I teach global and public health, so I can vouch for this being a good piece. My summer class just happens to be doing the failures of malaria policy this week, and I will probably assign this piece for extra credit today (I'm assuming this is unpaywalled, since it is linked on Twitter).
That said, I think one thing we should recognize is that the current failures of public health policy are, depressingly, not even a little bit new. We tend to have this idea that CDC, WHO, et al., used to be good and then lost their mojo, but the truth is that we have a few high-profile successes (besides smallpox eradication, the Obama-era ebola episode was a legit decent response to that crisis) and a lot of failures: AIDS, zika, malaria multiple times, every drug crisis so far, including opioid most recently--even, I would argue, the persistence of measles outbreaks in the US. And as that list of examples suggests, those failures go way beyond government. The much-touted malaria bed-net charities of the past twenty years are, with clockwork predictability, running into the problem that mosquitoes under selective pressure are shifting their feeding habits in places with high bed-net uptake.
All of which is just to reiterate and emphasize the point made in the article that these problems are very, very hard in ways that I have come to believe even the actors themselves underestimate. I think public health people genuinely underestimate the complexity of problems. We genuinely overestimate the efficacy of certain kinds of response (i.e. "if we just did the right messaging, X would happen," or "if people would just listen / could be forced / knew how to follow our advice, we could solve Y"). And we systematically commit certain kinds of cognitive errors, like misunderstandig how everyone else experiences and understands disease (for example, at the beginning of the pandemic, I told my students, "if this is the worst disease event of the last fifty years--if mortality is completely awful and we lose a million people next year--you might still not know anyone who died," and that held up, which helps to explain how you can have a disaster and also have the stupid debate we have over vaccination, because the two are not exclusive in human experience).
As a teacher, I try to help would-be public health professionals of the future to develop some tools against these problems. I try to help them see hubris and develop humility. We talk about the importance of not just telling the truth but telling it with precision and completeness. I'm a historian, so we do past episodes of failure and try to tease apart the complexities that get us places and the arguments and failures that recur (the unchanging nature of the vaccine debate, going all the way back to smallpox variolation, is simultaneously hilarious and depressing). And I think this all helps.
But as a historian I have come to the conclusion that the best we can hope for is to handle THIS episode and THAT episode correctly, because "public health" is, in some very real sense, too broad of a problem set for anyone to get their arms around. Like, how do you bind together a basket of issues that that includes needing to understand fentanyl production, monkeypox epidemiology, and maintenance of lifelong HIV antiviral drug production and delivery chains? It's a ridiculous claim on its face.
Of course, that raises a whole different set of policy questions, against which all the incentives of our system are set to produce non-optimal answers. So people yell about how bad the "official public health" response is, and they are right, and public health people yell back about how much they are misunderstood and under-resourced, and they are right, and everybody is right, and that sucks.
Thus concludes my professional public health downer rant.
I'd like a public health establishment that starts from the perspective that we should be honest with people about risk. Not "what should we tell people if want to produce a certain response?" or "what should we avoid telling people because we don't want to cause this other negative thing?" Just tell people the truth. It really undermines public faith in institutions when you don't do this, and it's not like the public health officials are such effective propagandists that they're even particularly likely to get the effect that they're trying to get.
Important to not separate the bad public health response with simply terrible political incentives - In 2009 in the face of swine flu the UK Health Secretary ordered £300 million worth of vaccines for it, and ended up being heavily criticised by the press as having been 'wasteful.' Sadly there's not much understanding about how sometimes you have to take financial risks in public health even if the worst of the downside does not materialise
The case that our public health experts are "just following the science", as opposed to the bad guys who act based on politics, is getting quite difficult to sustain.
MattY, the botched response here is much much worse then how you present it. Public health officials repeatedly refused to ship to us vaccine doses already bought and even donated some to Europe , *after* the current outbreak was already happening . They also dropped the ball on the strategic stock pile, letting it deplete from 10s of millions of doses to nothing. And this is just *some* of the mistakes made. Everyone needs to read this thorough NYT reporting on the botched response, I thought I was a skeptic about us public health agencies already, but this is just unbelievable:
I’m at the point where “make the global south richer” is probably a more realistic response than hoping for useful NGO and government responses on these things. It’s going to take a long time, but at least it’s been proven that poor countries can become wealthier, and the free market basically works when there is financial incentive for pharma. And monkeypox doesn’t worry me and more than Zika or dengue or other diseases that we have already failed to contain. Making NGO and government public health responses useful on the other hand is unproven and highly theoretical.
I found myself smugly brushing off the monkeypox threat, since I don't cheat on my wife, until I realized that my bi-weekly jiu jitsu class is essentially a worst case scenario if any of my dozens of training partners get it. I'd imagine similar risks exist in tons of martial arts and contact sports (as ringworm, staph, etc. always have). I'm frustrated that I am not vaccine eligible according to my county health dept. because I don't bang random dudes, when I do spend a few hours a week rolling around with them, sweatily trying to murder each other. Seems like another failure of imagination / blind spot from health authorities.
One of the single biggest public health lessons from the early days of COVID was that you need a government backstop to spend money on this stuff, even if it means "wasting" it. No politician wants to have attack ads run against them for supporting a boondoggle, so their incentives are to be risk-averse.
Pharma had the knowledge to do research around coronaviruses (both vaccines and small molecule drugs) but wasn't going to invest in this without a potentially large market share. And now we're re-learning the lesson with monkeypox, with the added frustration that there already is a vaccine and the government simply didn't prepare. This is going to be true with new antibiotics as well; it's only a matter of time before we have a widespread bacterial infection that we can't treat. We (and by we, I mean society at large) may learn this lesson eventually, but I'm not optimistic.
Jerusalem Demsas keeps hitting it out of the park. You should have her as a guest blogger.
Also, in many of the discussions of ACAM2000, it’s been unclear to me just *how* unpleasant it is. Is it as bad as actually getting monkeypox? The descriptions seem compatible with that.
Is there a knowledgeable person who can tell what else the public health people are fucking up?
Like, there seem to be a bunch of ebola vaccines stuck in development hell—what’s up with that? Do they actually have a distribution plan for the smallpox vaccine stockpile in case of need? Are we behind the curve on MRSA, swine flu, bird flu, etc. the way we’ve been on every other virus to turn up in the past 3 years?
I’m not anywhere close to a public health person, but I would think that someone—CDC, WHO, HHS, whatever—should be tasked with formulating a top 20 list of biological threats, wargaming them out, and then plugging the gaps in our prepared response. I get that it might be a big task, but we’re putting a lot of money into the alphabet soup of public health and they’re falling down on preparedness.
How does the gay community feel about this? Gay men in San Francisco during the early 80s experienced higher death rates than the French Army during World War I. My understanding is the community adapted a lot, became somewhat less promiscuous, created strong social pressures to use condoms during casual sex and saved alot of lives through these lifestyle changes. There must be some old, gay men who remember their friends and lovers dying with seering regret and who would be very effective advocates for cost justified interventions. Are younger gay men aware of the holocaust their predecessors endured 40 years ago? Is bathhouse culture still a thing? I’m genuinely curious.
Niche complaint but the focus on male/male sexual encounters may also cause people to overlook other activities as risky. Martial arts are what I'm thinking of here - a jujitsu student can be in close contact with maybe 6 or 8 people a class, 2 or 3 classes a week... I don't know exactly how promiscuous promiscuous people are, but that has to be in the same ballpark, right?
Niche conspiracy theory: both recent pandemics were engineered by The Illuminati specifically to prevent me from getting back on the mats.
I guess it's very understandable but people are very, very resistant to the fact that a new STD just exists now and probably isn't going back in the bottle anytime soon. Makes me wonder if there will ever be consensus again to allow another member into that class of diseases in the popular consciousness, because they're seen as stigmatizing and it could be seen as better to treat each new outbreak as sui generis.
I teach global and public health, so I can vouch for this being a good piece. My summer class just happens to be doing the failures of malaria policy this week, and I will probably assign this piece for extra credit today (I'm assuming this is unpaywalled, since it is linked on Twitter).
That said, I think one thing we should recognize is that the current failures of public health policy are, depressingly, not even a little bit new. We tend to have this idea that CDC, WHO, et al., used to be good and then lost their mojo, but the truth is that we have a few high-profile successes (besides smallpox eradication, the Obama-era ebola episode was a legit decent response to that crisis) and a lot of failures: AIDS, zika, malaria multiple times, every drug crisis so far, including opioid most recently--even, I would argue, the persistence of measles outbreaks in the US. And as that list of examples suggests, those failures go way beyond government. The much-touted malaria bed-net charities of the past twenty years are, with clockwork predictability, running into the problem that mosquitoes under selective pressure are shifting their feeding habits in places with high bed-net uptake.
All of which is just to reiterate and emphasize the point made in the article that these problems are very, very hard in ways that I have come to believe even the actors themselves underestimate. I think public health people genuinely underestimate the complexity of problems. We genuinely overestimate the efficacy of certain kinds of response (i.e. "if we just did the right messaging, X would happen," or "if people would just listen / could be forced / knew how to follow our advice, we could solve Y"). And we systematically commit certain kinds of cognitive errors, like misunderstandig how everyone else experiences and understands disease (for example, at the beginning of the pandemic, I told my students, "if this is the worst disease event of the last fifty years--if mortality is completely awful and we lose a million people next year--you might still not know anyone who died," and that held up, which helps to explain how you can have a disaster and also have the stupid debate we have over vaccination, because the two are not exclusive in human experience).
As a teacher, I try to help would-be public health professionals of the future to develop some tools against these problems. I try to help them see hubris and develop humility. We talk about the importance of not just telling the truth but telling it with precision and completeness. I'm a historian, so we do past episodes of failure and try to tease apart the complexities that get us places and the arguments and failures that recur (the unchanging nature of the vaccine debate, going all the way back to smallpox variolation, is simultaneously hilarious and depressing). And I think this all helps.
But as a historian I have come to the conclusion that the best we can hope for is to handle THIS episode and THAT episode correctly, because "public health" is, in some very real sense, too broad of a problem set for anyone to get their arms around. Like, how do you bind together a basket of issues that that includes needing to understand fentanyl production, monkeypox epidemiology, and maintenance of lifelong HIV antiviral drug production and delivery chains? It's a ridiculous claim on its face.
Of course, that raises a whole different set of policy questions, against which all the incentives of our system are set to produce non-optimal answers. So people yell about how bad the "official public health" response is, and they are right, and public health people yell back about how much they are misunderstood and under-resourced, and they are right, and everybody is right, and that sucks.
Thus concludes my professional public health downer rant.
This is from Kat Rosenfield last week:
2020 public health: cover your disgusting face holes and stay the fuck home you bunch of selfish troglodytes
2022 public health: maybe just put a lil gauze on your monkeypox boils before your orgy, y’know, if you feel like it
The ongoing lack of interest in reforming the CDC and FDA is baffling to me. I feel like I’m screaming into the void.
I'd like a public health establishment that starts from the perspective that we should be honest with people about risk. Not "what should we tell people if want to produce a certain response?" or "what should we avoid telling people because we don't want to cause this other negative thing?" Just tell people the truth. It really undermines public faith in institutions when you don't do this, and it's not like the public health officials are such effective propagandists that they're even particularly likely to get the effect that they're trying to get.
Important to not separate the bad public health response with simply terrible political incentives - In 2009 in the face of swine flu the UK Health Secretary ordered £300 million worth of vaccines for it, and ended up being heavily criticised by the press as having been 'wasteful.' Sadly there's not much understanding about how sometimes you have to take financial risks in public health even if the worst of the downside does not materialise
The case that our public health experts are "just following the science", as opposed to the bad guys who act based on politics, is getting quite difficult to sustain.
MattY, the botched response here is much much worse then how you present it. Public health officials repeatedly refused to ship to us vaccine doses already bought and even donated some to Europe , *after* the current outbreak was already happening . They also dropped the ball on the strategic stock pile, letting it deplete from 10s of millions of doses to nothing. And this is just *some* of the mistakes made. Everyone needs to read this thorough NYT reporting on the botched response, I thought I was a skeptic about us public health agencies already, but this is just unbelievable:
https://www.nytimes.com/2022/08/03/us/politics/monkeypox-vaccine-doses-us.html
I’m at the point where “make the global south richer” is probably a more realistic response than hoping for useful NGO and government responses on these things. It’s going to take a long time, but at least it’s been proven that poor countries can become wealthier, and the free market basically works when there is financial incentive for pharma. And monkeypox doesn’t worry me and more than Zika or dengue or other diseases that we have already failed to contain. Making NGO and government public health responses useful on the other hand is unproven and highly theoretical.
I found myself smugly brushing off the monkeypox threat, since I don't cheat on my wife, until I realized that my bi-weekly jiu jitsu class is essentially a worst case scenario if any of my dozens of training partners get it. I'd imagine similar risks exist in tons of martial arts and contact sports (as ringworm, staph, etc. always have). I'm frustrated that I am not vaccine eligible according to my county health dept. because I don't bang random dudes, when I do spend a few hours a week rolling around with them, sweatily trying to murder each other. Seems like another failure of imagination / blind spot from health authorities.
One of the single biggest public health lessons from the early days of COVID was that you need a government backstop to spend money on this stuff, even if it means "wasting" it. No politician wants to have attack ads run against them for supporting a boondoggle, so their incentives are to be risk-averse.
Pharma had the knowledge to do research around coronaviruses (both vaccines and small molecule drugs) but wasn't going to invest in this without a potentially large market share. And now we're re-learning the lesson with monkeypox, with the added frustration that there already is a vaccine and the government simply didn't prepare. This is going to be true with new antibiotics as well; it's only a matter of time before we have a widespread bacterial infection that we can't treat. We (and by we, I mean society at large) may learn this lesson eventually, but I'm not optimistic.
Jerusalem Demsas keeps hitting it out of the park. You should have her as a guest blogger.
Also, in many of the discussions of ACAM2000, it’s been unclear to me just *how* unpleasant it is. Is it as bad as actually getting monkeypox? The descriptions seem compatible with that.
Is there a knowledgeable person who can tell what else the public health people are fucking up?
Like, there seem to be a bunch of ebola vaccines stuck in development hell—what’s up with that? Do they actually have a distribution plan for the smallpox vaccine stockpile in case of need? Are we behind the curve on MRSA, swine flu, bird flu, etc. the way we’ve been on every other virus to turn up in the past 3 years?
I’m not anywhere close to a public health person, but I would think that someone—CDC, WHO, HHS, whatever—should be tasked with formulating a top 20 list of biological threats, wargaming them out, and then plugging the gaps in our prepared response. I get that it might be a big task, but we’re putting a lot of money into the alphabet soup of public health and they’re falling down on preparedness.
We're just going to not talk about that two-pronged needle thing?
https://en.wikipedia.org/wiki/ACAM2000#/media/File:Smallpox_vaccination_needle.jpg
Yeah, let's just not talk about it.
How does the gay community feel about this? Gay men in San Francisco during the early 80s experienced higher death rates than the French Army during World War I. My understanding is the community adapted a lot, became somewhat less promiscuous, created strong social pressures to use condoms during casual sex and saved alot of lives through these lifestyle changes. There must be some old, gay men who remember their friends and lovers dying with seering regret and who would be very effective advocates for cost justified interventions. Are younger gay men aware of the holocaust their predecessors endured 40 years ago? Is bathhouse culture still a thing? I’m genuinely curious.
Niche complaint but the focus on male/male sexual encounters may also cause people to overlook other activities as risky. Martial arts are what I'm thinking of here - a jujitsu student can be in close contact with maybe 6 or 8 people a class, 2 or 3 classes a week... I don't know exactly how promiscuous promiscuous people are, but that has to be in the same ballpark, right?
Niche conspiracy theory: both recent pandemics were engineered by The Illuminati specifically to prevent me from getting back on the mats.
I guess it's very understandable but people are very, very resistant to the fact that a new STD just exists now and probably isn't going back in the bottle anytime soon. Makes me wonder if there will ever be consensus again to allow another member into that class of diseases in the popular consciousness, because they're seen as stigmatizing and it could be seen as better to treat each new outbreak as sui generis.