Ep10: How to Restore Trust in Science?

Episode Transcript

John Tomasi: Sandro Galea, welcome to Heterodox Out Loud.

Sandro Galea: Thank you for having me. Great to be here.

John Tomasi: It's really a pleasure to have you. And, you know, many people outside the academy have criticized the government's response to COVID-19. But you're the dean of the School of Public Health at Boston University, and you've been in that position since 2015, I think. You've been an advisor to the CDC, Centers for Disease Control. You've been appointed, recently appointed by the mayor of Boston to chair Boston's Health Commission's Board of Health. You're an esteemed scientist, you're an insider's insider, and you're a critic of public health. We're going to discuss some of the reasons you're a critic and what that means for you to be a critic. We want to learn from you in those ways. I want to just start by asking you, how does that feel? So you're such an insider. You're so well-known and so highly regarded as a scientist. You're in all these, you zoom in with the CDC and so on. How does it feel to you before you go into the reasons? How does it feel being you when you join these various groups and play these roles?

Sandro Galea: Well, I suppose I don't see my critic. I see myself as somebody who is trying to hold a mirror to ourselves and to challenge us. I think the word critic implies, although I know it's not necessarily what it means, is that one is only pointing out flaws and weaknesses. I try to write a book that is challenging, that learns from what has happened, that is expansive in its deep respect for excellent work done by public health, and that has every intention of challenging us to be better. That's what I tried to write. And I think as long as the book is understood that way, I'm comfortable in all those circles.

John Tomasi: Lovely. That's lovely. I've heard you describe public health as a story or having a story. What struck me as a remarkably and unexpectedly literary remark from your side of campus. Can you tell us what you mean by saying public health has a story? Is a story?

Sandro Galea: Yeah, one of my mentors used to say that, you know, public health is above all an aspiration, and I think the story is what gets us aspirations. What I mean by that is we choose the narratives we live by, and one of those narratives is that we choose to be as healthy as possible for as long as possible, as many of us as possible, with no one being left behind. And that is a picture. You're painting a picture of the world that you want to live in. And if we can agree that that's the picture we want to live in, then there are things that we can and should do to get to that picture. So that's what I mean by public health is a story, because it then says, what should we be doing as a society to get to that place? And once you start thinking that way, you realize that there are things you want to put in place, that there are efforts you want to make to allow you to realize the story.

John Tomasi: Definitely. That's lovely. We'll be talking about ways in which public health became politicized during the COVID-19 epidemic, maybe in particular. And we'll be looking at, from an insider's perspective on that, on some of those ways that things went wrong. But just to frame that first, you've also written that, I mean, strikingly, I thought, that COVID-19 was in some ways public health's finest hour. Can you, which is kind of an interesting comment. Can you say something about that?

Sandro Galea: Yeah. I realize it sounds contradictory, but perhaps there's much truth and wisdom and contradiction. If it weren't for public health, many more people would have died from COVID. You know, during COVID, we saw the most rapid development of vaccines ever. Previously, it was like three times slower, the fastest thing we had ever done, that were delivered at record pace in the U.S. and all over the world. Many challenges to all that, but all of that remains true, that we did this extraordinary period of time. We found a test very quickly. Again, there were challenges to it, but still remains true that we found a test quickly. We acted quickly to implement efforts to test, to screen, to create isolation protocols, to protect people from transmission. All of that was the work of public health. All of that was the work of public health, of the people in public health and public health practice, the academic side of public health, interacting with media, interacting with government. So it was a public health challenge, and public health rose to the challenge. Nothing redeems the COVID tragedy. Seven plus million people died worldwide. One plus million people died in the U.S. But more people would have died. More people would have had COVID were it not for the really good work of public health. So I do think it was public health's finest hour. That does not mean, and it doesn't have to exist without also saying we should learn from this moment.

John Tomasi: Fabulous. Let's talk about your book. You've just published a fabulous book, highly readable, philosophically rich, and obviously timely with so much to be learned from it. And for HxA's membership, in particular, there are so many of the themes you talk about are themes that HxA members are always worrying about and talking about. And your application of it to the COVID-19 situation is just really, really, really magisterial. The book's called Within Reason, A Liberal Public Health for an Illiberal Time. In the title of your book, the word liberal appears, and liberal can be taken in an ideological sense, meaning one political party as opposed to another. But there's also a deeper historical meaning of the term liberal that connects to reason, another word that's in the title of your book. Can you just say a little bit about that?

Sandro Galea: Yeah, and I'm very clear about this in the book, that I do not mean liberal in the partisan sense in which it's interpreted in the common conversation in the U.S. Typically, we don't think of the word liberal as meaning leftist, meaning democrat, but that's not what I mean at all. What I mean is liberal in a more classic philosophical sense, going back largely to the European Enlightenment. So I mean liberal meaning a way of thinking that is based on empiricism, that moves us away from ideology and belief, where we are able to build a better world brick by brick by evaluating the available data and evidence, where we allow for a plurality of perspectives, because that plurality of perspectives allows us to be better in sharpening our thinking. It is in that sense that I mean the word liberal.

John Tomasi: We'll be talking now about some of the major themes from your book, including the politicization of science, the decline of trade-off thinking, and the displacement of trade-off thinking by something like absolutist or tribal thinking perhaps, the effect of social media on science, the social allure of power and influence, and all the ways these different things affected were seen in our COVID response. Let's just begin with the first of those about this aspect of this idea that public health has become politicized. You described the COVID-19 response as a crucible, as quote, another one of your lovely phrases, a crucible of politics and public health. Can you say a bit more about that? I think of public health, from my perspective as a longtime university professor, as being an ideology of a discipline, which has an ideological directionality, at least it's widely thought of that way. But can you just say something about that? In what sense did public health become politicized?

Sandro Galea: Yeah, it is perhaps one of the hardest concepts in the book, because public health has always been political. And it depends, of course, what you mean by political. But by political, I mean it is the business of our collective engagement in deciding how to allocate resources in our society. And public health is about allocating resources. So as a result, public health has always been political. But what I meant in the book, in my concern, is less about public health being political, as much as public health achieving political and partisan alignment with particular ways of thinking. And I think that is problematic. I think that is counter the liberal notion of pluralistic thinking. Now, I should take a step back, and I'm very clear about this in the book as well, that you almost cannot have this conversation without going back to the root cause of a number of these challenges, that I point out about public health. And this one in particular, one has to talk about the root cause. And in this case, the root cause was the moment in time when COVID hit. COVID hit the U.S. in February, March of 2020. It was in the run-up to a federal election. And the president, who was sitting at the time, who has arguably the most readily available bullhorn in the country, decided to treat COVID largely as an inconvenience in his path to re-election. And as a result, he adopted multiple approaches, some of which bordering on COVID denialism, vaccine denialism, on promoting therapies that were clearly quack therapies. So I think it's important that we actually label that, because public health's been what I call political ideological alignment, in large part in opposition to Trump, was provoked by a lot of things that Trump said. So I do think we need to understand that. To my mind, it doesn't exonerate public health from being the adult in the room. And to say that if you have a president who is antagonistic to fact and reason, we still have a responsibility to build what we do on fact and reason. But I do recognize the difficulty that the moment brought.

John Tomasi: You've spoken of a crisis in trust in around public health. And I have some statistics from the Pew polling. Pew says that the percentage of Americans who believe that science has a mostly positive effect on society dropped about 10% between 2016 and 2023, from 67% to 57%. Those who say that they have a great deal of confidence in scientists, was 39% in 2020, but it's only 23% now. So 23%, just 23% of those polled, say that they have confidence, a great deal of confidence in scientists. And those declines, there's some breakdown between the parties, but it's pretty widespread across people from both, respondents from both parties. I wonder if you could say something about that, about that crisis in trust.

Sandro Galea: Those data which I've used since, as you know, they were published roughly around the same time as my book was published. Actually, those came up in November, December of 2023. In many respects, those data make the case for why the book exists. That, you know, I wrote the book before those data were available from a place of feeling like we were losing the public's trust. Now, if you think about it, coupling the statement, we're losing the public's trust with the statement I made earlier, was public health's finest hour. I feel like it makes, it should make the most, the deepest believer. And as you said at the beginning, I see myself as a believer in the mission of public health. I want to be very clear about that. I think it should make the deepest believer ask why, what is going on? How could we have gone through this period when public health saved literally millions of lives and people trust us less rather than more? And I think that's the question that public health should ask itself. And in part, it was an instinct that that was happening that prompted writing of the book. And it was an instinct to say, I want to get ahead of this and I want to start us. I want to start the exercise of asking what were the challenges, what were the philosophical challenges we face so that we can learn and do better and reclaim the trust?

John Tomasi: That's interesting. And there's something about the role of expertise or maybe the social perceptions of experts and expertise. That kind of seems to lie within that trust, that lack of trust. Can you say something about that? Has the role of the expert, I think you would say it should be more exalted than it is, but it needs to earn that exaltation. Is that what you would say?

Sandro Galea: I would, you know, I think sometimes reflexively in the public conversation, we say things like, ah, well, there's, you know, lack of respect for experts. But I don't think that anybody who's listening to this wants a non-expert plumber. I don't think anybody who's listening to this wants a non-expert orthopedic surgeon. So I think we actually have a reflexive understanding of the importance of the expert. And so I think it is on the expert to make sure that people recognize not just their technical competence, which is experts bring technical competence, but also that people value the place that experts occupy in the constellation of how we go about doing what we do. And I find that I often find the public conversation about expertise a little bit simplistic. I think we all are surrounded by experts. We're okay with experts, but we just want to make sure that we trust that they bring value to what we do. And it is sort of on the expert to convince you of that. Like, let's go back to the plumber example, right? You know, you and I, we have a plumbing need in our home. We're going to go to an expert. Now, if I feel like, I don't know what the, what the plumber is saying, I can probably just do this myself. I don't really, I don't really believe that they know what they're doing. Well, I'm not going to go to the plumber. Now it's sort of on the plumber to say to me, Sandro, you don't know what you're talking about. If you do that, you're going to flood your bathroom, right? It is on the plumber to make sure that they earn my trust, both for me seeing what they've done in the past. And also from convincing me that they understand the problem well enough and they have a solution for me.

John Tomasi: But with a plumber or with a used car salesman or whatever other roles people play, it seems prudent to have a healthy skepticism of them as well. We want to know, this is your recommendation. Are we so sure? How do we know about that? And there seems to be a, that, that attempts to every profession as part of the society, having trust in people. But there seems to be a special challenge with public health. And it was revealed perhaps during the COVID experience because there seemed to be, it seems to be part of public health or you'll tell me whether it's part of public health. On occasion to tell a noble lie, for example, to indicate that perhaps masks are not needed or they maybe are needed. And that was part of the story of the experience, I think. Can you say something about that? Is there, is there something asymmetrical about trust and expertise?

Sandro Galea: I suppose it is then a core part of what I'm saying that I don't think we should be telling noble lies in public health. I think we should be telling noble lies in medicine, for example. You know, let me, let me go to medicine for a second. It used to be that in medicine, clinical medicine, now I'll come to public health, you know, that the thinking was 50, 60 years ago. Well, we shouldn't tell the patient that this is really what we need because they can't handle it. And medicine has moved well beyond that. I mean, medicine now, we teach our medical students to be honest with their patients, to present the options, to be upfront about what we know, what we don't know. And public health should be in that place. We should not be telling noble lies. We should be upfront about what we know and what we don't know. And we should trust people that people can handle that. People can handle the truth and they can handle it when we don't know. I think part of the thing that gripped us in COVID was we were worried that if we were to say we don't know, that people could not handle that. They would be upset at us. But maybe that might have been true in the short term, maybe that might have been true on, you know, that particular day, that particular hour. But in the long term, what we're seeing now are the consequences of people losing trust in us because they saw that we exhibited certitude when it wasn't grounded. That false certitude came back to hurt us in the long term. And I think the long term pain that comes from that was not worth any short term gain. And, you know, there's a lot of implications of this, John, because it has implications for how we communicate in public health. It has implications for how we deal with certainty and how we communicate uncertainty. But in part, the reason why the book exists is why at the beginning you asked me, you know, how do I feel about this? It's a challenge to us that says, let's learn how to communicate better.

John Tomasi: And that idea seems to connect to the idea of trade-offs, the idea that there's a, that people, there was a felt need for certainty on the part of experts in the face of this danger, this new threat that was so alarming to all of us watching on TV, watching the news broadcasts about people sharing ventilators and so on. People, I think, in a sense, want clarity in a moment like that. But a major theme of your book is that the idea of trade-offs in our discourse, in the public health discourse, were displaced by absolutist kind of language. I might even say tribal kinds of language. Is that, are those two things connected? Was the displacement of trade-off language connected to the need to project or the hunger, perhaps, on the part of the populace to hear clarity? Or is there some other cause that led in that direction?

Sandro Galea: Well, I suppose I'm arguing that even if the population, if we perceive that the population wanted clarity, wanted sharp answers, that we in public health in the future will want to refrain from offering sharp answers where we don't have them and be upfront about trade-offs. You know, one clear example is, was decisions made around closing schools, right? And it is entirely true that children were not at zero risk of COVID, but it's also true that children were at low risk of getting COVID, low risk of having severe COVID, low risk of transmitting COVID. So when we were closing schools, we were essentially trading off, minimizing what was already a low risk for the pretty clear certainty that kids were going to fall behind in education, and in particular kids in poorer schools, schools that were predominantly kids of color. So that was a trade-off we were making. And I don't remember that conversation explicitly in the front and center in the public health conversation in the fall of 2020, that we lean heavily into the minimizing risk around one dimension of our living, which is health as measured by transmission of infectious disease, versus all the other dimensions of our living, which include centrally, making sure children are on a life course trajectory to be healthy and thrive in the next 30, 40 years. That is a trade-off. And it is on us who understand the trade-off to be explicit about it.

John Tomasi: So there seemed to be something that I might describe as a confusion about roles in society that was going on during COVID. I would think, and I'll like to hear your take on this, that the role of science and of health professionals is to present a range of options with likely outcomes as best they can in the fog of the ongoing thing. And then it's the role of the government, the elected officials, to say, okay, this is what the public health people are saying they think is important. Here's what the educators are saying they think is important. Here's what the parents are thinking they think is important. Let me do this decision-making now as an elected leader. And it seemed that in many ways that there was a displacement of political leadership for something like scientific leadership. And that may have led the scientific leadership to becoming inevitably political. Is that too simplistic? Can you help me with that?

Sandro Galea: Unfortunately, I don't think it's too simplistic, unfortunately. So let me elaborate on that for a second. You know, one of my intellectual heroes was Geoffrey Rose, who was a British epidemiologist, really did a lot of foundational work in population health science. He has a quote, I'm not going to get it exactly right, but roughly it says, it's the role of the population health scientist to analyze all the options so that then decision-makers can use those to decide what the right step is. And I generally tend to agree with that. Perhaps my least favorite bumper sticker during COVID was follow the science. And the reason it was my least favorite bumper sticker, I want to be more clear. I am a scientist. I make my living by being a scientist. So do I think the science matters? Absolutely. Do I think the science is central? Absolutely. But I think that there are values and inputs that are larger than the data about how we mitigate risk of infectious disease that should guide how we act as a society. There is human dignity. There is love. There is the willingness, the desire to have joy. There is the desire to live a full life. And I read about this in the book. It is a misconception that we live to be healthy. We want to be healthy so that we can live. And that is very hard for those of us who are in health to see at all times. So coming back to your point, I don't think your point was simplistic. I think your point was correct. It is our role to analyze the data and to give society options that include trade-offs. Now, I've also written pretty extensively that data by itself does not sway today. We also need to make a moral argument. I think it's okay for public health to make a moral argument. In fact, we do that all the time. But at the end of the day, we need to have the humility to realize that there are other arguments that are being made and society is balancing those.

John Tomasi: So you talk about how we started not using trade-off language as much and falling into absolutist language. I wonder if you could give us some examples of that, of what you mean by absolutist language. And I'll put the question maybe this way. What do you think of the Great Barrington Declaration? Was that an example of people talking about trade-offs or at least producing a report that was a product of trade-off thinking? Was that a form of absolutism? Yeah. What do you mean by absolutism? And can you talk about that in light of the Great Barrington Declaration?

Sandro Galea: Yeah, the Great Barrington Declaration was an interesting example. As I say in the book, I disagree with much of the Great Barrington Declaration. But what it fundamentally was was a group of scientists got together and said that we should risk stratify. We should accept the fact that people under the age of 50 have lower risk. We should let them get COVID so that we have more herd immunity, less risk of transmission of COVID. There are a lot of problems with that premise. But the idea of risk stratification in and of itself is not such a bad idea. And there are different ways in which one could do that without leaning on the herd immunity. My challenge wasn't with us saying that the Great Barrington Declaration probably should not be driving policy. My challenge was with how we dealt with it. And in my book, I quote a couple of things. I mean, these are quotes from pretty mainstream venues. Quote, ill-advised and arrogant. Quote, an ethical nightmare. Quote, gives oxygen to fringe groups. And, you know, when you lead off by challenging any report by saying it's an ethical nightmare and it's ill-advised and arrogant, you're not really inviting conversation, are you?

John Tomasi: You are not. It's not a discussion of the report. It's a discussion of the people making the report. It's discussion of their motives.

Sandro Galea: It is close enough. You know, it is one of the ways in which people use speech to shut down speech. It is by offering non-rebuttable dispositive declarative comments that really do not invite conversation. But that is what I'm talking about, less about the substance of disagreement with the Great Barrington Report. As I said, I largely agree with the substance of disagreement, but it is about the approach we took to it that did not allow us to have a genuine conversation about maybe low-risk situations allow us to see other alternatives. That, of course, informs things like school opening. I mean, when you look at Philadelphia, there was a commissioner who was opening schools. I can remember, I think, the headlines on the day was, you know, leading children to slaughter. I mean, this is a dramatic use of language and ideological orientation that only one particular perspective matters that does not allow a genuine conversation and a hearing of different ideas. You know, the other example I use in the book by Mae John is the importance of human dignity. And the example is people who are dying, who are not allowed to see their loved ones out of fear of transmitting of COVID. Well, it is a trade-off that one makes, one may acquire COVID, but it's a trade-off that many of us will be willing to make to actually wish our loved ones a last goodbye, particularly if we happen to be younger and have to be at a lower risk group of both acquiring COVID and of severe COVID. But our stance and our rhetoric was such that it closed off conversation and that hospitals really swept up in what was normative at the time, essentially made it impossible for people to be with their loved ones at a moment when we really should have been holding human dignity sacred.

John Tomasi: We think about some of the, some of the sources of that, those, the feelings that led to those, those attitudes, social media is something you talk about. And one of your lines is that social media has become the new peer review. Could you say something about social media in science?

Sandro Galea: Yeah, there's a lot to say about social media. We can spend several hours talking about it. The, I make the point in the book and I've made a subsequent writing that this was the first tragedy lived in real time through social media. So as a result, we don't really know how to use the tool. It's, you know, the tool is ubiquitous now, but 10 years ago, five, 10% of us use social media regularly. So it's a very new tool. As a result, we entered into this moment where we were communicating at each other, and I use the term at intentionally here, through short bursts of declarative language, which is, of course, not really an argument. It is an assertion. And worse yet, those short bursts of declarative sentences were rewarded through greater visibility, through a whole range of other more established media sources, if they were the most, more declarative, more visible. And of course, that is deeply contrary to how science really works, because the best science is nuanced science. The best science is science that actually recognizes the caveats. The best science is science that says, under certain conditions, we should think of it this way, but let's be clear, there are other conditions. And the best scientists all know that. But our communication was so mediated through this technology that it resulted in a clatter of voices and an inability, I think, for us as a society to separate out who was thinking carefully and who was not, and essentially building policy on who was getting the most likes.

John Tomasi: Peer review is a process across all the disciplines in which expertise is brought to bear to sift the many comments and the many possible studies from the ones that are really important and need to get through and need to be recognized and studied as most likely to advance our understanding. So I just wonder about the, you said social media became a kind of peer review. Did you mean that it started affecting how scientists evaluated proposals?

Sandro Galea: I mean, there are, there have been studies that have been done, for example, that show that papers that are referenced on Twitter, that are visible on Twitter are 11 times more likely to be cited by other scientists, which, if you think about it, it's not too shocking, right? Scientists are human and you have limited capacity to absorb what's in the literature. And if you see something that's very visible on Twitter, you're going to say, okay, you're going to be more aware of it and you're more likely to cite it. So I think social media became a disproportionate influence on how we thought, we thought in the science and how we as a society thought. And I have, as I try to have in everything else I say in the book, deep sympathy for the challenge we in public health found ourselves in. This was a new medium. We're trying to grapple with how to communicate. There was a lot of pressure on communicating quick. There was a lot of fear. I have a chapter in the book about fear. And which is why I said at the beginning, John, I really tried to write a book that is forward-looking, not backward-looking. The book is very, just for those who are listening in, first of all, I challenge you to actually read the book if you're listening in. But secondly, the book is not a backward-looking naming names. The book is explicitly, is not looking back and saying, here's this policy, here's what we should have done differently. The book tries to extract lessons to say, how do we do better?

John Tomasi: On the peer-review question, I just want to just pause one more moment there. And this is a bit techie, but I can't resist. I was reading through your Substack and the comments on one of your Substack contributions where someone, I think an epidemiologist, said that there could be some advantages to having some aspects of social media brought into the peer-review process. They didn't, it was a comment on the Substack. But I just, as a tangent, I'm just curious. Do you see that, because I work in political philosophy and often the peer-review process, well, quite strong and very, very respectable in lots of ways. It's also very slow. Do you see advantages, do you see any possible advantages for social media, any role for social media in improving peer-review in the best sense of peer-review?

Sandro Galea: You know, I think the answer to that is, I would like to keep an open mind. Actually, I think it's an interesting new world. You know, things like in science, preprints, for example, did not exist 10 years ago. Preprints are papers that are put up before they have peer-reviewed, they're clearly labeled as preprints. And there's been quite a bit of discussion about preprints. There's some negatives to it. There's positives to it. I don't know. I can't really think of how one would fold in social media with peer-reviewed, but I also don't want to close my mind to it. I think that's okay. I'm happy to have that conversation. I'm happy to be convinced. Nobody's convinced me yet, but I'm happy to listen.

John Tomasi: So you're empiricist to the last. Okay, fair enough. You claim that.

Sandro Galea: I am deeply aware of my own biases, and I try very hard to reckon with them.

John Tomasi: So here within Heterodox Academy, we often talk about knowledge or truth being the telos of the university, the true end of the university and of all the disciplines in their various ways. In public health, you say that, quote, the pursuit of influence sometimes begins to outweigh the pursuit of truth. Can you say a little bit more about that? I mean, I can imagine just what we were just saying about social media. If people start becoming more concerned about their social media profile because that will give them more power and more influence, is that the kind of thing you have in mind? This idea about seeking influence, which seems to connect to the idea of towing a party line rather than engaging trade-offs.

Sandro Galea: That's largely what I meant. Look, it is very difficult, John. It's very difficult to speak outside what is normative within one's disciplinary world. And before COVID, I did some studies that looked, for example, about the public arguments around does reduction of salt in general population reduce cardiovascular disease? And I couldn't understand why there was so much public argument, but it struck me as an temporary question. When I looked at literature, what I found is there just seemed to be two camps of scientists who never were talking to each other. There was one camp who emphasized papers that say no, one camp emphasized papers that say yes. But what that taught me, and you can look at this in multiple different other aspects of science and scholarship, is that we have closed communities. And those closed communities, much of the time in science and scholarship, be it social sciences or communities, it doesn't matter so much, you know, because there's time to correct them. But when things are happening quickly, and when the world is depending on the output of our science, of our discipline, it is on us to make sure that we correct it. It is on us to hear voices that might be dissonant. And this is in part, you know, you mentioned Ray Berndon, and I gave you some quotes from that. This is in part why I bothered to write this book, so that next time this happens, in the rooms when these conversations are happening, somebody says, Well, maybe we should, you know, I understand that what X and Y are saying may be different than what collectively we're thinking right now. But let's just entertain it for a minute. And let's make sure that there isn't a different perspective that might actually be better at achieving our societal ends.

John Tomasi: Can you say a little bit more about this pursuit of influence? Is this sort of Fauciism? Everyone wants to be Fauci and be the great leader in that way? When you said the pursuit of influence, what kind of influence do you have in mind?

Sandro Galea: Well, you know, I think one can measure influence in many ways.

John Tomasi: But do you mean being appointed to?

Sandro Galea: Yeah, I mean less about formal appointments. I mean more about riding a wave of applause from your peers and your immediate community. And I suspect, you know, I don't know your field of scholarship, John, and I think...

John Tomasi: I work in political philosophy, which is partly why I loved your book so much. Because it's all beneath the surface. I love that aspect. I read you as a philosopher, not as anything like a scientist.

Sandro Galea: You know what you can say and tweet about or X about in your field that the most scholars in your field would say that John, he's just the greatest. He's just the smartest. Look, I know what to say in public health to make people applaud what I say as well, because there are certain things that become normative, that quickly become what the field considers to be the right consensus. And I suppose what I saw in the context of COVID is that that quickly overwhelmed other voices who thought outside of that. And I'm trying to ward us away from them.

John Tomasi: But I thought part of your point was that the pursuit of power in this instance among public health professionals was power, was influence in the more direct sense of having power over the people, power over governance, almost governing power. The power to say, these are the policies we should enact and enforce across a whole population.

Sandro Galea: Well, this gets us at the point of humility, right? And now I go back to the point we made earlier about science and the role of science. If you subscribe to my notion that science, population health science, our role is to evaluate the options and to present them to society so that then society weighs those against other values. That is a less, quote, powerful role than to say, no, no, society should just do what we tell it to do. And the follow the science slipstream is one trying to entrench and saying, no, no, no, we know the answer. And that is what society should do. Now, the challenge with that, of course, is that the answer, let's even assume that our science was all correct for a second, which, of course, there were many flaws with the science. Well, our science was doing one thing and one thing alone. It was modeling how we can reduce transmission of one infectious disease. Our science had very little space in it for the fact that overdose deaths were ticking up. Our science had very little space in it for the fact that we actually were recording more motor vehicle deaths than we had over the past several years. Our science had very little space for surfacing the fact that in 2020, 2021, 2022, more people in the U.S. died from drug overdose than died from COVID under the age of 65. So about 300,000 people died from drug overdose in 2020, 2021, 2022, and about 250,000 people died from COVID under the age of 65. Now, and there's a reduction in cancer screenings. You go through a whole number of these things. You know, I can talk about this all day. So the challenge with saying that the science should wield influence that is policy setting emerging directly from the science. The challenge with that is that a narrow view of the world with a particular set of outcomes that comes from a particular science should dictate how we structure societies. Now, the irony of this, of course, is that I am saying this as someone who has spent my entire adult life doing that kind of science. And I suppose I'm saying I recognize that there are many other inputs that should be important, not just this kind of science, this range of outputs.

John Tomasi: You say that public science has forgotten its philosophical roots. Is that, do you mean by that forgotten that empiricism is what rules the day in science or that falsifiability is a constant companion on the shoulder of every scientist and every scientific fact that you want to state? Can you say a bit more, what are those roots? And I guess, you know, if I may just return to your title of the book, you have these ideas about liberalism and you talk about illiberalism also in the book and about and about truth. What are the what are the what are the philosophical roots of public health?

Sandro Galea: Well, I mean, you sort of answered your own question, because what I mean by the philosophical roots are about calling a liberal philosophical roots. Now, what's interesting, since I published the book, you know, I've had exchange with a number of people who read the book. It's been very fortunate. And one of the challenges I've had is, well, was public health ever really liberal? And with the COVID simply highlight an illiberalism that is at the heart of public health. And I've actually been struggling with that, to be honest, John. And I would like to believe that public health is liberal because I see public health, to go back to the very first question you asked me, as a story. It is an aspiration and it is an aspiration of a world where everybody can live a fully realized, actualized life and health allows us to do that. And as I started grappling with where we were going with COVID, I think I found myself really challenging what I perceived to be underlying philosophy and what we're doing. For example, this very simple question, do you live so you can be healthy or are you healthy so you can live? It is such a simple question, but it is, I think, a profound philosophical question. If you live so you can be healthy, you act in a certain way. Well, if you're healthy so you can live, you act in a different way. You know, one example which I mentioned in the book is this notion which I learned from a colleague of mine about the human zoo. You know, I don't think any of us want to live in a human zoo where we are well cared for and, you know, our fur is glossy because we're well cared for, but we are in gilded cages. I don't think we want that. That means that we are healthy so we can live no day we're around. And that means that there's an element of risk that we're willing to tolerate. That means that we weigh trade-offs to allow that risk.

John Tomasi: Let me just make that an explicitly philosophical formulation of what you just said. Part of the liberal tradition is a concern for liberty, for the idea of individual autonomy, that decision-making by individuals matter. We can think about the liberal tradition as having a few elements, and you discuss them, I think, extremely well in the book. A connection to a reason, a certain methodological commitment to evidence, and something like empiricism, as you call it sometimes. But it has that element, the empirical element, we might say. The reason element, maybe it's the same. It also has another element, which is something like skepticism of authority, which goes closely with empiricism. We're always thinking, well, let's do another experiment. Let's try another way. But it also has this, liberalism also has this really important drive about individual self-direction. And in the moment of a pandemic, that concern we have for liberty and the priority and weight we give to liberty as a way of respecting our fellow citizens comes under kind of a very special moment of pressure and tension. Because individuals doing what they want to do during a pandemic might be the last thing we want. Can you say something about that? Is there something about a pandemic situation which is going to necessarily strain those liberal commitments more than other moments?

Sandro Galea: I think there's a lot about the pandemic that strains those. In fact, it's the third chapter of the book is about fear. And I did at the beginning because I do think fear and the urgency of the moment pushed us to do things. And this is in part why I am very careful not to be critical, to use your term, but rather to be reflective and move forward. Because fear pushes us to do things that I think we should have the generosity of spirit to forgive us doing some things out of fear. At the same time, I write about fear to acknowledge it and to say we should recognize fear and be able to rise above it. You know, I also write this chapter at the beginning of the second section, which is about why health, where I specifically try to push us to say, how do we think about health? And then there's a chapter in the third section called One Does Have Joys. And the idea behind that expression, of course, is just this, which is, why are you living? Why am I living? I want to have joys and I want to have joys in a way that we as a society allow to happen without unnecessary risk of disease and death. You know, just for the listener, we can talk about lines we draw as a society that allow us to have joys and lines where we think risk is too much and risk is too little. For example, motorcycle riding, in most states in this country, we mandate a helmet. Now, in doing that, we are depriving the motorcycle rider of the joy of having wind in their hair. But we will deem it as a society a reasonable trade-off, right? We say, look, the risk of injury and death is so high if you crash a motorcycle going 100 miles per hour, it's reasonable to impose a helmet. That's fine. And I agree with that. Now, we also know that if you're in a motor vehicle, in a car, and if you wear a helmet, and if you're in an accident, you're also less likely to get injured. But we don't require a helmet in a car because we deem the risk there not to be so high as to create it in position. So these are decisions we make all the time as a society, and that's okay. We should make those decisions. Now, in both those cases, it's a question of risk reduction. We know what to do to reduce risk. In one, we take the approach. In the other one, we don't take the approach. And that is okay. In COVID, we lost. We lost that compass. And we acted as though the only thing that mattered always was risk reduction. And it's risk reduction in the area of public health that comes with the coercive power of the state.

John Tomasi: Regarding your helmet example, people are free to wear helmets inside their cars if they want to. They can choose to or choose not to. But we require a certain baseline of safety, at least in most states. You have to wear a helmet on the motorcycle. And so, too, with public health, that risk reduction elements, it's a matter of, I think, two things. One's pointing out the kinds of harms or the risks that are so severe, risks to others, say, during a pandemic, certain behaviors one might want to engage in as an individual. So severe that we're going to allow the government to have prohibitions against those activities and lockdowns and a range of things we talk about. There's also a whole range of behaviors, like, for example, visiting a loved one in a hospital on their dying days during COVID that people maybe could have some permissions to do. So that's kind of a – public health seems to be tied to the coercive element, again, pushing on that liberty side. Do you see it that way?

Sandro Galea: Is there something intrinsically – Yeah, I would – as we started at the beginning, I would agree with you, but I would use slightly different words. I don't like the word coercive. It's such an unpleasant word. I think public health is promoting forms of liberty that are freedom from disease, and that is a form of liberty. It's freedom from disease is as much a form of liberty as is the freedom to do something that's going to hurt you. These are different forms of liberty, positive liberties, negative liberty. John Stuart Mill talks about this and all that. We could get into philosophical roots. So I don't think public health has to be antithetical to the idea of promoting liberty. And, of course, but to do that, public health has to be responsible and know when it promotes a particular idea and have the confidence of the populace that we have weighed the trade-offs. And we think this is a reasonable trade-off, and here's why. One of my favorite chapters in the book, perhaps, is not in the name of public health, because I try to illustrate in the book how when public health advocates for a very narrow approach of where our only goal is the limitation of transmission of one particular disease, it leads us to draconian approaches like what we saw in China with their zero-COVID policy, which, by the way, zero-COVID was advocated for in editorials and leading medical journals in the world. And that resulted in lockdowns affecting hundreds of millions of people. And that should not have happened in the name of public health. And I suppose I'm challenging us in public health to have the courage to say we recognize that the reduction of one particular disease is not our only outcome. There are other diseases, and there are other societal goals. And, you know, coming back to the purpose of the book and where we started our competition, we did not have much space in the public health conversation for that, because when you look back at public health comments in the media, in general media, social media, a lot of it was couched in, well, unless you follow this approach, you are killing people. And that, again, is part of that speech that closes off speech. You know, if you say to me, Sandro, when you just said that you're killing people, it puts me in an awkward position of now having to defend that I'm not a murderer. And that is not a way to create space for us to have a conversation to find the best place forward.

John Tomasi: I want to just move to, as you're heading toward the end of this interview, I want to just ask you to, I'm going to invite you to think more generally about the academy, if you might like to. So many of the concerns that you describe about public health echo concerns that Heterodox Academy members have about the academy more generally. Many of us are concerned about monocultures, about groupthink hurting our social science and humanities and other domains of science as well. Your book doesn't focus on academia and the travails of academia, but you are, of course, the dean of BU's School of Public Health. I just wonder if you have any thoughts on this. And I'll just put my cards on the table more completely. Part of what's so inspiring about your work to me is that it has this positive idea about we can be better than we are. And that lovely line of yours, holding a mirror to ourselves to the end of being better at what we do. In many ways, that's exactly what HxA is all about. We're people who love our universities so much that we want them to be better. And we're often called critics, but I think in your sense of the way you respond to this, that's how HxA finds its way around that. We want to make our universities better, and we're willing to hold them to that higher standard because we love them so much. I just wonder if you have any thoughts about this beyond public health. Do you see any lessons for the broader academy? And if you don't, that's fine. But I would just be curious whether you think there are things that you might have to teach us more broadly about the academy.

Sandro Galea: Perhaps it won't surprise you to note. Yeah, I do think there are echoes to what's happening in the academy. And, you know, it's been very interesting because a lot of these issues have really burst into the public eye in the past four, five, six months. They certainly weren't as much in the public eye when I wrote the book, submitted the book. I mean, the book came out in December of 2023, which means it was finished December of 2022, of course. We are beginning to see a reckoning with this, what you call monoculture in academic spaces. We are beginning to see a greater call for transparent engagement of a genuine plurality of perspectives in academic spaces, recognizing that we have strayed from that mission. And I think that's to the good. And I use the word which I actually use in the book. I write this book from a place of love. And I want to be very, very clear about this. My intention is not to tear down. My intention is to build. My intention is to make public health stronger. My intention is to challenge so that we can actually become better, you know, the phrases used at what we do. And one of the key aspects of liberalism and the classical sense of liberalism that we haven't mentioned is meliorism, this idea that liberals believe that we can make it new again and we can make it better. If we follow these methods and elevate ourselves and hold ourselves to higher standards, we can build a better world and make wiser decisions in a whole variety of ways. I've written in other papers, this doesn't feature as much in the book, about this notion of radical incrementalism. The idea is that we should have a radical vision, a radical vision of a better field, a better world, a better university, but be ready to roll up our sleeves and do the incremental hard work to get there. And one doesn't get to a radical aspiration, goes back to where we started about the story of public health, the radical aspiration, without the incremental hard work of listening to one another, tolerating and entertaining divergent ideas, thinking carefully about how we communicate, doing the difficult work of being upfront about trade-offs. And creating the space for those who we may disagree with to ask, why is it that others are agreeing with them and what is it that others are seeing? That doesn't mean we're going to agree with them, but it does mean recognizing that there may be germs of ideas that we want to incorporate into our thing to bring more people along to the end of doing better. And also so that we are not, frankly, you and I having this conversation in 2024 with a loss of trust in public health and in medical science, just after we finished the pandemic, where public health and medical science did a fantastic job. That is, at the end of the day, what this is about. You know, during the pandemic, often I would talk to the media and they would call me up about the issue of trust. So, and I'm starting to get the question, well, you know, how do we build trust? You know, you don't build trust during a crisis. You build trust when you're not in a crisis. So, I suppose what I'm challenging us to do now is to build the trust. And I think part of building the trust is challenging ourselves to say, what did we do? How did we do it? How can we do better?

John Tomasi: Sandro Galea, thank you for joining us on Heterodox Out Loud.

Sandro Galea: John, thank you for what you do. Thank you for having me.

John Tomasi: Thank you.

S2 Episode 10: How to Restore Trust in Science?

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