Why is this interesting? - The Public Health Edition

On science, unintended consequences, and the realities of behavior

Noah here. One of the recurring themes of the last eight months for me has been just how hard it is to do public health well (or at the very least how poorly-equipped most politicians are to its realities). Not that I should have been overly surprised. Public health is a classic complex systems problem in that it is about the intersection of behaviors, policies/interventions, and the underlying scientific realities of human health and disease. Here’s how they define public health at Johns Hopkins:

In the medical field, clinicians treat diseases and injuries one patient at a time. But in public health, we prevent disease and injury. Public health researchers, practitioners and educators work with communities and populations. We identify the causes of disease and disability, and we implement largescale solutions.

For example, instead of treating a gunshot wound, we work to identify the causes of gun violence and develop interventions. Instead of treating premature or low birth-weight babies, we investigate the factors at work and we develop programs to keep babies healthy. And instead of prescribing medication for high blood pressure, we examine the links among obesity, diabetes and heart disease—and we use our data to influence policy aimed at reducing all three conditions.

What makes COVID so hard to control isn’t solely about the properties of the virus itself, but rather the unexceptional spaces (such as homes, restaurants, and bars) and normal behaviors (like talking to people for an extended period of time indoors) through which it spreads. All of this is made hugely more difficult when you layer on the economic and social impacts of interventions like shutdowns of businesses and schools and then try to feed that back into a holistic model of public health. While one might cut down on COVID transmission it could also leave lasting damage in other areas of health. 

Public health experts recognized early on that expecting everyone to hide away from the world indefinitely wasn’t a good plan both because it could lead to negative health outcomes in other areas and it was never going to work anyway. Those experts pushed to open low-risk spaces, especially outdoor ones like parks and beaches, allowing for some amount of normalcy while also protecting people from the virus as best as possible. While there are many around the country that won’t come outside until there’s a vaccine, it’s unreasonable to expect most people to behave that way and it’s critical that public health is rooted in realities. 

Why is this interesting?

One popular refrain through all this has been to “turn to science.” But science, particularly in a pandemic, isn’t as simple as just delivering answers in the form of data. Because this is a public health issue, not simply a scientific one, the data that’s chosen and how it’s presented comes with its own set of implications. One piece of writing I’ve returned to often over the last eight months is an essay from David Kinney, a postdoctoral fellow at the Santa Fe Institute on this idea. In it he discusses the pressures scientists face to make value judgments that bleed into policymaking:

… scientists rarely possess an evidence base that allows them to be confident in a single assignment of probabilities to different possible outcomes. Much more often, and especially in the face of significant uncertainty about the behavior of a system, the best that scientists can offer is a range of probabilities that a given outcome will occur. Here, scientists face a clear tradeoff. Wide ranges are much more likely to be correct, but can offer limited guidance to policy makers. Narrow ranges facilitate political decisionmaking, but are more likely to be wrong. Thus, when scientists decide how to report results to policymakers, they have to balance the need for action-guiding advice against the risk of their advice being wrong. These are value-laden decisions that cannot be outsourced to policymakers. Thus, as politicians continue to call on the expertise of scientists in order to respond to the current pandemic, scientists must embrace the fact that they are being asked to make ethical decisions. This may not be the ideal role for a scientist, but it is one that each epidemiologist, virologist, economist, and anyone else in a position to provide scientific advice to policymakers finds themselves in, like it or not.

So what do we take away from all this? For me, it starts with the idea that public health is hard and must be rooted in the realities of behaviors. As Dr. Tom Friedan pointed out recently in The Atlantic, it’s likely that our current wave has at least something to do with overly-aggressive early closures in areas that weren’t yet hit by community spread. “The initial widespread closure in the spring poisoned the well,” he wrote in November. “Many parts of the country shut down too soon and for too long. By the time COVID-19 came to areas that hadn’t yet needed to close, people were tired of waiting and resisted continued restrictions. An effective closure needs to be nuanced, specific, and tightened and loosened based on real-time data about where the virus is spreading.” Recognizing that quarantine fatigue is real is the kind of public health work that’s often glossed over. None of this is to say that we shouldn’t hope people will individually make good and safe decisions, particularly when those decisions have very few obvious tradeoffs as with wearing a mask. Rather, it’s to say it’s complex, and we should acknowledge that and expect our policymakers to be more in touch with those realities and how you deal with them. While hopefully, we can now see the end of the road for this particular pandemic, there’s no shortage of other complex behavioral/policy/health situations in our future. (NRB)

DJ set of the day:

This Kruder and Dorfmeister live set in Belgium was a delight to listen to, and the A/V is quite something as well. For those unfamiliar, also start with their legendary The K&D Sessions which has managed to be a downtempo album that has stood the test of time like no other. (CJN)

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Thanks for reading,

Noah (NRB) & Colin (CJN)

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