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- [00:00]
A
Hey there listeners. Before we get going, I wanted to mention that we've got a few tickets left for our live show at the Comedy Cellar in New York City this Wednesday. Friends of the Pod, Nate Silver and Claire Malone, are going to be joining me and we'll dig into how the race for the House is looking after some big gerrymandering shakeups, plus a whole lot more. As usual, there will be beer, audience questions, plenty of laughs. There's a link to tickets in the show Notes. All right, here's the show. Hello and welcome to the GD Politics Podcast. I'm Galen Durie. Just about every institution in America has taken a reputational beating this century. And still the speed and severity with which Americans have turned on the public health establishment is striking. In March of 2020, when Covid began disrupting American life in earnest, fully 85% of Americans said they trusted the Centers for Disease Control as an information source. Today, six years later, it's 47%. Republicans were the first to lose faith, dropping to 40% during Biden's tenure. But Democrats have largely caught up during Trump's second term. For public health folks, it's an existential threat. If they can't be trusted, their information can't persuade, and public health itself becomes more of an academic exercise than an effort to save lives. The current hantavirus outbreak is a stark reminder of the stakes. It's easy to blame bad faith actors for the bind that public health finds itself in, but it's also hard to have lived through the past six years without a sense that experts have also brought this on themselves. In fact, they're increasingly acknowledging that and setting out to course correct. Sadhguru Galea, dean of the School of Public Health at Washington University in St Louis, and Salma Abdallah, professor at WashU, have launched a year long project called Purple Public Health, which aims to rebuild credibility with Americans of all stripes. Sadhguru came on this podcast last year to talk about Maha, and I'm excited to have them on again to talk about this. Not just because it matters on its own terms, but because there's probably something for all of us to learn about earning credibility in a polarized or even just a diverse world. So Sandro, welcome back to the podcast.
- [02:17]
B
Kalyn, great to be here.
- [02:19]
A
And Selma, welcome to the podcast for the first time. It's great to have you.
- [02:22]
C
Kaylan, thank you for having us.
- [02:23]
A
Let's start with the basics here. What is Purple Public Health?
- [02:28]
B
Purple Public Health is obviously a play on the notion of a purple country it's neither red nor blue. And we launched this project together as a way of encouraging public health thinking that gets to the purple, to push public health out of a ideological comfort zone. Be that comfort zone blue or be it red. Our fundamental premise is that as long as the world cares about premature death from heart disease, as long as the world cares about adolescence with depression, anxiety, as long as the world cares about preventing and screening cancer, the world is going to need public health. And the moment, which you prefaced well in your introduction, where we have loss of trust in institutions, loss of trust in public health is not going to serve us well. It's not going to serve us well as people, as humans. So how do we address that? And when one thinks about and talks about these extremes that are driving the conversation, it's not hard to realize that some of the solution must lie in finding ways we can talk across ideological divides, that we can think in a way that helps us understand how others think, and that public health will benefit from doing that. So the point of the project is, can we explicitly push ourselves to think differently, to reimagine a public health that really meets the full country where it's at?
- [03:58]
C
And I think Sandra and I know each other for a long time. Sandra is my mentor. So just be upfront. We agree on a lot of things, but I think part of why we wanted to create this platform is that we thought, even in our discussions, we agree on a lot of the science. We sometimes come to a decision or a policy from very different values. And in public health, we should be honest and clear about where the science is and where our values intervene to also tell us, this is a policy that I care about and Sandra does not care about, or the other way around. So I think we wanted to model disagreement in the Purple Public Health project to also allow others in public health to be very clear about the science, but at the same time also share when their values are shaping the type of science they want to pursue, but also the type of science they advocate for.
- [04:45]
A
How is Purple Public Health, the way that you go about this, different to what public health is right now or what it has been?
- [04:57]
B
You know, I'll pick up from something Selma just said, which is part of what we're trying to do is to create space for disagreement. And at some level that seems banal, like surely we should be able to disagree, but it actually has not been the case. Right. We have been going through a moment where many disciplines, public health included, have had a really difficult time with disagreement, where there has been a orthodoxy that has developed about how we think, how we talk and what we do. And in our assessment, that has also happened in public health and that serves us poorly. We have been. We want to be very clear that many people may not agree with what we're trying to do. And we are in no way trying to say that this is the only way about it. In fact, we're trying to be explicit that we are trying to push the margins of. Of how public health thinks and potentially inviting disagreement and encouraging us to think in a way that tolerates and listens to perspectives that are different than our perspectives. And that is in the moment and certainly has not been over the past few years, certainly was not during the pandemic era how public health operated, that there was a very particular orthodoxy. And it was difficult to have space for voices that were outside of that orthodoxy be heard.
- [06:15]
A
I'm curious, does this problem stem from COVID or is this a longer running issue? I mean, how do you diagnose, like, if the loss of trust in public health seems at least in part to come from an orthodoxy and a lack of disagreement or debate over public health issues, did that start in 2020? Does it go further back? Like, how do you diagnose this?
- [06:40]
C
I've been thinking about this a lot recently, I have to say, because I'm a physician by training. Sandra is a physician by training. I'm assuming almost. I think everyone who got into public health, either in academia or public health practice, are people who for some reason looked around and thought the world needs to provide structures for people to be healthier. I deeply believe that we can do better in creating a healthier population. So I got into public health with a lot of emotional attachment to what I think we can do to improve the health of the population. I left the medical field because I thought I can only help one patient at a time. In public health, I can help a hundred, hopefully thousands or millions, depending on the type of policy I try to pursue. So I think this emotional attachment runs deeper than Covid, but it also makes it harder for us to distinguish between what do I think is the more correct answer for something versus what does the science provide us with? And I think for a long time, public health attracted the type of person who just wants to create a change in the world, and they want to create it quickly. And over time, that type of person also intersects with the type of politics that also aims to try to improve the health of the population. Or we think. I think I care about the type of social and economic policies that improve the health of population. I might think that there's one party that might actually help push those type of policies versus another parties. So I wouldn't say that Covid was responsible for creating this fissure or this distrust that we see from the population. I think just Covid, it was a stark moment that a lot of the decisions were happening in real time. They were happening where everyone was watching. And it was then clear that there a lot of emotional attachment to the work we do. And that sometimes lets our values seep into the type of science we think should be produced and then also makes us assume that everyone else who disagrees with us is not someone who maybe has different values than us. It just might be someone who's just evil. We just think this person doesn't care about the health of people. That's why they're opposing what we think is needed to be done.
- [08:44]
B
So, yeah, I agree with Selma's assessment, and perhaps I think maybe Salma's assessment is polite. So let me try to be a bit more stark. You know, I've been in the field now for about 25 years, and I think I can say I don't think Covid created anything. I think it changed the slope of things that were already there. But I do think that the past 10 years, starting about 2015, were a real inflection point. And that's before COVID And I think a lot of it came with the explosion of social media and the ascent of a president who really was willing to roll up his sleeves and engage in a very, very disputatious approach to all his communication. And my read is that those of us who were in a field that often was in opposition to what the president was saying started shifting towards a mode of interacting that mirrored that. So all of a sudden you started having this hardening of positions of public health because of a sense that there was deep rejection of those positions from people with the highest, loudest megaphone. So that started in 2015, 2016. And then of course came Covid and Covid, and we can't Forget this, that 2020 was a really difficult year where people who are public health, who, as Salma said, came to the field because they really believe they're trying to save lives, had a hard time when you had people with very loud megaphones who were opposed to policies and approaches that those in public health felt strongly were important for people's health. And my read is that that resulted in hardening of positions. It made public health feel like the only way to defend what is right is by us taking a harder stance. And unfortunately, that then is difficult to disentangle. It's difficult to get oneself out of. And if I were to be hopeful about something in the moment, it is that we are having this conversation, that others are having these conversations, and that we're beginning to say, look, we hardened positions, we took very rigid perspectives over the past 10 years, but now it's time to take a step back, ask ourselves, how do we make sure that we take perspectives that allow others in?
- [11:12]
A
I want to get into some of the specifics of where the public health orthodoxy may be wrong or places where you're looking for more heterodoxy or a more purple public health. But I do. I think there's a really important tension here that Salma described, which is if people get into public health because they care about creating structures that solve problems, I mean, that doesn't sound so different from politics itself. Like the definite, the easy definition of politics is how groups of people make collective decisions, especially when they disagree. And it sounds like you are describing public health as a way of doing politics about health. Am I wrong here? And if that is the case, where do you draw the bounds of public health? Where, you know, this is the kind of thing that we should be concerned about. You know, like, conventionally, I think a lot of people would say, great job on getting Americans to put down cigarettes, to buckle their seatbelts, to provide an environment where we can safely drink tap water for the most part. But then I think around 2020 in particular, people started to get a sense that while the bounds of public health expand to gun violence, poverty, racism, all kinds of things that are kind of just politics or easily understandable as politics. So is public health just politics?
- [12:39]
C
I think health is political by nature. It's very hard for me. I practice medicine in Sudan, and I saw there, when you have a government that is corrupt, that is just not functional, there is no competency whatsoever. I saw there what that meant for healthcare, but also what that meant for the structures that should promote the prevention of the diseases that people get into the healthcare system for. So, for example, and I tell this story a lot, I saw people in Sudan where we had a family that brought their child every three months because they needed food and the child didn't have enough food, and then they had malnutrition, and then they came to the hospital to help them with the malnutrition. And that happened over and over and over again. And that's why I got into public Health, if I'm being completely honest, I wanted to create a structure or a system where the government can then be held accountable if someone is actually. If a child is having malnutrition. But I think political does not equal partisan. We discuss this a lot. Sandra and I both agree public health cannot be partisan by nature. It's just because of all the things we're asking for, especially the type of public health that we work on, the type of analysis that we do. One could argue that public health is something not a political entity we care maybe more about. How do we create a space where there's clean water that is public health. Hopefully most of the time most people would agree that is something that is not partisan. But we also. I care about the type of food policies that would lead to healthier populations and reducing obesity. We can also argue about the type of policies that lead us to the place that I want to be in. I think, or at least we know from the literature, it's very clear that if you get people healthier food or better spaces for them to walk in, that would make uses, obviously. So for a long time I was very much interested in food deserts as a policy that can reduce obesity. I think what then separates public health as a science from public health as a practice is when we get more literature that shows that food deserts, and which is this is economic literature that we're getting right now. Food deserts are responsible for only about 10% in differences between high income and low income households in the type of food they eat, then it would be very futile for me as a public health scientists to continue pursuing policies that only focus on food deserts to reduce obesity. I think that would just be malpractice for me as a public health scientist. Then maybe as someone who also works in a political landscape, or if someone who's interested in advocacy, I might continue to advocate for food deserts because I think that's a justice issue. But as a public health scientist, if I continue to advocate for food deserts, policies to reduce food deserts, I think that would be something, something that we should not tolerate from scientists. So I think this is where I would divide what I think I should produce as something that has scientific value, that should improve the health of population, or the type of policy I should advocate for because of my values. The values here being that I think everyone should have access to healthy food.
- [15:28]
B
You know, I'll just add that definitional note. You know, Galen, you define politics and I like the definition. It's how we decide together. What we do is if one Accepts that public health is about creating the conditions that make us healthy. Well, by definition, creating those conditions is a collective decision. And by definition, then it's political. So public health is definitionally political. The question becomes, how does one operate in terms of. Within those politics? And some, I think, raised a tension which was. Took your question to the next level, which is, while public health is political, public health should engage with those politics from a place of science and understanding of the facts. And what we need to do is be very clear about what the facts are so that we can inform those political decisions. And it is then up to society to balance those facts with other societal priorities. You know, we can talk about many different examples this way. One of my favorite examples is speed limits. We know that speed limits, the lower the speed limit is, the lower the risk of injury or death on the roads. But we as a society set speed limits at a particular level where we're juggling presumably that science with other societal priorities, like how fast we want to go. And that is sometimes hard for public health to wrap its brain around. Right, because when you're focused only on the goal of public health, you forget that there are other goals of society. So we need to engage with the politics, inform the politics. But fundamentally the politics are larger than
- [17:06]
A
how do you deal with mission creep or maybe even understanding that so many things can be public health, and from a functional standpoint, but also, maybe also from a trustworthiness standpoint, you gotta draw the bounds somewhere.
- [17:24]
B
So I disagree with the framing of that. I don't think it's about mission creep. I think it's actually about the understanding, clearly the role of science. When we say public health is about the conditions around us that generate health, well, those conditions are many and nearly everything. So I don't think that any of those conditions should be outside of our remit. However, how we approach them is very important. As long as we approach them from a place of science having the integrity to know what we know, to be explicit about what we don't know, then I think it's okay. So the notion of mission, Greek for public health, I think is mistakes. The idea of science versus advocacy, which I think Selma surfaced. As long as we ground what we do in the science, I think all conditions that might affect the health of populations, which is really essentially everything in the world around us, can well be subject of inquiry and a subject of public health engagement. As long as we engage along the terms of what we do, which is a science informed effort to inform societies about what choices we should make to create a healthier world.
- [18:32]
C
So, Gail, and like Sandra, I actually think a lot about mission creep in what we do in public health. I really struggle with it, especially because. And I wonder now if you can come in and teach my foundations to public health class. Because we say exactly that. And then the students wonder, what does it mean for me to work on the social and economic policies that shape health outcomes? Because that could mean anything. So I have two answers to this because I am really struggling with this for the type of work I do. So the first answer would be on a practical level. If a student asks me, I usually say, well, you learn all of this here. And my hope is that you don't go work in a public health department. You go work in a different entity. What you need to do then is whatever there is a conversation about something, let's say work in a company that works on transportation. You bring a health lens with an understanding that health is a component of what people care about instead of health is the final goal for everything that we do. So my hope when we teach people about public health being connected to everything, is to just say exactly what Sandra just said right now, which is, well, you should just take health into consideration whenever we make decisions. And this is where the science comes in. Because then the science can say this is how much health or public health is affected by this decision A or decision B. And then we take the value conversation and then and discuss do we really all want to be driving in our cars with a helmet or do we think that is too much of a risk averse behavior when it comes to public health and we're willing to take that risk. That's the first part, the second one, and I'm increasingly more comfortable with having public health that cares about everything because no one asks economists if there is a mission creep when it comes to economic analysis. Economists publish on everything. They do analysis in education. They do analysis on health a lot of the time. I disagree with some of the work they do on health. And no one seems to ask them, why do you think this is relevant to economics? So I think we should also say health should be a component of all discussions about all policies.
- [20:25]
A
Okay, so you said that where things go awry is when the evidence and values piece are not properly distinguished. So what are some areas where public health has gone astray there?
- [20:41]
B
Well, we can start with the COVID example, just because it's fresh on our minds. And I think it's not difficult to anchor to Covid and to recognize that public health was Unclear. I'll use the word unclear charitably, about the downstream consequences of encouraging restrictions on children's in person schooling. So children's in person schooling, which I think most credible analyses today show that American children who are of school age essentially lost six months of educational social development that they're never going to get back, which is a high price to pay for society, emerged from a public health endorsement of policies that kept children at home or learning remotely, despite the fact that we knew that if children were to get Covid, they were less likely to get Covid and they were less likely to get severe Covid and less likely to transmit it. Right. So I think it's a good example of where a value decision that no amount of COVID was acceptable, no amount of risk on Covid was acceptable, outweighed the evidence that was both the risk of transmission and the. The other risks that we're not factoring in. So we struggled with values and science. Now, anytime I use a Covid example, I feel like I need to put in a disclaimer, which is, 2020 was a very difficult time, very good. People thinking very hard had to make decisions under times of extreme duress, not just because of decisions that had to be made quickly, but also because of political pressure. So I think it's only fair to frame it in that context. And I think it's only fair to say this is an in retrospect analysis. But nonetheless, you asked the question. And I think in retrospect, it's a clear example where we were not explicit that it was values that was driving these decisions rather than science.
- [22:38]
A
I think people are pretty familiar with the COVID examples at this point. And I'm curious if there are others where you feel like public health has missed the mark.
- [22:49]
C
I wouldn't say missed the mark, but I think our framing of taxes on sugar drinks puts a lot of emphasis on values disguised as science. And we should be clear about what the science says versus what our values say. That's one conversation where I'm not sure if public health got it wrong versus just recognizing that different values of what people care about, and we should be clear about those. So, for example, sugary drink taxes are usually used to get people to stop drinking as much soda as they do in the US or in different countries, whatever sugar drinks they, they, they take. And usually the rationale behind that or how they're advertised is that this is good for the health of the population because we have attacks that reduces consumption, and once we reduce consumption, that reduces obesity rate, cardiovascular Disease rate, other types of non communicable diseases. I think that framing takes the science which is correct. It reduces consumption. But I think we should be honest that when we're doing that, this is actually a regressive tax. It affects poorer people more and we are trying to control the lives of people that we know we can control easier. The poorer people because they can't complain as much as people who are richer. I think even Sandra, if I may say when I say this, a lot of people in public health feel like this is not something we should say because we're doing this. And the benefits to people who are poor is much, usually higher because a lot of the countries who use those taxes ultimately take the money and use it in low income settings. So this is helpful for people. I disagree with that. I think this should be a decision that is left to the public. It should be framed as a values decision where health is one component. But we are still creating a system that impacts a certain group of people more. But we really don't frame it that way when we talk about it in public health.
- [24:47]
B
Let me build on Salma and give you two other examples that are both pretty quick. So number one, I'll build directly on what Salma said. There are plenty of examples where a society could take a fixed amount of money resources and apply them in a way that improves overall health but also widens gaps between those who have more assets and fewer assets. For example, you might want to do a screening program in a society if you have a fixed amount of money, you are going to achieve more screening if you actually target those who are, who have high levels of access, high levels of health literacy. And you're going to probably increase screening in aggregate in society, but you're going to widen the gaps between those with more or fewer assets. The scientific approach, if your outcome is only aggregate health, would be just not to worry about health gaps. But there's a good values argument that says actually we care about not having gaps between health haves and health have nots and that should change what we do. So that's one example, another example where we might actually act on values without the science, it's this current discussion around role of social media. So I happen to be an editor of a large national Academy of Science report around the Sciences in 2023 about does social media affect kids mental health? The bottom line is our science is very poor on this. Around the same time as the report was released which said we don't really have evidence on this, the Surgeon General came up with recommendations which said, among other things, you know, parents should make sure that kids are not using their phones at the dinner table. And I found myself talking to journalists who say, what's the evidence for that? To which, to be honest, my answer is there's actually very little evidence for that, but sort of doesn't matter. I think it's reasonable for society to have a value that say we want to encourage families and parents and children to talk to one another at the dinner table. I don't think we need science to show us that that phone at the dinner table is necessarily not a good thing. So I think it's okay sometimes to be driven by values. It is okay at other times to be clear what the values are and say that values trump science. But from a place of honesty and integrity and what we owe populations, we should just be very clear where we sit on both.
- [27:03]
A
So level with people when you say this is what the evidence shows. Now, this is my personal interpretation based on my understanding of the world as it is today and my values. But that's me. And me is a different thing from what the science is.
- [27:18]
B
Well, this is where the question comes in then. Who is the decision maker? Right. This is why the decision maker, in some sort of idealized construct of a democratic society should be somebody who is elected by and accountable to the public. Because we entrust those who are elected to make decisions and weigh these values. Which is where having public health be the analyst, but also decision maker is problematic, because public health fundamentally is. Is not accountable to the public the way somebody who's democratically elected is.
- [27:52]
A
GD politics is powered by you, the listeners. If you enjoy the show, the data driven analysis, the genuine curiosity and lack of partisan bs, and yes, sometimes the silliness too, please consider becoming a paid subscriber at gdpolitics. Com. Paid subscribers help make the podcast possible, and they also get twice the number of episodes and access to the paid subscriber chat where you can send me whatever questions you've got. Independent political media only works if the people who value it support it. So if GD Politics is part of your week, head to GDPolitics.com and become a paid subscriber. That's GDPolitics.com I so appreciate it. Thank you. We've talked plenty about where public health has gotten itself into hot water. And you know, I'm sure you're gluttons for punishment, but I think you probably also are pretty frustrated with the current moment that public health finds itself in. In that I've read in your analysis that you say there are bad faith actors out there who just want to discredit us and we also need to draw a line between where we've messed up and where it's bad faith actors and not give them too much credit. Where do you draw that line? How do you go about deciding what's a bad faith actor and what's a sincere critique?
- [29:15]
B
Well, I think one should have generosity of spirit and heart and assume that people come at this with good faith intent. Having said that, there clearly are bad faith actors who have cynically used the moment to discredit public health. I think the challenge that I face, and I think Salma, I'll let you jump in on this is, you know, we have been criticized in a moment when public health is being so criticized, it's under such pressure. Why would you want to critique the field like that? Isn't this time to just hunker down and the field at all costs? And I suppose my approach to that is no, it is important in this moment to be honest about the shortcomings, but also to be clear that our critique of the shortcomings comes from a place of deep commitment to the field. Because as I said earlier, I care about living a longer, healthier life. I care about our kids living longer, healthier lives. I care about preventing premature heart disease. I care about making sure that mothers do not die in pregnancy. I care to make sure sure adolescents don't have anxiety and depression. And that means we need a strong, robust public health. So we are, I see us as critiquing from a place of commitment to the well being of the field.
- [30:22]
C
Being as generous as possible should be the strategy for public health moving forward. Given the distrust that we have. And the population seems to be depending on whomever is in power right now, the other party seems to just not believe whatever comes from public health and institutions. Being as generous as possible is probably just a practicality that needs to happen for us to continue to have institutions that could function and institutions that people might be able to trust. Again, where I draw my line because I was thinking about this as Sandra was speaking, I think would be if an actor is benefiting from something they're doing financially, I think that's where it would be very hard for us to have a generous conversation that is more good faith. If an actor is also trying to use an issue politically to advance their goals, I think that is also much harder for me to engage with them in good faith. So those, those would be the two lines for Me, I don't know if there are other lines. It is very hard to argue with someone who just cares deeply about the health of their kids. So they worry that a vaccine might be bad for them to say those are people who are acting in bad faith. Those are people I'm willing to engage with. If someone is trying to use that argument to sell their own products to people in a set of vaccines, that is someone white might have a hard time engaging with in an honest conversation.
- [31:40]
A
I think so much about what you're talking about and why I really wanted to have this conversation is because you're talking about being curious, right? Not coming to science or health with answers and then trying to find evidence that backs them up, but coming with questions and being open to having your minds changed and being transparent about that process. I think there's probably too little of that, not just in public health and academia, but probably also in public life. As you go through this process, are there places where you've had your own minds changed? I mean, what have the benefits of curiosity been for you?
- [32:24]
C
I have to say, a lot of places, it's a bit humbling. So that's, that's great. But two that I think of right now are, and it's surprising to me, the first one is universal basic income in public health. We talk a lot about poverty is a fundamental cause of diseases. We need to address poverty. So I always thought, of course, then having universal basic income will just be very helpful for the improving the health of population. It has been humbling to see that the science here, at least in the US does not support that thesis. And it's. Then it's up to me to think through what are the type of policies that improve health outcomes that are not necessarily something that I would have just advocated for because of my values instead of because of what the science is saying. So, and just to. To be clear to your listeners, so the science about universal basic income in the US is a bit murky. We don't necessarily see a lot of benefits to people's health outcomes that is compared to better outcomes that we see for universal basic income in countries like Kenya. So I have to just reassess my thinking there. And I think also it helped me to think that maybe there is not a single political party that might have a monopoly on good ideas of what improves health outcomes. And we should be open about that. That's one. The other one I should also just throw to Sandra because I've been very surprised by how reluctant public health is to think about JLP1 drugs as a potentially helpful innovation to improve the health of populations. It made me wonder so again to say it's clearly seems to be very helpful for obesity. We might have to think about long term implications, but if we think that obesity and cardiovascular diseases are a big issue for public health to deal with. As someone who works on prevention, at first I was very skeptical of the use of GLP1 drugs. I'm still waiting for the evidence about a lot of long term impacts. But the resistance, both from me as something that could be helpful, but also just walking around and asking colleagues, made me wonder if we're really stuck also in the ideology that only structural interventions can improve health outcomes. We shouldn't really pay attention to pharmaceutical interventions as a way to improve health outcomes. Sandro, I think I'll push this to you because I've also been asking you about what you think about GLP1, for example.
- [34:35]
B
Yeah, I actually don't know what I think about GLP1 drugs, so I'm going to sidestep that one. I think the answer to your question, Galen, is, I mean, I sort of think I'm wrong all the time. But although I like to frame it, to paraphrase former President Obama, as I'm just evolving in my thinking, I mean, I'll tell you one concrete example, something Salma and I work on quite a bit, is how we think about mental health. I'm trained, my doctorate is in psychiatric epidemiology, which is a pretty classic training about. There is a psychiatric disorder. What are the causes of that psychiatric disorder? I actually have come to feel like the very foundations of that field is predicated on a rigid notion of something called a psychiatric disorder that is much more complicated than that, that involves a full range of expression that might involve fewer or more symptoms and requires a whole rethink of how we engage with the science and let alone then the policies building on science in that field. And that is, it's sort of a profound, let's say, rethink of my entire mental architecture about the field, which I've been in for 25 years. So, you know, I don't know if I can say, well, I've written hundreds of papers that are wrong, or I've written hundreds of papers that now my thinking has evolved beyond that. And I suppose if I'm trying to be charitable, I think that's okay, that is how it should be. But you know, to be frank, it's hard to do like, it's hard to evolve and to take in new data new inputs and to think about the implications of those new data for how we do our science.
- [36:17]
A
Can I, both for my own edification and for listeners who are curious, can you be a little more specific here? What kinds of things are you rethinking in psychiatry?
- [36:28]
B
Well, for example, 10 years ago, within the field of epidemiology, which is fundamentally the science of public health, the core science of public health, we would not take seriously somebody who had a couple of symptoms that are calling towards depression, feeling down, not having enough energy, not eating enough, unless they met criteria for a depressive disorder. We would say, well, those are not really important. But we've learned over time that when you have more millions of people with a few symptoms, it results in a population where these symptoms really matter and we should take them seriously. So then it pushes us to study those few symptoms. It pushes us to think of those few symptoms as being meaningful for the health of people. And it is quite a shift to go from something that the science did not consider meaningful and a subject of study to a place where the science should be thinking about studying these symptoms.
- [37:25]
A
I want to go one step deeper here in what we're talking about, in that you're willing to update your priors when there is new science that comes out. I think one of the challenges, and this gets to distrust in academia as well, is that there are lots of questions that don't get asked. I mean, there's like an infinite number of questions that you can ask, and we create our own ecosystems in which the bounds of public debate get well established, and we have a sense of what questions we can or can't ask. So there's the problem of, like, there's infinite knowledge that we could obtain eventually, and a lot of it we're just never going to engage with, but also a lot of it becomes confined by politics and social norms and expectations, whatever. I think you even have pointed to research that suggests over 40% of public health practitioners or experts have censored themselves in academic settings, essentially because of social pressure. How do you create an environment where people can ask questions, engage in science free from fear? You know, and one example that I'll just bring up, which is like really touching a hot stove here. But there has been a lot of debates about trans people, in particular trans kids. And, you know, the sense has been that European universities were willing to engage in asking certain questions that American universities were not willing to engage with. And so Americans have ended up relying on European research to update sort of their information about how to help trans Kids, we can get into that specific example if we want to, or we can talk about other examples. But how do you create an environment on campuses where people can pursue all different channels?
- [39:20]
C
My answer here might be too simple and I'll start it because Sandru will not say it himself. But I think it starts by doing something that we're doing here at the School of public health at WashU, step by step. It is very hard. I think the 40% number that you mentioned actually is all academics, if I'm not mistaken, necessarily just public health academics. We started something here, started by Sandra, called Thinking Public Health, where we have a conversation every month about a difficult issue, exactly what you've described. We say in those conversations, this is Chatham Howard's rule. Everyone gets to say whatever they want to say with an understanding that we all here care about the health of population. So we should not think that if someone says something I don't agree with, that means they don't care about health, or that means they're evil or they don't care about equity. And I think that been very helpful because Sandra, I think you can attest to this as well. After we have those conversations, usually we'll get a faculty or two we have a conversation with after the meeting that say, oh, I never thought I would actually could discuss this issue. We have someone who says, oh, I actually have been thinking about how do I space out not endorsing it, but I've been considering thinking about how do I space out later vaccines for my kids, for example. That is not endorsing the type of vaccination schedule those people want to have for their kids. But it's fascinating that a public health professional feels like that is something that I can't really discuss among other colleagues because they might look at me differently. So I think just starting with something as simple as that is probably a good first step.
- [40:50]
B
I actually think it's about culture shift. And in part, I mean, I echo everything some said, but I actually see the Purple Public Health Project as entirely a project aim to do that. Galen it is intended to get out into the, let's say, our ecosystem bloodstream, that there are difficult topics, difficult conversations to be had, that we should be thinking differently and somebody may agree or may disagree, and that's okay. But the very surfacing of the idea shifts how we collectively think and how. I suppose I come at this from a place of optimism about the collective goodwill of good people who intend to do well and that when we shift how we all think, we will head in the right direction in time.
- [41:40]
A
I think we're mostly addressing here skepticism that comes from the right of the political spectrum in America. As I mentioned, at the top, there's increasingly skepticism of the public health establishment from the left. And I think that comes from essentially the other party being in power and Democrats not trusting the Secretary of Health and Human Services, RFK Jr. Trump, et cetera, on a number of different things. I think the most high profile have been vaccines and changes to advisory boards on vaccines and things like that. And, and I'm curious how you assess the, I don't know, severity of what has happened at the federal level. Like, if I'm looking at the graph, I think trust amongst Democrats declined from something like 80 some percent down to 55% since Trump took office. Trusting, you know, the information coming out of the cdc. Do you think that's warranted? Would you say, like, you should slow your roll? Like, this isn't all just BS information that's now coming out of the federal government?
- [42:46]
B
Well, we should be clear, first of all, that the challenge of trust in institutions is pretty universal right now. It's not just about public health. So, you know, we need to recognize that, number one, it starts.
- [42:58]
A
It starts. I think the media is less trusted than.
- [43:02]
B
I think the media is bringing up the rear.
- [43:04]
A
I'm a glutton for punishment, too.
- [43:06]
B
Yeah, so that's number one. Number two is, look, the CDC has been for decades perhaps the most distinguished public health agency in the world. I mean, the CDC has done extraordinary work. There are extraordinary people working at cdc. And do I think the lack of trust in CDC is unwarranted? Of course it's unwarranted. The CDC has gotten itself caught up in this partisan wrangling. And this, what we talked about earlier, this use of the moment of mistrust and authority for cynical political leverage, and that is deeply unfortunate. I mean, we should be very clear as we're having this conversation that cutting CDC staff by a third is not good for the country. We should be clear that the effective freezing of substantial chunks of federal funding for research is not good for the health of populations. We should be clear that acting rashly to dramatically change the US's engagement in global health is a threat to global health security. I mean, these are, I think one can say the statements I just said and still be consistent with a questioning, heterodox mind that tries to make sure that we are asking ourselves hard questions and being based in the science and being clear to separate our science from our values, which is the been the theme of this conversation that does not in any way exempt us from having clarity of mind about federal action that's been happening right now that is frankly self destructive.
- [44:42]
A
Do you have thoughts on this, Salma?
- [44:44]
C
I only have worries on this, a sentiment that I follow a lot. I love data. Was that how you feel about the economy and who's president were usually not correlated until about 20 years ago and then it started diverging. So when you ask people how do you think the economy's doing, that usually just correlates now with which political party they're in. If their political party is in power, they usually just say the economy is doing well, generally speaking, until it's really doing badly. And then if their political party is they're not in power, they say it's not doing great. I am really worried that public health and how people feel about public health is going to follow a certain a similar trajectory where whether you trust what's coming out of the CDC is going to be dependent on which political party you voted for. That is my main worry. That's why I think we should be investing more work like the Purple Public health. I don't have the answer for it, but it keeps me up at night.
- [45:42]
A
I think the most, at least one of the most high profile public health fights in America today is on vaccines. And you mentioned it, Salma, briefly. But where does public trust in vaccines stand and how much has federal policy changed on vaccines over the past year and a half?
- [46:06]
B
Well, there's been, I mean there have been a number of changes in terms of the regulatory structures and the oversight groups around vaccines. The actual implementation has lagged quite a bit and there have been some changes to vaccine schedules, but really only around the margins. You know, the stand on vaccines that has emerged from the Maha movement is an unusual joining of disparate impulses. Right? The Maha movement, which comes from a wellness movement, skepticism about putting things in your body that shouldn't be there, ultra processed food, skepticism of corporations. It is a very heterogeneous movement and how it has manifested in the federal government action I think reflects that heterogeneity. Like it's been poorly coordinated. There has been some skepticism around vaccines which has been reflected now in the oversight committees and some tweaking around vaccine schedules. The reality is that most vaccine schedules, particularly pediatric vaccine schedules, have held. And they've held, frankly, because the vast majority of people, the vast majority of the time recognize that this is a science that has saved millions and millions of lives. And fundamentally we don't Want to endanger our kids lives despite the heat of the political moment.
- [47:24]
C
Yeah, I would have to say I think the rhetoric changed a lot more than the actual schedules on the ground. We are seeing lower vaccination rates, but not as low as I expected them, given maybe this is where we talk more about the media, given the media coverage. But the worry here of course, that for example, something like measles, we need a vaccination rate of about 91% to 92% for a population to continue to be healthy. So if we slip a bit, that might have a large impact on the health of population. But so far it seems to be that we're standing still.
- [47:56]
A
Yeah, I mean, what do you chalk up the measles outbreaks around the country to? And maybe, I mean I mostly consume this information through the media that I don't know, often has has an incentive to make things feel really intense. And maybe it is. But since I have two incredible public health experts in front of me now, how seriously should I be taking the measles outbreaks?
- [48:21]
B
I think we should be taking them seriously. I mean they have been focal outbreaks. I mean we have been under the threshold, the national threshold required for community immunity for quite, for about more than a decade actually. But of course that's very heterogeneous, depending on the communities. And you've seen these outbreaks in communities where the threshold is lower, where you have an influx of people who bring in measles. So yeah, we should take them very seriously. All the flare ups we've had have been contained again because we still have public health systems, we have good public health systems and we have vaccination available to deal with these outbreaks. I mean, do I worry about them? Absolutely. You know, I don't think that they have risen to the level of a national crisis. But of course at some level I guess there's an argument to be made that any single measles outbreak is at a level of national crisis because we should have none of them.
- [49:11]
A
Yeah, one of the challenges you all face in boosting credibility trustworthiness is that when everything goes right, nothing happens to be trite about it. I mentioned earlier in the conversation things like putting down cigarettes, being able to drink tap water, you know, buckling seatbelts, it's not a news event anymore. When the number of traffic deaths goes down or you know, the number of lung cancer death, I, I mean maybe we're still paying attention to lung cancer but like a lot of these successes go unsung or took root so long ago that we're not paying attention to them anymore. So part of engendering trust is shoring up your vulnerabilities, like making sure that you're doing things right where you were doing them wrong, which is maybe not being open minded enough, being too orthodox, et cetera. How do you get people to understand when public health interventions are positively affecting their lives?
- [50:12]
C
That is a hard one. And I would, I would add to that. It's not just highlighting our successes. It's also highlighting the issues that are so slow that it's hard for people to think of them as a larger issue. So, for example, cardiovascular diseases. Cardiovascular diseases are the main killer in the United States. But it's boring to talk about cardiovascular diseases as compared to talking about, let's say, cancer. Cancer. You get a lot of movies recently about how people fight cancer and that's. That is brightly something that we should focus on. But we don't get a lot of movies about how we prevented someone from getting a stroke by creating spaces where they can run. I think it is very hard. I do think though that the age where public health can say our successes speak for themselves, it's just not something that we can afford anymore. Public health should be engaging more in something like what you're doing right now, where we speak about our successes to the larger public, where we don't assume that what we do is self evident enough that people will take us seriously, that we need to put ourselves out there and communicate about those successes more. I think as a school, or at least in our work, Sandra and I, we're trying very much to think about what does health communication look like. I just, I don't know the answer yet. It's just something that we're really deeply thinking about.
- [51:26]
A
Maybe something like, you know, like the FBI does, where when you catch like a terrorist plot or whatever, you plaster it all over the news. You gotta like, I don't know, catch a pandemic or something in Times Square and get CNN to, you know, look over your shoulder.
- [51:40]
B
Yeah, I have no disagreement. We need to get better at telling our story. We need to be trying to get
- [51:44]
C
Sandro to create a TikTok where he's like, today this number of people have not died because of vaccine.
- [51:50]
B
I am counting on the next generation to tell that story.
- [51:53]
A
Well, thank you so much for taking the time to talk with me tonight. One final question here. So maybe to prime people who want to follow your purple public health journey, you're going to be engaging in different heterodox conversations throughout the year focusing on maybe a new topic each month. What are some of the conversations that, I mean, we discussed a lot of places where there's room for heterodoxy today. What are some of the conversations, maybe even the most sensitive conversations that you're planning on having for the rest of the year?
- [52:23]
C
We're having conversations next month about autonomy and public health where Sandra and I also differ or disagree on where we draw the line on autonomy and public health interventions. I think the one that is a hot stove, but I'm interested in how do we have a conversation on is the discussions on abortion and public health science, but also public health values. I think that would be a later conversation that we would be engaging on in at the end of this year. So that would be an interesting one. Another one, I am deeply interested in the mission creep conversation. Where do we draw the line on what is public health science and what is public health practice? Sandro?
- [52:59]
B
No, I think touch the hot stove.
- [53:02]
A
What do you want to talk about?
- [53:03]
B
I think we are, you know, we're trying to approach this both from a place of articulating our values. And Salma talked about autonomy and, you know, paternalism and the role and the scope and the scale of paternalism that should be acceptable, the role public health should play in determining societal action or not. And then particular sensitive topics like the place of abortion, which is a really difficult topic that, you know, different people feel very differently coming from a faith based perspective. And, you know, it's not like we have clear answers on these. And I hope that has emerged in this conversation. What we are trying to do is to surface these topics and to create a space where we may not agree and it's okay not to agree. And that strengthens us because at the end of the day, we are all better to have a field that is strong and that's committed to creating a healthier, better world. I mean, who does not want that?
- [54:01]
A
All right, well, I think that is a positive note to leave things on. Thank you, Sandra and Salma, so much for joining me today.
- [54:07]
B
Thank you, Galen.
- [54:08]
C
Thank you, Galen.
- [54:09]
A
My name is Galen Drooch. Remember to become a subscriber to this podcast@gdpolitics.com and wherever you get your podcasts. Paid subscribers get about twice the number of episodes. You can also join in our paid subscriber chat and pass along questions for us to discuss on the show. And you ensure that we can keep making a podcast that prioritizes curiosity, rigor and a sense of humor. Also, be a friend of the pod and go give us a five star rating wherever you listen to podcasts, maybe even tell a friend about us. Thanks for listening and we will see you soon.