CommonHealth Live! with Dr. Sandro Galea

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This transcript is from a CSIS event hosted on March 21, 2024. Watch the full video here.

J. Stephen Morrison: Welcome. We’re here today with Dr. Sandro Galea of Boston University. This is CommonHealth Live!

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This is the CommonHealth from the CSIS Bipartisan Alliance for Global Health Security, engaging senior leaders on questions of how to address our common health security challenges in this post-COVID moment.

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Good morning. Good afternoon. Good evening. I’m J. Stephen Morrison, senior vice president here at the Center for Strategic and International Studies, CSIS, in Washington, D.C. This is CommonHealth Live! We’re thrilled today to be joined by Dr. Sandro Galea. He is a physician, epidemiologist, author, and dean and Robert Knox professor at Boston University School of Public Health. He became the dean in 2015. He’s one of the most widely cited scholars in the social sciences, published more than 1,000 scientific journal articles, 75 chapters, 24 books.

Of special note for our purposes here at CSIS in this conversation, he’s concentrated much of his academic work on the social causes of health, mental health, and trauma, with a special focus on mass trauma and conflict worldwide across a diversity of settings, which I think was a quite apt preparation for dealing with the consequences of COVID-19, which we’ll be discussing today. He authored and published at the end of last year, “Within Reason,” a volume that we’ll begin talking about momentarily.

Sandro, thank you so much for being with us today and coming to CSIS.

Sandro Galea: Thank you for having me. It’s great to be here.

Dr. Morrison: I want to start with your book, “Within Reason.” We had a long conversation about this over a podcast. That was a terrific conversation. I think for our audience, it would be useful for you to summarize the basic proposition of “Within Reason,” the drift into illiberalism and the decline of trust that you identified as a phenomenon within the field of public health during COVID. Describe for us what you mean.

Dr. Galea: Yeah. I suppose I feel like the book title almost captures the entire proposition, “Within Reason.” But the subtitle is, “A Liberal Public Health for an Illiberal Time.” So the fundamental proposition is that when COVID hit, it was this crisis of unprecedented proportion. Nobody alive had actually been through a pandemic like this. And a lot of things happened. A lot of things happened quickly. And leaving aside the urgency of the first couple of months, as we settled into our patterns of dealing with COVID-19 as a society, with public health right in the middle of all this, that we lost our way a little bit. And I call this illiberal.

And now I want to be careful about the word “liberal.” I don’t mean “liberal” in the leftist sense. I don’t mean liberal as a proxy for Democrat. By liberal, I mean building on Enlightenment-era traditions. And that means building what we do on reason, being free, as much as possible, from ideology. Listening to a plurality of voices. Centering the autonomy and the rights of individuals. And to my mind, that has always been what should animate us in public health. And it should animate what we do in public health.

And I argue in the book that we drifted from that. And you know, I think another part of the fundamental proposition of the book is captured in the title, in this – in the title, “Within Reason,” because I’m careful not to offer too many prescriptions in the book. Which I realize for reader might be frustrating, because I often get people saying, well, what should we have done? And I’m careful not to offer prescriptions because, in my assessment, there is no easy answer to any of this. And I think the answers are all, within reason. And the answers all should rest on robust public discussion and debate.

Dr. Morrison: So, just for our – for our audience, describe what were the manifestations of illiberalism within the field? Give us three or four key examples that that kind of got you paying attention – sitting up and paying close attention to what was going on. Give us a few examples of illiberalism.

Dr. Galea: Yeah, so let’s talk about three examples. I think number one would be false certitude. I think the field – because the field is under pressure – and, in the book, I try to be very careful to acknowledge the pressures the field was under. The field leaned into false certitude, being – saying one day: Our predictions are as follows. And we are pretty certain about this. And then the next day, saying, well, actually, we weren’t so certain. Here’s our next set of predictions. So there was a lot of false certitude.

Number two is a contradiction without acknowledgement. And that builds little bit on the false certitude. Which is we – as data evolved we changed our mind, which is appropriate. But we did not have the confidence to explain uncertainty to begin with. And as a result, the mind-changing seemed abrupt and it confused people.

I think number three was intolerance of disagreement, intolerance of different viewpoints about what we should do. And I think that came from a place where public health felt under such threat that we were worried that if we allowed a plurality of perspectives people would be confused. And I think now we have learned –

Dr. Morrison: And that threat was coming mostly from Trump?

Dr. Galea: I think the threat was coming from everywhere. I think, first of all, there was a – there was a very real sense of threat about people’s lives are being lost. There was there’s an immediacy to that. And I think we need to understand it and we need to have deep compassion for those who are on the frontlines for doing that. And there was also –

Dr. Morrison: So there was fear. There was pervasive fear.

Dr. Galea: There was fear. And it was also a moment, though, when – you brought up Trump – when the president was using the world’s biggest bully pulpit, as has been said many times, to really flirting with COVID denialism. I mean, you know, the president acknowledged COVID. But then he was promoting treatments that were ineffective, pushing back on his own advisors. So I think that put public health on the defensive. And I think public health felt that the only way to counter that would have been to lean into its own illiberal tendencies.

Dr. Morrison: Yes. So you’ve mentioned a few of the factors that drove this – fear, political leadership, the urgency, the uncertainty. What else drove the push towards illiberalism?

Dr. Galea: Well, I think the – you know, public health is always in a really interesting space, right? Because public health succeeds when it’s invisible. You know, the world is better because of the work of public health, because of the work of vaccination, the work of clean air, clean water. So as a result, public health doesn’t get much time in the limelight. All of a sudden, COVID happens and public health is on every front page every day. And I think public health –

Dr. Morrison: Was that intoxicating?

Dr. Galea: I think public health – well, intoxicating’s a strong word. Let’s say ill-prepared for that moment.

The other element that was challenging, I think, for public health – but for all of us, really – was the fact that this was the first large scale crisis lived in a time when our predominant public square was social media. And social media is a very particular medium. It is a medium that rewards assertion over discussion. And, you know, I go back to my point about false certitude. It’s very difficult on social media to say what we think is going to happen is the follows, but let us explain the caveats and the uncertainty around it. Social media doesn’t reward that. Social media rewards us saying: Here’s what’s going to happen, and I’m sure of it. So I think we struggled with knowing how to use that medium in this moment.

Dr. Morrison: So what were the consequences, do you think? Right, talk about trust, talk about alienation, talk about the polarization, and the degree to which public health itself now has a particular negative stand with a large portion of our population?

Dr. Galea: Yeah. You know, I’ll start with an anecdote. It’s an anecdote I opened the book with, and then we’ll talk about data for a second. You know, I open the book with this anecdote about the bakery close to my house, which had a sign on the door sometime towards the end of 2021 which essentially said: The town has said that you don’t need to wear a mask, but we disagree with the town. You should wear a mask. And the only reason I use that anecdote – which, for many of us is almost, like, yeah, we’ve seen that all around the place – is simply to remind us that in 2019-2018 it would have been unthinkable for a non-health establishment have a sign that says: The health experts say X, but we think you should do Y. And now we’ve sort of come to accept it. So that’s the anecdote.

Now, look at the data. The data reflect this. Trust in medical scientists, trust in public health, trust in authority has gone down dramatically over the course of COVID. Now, if you think about it, COVID was an enormous public health success story. We got to vaccines, effective vaccines, multiple vaccines, within eight months. The fastest we’d ever done this was three years. That was the fastest. So it was an extraordinary story. And public health mobilized quickly, with rapid testing, contact tracing, isolation – all the fundamentals of public health.

So we should have emerged from this moment with trust in public health soaring, not declining. Which I think then should make us say, why is that? What is going on? And when you look at the data, there is this alarming split between those who identify as Republican and those who identify as Democrats. Trust in medical science is down 25 points among those who identify as Republicans. When you look at Democrats, overall it’s only down a few points.

But if you look at Black Democrats and Latino Democrats, down 10 to 15 points. So I think those numbers should make anyone who thinks about these things pause and say, why is that? What is going on? And I think what these numbers are reflecting is that the public did not really see public health acting in its interest, even though public health was. Public health actually was acting in its interest. And I think that should make us say, what’s going on? Why is that?

Dr. Morrison: Now, one of the things that you talk about in your book is the distance, the separation in class between the field of public health and those most vulnerable, and the consequence that has in terms of understanding the implications of mandatory business closures, or disruptions in schooling, and the like, in terms of the burden borne. Take a few minutes to describe how you – see the field as somewhat separate and isolated, in a way, by status, by economic privilege or benefits.

Dr. Galea: Yeah. I think it’s I think it’s always difficult, right, when those who are in a position of – a decision-making position really do not have the lived experience that those who are experiencing the decisions tend to go through. It’s a problem with Congress all the time in this country. But let’s focus on public health.

You know, one of the things that happened right after the COVID became – it became a thing was – it’s an infectious disease, transmitted person to person, and we should think about how to limit the transmission. One of the things that became really very quickly orthodoxy is that anyone who works from home – who could work from home, should work from home, which, at face value, sort of makes sense, until you look carefully at the data. And the data before COVID – so we knew this before COVID, from Bureau of Labor Statistics – where that those in the top 25 percent of income, a majority of those could work from home, but everybody else in the lower 75 percent of income in this country, it’s only a minority of those people who actually could work from home.

So when you adopt a policy that says, if you can work from home work from home because there’s an infectious disease, what you’re effectively saying is, we are protecting a particular group, which is the people in the top 25 percent of income, more than other groups. Now, I’m often asked, well, what else could we have done? And I really do think it’s a difficult question. I’m trying to be careful not to be – not to make the mistake that I’m myself decrying, to say there’s a clear, assertive answer. Because I do think it’s a very difficult question. But I will remind us that we never really had this conversation when this happened.

And we never really had the conversation that said, maybe, until we get a grip on this for the first couple of weeks, let’s work from home as much as we can. But let’s be aware that in so doing, we’re exposing some people to more risk than others, and that this is something that we should reverse very quickly, as soon as we get a grip on it. And there’s a big difference in our fear and our understanding of the disease in the end of March of 2020, say, versus beginning of May of 2020. But we did not have the dexterity – the intellectual dexterity to pivot, because we leaned into these positions and then – and then really developed an orthodoxy around them.

Dr. Morrison: How has this argument been received among your peers, and other faculty, and students in the field of public health, and officials in public health? How has this analysis been received?

Dr. Galea: I think in the main, I’ve actually been grateful to my peers, in that they’ve been willing to entertain the idea. So I’ve had many people who have said to me, I disagree with what you’re saying but I’m glad that you wrote it. And to be honest, that’s all I asked for. I actually – I think I think there’s plenty of room for disagreement. But what I’m saying – and I say this in the book. I actually say explicitly in the book that I actually look forward to learning from others who analyze the situation differently.

But what was clear to me is that we should surface these questions and we should have this conversation. And I’m looking for others to show me ways in which one can see what happened differently. So I suppose what I tried to do was to open up the conversation. You know, I think one of the criticisms of my writing this book has come from some colleagues who have said, well, there is a problem with turning your gaze onto the work of public health, because you are exonerating, say, the media. You’re exonerating politicians.

Dr. Morrison: Misinformation, disinformation.

Dr. Galea: You’re exonerating them. My point is, I’m not exonerating these sectors. In fact, I acknowledged them in the book. But I also say in the book, that’s not the sector within which I operate. And I think public health and the health establishment broadly, needs to have the self-confidence to say: Let us take a look at ourselves. And also, throw down the gauntlet and challenge the media to take a look at itself, challenge to political sector take a look at itself, challenge the think tank sector to take a look at itself. And say: If all the sectors can honestly examine what they did, what role they played, and how they can do better, I think it’ll be better for us as a world.

Dr. Morrison: Mmm hmm. I read recently Donald McNeil’s book, “The Wisdom of Plagues,” which just came out recently. Which is another very interesting reflection on what’s happened and look back historically over pandemics through the decades. He’s making an argument that one of the lessons from this period – he’s calling for introspection, and self-criticism, and taking another look. But he’s saying that the field needs to be much tougher politically. He’s making the case that in the past public health officials were much more inclined to be fairly authoritarian in their approaches. And that political assaults and this experience has melted that away. And he’s saying, wait a second, defending against these threats requires people to take a stand and hold their ground and be a little tougher politically. What do you make of that argument?

Dr. Galea: Yeah, I read his book as well. I think it’s – I also think it’s a good book. And then the last chapter, I was fairly diverging. I like that argument. And I would like to like that argument. And I think if public health is going to lean into that argument, then public health has to hold itself above reproach. One of the terms which I’ve used in my other writing is that public health has the responsibility to be the adult in the room when everybody around is afraid.

And to be the adult in the room, it means tolerating a lot of misbehavior. It means listening to a plurality of ideas. It means guiding people and being confident enough to show when you don’t know. I think if public health can do that, then not only would it be good for society if public health took this more muscular role, I think society would be happy to have public health take that role. I think a lot of the tensions we’ve seen is because people have not been convinced that public health inhabited the role in a way they want somebody who’s going to take authority to inhabit the role.

Dr. Morrison: We have a project here that we’re doing jointly with Brown University, with Beth Cameron, and Jennifer Nuzzo at Brown University, and a third party is the COVID Collaborative with Gary Edson and John Bridgeland. And that project is looking predominantly at four states in the United States – Indiana, Nebraska, North Carolina, Washington state. But we’re also looking at Alaska, and Maine, and Texas. And we’re – and the proposition there is that COVID’s two stories, really. It’s a story of failure and disappointment and mistakes and blunders. But it’s also a story of ingenuity and courage and lamplighters – people who, in the midst of this darkness, figured out ways to move forward, and build new partnerships, and create things that didn’t exist before, and the like.

And I want to first ask you, you know, the question, I mean, one of the things that emerged from a series of interviews that we’ve had over the last year is the proposition that public health did best when it wasn’t in charge. In other words, when governors said: Yes, public health has to be at the table. It has to be empowered. We have to listen. We have to respect. We have to – they have to have confidence, as you say. They need to be assertive. But you don’t necessarily want them in charge. What do you make of that idea? Because there are several cases that you can point to where things went reasonably well. And it wasn’t by political identity. I mean, the performance in states – the good performance in states was red states, blue states, purple states. It wasn’t really according to political identity.

Dr. Galea: You know, I’ve spent my entire academic – my entire adult life in academic public health. So it’s in my interest to say public health should be in charge. But I’m not sure public health should be in charge. And I think this is a philosophical discussion. I see the role of the scientist – let’s talk about the population of scientists for a second – as analyzing the data and providing those who are in a position of authority and responsibility, and accountability, to then weigh the pros and cons and weigh multiple inputs, and make decisions accordingly. I think the question is one of transparency and accountability.

And if you think about it, certainly population health scientists are not really accountable. I mean, public health scientists are working in universities where accountability is pretty fuzzy. Public health practitioners are implementing the work of population health science. It really – in our society, it is our elected leaders who are actually accountable for the decisions they make. So I’m reluctant to say that anybody but elected leaders should be the ones who are ultimately making the decision. Because we don’t have systems of accountability for any of the rest of us, even public health, regardless of how good our intentions are.

You know, Geoffrey Rose, who’s one of the seminal figures in population health science, has a quote. Which is, you know, our job is to analyze the data so that society can then make the right decision – something like that. And I largely agree with that. That’s what made, for example, the mantra “follow the science” so problematic during COVID. Now, taking a step back, I realize where it came from. It came from a place really of reaction to Trump. When you had a president who was very visible about disavowing science, that’s a really difficult place to be. But accepting that, you know, “follow the science” suggests that the science points to one specific course of action. The science does no such thing. The science gives you a narrow answer about a narrow question. What the right thing to do is, is much more complicated.

Let’s use one example, which I use in the book.

Dr. Morrison: Right, a political choice that takes into account multiple factors.

Dr. Galea: Multiple – let’s take one that perhaps takes into account emotional inputs. Let’s take the issue of – in the context of a pandemic, do you allow people to visit in hospital, without a plastic wrap between you and them, dying loved ones? The science is very clear. You have a dying loved one. You have a greater risk of transmission of the virus if you visit a dying loved one. So the science would say, absolutely not. But how many of us want to live in a world where you can’t give your loved one a last hug and a last kiss? That is not a scientific input that. That is very much a human input.

Now, in saying this one has to hope that those who are elected, those who are in positions of decision making, have the wisdom to make those kind of decisions. Yeah, I think COVID challenged us in that I don’t think there was much confidence that those who were actually in decision-making authority – a position of decision-making authority had that kind of wisdom. But I would like to live in a society where those who we elect have that kind of wisdom.

Dr. Morrison: How does the field move beyond the polarization and lack of trust right now? What’s it going to take, do you think?

Dr. Galea: I think it’s going to take a number of things. And I suppose I felt like one of the things it’s going to take, first of all, is for public health and those who are engaged in the health enterprise to be honest about our shortcomings, and to engage in these kind of conversations. So in large part, and I say this in the book, I wrote the book from a place of love. I wrote this book from place of someone who believes strongly in the mission of creating a healthier world, believes strongly in the role of academic public health and public health practice, and wants the public to trust us.

But I don’t think the public will trust us unless we say, look, let’s look carefully at what we did wrong. Let’s think about how we could do better. Let’s have the humility to accept that there are things we may do better, but also have the confidence to say: If you, society at large, see us having this conversation, you will not lose more trust in us. You will simply say, we are actually thinking carefully, and that is appropriate for anybody who is entrusted with any societal responsibility.

Dr. Morrison: So you’re leading Boston University School of Public Health. So you’re charged with thinking about reforming, or upgrading, or modernizing curriculum. You’re charged with what’s the balance of disciplines that we now need to deal with this world that we now see, in the aftermath of the pandemic. We’re in a world of misinformation, disinformation, conspiracy thinking. We’re in a world that’s so divided that requires political acumen of a different kind than we thought was necessary before. Our communication – our communication capabilities, our outreach capabilities have to be changed, in some ways. Tell us how you’re going about shaping the next generation of public health leaders, because my expectation is that in 10 years’ time we’re going to be dealing with adult practicing public health experts who are coming out of schools like BU, and they’re going to look different and think differently.

Dr. Galea: Yeah, I think they will. And I am – look, when I talk to our students, it’s what always gives me hope. They are better and more thoughtful than their peers were 10 years ago. And emerging from this moment of COVID, we are seeing the people who enter a school, leaving aside what we teach them, who are coming into with eyes wide open. They are deeply committed to the mission of creating a healthier world where everyone can live long, rich, fulfilled lives. But they also have been coming to us recognizing that getting there is not so straightforward. I think they’re value-aligned with what public health is trying to do, but skeptical about how to get there. And that to me is a fantastic foundation on which to build.

Now, you asked about my responsibility, and the school. And one of the things that we’re doing is trying to think about the curricularly. What does this mean, right? For example, one of the things that to my mind is – we have shown to be pretty broken is how we teach communication, public health communications. I’m not sure that anybody has quite shown me what – where we should go to. But I’m pretty convinced that where we are right now is not quite right. This is going to evolve. And this will evolve over the next few years.

Dr. Morrison: Right. And how do you deal with the – with the distance between – a graduate student and a faculty member at Boston University is quite a far away – quite far away from a rural population that’s highly populous that distrust them. How do you – how do you cross that divide and build a greater identification, or empathy and understanding, and ability to engage with a population that, as we’ve talked about, is so skeptical?

Dr. Galea: With difficulty, is the truth. I think we all have a difficult time. You’re in Washington, I’m and Boston.

Dr. Morrison: Yes.

Dr. Galea: It’s actually – it’s very hard to actually say, what’s it like if I lived day-to-day in Wyoming? And I think, conversely, it’s hard in Wyoming to say what’s it like living day-to-day in Massachusetts. But I think, certainly the first step is to talk about it. And, you know, we talk about this all the time in our school. We’ve been very public about the fact that we need to make sure that a school of public health in Massachusetts, which is a blue state, needs to make sure that it’s a welcoming, inclusive environment for people from red states, to make sure that there’s space for political disagreement.

That does not mean that people cannot have particular values that inform how they think. It simply means they want to have the space where people can have the conversations where they can try to find common ground. And we have been very, very visibly public about this at the school. And to try to create an environment where people with different perspectives can get together. I will not say that we’re perfect at it. I think we still have a long way to go. But I’ve become pretty convinced that unless one labels it, unless one genuinely engages with these questions, what ends up happening is, we as humans. end up drifting in one direction, where we very quickly form orthodoxies of thought that reflect only the people around us. And, of course, this has been well-established in political science. When you look at voting enclaves where all Democrats – only Democrats, then they think there’s only one perspective. And vice-versa for Republicans.

Dr. Morrison: I joined a breakfast this morning up on Capitol Hill. It was with a prominent Republican member of the House. Relatively young guy, very talented, very urbane, very accomplished, from a Midwest state in a leadership position in the House. And in the course of his remarks, he went through a series of talking points that were, I think, now official talking points within the Republican Party, that was just a roundhouse condemnation of public health. I mean, it was – it was painful.

But it – that litany is being repeated on the campaign trail and being repeated at breakfasts and luncheons of this kind. And it went largely unchallenged too. I mean, it was, like, we just went through a period of repression. We just went through a period in which our rights were abrogated and the wrong decisions were imposed on us – whether its mandates on vaccines and masks, whether it is closure of businesses or closure of schools. And we’re not going to do that again. And we’re going to make sure that doesn’t happen again.

And I came out of there thinking, you know, this is the thinking that accounts for the rollback of the authorities of public health in two-thirds or more of America’s states, through state legislative action, actions by the governors, and the like. It’s a – it’s a really serious political challenge. And it sort of crossed my mind – I knew I’d be talking to you – and I’m thinking, wow, how does Sandro deal with this, right? (Laughter.) Because you should have that congressman talking to your students, it seems to me, or at least playing video records of this is – this is the world that’s out there right now. A good part of America is talking in these terms. And they’ve got a kind of coherent battery of talking points that get rolled out on the – like, bullet proof – I mean, bullet points.

Dr. Galea: I mean, this is a – there’s a standing invitation to the congressman that he would be more than welcome to come to our school. (Laughter.) And I actually mean that, because I think it is important for our students to hear that. And I don’t know exactly what he said, but I’m sure he will disagree with some things he said. I’m sure it will agree with some things he said. But it seems to me like even having this conversation. To say, let’s – here are the things we disagree on, here are things we agree on.

And it’s also – I mean, the fact that somebody who you describe as accomplished and impressive would hold such viewpoints seems to me to really push public health to say: Let us ask ourselves which from this is warranted? And I think having the confidence to push back on the criticisms that are unwarranted. I think that’s OK. I am in no way – I mean, I’ve written about the need for a muscular public health. But I think a muscular public health comes from a place of confidence, which says we are – we are willing to and we’re open to – honestly, open to ask questions about how we did so that we can be better, without losing sight of the fact that public health did remarkable things during COVID. And public health is – a strong public health is a good for all of us.

Dr. Morrison: Well, there was acknowledgement – I want to add – there was acknowledgement that on the scientific and R&D side of things – Operation Warp Speed and other things – there were vaccines and great achievements of historic value. But I must say, I was just – I was I was just reminded of how much this doctrinal indictment of public health has been embraced.

Dr. Galea: For political ends, yes.

Dr. Morrison: And repeat – it gets repeated by very smart people over and over – and respected people. And it sets off a disquiet and alarm in me because I’m thinking, gosh, how are we going to – how are we going to work with this? How are we’re going to work around this? How are we going to work to change this so that this does not become permanent doctrine in a large part of America? Which I think it could.

Dr. Galea: No, I think it could as well. So, first of all, Congressman, you have a standing invitation. Just let me know. That’s number one. Number two, I think – you know, I thought carefully about when to write this book and how to pitch this book. And, obviously, for a book to come out in the end of ’23, it was written in ’22. You have to be careful in a book like this not to write it too soon, because people can’t pay attention, not too late and then people have moved on. And at the same time, I’ve also been very much aware of the fact that there is a danger of a book like this being misused, and being misused to say, you know, here is a wholesale criticism of public health.

So I’ve been trying to be very careful in my conversations to be clear that a book like this occupies a place of self-examination. And it’s a place of self-examination that rests on the fundamental notion that the field has much to offer, has shown it has much to offer. And also, really, the only way to push back fundamentally at those who are using the field’s shortcomings for political ends is to show that we are willing to examine ourselves and be better, because that strikes me as the way to make sure that the public recognizes that the contribution that we can make will evolve and will stay with us.

Dr. Morrison: Yes. Thank you. I’d like to come back to the project that I referenced that we have together with Beth Cameron at Brown and Gary Edson and others at COVID Collaborative. I wanted to ask you what – as you were watching – you were writing your frequent blogs, that then became – were amalgamated and emerged as the as the foundation for the book. You were watching what was evolving. And I wanted to ask you what you were seeing in terms of patterns of ingenuity at state and local levels, and what kind of leadership – I mean, we had – you’ve acknowledged that the pressures coming from a denialism at the level of the president was going to have a counterreaction in public health, right?

And that was going to lead to a closure of minds, in some ways. But also, there was going to be – the field – responsibilities for finding solutions were oftentimes sort of thrust upon state and local public health officials operating with elected officials and the like, to come up with solutions. And the story that we’re arguing, of COVID, is really two stories. It’s two truths. It’s the truth of a failure and darkness. And it’s the truth of finding new ways forward. What did you see in terms of ingenuity, innovation in leadership form? Are there some instances you can point to that you’ve found inspiring?

Dr. Galea: I like how you’ve captured it, the story of darkness but also of ingenuity. It’s really nice. I go back to something you said earlier, Steve, which I actually agree. That my assessment, the places that the best are places where strong elected officials listened to public health, put public health front and center, but then were not afraid to balance what public health did with other needs of their communities. And I think – I’m reluctant to sort of name person X, person Y. But I also agree that we saw those kind of good examples in cities in red states and in blue states.

One of the areas of research and scholarship I’ve done over the years has actually been on cities, and cities, and how cities affect health. And I’ve long felt that a lot of – in this country, in particular – a lot of ingenuity, a lot of innovation, a lot of interesting efforts are arising in cities. Where you have particular mayors who work closely with public health, but then clearly have their own mind. I mean, in Boston, where I live, I have the privilege of chairing the Board of Health. Which means sort of I oversee the health department. And, you know, our mayor in Boston –

Dr. Morrison: And you did the same in New York.

Dr. Galea: In New York I was on the Board of Health. I didn’t chair it. You know, our mayor in Boston is – I think strikes the right balance, where she’s very clear that she has her own priorities, her own agenda. Listens very carefully to public health. I don’t always agree with her, but I very much respect the fact that public health is heard, and that it’s her responsibility to balance multiple inputs. And to my mind, that’s the direction that we want our cities to go. And I think that’s where you have ingenuity and innovation.

Dr. Morrison: Now, we know there were these flashpoint issues that triggered division and controversy – around schools, around workplaces, around masking and vaccine uptake. What did we need – as you look back, what did we need to put in – to have in place that we didn’t have in place to manage these? Because the next time the flashpoint issues are going to be there, right? I mean, people may not reach for mandates as quickly as they did earlier, but nonetheless what do we need to have in place today that we didn’t have in place during COVID?

Dr. Galea: Well, I think – knowing now what we know now – I think we need a lot more science. And I’m hoping that the next large-scale pandemic takes a while so we can build the science. One perfect example is mandates. You know, we can have polemics all we want, and you can have your opinion, I can have my opinion. I mean, we respect each other’s opinion. But I care more about what does the science show us. I think it’s a really interesting and important scientific question. Did mandates have the desired effect, or not? There’s been some early studies, for example, that have shown that actually mandates had the converse effect, which is once people were mandated they were less likely to do it. There’s been some other work that has shown that people were much more likely to change behavior spontaneously, and then looked askance at mandates.

I don’t know the answer. I don’t think any scientist today can sit here in your studio and tell you definitively that we know the answer. So I think we need science on that. School closure is a good example. We suspected, but we did not have the data that we have now, about the deep impact that school closures are going to have on kids, and about how hybrid learning is not even remotely a subsidy for in-person learning. I think most studies now are coalescing on the observation that students lost about six months of schooling on average. Those six months are a range from one to two months to about 12 months, depending on whether or not they’re schools that are well resourced or not.

So that science is emerging there. So I think we’re at a place where we need science on these questions, so we have a better body of science. And I think we’re at a place where we need to have the arguments hashed out, so that we’ve thought about it. You know, somebody asks me not infrequently, well, what’s your hope for the book? My hope is that next time there is a crisis, there is at least somebody in the room – any – in all of these rooms – who says, are we thinking about tradeoffs? Are we balancing these things? And are we – are we looking at it dispassionately, non-ideologically, to try to make sure that we really are doing what we’re trying to do, which is protect ourselves from disease, while also continuing to allow people to live their lives.

Dr. Morrison: With that new science that you’re talking about, which I think is a great point. That really we need to – we need to scramble to fill those gaps. Would that then be the foundation for a new set of playbooks that would be prepared for policymakers, that – where policymakers would have more of a game plan grounded in facts or studies that would give them more confidence?

Dr. Galea: I think that’s exactly right. And I think the playbooks that we had, which were, you know, based on the science that we had, based the models we had, were largely not useful because, actually, we did not anticipate an event like this. I mean, obviously, they – (inaudible). The other thing – the other function science serves is it socializes those who are in public health practice, and it also informs elected officials who are more adjacent to health. You know, just like in Congress there’s a health caucus, and all that. There are always influential people within leadership, within the elected officialdom, who are – pay more attention to health. And their colleagues listen to them when these things happen.

So the science will shift how we think. You know, there’s this concept of the Overton window, right? That’s the things that are acceptable that we talk about. Well, that is shifted by two things. That is shifted by the data and that is shifted by – shifted by persuasive argument. I think we’re at a point where we need to generate data and have the argument, because the time to do that is now when we’re not in an acute phase of pandemic. I would hate us to go through another pandemic where we are having these arguments when we are rapidly trying to protect ourselves from something that may kill us.

Dr. Morrison: Yes. Thank you. In the last phase of our conversation, I’d like to turn to some of the themes and topics that you’ve covered in your blogs, which are beautifully written and very easy to easy to consume. But you take – you’ve taken on, it seems to me, in your – in your responsibilities as a leader at BU and a leader in the field, you’ve taken on the – by choice – the responsibility to comment on some of the most difficult and controversial topics: Hamas-Israel war; violence against LGBTQ, I mean, the Nex Benedict death. Tell us a bit about your approach on that. I was – I was struck when you talked about Gaza and Hamas that you said something – I’m not going to – I’m going to butcher the quote. But you said something around I can’t begin to know what I should know, something along those lines. In other words, an admission of I find this so – we have to talk about this, but it’s so difficult with the traumas on both sides and the complexities of this.

Dr. Galea: Yeah. So first of all, thank you for reading. For anybody watching, it’s The Healthiest Goldfish, is name of the blog. You know, recently I wrote a piece about why I write, which is where I try to grapple with some of these questions. And articulated sort of these three points as to why I write when I write.

Number one is, when there’s something which I feel is adjacent enough to what I do, what I have thought about, that I have something to contribute. There are many, many things which I care about in my role as citizen that I don’t comment on. That’s number one. Number two, I feel like I have a pastoral responsibility, is a term that was taught to me actually by our chaplain at our university, that, you know, in the field, in my school, in the field there’s a responsibility to actually give voice to things that people are thinking about. And number three is I think one writes when there is an opportunity to shed light. When there’s opportunity to shed light on things around which there is noise.

And I try to be very honest in the writing to explain why I’m writing. That’s why the point that you made about Gaza. I mean, I started at peace with it is such a difficult moment. It’s so heartbreaking in so many ways that it’s very difficult to find the words. And I was trying to be honest about that, sort of a common thing to write. And I try to also be honest that I have a set of values that guide my writing. I think anybody who pools what I’ve written, it’s very clear what my value set is. And I try to be upfront about that and explain how they inform what I write. But also try to be dispassionate and skeptical about the science and try to bring it together. So what I’ve been trying to do is to create space for an engaged conversation around issues that should matter to any of us who care about health.

Dr. Morrison: Thank you. Thank you. I’ve really enjoyed – I really do enjoy your blogs.

Dr. Galea: Thank you.

Dr. Morrison: And really appreciate them. One last question. You’re Maltese.

Dr. Galea: I am.

Dr. Morrison: I feel like I have to bring a Malta question to the table.

Dr. Galea: (Laughs.)

Dr. Morrison: Malta and Barbados are the lead – the leads on the High-Level Meeting on Antimicrobial Resistance that will be held on the margins of the U.N. General Assembly in September. And the lead negotiators were here last week to have a consultation. And they were – it was really fascinating listening to both of them talk about the difficulties of getting a political declaration together, the difficulties operating in this environment, and how they’re approaching all of this.

And I was scratching my head thinking, how did Malta and Barbados find themselves in this position where they were tapped to do this? Because it’s – first of all, it’s not guaranteed of success. And it’s a lot of effort. And a lot of effort to lead in this way. And one of the responses from the lead Maltese negotiator, who was a former defense minister, was: You know, during the collapse of Libya, during the Libyan crisis, we medevaced victims of the violence into the hospital – main hospital in Malta. And suddenly we found we had introduced highly resistant organisms into that setting. And we had to deal with it. And was just hugely disruptive. And it left a deep imprint in the high-level leadership of the country.

And that sort of got us thinking about, as a small society, as an island community, as a –you know, that these are – these are threats that are, in some ways, better understood than they are in Indonesia or Brazil. I just wanted to put out to you – first of all, I thought that was an interesting anecdote, as to the origin of the interest coming from there. But also this observation that while AMR, there’s a lot of momentum around AMR in North America, and in Europe, and in Britain, we see less momentum in the big, lower- and middle-income countries. And yet the proposition is that smaller countries and low- and middle-income ranks may be much more open to thinking about this, because just their own experience in climate change is around those. I just wanted to ask you.

Dr. Galea: Yeah. I mean, don’t know what the political alignment that resulted in Malta and Barbados together, but, you know, they’re both small island states. And as we were discussing earlier, Steve, it’s hard to – it’s really hard for us as humans, right, to see the world through the eyes of others who have different experiences. And, you know, being a small island is a very particular view on the world. And it is – it is one where one recognizes that there are threats to you that are much larger than you, are and that you’re never going to have the size to be able to aspire to actually push back on these threats. So there is almost an imperative for you to figure out a way to engage with the global community to help mitigate those threats. And, you know, Malta has 300,000-400,000 people. So it’s a really – it’s a very small place. And you tend to grow up seeing the world that way. So I’m actually delighted, that Maltese – that you also have people with my accent in your studio two weeks in a row. (Laughter.)

Dr. Morrison: Well, thank you. Let’s close with the question that we try and put at the conclusion of all of these conversations. Which is, what gives you the greatest hope and optimism today? In your position as a prominent intellectual, and teacher, and leader, and dean in this field of public health at this moment in time, what gives you the greatest hope and optimism?

Dr. Galea: I think two things. I think, number one, it’s the students, the next generation. I mean, they are great. They are just better than we were. And that is fantastic. And number two is the very fact we’re having this conversation. I really believe in the power of conversation in societies. And it is critical that we do that to move ideas forward. So I’m grateful to you for having the conversation. Thank you.

Dr. Morrison: Thank you. And, again, congratulations on the book, “Within Reason.” It’s a terrific book. I really have enjoyed it. I think it’s a valuable contribution. So thank you.

Dr. Galea: Thank you, Steve.