It’s Not “Unreasonable” to Want to Change Our Rotten Health Care System

It’s Not “Unreasonable” to Want to Change Our Rotten Health Care System

It’s Not “Unreasonable” to Want to Change Our Rotten Health Care System

The pandemic showed how callous, unequal, and ineffective American health care can be—but some medical bigwigs seem to want people to stop pointing that out.

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With classes over for the semester, I recently picked up a book I’d been eager to read over the past few months: Princeton sociologist Matthew Desmond’s newest, Poverty, by America. In the book, Desmond makes the case that American poverty is the result of active policy decisions. As he writes: “Tens of millions of Americans do not end up poor by a mistake of history or personal conduct. Poverty persists because some wish and will it to.”

This indictment reminded me of another book and another passage: “Poor countries are poor because those who have power make choices that create poverty. They get it wrong not by mistake or ignorance but on purpose.” This is from Why Nations Fail: The Origins of Power, Prosperity and Poverty, written in 2012 by MIT’s Daron Acemoglu and the University of Chicago’s James Robinson. For all three scholars, the problem of poverty starts with the well-off and with predatory elites, who enact extractive and exploitative policies to create poverty and entrench it, in America, across the world, and across history.

I’ve used the Acemoglu and Robinson quote for over a decade in talks I give, with one alteration: I always cross out the word “poverty” and replace it with “ill health.” Why? Because ill health is manufactured in America in the same way poverty is: by decision-making that creates it and entrenches it. According to a 2021 Commonwealth Fund study of health spending across countries in the Organisation for Economic Co-operation and Development (OECD) the United States spent more than 17 percent of its GDP on health care—almost twice as much as Germany and three to four times more than South Korea, New Zealand, and Japan. What do we get for it? Among the OECD countries, “the US has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates.” Clearly, we’re spending more and getting less. Rather than see this as an enduring mystery of some special American phenomenon, perhaps we should consider, as Desmond does about poverty, that all this persists “because some wish and will it to.”

I’ve written many times about the ways in which our terrible response to the pandemic has been a choice, an example of “structural violence, social murder, and our national policy of organized abandonment.” I’ve also talked about how these choices are no surprise, given how we’ve dealt with health and disease among the poor and marginalized in this country for over two centuries.

However, this kind of analysis, in which the roots of America’s social and health crises are traced back to the powerful and privileged people who have created them, isn’t popular even in the so-called bastions of liberal America, the elite East Coast universities that Republicans love to hate after graduation. Here is another quote from Desmond’s new book:

Years ago, I presented a paper titled ‘Exploiting the Inner City” at Harvard’s Kennedy School of Government, a paper that documents the business strategies of landlords in poor neighborhoods. The paper was straightforward. It showed how some landlords make a living (and sometimes a killing) by renting shabby housing to very poor families. After my talk, a senior scholar looked rather alarmed. “You’re going down a Marxist path,” she said. “You know that, right?”

This quote is, in parts, amusing and instructive. It’s amusing because one doesn’t need to be a Marxist to make the well-documented claims that Desmond and others do in examining the exploitation of the poor in America. It is instructive because it was a warning to a young academic: Don’t tread too close to home in your research—don’t make us uncomfortable with inconvenient truths.

I started reading Desmond’s book the same week I picked up an article in Psychology Today by Sandro Galea, dean of the Boston University School of Public Health. In the piece, which is a précis for his upcoming book Within Reason: A Liberal Public Health for an Illiberal Time, Galea stakes out a claim for a “reasonable,” liberal version of public health, against what he perceives as an “unreasonable” variant that has sprung up during the pandemic, replete with hysterical scolds trying to rid the world of all risk, martinets oblivious to the fact it’s often just human nature to make unhealthy choices in one’s life, and moral absolutists assuming that anyone who didn’t follow all of their rules during the pandemic was a monster.

Setting aside the fact that Galea is fighting a set of crude caricatures rather than engaging with serious arguments about the future of public health, it’s important to take a step back and look at what’s happening here. Just like that scholar at Harvard who warned Desmond, Galea is attempting, even as he supposedly argues for a free exchange of ideas, to police the bounds of what is considered a “reasonable” debate about the state of public health in this country. If you read between the lines, it’s easy to see what Galea’s real goal is: to marginalize a certain viewpoint and get some of his colleagues in the field to just shut up.

“You’re going down a Marxist path,” she said. “You know that, right?”

One of the canards of the past three years is that public health has become politicized and that we’ve got to get back to the pristine world we used to live in where it was something else entirely: an academic pursuit and a benign technocratic enterprise, always refining its methods, offering up its findings, and never wading into the wider world to make a difference.

Galea has written about the dangers of reducing public health to this kind of inward-looking science, calling for a more engaged, consequentialist epidemiology, where the goal of our profession is to intervene and make the world better. This is why I find his plea for reasonableness so surprising. If the history of social movements is any guide, those trying to make the world better were often called unreasonable or worse. However, here, like the Harvard professor in Desmond’s book, Galea seems to want to set guardrails for action, centered around what is reasonable, pragmatic, and liberal, and he wants to take back public health from, well, who exactly?

Before figuring this out—the mystery of who the great, unwashed unreasonables are—I think we’ve got to interrogate the call to reason at something more than face value. Kirsty Sedgman, the British cultural studies scholar, has written memorably about the “’reasonable moderate centrist’ commentariat, who have colluded in positioning morally-unhinged policies as the rational middle-ground while radical ideas like ‘pls don’t dump sewage in our waterways’ get smeared as unreasonably leftist.” I think that Galea is indulging in some of this “reasonable moderate centrist” urge. A case in point is his key underlying assumption that “most people are acting in good faith and share our commitment to being reasonable.” First, this is a tragic misreading of America in 2023. Second, he suggests that some of the conversations during the pandemic were unnecessarily fractious and that we should have prized comity above push-back.

For instance, Galea suggests that people met “conversations about herd immunity—an epidemiologically sound concept—with vitriol. Had we acted more reasonably, I cannot help but think that the moment might have unfolded differently, and that public health would not face the crisis of trust it now confronts.” Of course, the concept of herd immunity, as Galea says, is an epidemiologically sound one, but may not apply so neatly in the context of Covid. However, beyond the technical details, it was not deployed in good faith during the pandemic. Back in 2020, I, along with Marc Lipsitch, Carlos del Rio, and Rochelle Walensky described in The Washington Post why it was indeed a dangerous delusion. More importantly, as Jonathan Howard writes in his new book, it was part of the Trump administration’s policy:

We want them infected. Those four words come not from some random crackpot, but from Dr. Paul Alexander, an epidemiologist and official in the U.S. Department of Health and Human Services during the Trump administration. On July 4, 2020, before anyone had been vaccinated, he said:

Infants, kids, teens, young people, young adults, middle aged with no conditions etc. have zero to little risk….so we use them to develop herd…we want them infected…

Herd immunity was weaponized by the Trump administration and ultra-libertarian think tanks like the Brownstone Institute, and, as Howard importantly notes, was supported by some public health experts and clinicians who minimized the risk of the pandemic. “Can’t we all just get along?” doesn’t seem like the right answer to what transpired during these times.

While he doesn’t name names, Galea’s rogues’ gallery of unreasonable scolds, martinets, and moralists doesn’t really represent the thinking of most of us working in public health at all. In fact, most of the current generation of us came through the cauldron of the AIDS epidemic during our youth or our training, or had the tales told to us of those years. The lessons from back then were to meet people where they were at, give them what they need to keep themselves safer, address the underlying social determinants of health, and respect human rights and dignity.

All this leads me back to Matthew Desmond’s insights that poverty exists because we want it to, that our lives are sustained by the misery of others, and that we’re fine with that as a country. I suspect that Galea’s great, unwashed unreasonables are not the caricature of public health experts he provides in his article, but those who pushed back on people who prioritized getting “back to normal” even as the toll of death and suffering continued, just as long as it wasn’t happening to them. (This group includes the current and former presidents of the United States, in case you need a reminder about which side of this conflict has actually prevailed.)

“You’re going down a Marxist path,” she said. “You know that, right?”

There have been a set of politics during the past three years reflected in our professions—in public health and medicine—which need to be named.

First, as Jonathan Howard describes, are those experts who have been allied with the Brownstone Institute, the anti-vaccine movement, and the anti-science movement in general; some of those people are now advising Republican presidential candidate Ron DeSantis. They include current and former professors at large research universities, including Stanford and Harvard. People in public health know them, have worked with some of them, published with them, and written grants with them.

Next, there are those who you might call the reasonable liberals, who favored a you-do-you approach to the pandemic and became ardent defenders of the Biden administration’s pandemic policies, even as Biden slouched toward a dismantling of almost all pandemic-era support in 2023. I think this is the reasonable, pragmatic liberal version of public health that Galea espouses, though I’ll have to wait for his book to see where he goes with it. The mantra here? We did all we can do. Stop asking for more. Stop being unreasonable.

Then, there are the “unreasonables” who cannot help but keep pointing out that the “urgency of normal” is about class and race privilege, or that putting the pandemic “behind us” is really about making things easier for people with money and good health insurance who think they can pop some Paxlovid, sit in bed with their laptops propped up beside them if they get sick, and power through it all like it was “just the flu.” This group of “unreasonable” public health and medical experts still talks about what more needs to be done to protect all Americans, not just those with resources, from SARS-CoV-2 even now, when most others in the profession have moved on. Sadly, they have never been able to politically mobilize to build momentum for this vision.

It’s interesting to me that Galea looks rightward—toward those who espoused herd immunity—instead of leftward toward a more robust version of public health. It’s also interesting that he paints a picture of illiberal zealots to his left, not to his right. For Galea, it’s important to leave the “unreasonables” behind and let the field move forward without them. It’s hard to square this with a call for a consequentialist vision of public health that makes a difference in people’s lives, but it makes sense when you read recent history through the lens of class solidarity, in which the sacrifice of those with resources for those with less is no longer tenable after three-plus years.

We need a new politics from which to move forward—a politics that suggests that our status quo of sickness, death, and poverty is what is truly “unreasonable.” We can do more. We have to acknowledge as well that part of the problem is that we benefit from the baseline, in keeping things where and how they are. This is where we need to start.

Correction: the initial version of this piece incorrectly referred to Kirsty Sedgman as Kirsty Sedgwick.

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