Has Public Health Lost Its Way? This Public Health Dean Thinks So.

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Dr. Abdul. I'll say it.

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.

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 Sandra 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 lost 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 Sandra when I was a college senior, and he was junior faculty at the University of Michigan. This is no exaggeration. Sandra was 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 talked 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 Sondra 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. Sondra, 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 in 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.

Sandra 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, Sandra was gracious, kind and thoughtful. Here's my conversation with professor Sandra Galea.

the public facing books on was written in many of the papers and have had the Privilege and honor of writing some of them with him. so, Sandra, 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 a Critique of an expansive public health. Why did you write this book?

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 as I read the book, you know the the.

Yeah. Yeah.

Italy, we're seeing what's happening. We see what's happening in Iran. It comes to the US, and You're thinking this is, you know, should everything we need to do to mitigate it. and then, Once we figure out what's going on, we get our handle or 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 the 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 in those beliefs, to improve things gradually and without Disrupting people's lives unnecessarily. and I think that's when, in the summer and fall 2020, I developed this to use your word on we, which it really were, the seeds of them writing this book two years later.

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? 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 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. It's, I guess I, 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 of having to do something?

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 the time 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 when 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. 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.

We became and to use your words, illiberal. I won't ask you. What do you mean by illiberal? How do you think about that? And why do you think that that we tipped into that direction?

on the left of 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 we're a lot of responsibility lies at the feet of the person who was present at the time, who pushed public health to feel defensive, to feel like Oh, My goodness, there is somebody who is saying that 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 actor.

Overtorque the analogy here, but you know, in epidemiology were 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 kovat pandemic. the host was us and then the environment was a Moment in which and I don't want to say that we've lost Liberal values in the sense that you've defined them and in the ways that I think in local context We we think about and trying trying to adjudicate the world around us, But that we have built a method, a mechanism of communication that is 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 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 most makes the most extreme argument, is going to be picked up by the algorithm Amplified, and then that's gonna 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 reason to 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, 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 Gia Tolentino's words, a trick mirror of a public conversation. I.

So, you know, one of the things that I've been criticized in the book is to say well, who's to say what's reasonable, you know, the books called within reason, and my answer is I don't know. We should collectively decide. it was reasonable by through public conversation. So I don't think we should ever Sacrifice nuance, and complexity is number one. now number two.

I'm not so naive. It's not to realize that the tool at our disposal, which largely Dominated public conversation, 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. 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 mentioned 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, just like you're 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 you and you know, I think you can reasonably say to me. Well, but what can we do? We're just human, and 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 future?

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You, you, you wrote an essay, in effect, in defense of the faceless bureaucrat, and I did. I did. one could argue that your Call in that essay, and, frankly, throughout the book, is that, rather than venerating platforms 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 in the science? And obviously, 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 this 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 they choose to or they don't. 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 literally your student and a student of your writing, you know It wasn't more than 10 years ago where you talked about a consequentialist public health, which you know Almost seems in in direct opposition to this right. consequentialism, by definition, Engages with the outcome in the object oriented approach. in here. You're saying this is a process question.

It's almost a technical deontology. So I want to. I want to get your sense on.

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 and 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 kovat. So, you know, people's grandmothers are dying in hospitals, heartbreaking.

they can't go to them, or at least they can go through them through plastic. and And that was the science was clear that if you go around these people, you're more likely to actually get kovat. But people were gladly willing to trade getting kovat 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 examples I use in the book Is the fact that in this country, in the u.s?

We never had a conversation about whether or not Kovat vaccines should be mandatory for children. We just said they need a mentor if you're going to school now in Europe They actually didn't vaccinate 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 less likely to get kovat less likely transmitted.

if they get it, They're actually going to get Weaker form of kovat now. I did say in the book that I got my children vaccinated for kovat, But there was a trade-off. There was a trade-off that I was willing to make. These are societal trade-offs that we must make that combine Empiric inputs and moral input. So no, so I'm not.

I'm 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 will make a society and need to balance the science with our other inputs and our other prerogatives that we.

and When you start thinking about equity, Then you have to think upstream in. you know, And everybody who listens 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 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 air and and quality food?

who doesn't? who gets to walk in their community? Who doesn't? 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 would 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.

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. as you know, Everybody here has the experience of you.

go to a public pool, right? And there's a sign in a public pool that says don't run, no drinks. Stay away from the wet, from the wet pavement 20 things and nowhere on 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 another example. You probably drove your car on a highway today in Michigan and you probably drove at a speed limit of 55 miles per hour. I know you might would have been under the speed limit just 54..

Let's say.

As you are doing that up, though, you know, because you're an epidemiologist by train, That actually being an accident, 55 miles per hour makes you twice as likely to die than if you were an accident at 25 miles per hour, so Why is the speed limit at 55 miles per hour? Why is it that we as a society don't say? No, nobody should drive over 25 miles per hour. Well, the reason is that we Determine a balance. we find a balance between the bounds that keep us safe and how we want to live 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 a society with other inputs, other desires, that we have 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 kovat happened, When I realized that public health forgot that in the context of a crisis, We said 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.

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 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, even if you talk to the people whom you're advocating for, Ostensibly there 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 you know, with the caveat that there's a limitation here, but I Guess that the question I want you to help me reflect on is what is the space for advocacy beyond health? from public health? because that 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. 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?

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 a seatbelt, 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 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 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.

You know one of the most articulate spokespeople for ideas of health. up to why is it that you are not advocating for all of us?

Under normal circumstances, are willing to tolerate. in the context of kovat, We forgot to tolerate that, for example. One of the things that emerge 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 There's a trivial. I mean sort of inconvenient.

a lot of people really hated it. A lot of people hate 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 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 is a reason why many people are Disagreeing with us. and now you can say to me look, Sandra, the data tells us what we should do, but 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, inhibiting it until we win.

Well, is there a cost of that? of course there's a cost of it. the cost of that is the people gonna tune us out. stop listen to us and Stop trusting us. and that's exactly what happened in Kovac.

when you look at the Pew data that just came out last month, Which is from their annual essentially survey around trust and government trust in science, trust in public health, public health science is 25 points less trusted now. that was before Kovac. now, if you think about it for a second, it's extraordinary. after this an incredible Crisis, there was a public health crisis where public health objectively did better. Then we could have hoped like we saved millions of lives.

the rapid vaccines, the rapid testing, screening, Mitigation measures saved millions of lives. You think that trust. the public health should be through the roof? But no trust. the public health is much less than it was before Kovac.

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 into bumper stickers Like follow the science. we leaned into ideas that the only thing that mattered was a narrow definition of health.

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.

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 other values that people valued correct.

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 best faith actors.

We cannot say anything until we know everything, and Then we can say something.

I worry. I worry that we're gonna, we're gonna pull out and We're gonna say well, I don't know that I'm being reasonable. I don't know that I'm. I'm offering, 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.

but You know to use the old aphorism, you know mistakes were made and we should learn from them. I appreciate that.

Therefore you're advocating for genocide. You're a 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 won't call it, but 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 will say well, Actually, we should be asking everybody to wear a mask, because there are some people For whom the consequences of getting kovat 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 predict that your point would be okay. Listen, the 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 Found 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 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 asked them 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. So I want to get your thoughts on that.

I.

now, Why, why are you doing? why are you saying that? where 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 in terms of risk 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 add 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 I Do that, then nobody's gonna listen to me and I'm gonna 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 society. So, you know to your point about Americans don't like sacrifice, American 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.

I want to finish on a final note, you know You you trace out, I think, beautifully in the book. your argument about in a liberal public health and some of the consequence and it's it 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, in your mind, public health's failure to be to be more conscious of Our need to focus on reason and to create and foster a space for debate?

But the reason I point that 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? With put up a sign on door. It said the health experts say X, but we don't believe the health experts. We think the answer should be why, like it was Inconceivable before COVID, and since COVID that's become commonplace and that's a real loss. now.

I appreciate that.

We really appreciate you taking the time to to join us and for a vigorous conversation today.

what happened? Insurance has gotten less sure. Who's got my soapbox? Because you know your boys 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 onto the bad news more young people are getting cancer, particularly colorectal cancer. Whenever you talk about cancer incidents, 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 gonna 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. Those 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, risks 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 crooked medium and me at Abdul El-Sayed No dash on IG tick tock and the website formerly known as Twitter.

America Dissected is a product of Crooked Media. Our producer is Austin Fisher. our associate producers are Tara Terpstra and Emily Frank. Charlotte Landis mixes and masters the show Production support from Ari Schwartz. Our theme song is by Takaya Sazawa and Alex Uguiera.

Our executive producers are Leo Duran, Sarah Geismar and me, Dr. Abdul El-Sayed, your host. Thanks for listening.