and easily recalled, 4. Easily stenciled, 5. Symmetrical, in order to appear identical from all angles,” and finally, demonstrating a social sensitivity far beyond the times, the symbol must be “acceptable to groups of varying ethnic backgrounds.” See: https://99percentinvisible.org/article/biohazard-symbol-designed-to-be-memorable-but-meaningless/ and https://web.archive.org/web/20120213165520/http://www.hms.harvard.edu:80/orsp/coms/biosafetyresources/history-of-biohazard-symbol.htm .
Notes
[ 1 ]
US deaths as of September 4, 2020: https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html
World deaths as of September 4, 2020: https://www.nytimes.com/interactive/2020/world/coronavirus-maps.html
[ 2 ]
The quote is from The Atlantic, The Next Plague Is Coming. Is America Ready?, July/August 2018, Ed Young. https://www.theatlantic.com/magazine/archive/2018/07/when-the-next-plague-hits/561734/. The figures Young quotes may have come from Science, The Global Virome Project, February 23, 2018, Dennis Carroll, et al. https://science.sciencemag.org/content/359/6378/872. The Science authors, in turn, derived these numbers from American Society for Microbiology, A Strategy to Eliminate Unknown Viral Diversity in Mammals, September 3, 2013, Simon J. Anthony, et al. https://mbio.asm.org/content/4/5/e00598-13?ijkey=1535127d1217933cd47430c175a04125d911ff02&keytype2=tf_ipsecsha. Interestingly, Young’s article is referenced by Bill Bryson in his book The Body, Doubleday, 2019, page 324, though he rounds the range of possible vectors to “as many as 800,000,” a compression that makes the number more memorable and somehow also more disturbing.
[ 3 ]
For more than 40 years, Laurie Garrett has been calling attention to, as the subtitle to Betrayal of Trust put it, the “the collapse of global public health,” and continues to be a voice for a reinvigorated public health system. (See https://www.lauriegarrett.com/about ). And physician/writers like Siddhartha Mukherjee have pointed to medicine’s shortcomings (as well as proposing solutions). See http://siddharthamukherjee.com and https://www.newyorker.com/magazine/2020/05/04/what-the-coronavirus-crisis-reveals-about-american-medicine .
[ 4 ]
https://simonandschusterpublishing.com/why-were-polarized/ You may also want to listen to this WAMU interview with Klein: https://wamu.org/story/20/01/24/voxs-ezra-klein-on-people-parties-and-political-polarization/
[ 5 ]
To be clear, Klein doesn’t use the term ‘de-stacking’ in his book and I don’t believe he discusses the concept in relation to organizations or institutions, though it’s entirely possible I missed it.
Biohazard symbol by Rupert Russell — Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=68044324