Miami Dolphins quarterback Tua Tagovailoa’s third concussion last September elicited calls for his retirement. Weeks later, Hall of Famer Brett Favre revealed that he has Parkinson’s disease due to the many concussions he believes he sustained while playing.

Concussions are mild traumatic brain injuries that can result in a constellation of physical, cognitive, and emotional symptoms. Since 2015, NFL players have logged more than 2,200 concussions in practices and games. It’s harder to get clear numbers in youth football, but we know that each young player sustains about 375 head impacts per season.

Despite the growing concern around concussions and their long-term impact, about 1,700 active NFL players, about 81,000 college students, and two million local youth play football each year.

What will protect these athletes from brain injury and long-term consequences? According to the NFL and companies looking to profit, it’s new protective gear like the Guardian Cap. The problem is that some players, coaches, and football fans conflate the use of this and other gear with brain injury prevention—a feat no piece of equipment can currently achieve in tackle football.

Players are also not required to wear the protective gear. Tagovailoa announced he would not wear one, even after his third concussion.

Concussions in the NFL did decrease this year—182 concussions were diagnosed in NFL players, 17 percent fewer than last year. But football players still experience more concussions than any other athletes, and the risk will never be zero. Safety equipment also cannot prevent the damage associated with repeated head impacts.

CTE is caused by an accumulation of an abnormal protein in the brain from repeated head impacts. Research indicates that lower-grade head impacts are more strongly linked to the disease due to their frequency. CTE symptoms include aggression, memory impairment, and suicidal ideation.

About 90 percent of the 376 deceased former NFL players who donated their brains to Boston University’s CTE lab had CTE. A Harvard study of living former NFL players found that one-third believe they have the condition.

New gear is supposed to alleviate the CTE problem. The Guardian Cap fits over a football helmet and is meant to absorb and spread the force of a hit, purportedly by up to 25 percent. Since 2022, they have been mandated for some players during practices. In 2024, they were approved for use in the regular season.

But only an average of six players wore them each week in the NFL and the Canadian Football League combined, even though Guardian and the NFL claim that concussions are down by over 50 percent in the players who wear them during practice. 

Perhaps the players are aware that at least three independent studies have shown that the caps make no difference. In one study of college football players, lab testing indicated that Guardian Caps reduced head acceleration and the force of impacts, but when the researchers replicated the testing on the field, the caps made no difference at all. Another lab-based study and a third, on-field study confirmed the first study’s field findings.

Also being marketed is the Q-Collar, a Food and Drug Administration-approved piece of equipment meant to minimize the brain’s movement inside the skull. Modeled after the anatomy of woodpeckers, it sits around the neck, applying pressure to the jugular veins to slow blood flow out of the head. Q-Collar creators say this increases blood around the brain, cushioning it and reducing its movement within the skull after impact.

The company that makes the Q-Collar doesn’t claim it prevents concussions and critics note that we don’t know if it actually protects the brain from future harm. And in 2022, scientists found that woodpeckers’ brains are protected from damage simply due to their size and orientation within their skulls.

Like the Guardian Cap, uptake of the Q-Collar among football players is low.

More helpful than the questionable effects of gear would be a better response to head trauma when it happens.

A good first step would be establishing standardized return-to-play protocols across all levels of football. The NFL’s five-step protocol that concussed players must follow before returning to practice doesn’t have guidelines for how long players must spend in each phase of recovery. Yet one study shows that adult men need about 25 days, and women about 35, to recover from a concussion. NFL players typically return to play nine days post-concussion.

Return-to-play protocols are overseen by team physicians who may feel pressure to quickly clear star athletes. Standards could prevent incidents like Tagovailoa’s 2022 event, when he sustained a concussion during a game and was cleared by team doctors to play four days later. He suffered a second concussion during that game and had to be hospitalized.

Other sports have clear rules about required rest. The Australian Football League mandates a 12- to 21-day rest period following concussion. The World Boxing Association requires at least a 60-day suspension for any boxer who gets knocked out from a hit to the head.

Oversight will be needed to make return-to-play protocols effective. Over one-third of American high schools don’t have athletic trainers. As a result, young athletes rely on teammates, coaches, or parents to recognize a concussion and seek appropriate treatment. Without professional support, and a mandated recovery window, many athletes may never seek care and return to play too quickly.

Of course, rest does not reduce the risk of head trauma once a player is back on the field. Whether you’re rooting for star quarterbacks Patrick Mahomes (two confirmed concussions in his career) or Jalen Hurts (concussion in December) this Sunday, know that they along with every player on the field face a hidden threat on every play.

The only sure way to prevent head injuries in football? Don’t play.

Source images: Adobe Stock, iStock

The post There’s a way to deal with brain injuries in football. It isn’t safety gear. appeared first on Harvard Public Health Magazine.

Ball was part of a 25 percent jump in traffic fatalities in the United States in the past decade, including a surge in 2020 and 2021. Transportation experts attribute the rising number of deaths to factors such as increased speed limits, bigger and heavier vehicles, and the distractions of smartphones. But they also say these deaths are entirely preventable. For instance, Vision Zero, a road safety system widely adopted in Australia, Canada, and the European Union, has helped reduce both fatalities and severe injuries. It uses bike lanes, pedestrian walkways, and other design elements to encourage drivers to slow down in places where they share the roads with cyclists and pedestrians.

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In the U.S., although cities such as Alexandria, Virginia and Hoboken, New Jersey can point to Vision Zero as helping them eliminate traffic deaths, the program has run into roadblocks. The web of federal, state, and local jurisdictions that control decisions about—and funding for—roads is partly to blame. But advocates for safer roads argue that reframing traffic fatalities as a public health crisis would create public awareness and boost support for developing safer infrastructure. They are seeking greater collaboration between transportation engineers and public health experts to change how decisions are made about road design.

“We excuse things that have to do with cars that we don’t with other public health norms,” such as health risks from second-hand smoke, says Tara Goddard, an associate professor in the Department of Landscape Architecture and Urban Planning at Texas A&M University. Goddard’s research shows that an overwhelming majority—almost 84 percent—of respondents think the risk of serious injury is part of driving (less than 40 percent feel the same way about work). At the same time, two-thirds said society should not simply accept the consequences of driving.

A public health approach could help transportation engineers promote and execute Vision Zero as a series of systemic changes that address road safety challenges. “When you design roads, when you design routes, when you design even where a bus stop is located or where a transit center is located, that is public health,” says Sophia Peerzada, a public health expert who specializes in traffic safety but is commenting as a private citizen. “Because [design] directly impacts people’s safety on the roads, and their ability to safely get around.”

Road design shapes driver behavior

The majority of traffic fatalities happen in what transportation researchers call high-injury networks. These are typically locations where people walk or bike on or near roads with speed limits set at 35 to 45 miles per hour, and are where the majority of traffic fatalities occur. “Thirty-five miles per hour is really a sweet spot for killing people,” says Patricia Tice, a transportation researcher and founder of the consulting company ProFound Insights. Tice observes that cyclist and pedestrian deaths often occur in what are called “origin-destination pairs,” where a person has to cross a busy street to reach home, work, or shopping.

Vision Zero policies focus on identifying high-injury networks and making them safer. A major tenet of the approach, which is backed by research, is that the built environment influences driver behavior. It also holds that road design should account for potential human error, so people aren’t killed or severely injured if a crash should happen.

The approach cut traffic fatalities by 36 percent between 2010 and 2020 in European countries where Vision Zero has been implemented, such as Sweden and Denmark. Fatalities in Edmonton, Canada, fell 50 percent in six years, and serious injuries by more than one-third, after the city put Vision Zero into practice in 2015. The U.S., meanwhile, has invested more in public awareness campaigns about the risks of speeding or police officers writing more tickets, say advocates. “We are never going to educate and enforce our way out of this crisis, which is what most of the United States is doing at the city, state, and federal level,” says Amy Cohen, the co-founder of Families for Safe Streets. Cohen started the organization, which advocates for traffic safety legislation and offers support to the families affected by what it calls “traffic violence,” after her son was killed by a car in front of their New York City home.

Certain road features, such as wide lanes, encourage faster driving and increase the risk that cyclists and pedestrians will die in a collision. Further, there is evidence that when drivers can make eye contact with other people while driving, they tend to slow down. Lower speed limits, sidewalks, and crosswalks all encourage eye contact and make streets safer for pedestrians. “If you’re actually laying eyes and interacting with someone one out of every four times you go through a space, you treat that space as a social space, and you’ll go less than 25 miles an hour,” Tice says.

But research also captures a mismatch between what most people feel is safe and what is actually safe. Narrower lanes make drivers slow down, but often make them feel more nervous. “A lot of traffic engineering is counter-intuitive to people who don’t study it,” says Veronica Davis, author of the book Inclusive Transportation: A Manifesto for Repairing Divided Communities, and the director of cities programs at AtkinsRéalis, a design, project management, and engineering company.

Goddard thinks public health professionals can help address this disconnect. “We have more than enough research to know what design makes people safer,” she says. “What we don’t know is how to implement it.”

Systemic change is difficult

Some of the U.S. cities that have passed measures to implement Vision Zero include New York, Chicago, Austin, and Boston, with mixed results. In addition, the National Roadway Safety Strategy from the U.S. Department of Transportation requires states and localities to have a research-backed approach to improving safety to get federal funding for road projects.

“If you don’t have a Vision Zero action plan, there’s this giant pot of money you don’t get to ask for,” says Jay Blazek Crossley, the executive director of the nonprofit Farm&City, which is dedicated to improving transportation and urban planning in Texas. But money by itself is not enough.

Joel Meyer, Austin’s transportation officer, points to several challenges in implementing Vision Zero. The biggest is needing to redesign city streets. “We are making progress where we are making investments,” Meyer says. “It’s really just going to take time and resources to retrofit that environment.”

Austin committed to Vision Zero in 2016, as part of a mobility bond that was approved by voters. But it has only been able to apply these improvements to streets under its jurisdiction. Fatalities on these streets have remained flat. However, Austin does not have jurisdiction over streets that are controlled by the Texas Department of Transportation (TxDOT), and on those streets, fatalities have increased. TxDOT adopted a Vision Zero plan for the state, Road to Zero, in 2019, with the goal of eliminating traffic fatalities by 2050. TxDOT said in a statement that in November 2024 it worked with the Texas Department of Public Safety to share tip cards on safe driving during traffic stops, and it launched a safety initiative in December. It noted that “there’s not one solution, it will take all of us working together to save lives on Texas roads.”

In contrast, the city of Houston, which committed to Vision Zero in 2019, has a new mayor, John Whitmire, who is rolling back many of the implemented safety measures. For example, the city removed a median that had been installed to slow down traffic on a road that had recently been the site of a bicyclist fatality. Whitmire’s rationale, as reported by Texas Monthly, was that the median made it harder for first responders to get through.

The city has also reversed a decision to narrow the car lanes in the planned redesign of another road, which would have slowed traffic, while adding bike lanes. Instead, the plan is to add the bike lanes while keeping the wider car lanes. “The lack of bike lanes is not what is dangerous, the fast cars are what’s dangerous,” says Farm&City’s Blazek Crossley. “They are keeping the fast cars.” He says the rollbacks make Houston an outlier in Texas, as the rest of the state is moving in the direction of implementing evidence-based safe systems design.

Since the rollback started, traffic fatalities in Houston in 2024 set a record, though fatalities combined with severe injuries were down slightly from 2023. At the same time, Harris County outside of Houston, and Texas overall, saw traffic deaths decline. Vision Zero proponents argue Houston’s results point to the need for safer infrastructure.  City officials declined an interview request.

In Decatur, Quanisha Ball’s mother Courtney Thompkins feels her daughter’s death was preventable, and has started volunteering with Families for Safe Streets helping Cohen advocate for Vision Zero. The Georgia Department of Transportation in early 2024 changed the timing of the traffic lights at the intersection where Ball died and, a year earlier, another pedestrian was struck. That change is designed to help make pedestrians more visible to drivers, and Cohen calls it a “modest” improvement.

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Meanwhile, the city of Decatur is developing its own Vision Zero plan through a Safe Streets and Roads for All grant from the U.S. Department of Transportation.

Thompkins, who recently marked the second anniversary of her daughter’s death, sees these changes as headed in the right direction. Still, she considers the challenges ahead to be significant. She hopes her advocacy efforts will make it less likely that other families suffer. “We have to fight to protect other lives,” Thompkins says.

Top image: Marilyn Nieves / iStock
Tara Goddard: Courtesy of Tara Goddard
Amy Cohen: Courtesy of Amy Cohen
Joel Meyer: Austin Transportation and Public Works Department

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The figures are subject to shifting methodologies and variations in weather. But they show a clear, worsening trend, including in one of America’s most progressive cities. The visibility and intractability of people living on the streets have dominated civic life in Seattle for a decade, blending with rage over petty crime and despair over housing costs—a set of overlapping crises that politics has seemed powerless to change.

In Way Home: Journeys Through Homelessness, author Josephine Ensign acknowledges the “palpable mixture of compassion and frustration” with which many in Seattle and across the U.S. have watched this modern era of homelessness unfold. She recognizes that most readers encounter homelessness from a distance—glimpses into alleys, glances on the bus, flashes of color signifying tents threaded into urban greenways. These can elicit overpowering emotion but leave a void of information with which to process it.

Ensign, a nurse and academic, aims to fill this void with 300 pages detailing the lives of people on Seattle’s streets and years of attempts by policymakers to alter their circumstances. The city, fourth in the U.S. behind New York, Los Angeles, and Chicago in the number of people without stable housing, has earned its status as a microcosm of American homelessness. Enchanted by Seattle’s liberal ideals when she moved there decades ago, Ensign poses a challenge to this identity: “How do we reconcile the fact that Seattle is both a progressive, hopeful city and a place in which homelessness is such a large, growing, and deeply entrenched problem?”

Perhaps no story in Way Home tackles this question more directly than that of Lisa Vach and Travis Berge, a couple whose lives ended in a spasm of violence at a point where the city’s homelessness crisis converged with its tradition of radical activism. As Ensign stitches together their stories through interviews and public records, it’s impossible to ignore the extent to which Berge conformed to the least generous stereotypes of unsheltered people. A one-time street musician, his methamphetamine use, shocking behavior, and frequent arrests had made him a fixture of TV news coverage. Vach had worked low-paying jobs around Seattle, including in the gift shop of a tour company, but by the start of the COVID-19 pandemic in 2020 was unemployed and staying in a downtown shelter.

 Like many Seattleites living on the streets that summer, they gravitated to an encampment in the Capitol Hill neighborhood, where activists were protesting police violence. Mutual aid and security volunteers struggled to meet the pair’s complex needs. Berge’s meth use sent him into “violent rampages.” His abusive relationship with Vach was marked by “frequent and escalating physical fights.”

Their spiral culminated in the fall, as protests faded and the couple stayed in the scattered remnants of the encampment. Berge murdered Vach there, then drowned in a nearby tank filled with bleach solution during a standoff with police. (It’s not clear whether he died by suicide or accident.) The story leaves readers awed at how the couple’s personal challenges, the evaporation of affordable housing, the pandemic’s upheaval, and the confusion of the protests compounded to produce this degree of horror.

The contrast between Seattle’s professed ideals and the suffering on its streets reappears and grows more complicated throughout Way Home. The city was among the first in the country to embrace “Housing First,” a philosophy of moving chronically homeless people into permanent homes before addressing their mental illness or substance use. It was also among the first to provide safe, legal parking areas for people living in their vehicles.

But, we learn Seattle has more ordinances that criminalize living in vehicles than anywhere else in Washington state. And that a 1996 law targeting teenage runaways and school truants made Washington the nation’s leading jailer of children. We see how life on Seattle’s streets corrodes the body and mind through unrelenting displacement, danger, and exclusion by mainstream society.

Take the case of John T. Williams, a First Nations Ditidaht woodcarver whose grandfather moved to Seattle in 1900. Williams spent decades on the city’s streets. By 50, he was limping, partially blind, and deaf in one ear from the effects of living outdoors and heavy drinking. In 2010, Williams was living in a subsidized apartment where his alcoholism wasn’t disqualifying, thanks to the Housing First policy. One day, he met with his brothers in a park and agreed to return to Canada with them. After stopping at his apartment, he was returning to the park when a police officer shot him dead in an intersection. The officer, alarmed by a knife Williams was using to shape a piece of cedar into an eagle figure, had shouted a warning that Williams seemingly could not hear.

Homelessness defies most attempts to contain its complexity. Almost no one can hold all of it, the way it braids macroeconomic forces with the vicissitudes of a person’s life. Ensign—equipped with decades of experience as a nurse who has worked with homeless people, well-honed skills as an academic researcher, and the memory of her own homelessness during several months in her youth—has the perspective to guide us.

But if she has ideas that could help us find patterns in the stories she collects—and from them, identify better solutions—she keeps them mostly to herself. Way Home promises to show how the Seattle area’s “innovative local solutions can be scaled up nationally.” But in Ensign’s telling, the city looks less like a national model and more like a case study of how well-intentioned efforts are undermined by something that floats just beyond our perception.

How do we make sense of the intractability of homelessness in a city that professes to care so much? Ensign points out that conservatives have an emotionally satisfying answer: Progressivism itself is the culprit. But the stories in Way Home hint at an alternative: an American reflex to punish, avoid, and exclude that overwhelms any countervailing ideal.

Book cover: John Hopkins University Press

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As a public health professional, I am baffled by the vitriol. I fear the new administration will worsen our already poor health outcomes. But the reality cannot be ignored. Public health has lost the public’s support and we must work to bring it back.

The results, though, do not show a landslide. Just under 230,000 votes would have changed the presidential outcome and policies supported by the public health community performed well. For example, seven of the 10 abortion referendums passed, paid sick leave was approved in three states (Missouri, Alaska, and Nebraska), and two states raised their minimum wage. This means that some people who voted to protect abortion also voted for the candidate who appointed Supreme Court justices who overturned Roe v. Wade.

If some public health policies are popular, then what went wrong? One diagnosis is the communication style. Sen. Chris Murphy of Connecticut posted on social media that Democrats should “be less judgmental” and Washington Rep. Marie Gluesenkamp Perez, a Democrat who won a rural, red area of Washington state, later said in an interview, “The fundamental mistake people make is condescension.” This advice echoes what some health leaders said post-election: “Don’t underestimate or talk down to those without a medical degree.”

To elect more pro-public health leaders in 2028 or even 2026, the public health community must improve our communication style. We should start by getting rid of the patronizing framing of issues between science/anti-science and health/anti-health and instead show more humility.

We must remember that science does not beget policy. Science is knowledge of the world while policy tackles political problems. It is impossible for a description of the world to lead to a prescription—a problem referred to as Hume’s Law.

Describing others as “anti-science” or “anti-health” closes off debate and sounds arrogant. Instead, health should be thought of as a multifaceted concept, as in the famous definition from the World Health Organization: “Health is a state of complete physical, mental, and social well-being.” Each part is unique: physical well-being relates to the functioning of our bodies, mental to how we cope with our lives, and social to our relationships with others.

We make tradeoffs between each component daily—some choose to ride a motorcycle, play professional football, or refuse medical care for religious reasons. Francis Collins, former director of the National Institutes of Health, implied as much when he spoke of his regret about COVID-19 policies that focused entirely on saving lives, overlooking that they impose a societal cost that “totally disrupts people’s lives, ruins the economy, and has many kids kept out of school.”

Instead, public health leaders should follow advice from Sandro Galea, dean of the School of Public Health at Washington University in St. Louis, who recently suggested being “humble in our approach, open to learning more about the world and about how to become ever better at making it healthier. This includes having the humility to ask questions even when the answers run counter to what we think, or hope, to be true.”

Humility is vital because there are real problems in our health system. Just weeks before the election, the Commonwealth Fund released a report comparing the U.S. system to nine peer countries. The U.S. was “in a class by itself in the underperformance of its health care sector,” the report concluded. Our life expectancy is four years less than the average from those countries, we have the highest rates of preventable and treatable deaths, and suffered the most excess deaths from Covid for everyone under the age of 75.

But post-election responses from the public health community have not heeded these warnings. Georges Benjamin, president of the American Public Health Association, warned that the country’s new leadership can enact policies that take public health “back a few steps.” Katelyn Jetelina, in her popular newsletter Your Local Epidemiologist, wrote that in light of the election, the “biggest challenge will be fighting for the truth.” Recent petitions protesting cabinet nominees urge senators to “prioritize science” and the “well-being of Americans.”

These statements misunderstand the disrespect for expertise in our country today. According to a poll from Pew Research, there are large differences between Republican and Democrat voters’ beliefs in the qualities of scientists, including honesty, closed-mindedness, and empathy, an issue described as the “institutional-trust divide.” Stating respect for expertise and institutions is not everyone’s priority.

Changing our communication style may not feel right to many public health professionals—it doesn’t feel completely right to me, either. I wish things were different and I sympathize with the statements by Benjamin and Jetelina. But the 2024 election showed that many Americans feel differently. Reflection and change are needed.

In our political system, success requires large coalitions, and we should expect more antagonistic leadership in future elections if nothing changes. But if the public health community shows humility, stops name-calling, and endeavors to get the public to support our work, then the politics may follow. The health of all of us depends on it.

Top image: stellalevi / iStock

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Even given the high lethality of the disease among the old and medically compromised, many nursing home deaths could and should have been avoided—with better infection control, paid sick leave for employees, and other public health measures. This is the core message of Margaret Morganroth Gullette’s provocative but often frustrating book, American Eldercide: How It Happened, How to Prevent It. The title posits that something akin to mass murder took place in nursing facilities—an overstatement that embodies Gullette’s righteous anger at what she calls “the humiliating and lethal governmental abandonment of these people.”

Gullette, an anti-ageism pioneer and resident scholar at Brandeis University’s Women’s Studies Research Center is, above all, a cultural critic. In Eldercide, she blames the tragedy of runaway nursing home deaths on “[i]ndifference, rooted in preexisting ageism.” The problem was compounded, she writes, by other prejudices, including sexism, sizeism, ableism, racism, homophobia, classism, and “dementism, or dread of Alzheimer’s-like memory loss.”

This emphasis won’t surprise anyone who knows Gullette’s previous work, including her award-winning 2017 book Ending Ageism, or How Not to Shoot Old People. Here, her primary aim seems to be to shock readers out of complacency. Although she proposes solutions to prevent a future catastrophe—a federal long-term care benefit, a new department of elder and disability affairs, and the nationalization of nursing homes—her modest public health points are embedded in an overstuffed, meandering cultural critique.

Gullette’s principal argument is that society simply decided that nursing home lives, in contrast to those of the younger and more able-bodied, were expendable. She decries the Covid debacle as an intensification of “a silent eldercide [that] had been going on for decades” in these facilities. She cites research that a “pattern of understaffing for profit led to abuse or neglect and thus extra deaths.” But the evidence previously was sparse. The blizzard of deaths from Covid made the shortcomings of nursing homes impossible to ignore, she contends.

One might argue, and Gullette more or less does, that the real culprit is less deliberate criminality or malicious intent than the exigencies of capitalism, combined with ignorance and incompetence. Safety concerns notwithstanding, placing nursing home residents in private rooms would have cut into profits. Not only were the facilities understaffed; employees were low-paid and minimally trained. When vaccinations became available, many aides—in contrast to the residents themselves—refused them, with deadly results.

That the massive death toll was not inevitable is evidenced, Gullette suggests, by the existence of facilities that kept the pandemic largely at bay. Nonprofit homes, she notes, generally fared better than for-profit facilities. Gullette singles out one Baptist-run nonprofit in Baltimore that brought in personal protective equipment early and also had a full-time infection control specialist. Her pandemic wish list—probably all of ours—would have included more personal protective equipment, testing, contact tracing, and staffing.

An investigative account detailing more precisely what occurred in these settings, where lockdowns imposed extreme hardship without guaranteeing safety, would be an indispensable addition to the public health literature. That book remains to be written.

The specific differences between nursing homes that turned into death traps and others that did not would also offer valuable lessons for future pandemics and for public health in general. But Gullette wrestles unsuccessfully with the complexity of these issues. She bemoans the social isolation that bedeviled residents, a form of psychological torture, and, at the same time, seems to wish that it had been more thorough. She laments the death toll but also stresses repeatedly that many nursing home residents survived Covid. They are witnesses, but, so far, mostly silent ones. In lieu of tracking survivors down and doing her own interviews, Gullette complains that the media, besieged by the crisis and largely shut out of these facilities at the height of the pandemic, didn’t publish more first-person accounts.

Gullette’s writing style can be clear and punchy, if not always succinct. Early, graphic accounts of the pandemic, she suggests, confounded the nursing home residents with their residences: “Squalor became attached to the dying inhabitants as a group. The result was, I fear, a perverse appeal to a squeamish side that many of us possess. Lacking fuller context, this side is third cousin to bullying. It is first cousin to aversion. It is the bad brother of indifference.”

For better and sometimes worse, Gullette touches on a dizzying range of topics, from the imperatives of ventilator triage to grocery store senior hours and cultural representations of dementia. The narrative is powered by indignation. But it is also insistently nonlinear, unfocused, repetitive, and larded unhelpfully with quotes from the likes of Simone Weil, George Orwell, Hannah Arendt, Emily Dickinson, and Albert Camus.

The pandemic, Gullette writes, “was a superstitious time, filled with bad magical thinking.” Now she wants more testimony about that time, and a monument to one particular group that perished: the National Eldercide Memorial for Nursing-Facility Residents Who Died of COVID. That’s not a proposition any Congress is likely to embrace.

“Forgetting the residents is our problem as a nation,” Gullette concludes, with characteristic passion, “because the Eldercide goes on.” In her view, it is a “cultural deformity” that both preceded the pandemic and aggravated it, and now seems primed to outlast it.

Book cover: The University of Chicago Press

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Elias Zerhouni, director of the NIH under George W. Bush, and Tom Frieden, who directed the CDC under Barack Obama, met on Zoom in late December with several dozen journalists to give a bipartisan perspective on what might transpire for public health.

The discussion was organized and led by Larry Tye, director of the Health Coverage Fellowship of the Center for Health Communication at the Harvard T.H. Chan School of Public Health.

What follows is an edited and condensed version of the hour-long discussion, which included opening remarks by both Zerhouni and Frieden, followed by questions from Tye and from some of the journalists in attendance, representing KFF Health News, Politico, STAT News, the Washington Post, WBUR and others.

• The transition process between administrations
• The future of the CDC
• The future of NIH
• The U.S. and global health
• Can U.S. health care be fixed?
• Robert F. Kennedy, Jr. and vaccines
• Robert F. Kennedy, Jr. and what we eat
• Addiction policy
• On health equity
• Biggest fears
• How can the media rebuild trust?

What’s unique about this transition between administrations?

Elias Zerhouni: Every transition [between presidential administrations] is different. [This one is] going to be very different than [Trump’s] first term, because the group in charge seems to have very, very determined views on how to run the government for the next four years. They know what they want to do. They don’t want to hear from the current administration. Naming your whole cabinet and nominating the head of NIH, the Food and Drug Administration, the CDC, the HHS secretary before the beginning of the administration, that’s unique. It took me 16 months after George Bush started his tenure to be nominated and confirmed by the Senate.

There are lots of rumors that are, in my view, a little bit premature. You never really know what’s the balance between what you think they’re going to do and what they will do, because there are political considerations at all times. The key thing here is going to be protecting these agencies from becoming political footballs.

Tom Frieden: When the new gang gets in [to office] they’ll have fixed views, but they’ll also need to learn and understand some of the nitty gritty of the entities that they’re trying to lead, even if they want to change them. As Elias said, it’s striking how quickly they’re moving to get people nominated and likely confirmed, or at least many of them.

But to hit the ground running, you have to actually know how to make the government function.

On the future of the CDC

Frieden: Every institution could be better, right? There are things that do need to improve. But in government, it’s not usually the case that blowing something up makes it better.

I’m really quite concerned about CDC and proposals to break it up into multiple agencies, or proposals to eliminate the Injury Center or [National Center for Chronic Disease Prevention and Health Promotion] or [National Center for Environmental Health].

Obviously, one risk to CDC is budget cuts. There have been very misguided proposals to break the agency up and have it only deal with infectious diseases. It would be a little strange to end the chronic disease programs at the leading preventive agency in the U.S. [Chronic diseases] are the things that kill most Americans and make infectious diseases more deadly, so [the CDC] need to deal with them.

The second major threat is to vaccines. It’s much more pervasive than [anti-vax]. If you look at just one example, the Advisory Committee on Immunization Practices—there’s no industry influence. Parents and pediatricians are all involved. If the ACIP is disbanded or packed with anti-vax people by the HHS Secretary—who appoints the members—not only do the recommendations change, but that’s what drives insurance reimbursements and school requirements.

It’s important not to overstate the loss of trust in CDC—the data shows that the decrease in trust is among Republicans, that there’s been essentially no decrease in trust among Democrats. This may be cold comfort. And it’s not specific to CDC—it’s about science expertise [and] government in general.

It reflects a frustration that I think we can have a lot of sympathy with. It’s a frustration with our lack of control of our economic future, our lack of understanding of what kind of toxins are in our environment, our lack of access to decent health care. One hundred million Americans lack a primary care clinician, despite the fact that we spend more than four trillion dollars a year on health care, twice as much as the average of rich countries.

On the future of the NIH

Zerhouni: In my time, it was one of the few agencies that had strong bipartisan support, and was really considered the crown jewel of federal agencies. Things have changed with the pandemic. You have a whole faction out there, Sen. Rand Paul [and] others, who have it in for NIH. It’s lost its apolitical status, and it’s lost some of its bipartisan support, and I think trust in science generally is down. There’s going to be a readjustment, and Monica [Bertagnolli, NIH’s director since November 2023], unfortunately, has not been here long enough to establish those good relationships that you need as an NIH director with Congress and the appropriators, including within the administration. [Editor’s note: Bertagnolli resigned January 14.] So I think it’s going to be rocky, and I am worried about NIH.

Frieden: We absolutely need to look at NIH because it is a jewel. But we need to look at all of the agencies, including the ones that are not so visible but may have really important roles to play, whether it’s in regulation or specific programs.

On the U.S. and global health

Frieden: PEPFAR [The President’s Emergency Plan for AIDS Relief] is at great risk. PEPFAR is, without a doubt, a huge success story. Twenty-five million lives saved, seven million children born without HIV because of it, economies all over Africa renewed from it. And huge goodwill toward the United States as a result—I’ve had multiple career ambassadors say to me nothing we do advances U.S. interests as much as the good work we do in PEPFAR.

It’s likely that the Trump administration will pull out of WHO, as it did before. That will make the U.S. and the world less safe and give us less of a voice in what happens in global health.

Zerhouni: One other topic I would put on your radar screen is genetically modified organisms and foods. Kennedy seems to be against it like Europe is against it. Facts tell you that [banning GMOs] would be very, very destructive to a lot of emerging nations and poorer nations. It was 20 years ago when a country that was under a famine was prevented from importing GMO foods by the Europeans, and they had hundreds of thousands of deaths. [Editor’s note: Zerhouni is referring to Zambia in 2002. Several other southern African nations, Malawi, Mozambique, and Zimbabwe, also declined GMO food aid that year.]

The central issue is the concept of individual rights versus community rights. And leaning towards saying, “Well, community has no rights, we decide whatever we want for our kids” is really the issue that comes up all the time between the risk and benefit of public health activities.

Can U.S. health care be fixed?

Frieden: Primary care is an area where there could be some motion over the next four years. It’s really shameful and shocking the degree to which the U.S. spends a lot of money and doesn’t get a lot of value out of health care. We have fantastic, high-tech health care, second to none, but in terms of health outcomes from the essential services that most people should get, we do a terrible job. There are plenty of countries that do better, and in terms of health policies, including food policies that RFK Jr. has talked about, countries as varied as Chile and Argentina and Mexico have much better policies than we have.

In health, America isn’t first. America is like 49th in health status in the world. If we want to be first in health status, what would that look like? Well, it would be a very different set of public health policies, health care policies, and broader policies on things like air quality and other issues.

Zerhouni: [Health care is] a monster, if you talk to economists. Even the Federal Reserve considers health care and its runaway costs one of the major, major threats to the American economy in the future. And yet nobody talks about it. The [outside] comparisons are very useful. I’ve been a global traveler and had to deal with many health systems, and I would say that our health system is probably the worst in the world right now, from the point of view of developed economies.

What about RFK Jr.’s anti-vax ideas?

Frieden: I don’t know whether or not he will be confirmed. The anti-vax stuff is very concerning. If you look at what he and his group did in Samoa—there was a tragic incident [in 2018] where a nurse made a mistake, she put an expired muscle relaxant into the MMR [measles, mumps, and rubella] vaccine and gave it to two children who died. It had nothing to do with MMR.

[RFK] went there [in June 2019]. They lifted up the anti-vax groups in Samoa. When vaccine rates went down, more than 83 people died, most of them kids. You also have [Dave] Weldon, the nominee to head CDC, having repeated the debunked claim of a link between vaccines and autism. More than 25 studies have looked at this. We know that the suggestion that this was occurring was promoted by Andrew Wakefield in a fraudulent claim to make money.

Zerhouni: We always talk about foreign countries like Samoa and Zambia, but you know, deaths from measles have arisen here in California, in Germany, in France. So it’s not like it’s going to spare us because we have herd immunity.

What about RFK Jr.’s talk about food?

Frieden: A lot of what he says makes sense on the face of it. But is he actually going to do things that make a difference, or is this just performative, just for PR? We know about the main things that cause chronic disease in the U.S.—it’s tobacco, it’s alcohol, it’s soda and sugary beverages, it’s PM 2.5 [the technical term for] soot. That’s what causes the vast majority of the preventable heart attacks, strokes, cancer, diabetes in the U.S.

If you want to really make progress, you have to do things like take on big tobacco, take on the industries that put things into our environment that are harmful. And that hasn’t been a traditional Republican priority.

Zerhouni: I believe that Kennedy’s programs have both a bad side on the vaccines, but a good side on chronic disease and the environmental effects. His position on chronic diseases is a good one. Eighty percent of our [health care] costs are related to chronic diseases, and of that, 50 or 60 percent is related to lifestyle choices [like] food. In 1920, Americans consumed about 18 to 20 pounds of sugar [annually]. Now it’s 200 pounds, coming from different sources, enhanced sugars in food and processed food, and so on.

As Tom said, it’s not that easy to get [change] through, because you have a lot of vested interests. When I was the NIH director, I was asked to do a study on obesity, and we came up with the conclusion that, number one, [to address it] you had to really change the food chain, and sugar in particular. I went to my appropriations head, and I said, “We have to do something about [sugar]. We should do it like tobacco. We should tax it.”

And he said, “Are you kidding? I won’t be reelected if you do that.” And he was saying, “The most important bill I deal with is the Farm Bill, which gives 60 billion dollars of subsidy to the corn syrup industry. How do you want me to fight that?”

Frieden: To be clear, the phrase “lifestyle” implies that it’s people’s fault. If we want to address chronic disease, we’re not going to do it by hectoring people to do calisthenics and eat healthier. We’re going to do it by changing the default choices so they’re healthier, and that is with things like taxation and more availability of healthier foods. Other countries do very good work with making information apparent when you’re buying something at the supermarket. So if it’s really unhealthy, it has a warning label on it like tobacco.

Zerhouni: You’re not going to change the system overnight, but I think the incentives are actually stacked against us. And we need to change that. For example, you know the [farm] subsidy, which is 60 billion dollars a year, going mostly to large companies, not farmers, could be used to transition the agriculture economy from an unhealthy to a healthy landscape. To promote that notion over time would be a real, real benefit for the American people. Because the food supply chain is the problem. It’s been shaped by context, by addictive behaviors—liking sugar is addictive in some ways. We tried twice to create an Institute of Nutrition [at] the NIH, and twice we were opposed by a lot of vested interests.

Frieden: To give two examples of the kind of interference that comes up, Congress one year mandated that CDC and three other federal institutions come up with an analysis and recommendations on what to do about marketing of unhealthy food to children. The industry then woke up, and in the following year we were mandated not to do that report. And it’s not just sugar. High salt probably kills more people than high sugar, and it’s everywhere. It’s in breakfast cereals. It’s in baby food. It’s way more than you would put in at the table, and it gets you accustomed to that amount of salt. We were mandated by Congress not to work on sodium reduction at one point. The economic interests here are very powerful.

Zerhouni: There are inherent obstacles to change. We need to really tackle that. I’m hopeful that perhaps Kennedy will be able to move the needle a little bit, because that’s the one good side of his political or policy statements that I’ve heard from him.

Will addiction policy change?

Frieden: My number one concern is the CDC’s National Center for Injury Prevention and Control could be eliminated. That’s the lead agency that guides public health response to this crisis. There’s been good bipartisan support to address the overdose crisis. I have always believed that interdiction is important. Not all public health people agree with that. If you make the analogy to tobacco, there’s price elasticity. The harder it is to get and the more expensive it is, the less people will use it. And I think we’re seeing that.

You have leaders in Congress like [Rep.] Hal Rogers [R-Kentucky], who has really understood the whole gamut of interventions needed to address opiate overdose, from education, to treatment, to enforcement, to community development things. We’re seeing an openness to other approaches, including finally making buprenorphine policy more rational to improve access to and quality of treatment for addiction. We’ve seen a major lifting of restrictions on buprenorphine. We’ve seen Narcan become much more available. We’ve seen experiments with safe injection spaces. I think you may see more openness to some of the newer treatment modalities, including psychedelics. I don’t think they’re going to be a magical cure for people, but they may have a role.

To the extent you weaken the capacity of public health to track trends and respond to them, you risk the little bit of progress [we’ve had] in the last year or two going in the wrong direction.

On equity and health

Frieden: One of the major risks is the elimination of programs that are intended to address the populations in greatest need. That includes CDC programs, NIH programs, HRSA programs and others. Another very major risk is Medicaid. The [Trump] administration has talked about not cutting Medicare. But they haven’t said they’re not cutting Medicaid.

There’s also the public discourse, what gets talked about, what gets studied, what gets prioritized. One way forward could be looking at all groups that have disproportionate needs. That includes rural Trump voters.

Sometimes public health can have a little bit of a blind spot. We understand why some groups, because of historical injustices, need particular outreach. But if we’re going to reach everyone to get vaccination rates up or cancer prevention done or opiates addressed, we have to address each community.

Zerhouni: I separate health disparities from DEI. They’re two different topics in my mind. Fundamentally, access to good health care was not assured in socioeconomic environments that could not afford it. It wasn’t an issue of race only. You saw it in West Virginia. You saw it in areas where there was no racial disparity. You saw it in Mississippi. My conclusion was that the structure of our health care system is basically biased against folks who don’t have a socioeconomic situation that allows them to access [the system].

Our health care system needs restructuring. We need to cover everybody. It’s unacceptable for a country that spends four trillion dollars [on health care] to have all these Band-aid programs. But if you look at the statistics, it hasn’t improved [outcomes] over the past 20 years.

DEI is another issue, part of the culture wars that are ongoing. I don’t think it has a direct impact on the health disparities themselves. We have had proper programs, like Tom said, for years, and they haven’t really moved the needle. We have 4,500 federally qualified health care centers. They do a lot of good work, but they leave a lot of people out, as we’ve seen during the pandemic.

Biggest fears with the new administration

Zerhouni: Because [Trump administration officials] will be sort of talking to themselves, [I fear] they will address many things all at once and solve nothing. The second is for my field, biomedical research, maintaining our science and technology strength. Research has gone from small labs that do their things to truly team science and studies of populations and studies of diseases that are affecting the great majority of people. Utilizing AI, utilizing new technologies, and the competition for that is going to be a global competition, including with China.

Frieden: [I fear] a lot of people in the U.S., and around the world, could die because of the disruption of effective programs and the continued undermining of trust in government and science.

How can the media rebuild trust?

Zerhouni: I think the role of journalists is to focus on data. For example, you hear from Trump, “Well, you know, autism just exploded in the country, so there must be a reason,” but that is not correct. There was a change in diagnostic categories, and if you looked at it from that point of view, you see that there was a diagnosis that was very, very common in the past—developmental delay or inappropriate development—that has gone down tremendously. There’s no more of that diagnosis. It’s all autism and autism spectrum disorder. That kind of fact setting, and that truth, should be really [journalists’] duty, because no one else can really do this and not be accused of having a bias.

The other thing is, analysis of positions is primarily about the messenger, not about the message. Oh, is he a Democrat? Is he a Republican? Did he work for a pharma company? Well, therefore it’s biased. The unbiasing of the information and the factualness of it is really the essence of the work we need to do in a democracy. If you don’t have a ground truth, you really can’t govern, and that’s what’s happening a little bit here. There’s a tremendous amount of ad hominem dismissal of ideas.

Frieden: It is telling that trying to point out what is fact and what is fiction is considered partisan.

There are things that are debatable. Much misinformation has kernels of truth. We don’t want to oversimplify and say, if there’s a kernel of truth, “Oh, this is totally wrong.” But the way it’s used, it gets weaponized.

So if we talk about vaccines, look, Covid vaccines are extremely safe. They greatly reduce the risk of death, particularly in people who are older. Is there a valid debate about whether everyone should get them every year? Absolutely. The U.S. recommends every six months for the highest risk people, every year for everyone else. But some other countries say, “We’ve got a good health system, so we’re not going to vaccinate younger adults because we’re going to save the money.”

Top image, Zerhouni: Dennis Cook / AP Photo, File; Frieden: Molly Riley / AP Photo, File

The post A bipartisan perspective on public health’s uncertain future appeared first on Harvard Public Health Magazine.

Preparing cancer patients for difficult decisions is an oncologist’s job. They don’t always remember to do it, however. At the University of Pennsylvania Health System, doctors are nudged to talk about a patient’s treatment and end-of-life preferences by an artificially intelligent algorithm that predicts the chances of death.

But it’s far from being a set-it-and-forget-it tool. A routine tech checkup revealed the algorithm decayed during the COVID-19 pandemic, getting 7 percentage points worse at predicting who would die, according to a 2022 study.

There were likely real-life impacts. Ravi Parikh, an Emory University oncologist who was the study’s lead author, told KFF Health News the tool failed hundreds of times to prompt doctors to initiate that important discussion—possibly heading off unnecessary chemotherapy—with patients who needed it.

He believes several algorithms designed to enhance medical care weakened during the pandemic, not just the one at Penn Medicine. “Many institutions are not routinely monitoring the performance” of their products, Parikh said.

Algorithm glitches are one facet of a dilemma that computer scientists and doctors have long acknowledged but that is starting to puzzle hospital executives and researchers: Artificial intelligence systems require consistent monitoring and staffing to put in place and to keep them working well.

In essence: You need people, and more machines, to make sure the new tools don’t mess up.

“Everybody thinks that AI will help us with our access and capacity and improve care and so on,” said Nigam Shah, chief data scientist at Stanford Health Care. “All of that is nice and good, but if it increases the cost of care by 20 percent, is that viable?”

Government officials worry hospitals lack the resources to put these technologies through their paces. “I have looked far and wide,” FDA Commissioner Robert Califf said at a recent agency panel on AI. “I do not believe there’s a single health system, in the United States, that’s capable of validating an AI algorithm that’s put into place in a clinical care system.”

AI is already widespread in health care. Algorithms are used to predict patients’ risk of death or deterioration, to suggest diagnoses or triage patients, to record and summarize visits to save doctors work, and to approve insurance claims.

If tech evangelists are right, the technology will become ubiquitous—and profitable. The investment firm Bessemer Venture Partners has identified some 20 health-focused AI startups on track to make $10 million in revenue each in a year. The FDA has approved nearly a thousand artificially intelligent products.

Evaluating whether these products work is challenging. Evaluating whether they continue to work—or have developed the software equivalent of a blown gasket or leaky engine—is even trickier.

Take a recent study at Yale Medicine evaluating six “early warning systems,” which alert clinicians when patients are likely to deteriorate rapidly. A supercomputer ran the data for several days, said Dana Edelson, a doctor at the University of Chicago and co-founder of a company that provided one algorithm for the study. The process was fruitful, showing huge differences in performance among the six products.

It’s not easy for hospitals and providers to select the best algorithms for their needs. The average doctor doesn’t have a supercomputer sitting around, and there is no Consumer Reports for AI.

“We have no standards,” said Jesse Ehrenfeld, immediate past president of the American Medical Association. “There is nothing I can point you to today that is a standard around how you evaluate, monitor, look at the performance of a model of an algorithm, AI-enabled or not, when it’s deployed.”

Perhaps the most common AI product in doctors’ offices is called ambient documentation, a tech-enabled assistant that listens to and summarizes patient visits. Last year, investors at Rock Health tracked $353 million flowing into these documentation companies. But, Ehrenfeld said, “There is no standard right now for comparing the output of these tools.”

And that’s a problem, when even small errors can be devastating. A team at Stanford University tried using large language models—the technology underlying popular AI tools like ChatGPT—to summarize patients’ medical history. They compared the results with what a physician would write.

“Even in the best case, the models had a 35 percent error rate,” said Stanford’s Shah. In medicine, “when you’re writing a summary and you forget one word, like ‘fever’—I mean, that’s a problem, right?”

Sometimes the reasons algorithms fail are fairly logical. For example, changes to underlying data can erode their effectiveness, like when hospitals switch lab providers.

Sometimes, however, the pitfalls yawn open for no apparent reason.

Sandy Aronson, a tech executive at Mass General Brigham’s personalized medicine program in Boston, said that when his team tested one application meant to help genetic counselors locate relevant literature about DNA variants, the product suffered “nondeterminism”—that is, when asked the same question multiple times in a short period, it gave different results.

Aronson is excited about the potential for large language models to summarize knowledge for overburdened genetic counselors, but “the technology needs to improve.”

If metrics and standards are sparse and errors can crop up for strange reasons, what are institutions to do? Invest lots of resources. At Stanford, Shah said, it took eight to 10 months and 115 man-hours just to audit two models for fairness and reliability.

Experts interviewed by KFF Health News floated the idea of artificial intelligence monitoring artificial intelligence, with some (human) data whiz monitoring both. All acknowledged that would require organizations to spend even more money—a tough ask given the realities of hospital budgets and the limited supply of AI tech specialists.

“It’s great to have a vision where we’re melting icebergs in order to have a model monitoring their model,” Shah said. “But is that really what I wanted? How many more people are we going to need?”

Image: Viorika / iStock

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But the UK very quickly created what has been called one of the world’s best data responses to the pandemic. Still, nearly a quarter-million Britons died from Covid. An ongoing public inquiry seeks to find out why—but it is already clear that politicians struggled with balancing the economic and social disruption of locking down the country against the rising death rate.

At the start of the coronavirus crisis in January, the UK mobilized its Scientific Advisory Group for Emergencies, or SAGE, a group of roughly 20 public health officials and scientists formed specifically to advise on the crisis. Unlike in the United States, where data sources were so fragmented that it was hard to build a clear picture of the pandemic, SAGE initially pulled together available data and played a key role in information gathering and informing the response, eventually meeting more than 100 times during the crisis. At the start, the group understood the problem it faced: “We didn’t know exactly where we stood with the epidemic, how quickly was it growing,” says John Edmunds, a SAGE member and infectious disease researcher at the London School of Hygiene & Tropical Medicine.

SAGE immediately called for setting up a host of surveillance studies and research projects. By early February it had working models good enough for the SAGE team to form a consensus around how to suppress the spread of the virus: Reduce contacts in the community by 75 percent.

How to achieve this was less clear. Patrick Vallance, SAGE’s cochair and Boris Johnson’s chief scientific advisor, told the inquiry that there were concerns from medical advisors about the impact of lockdown on mental health and on care for patients who didn’t have Covid. Operational factors such as getting policies and legislation in place also played a part in the delay.

Johnson, in a written statement submitted for the inquiry, said he feared the economic effects of a complete lockdown could cause public dissent. “Science could guide us and help us but many of the decisions would involve such complex moral and political dilemmas that only elected politicians could take them,” Johnson wrote. He authorized other steps to restrict interactions.

By late March, it was clear that those steps had failed. Johnson and his team had in late February and early March been presented with models projecting that the UK could face more than half a million deaths from Covid. “We could see the shape of the curve,” says Hancock, but it was difficult to tell whether the cost of not acting was higher than taking the unprecedented step of locking down. Johnson finally instituted a lockdown on March 23.

That decision came too late for some observers, who say the data had been suggesting locking down for weeks. “The political and policy decisions were too slow,” says SAGE member Jeremy Farrar, now chief scientist at the World Health Organization in Geneva. “A week is a long time when the doubling time of the epidemic is two days. A month is an eternity. Not making a decision is a decision itself.”

How to build a great pandemic response system

As the pandemic raged through the spring of 2020, SAGE was readying a robust data arsenal. Three projects in particular became invaluable to that effort: genome sequencing of the virus; a Coronavirus Infection Survey; and the Recovery Trial, a clinical study that helped researchers identify which treatments worked best against severe Covid.

The Recovery Trial initially enrolled 40,000 people across 185 sites in the UK and identified dexamethasone, a cheap and readily available steroid, as one of the first effective treatments for Covid. Estimates suggest that within a year of the trial’s start date, the drug had saved the lives of 22,000 Covid patients in the UK, and one million worldwide.

The Coronavirus Infection Survey (CIS), meanwhile, was a random sampling exercise led by Farrar and officials from the Office of National Statistics and set up in just 10 days. Launched April 26, 2020, it tracked symptoms by age and region and estimated the average number of new cases per week. At its peak, the CIS was collecting 400,000 samples per month. The project “was virtually unique around the world,” says Edmunds. It would become fundamental to the pandemic response in the UK, where policymakers showed its graphs in nightly televised press conferences. The World Health Organization also used the data to help measure the pandemic globally, says Emma Rourke, the UK’s deputy chief statistician.

Genomic scientists started discussing creating a network to rapidly sequence samples of SARS-CoV-2 recovered from patients in February 2020, seeing it as a tool to track how the virus was spreading and mutating. Some researchers resisted because coronaviruses tend not to mutate as quickly as other viruses, meaning there might not be enough variation within the samples to trace outbreaks.

But the genomic scientists’ group, which became known as COG-UK, decided it was a risk worth taking and secured a £20 million (about $23 million U.S.) grant from the government to set up a consortium of nationwide sequencing hubs. Samples came from the National Health Service, public health laboratories, and Covid testing centers. At its height, COG-UK was registering more than 50 percent of the SARS-CoV-2 sequences in the world.

Data vs. disease

Despite the lockdown and SAGE’s work, by early May the UK had the highest Covid death toll in Europe (when the UK later adopted different reporting criteria, that rate was more in line with those on the continent). It also had “the most comprehensive and informative data on Covid of any country in the world,” says Marc Lipsitch, an epidemiologist at the Harvard T.H. Chan School of Public Health. That data was about to make a difference. The UK established a command-and-control hub for all things Covid, called the Joint Biosecurity Centre. Its dashboard was immediately helpful in pulling data together for use in decision-making. Combining the tools and data was “very, very powerful,” says Mark Woolhouse, an epidemiologist at the University of Edinburgh, who advised the Scottish government on its pandemic response, “much more valuable for informing policy.” 

When the Office of National Statistics published the results of its first CIS on antibodies on May 28, it showed that only five percent of the UK public had developed antibodies to the virus, meaning overall infection rates were low. This knowledge “was critical for the strategy for how to get through,” says Hancock. It showed that it would have been “a disaster” to let the virus run its course, and it meant that ultimately, “there was no way out without a vaccine.”

Antibody surveys are critical tools in any pandemic scenario, Hancock says. The government also drew on data from the Covid testing service, the National Health Service, and research projects such as the REACT (Real-time Assessment of Community Transmission) study, another massive surveillance exercise led by Imperial College. Together they showed that infection rates had peaked in April, so officials could plot a course out of lockdown based on meeting thresholds for daily infection rates and a sustained drop in death rates. By mid-July of 2020, all lockdown restrictions were lifted.

Six weeks later, in September 2020, a second wave of the coronavirus emerged.

When the data doesn’t make a difference

By the second wave, SAGE—and UK politicians—had become comfortable working with the wealth of data they had. They had been able to draw on their dashboard to make recommendations about how best to protect public health. They had seen how to bring a lockdown to a close. But now they were faced with models suggesting the number of infections was growing two to seven percent per day, and a rapid increase in hospital admissions loomed.

SAGE’s team did the obvious: They called for tighter restrictions to curb the virus, including another short lockdown. But Johnson did not do that; instead, he introduced a series of measures including limiting social gatherings to six people, working from home for non-essential businesses, and establishing a 10 p.m. curfew for the hospitality sector. The government also announced a tiered system of restrictions by region, depending on local infection rates.

Hancock told Harvard Public Health that the wealth of data should have made the lockdown an easier call. But in the room where these decisions were made, other politicians opposed a lockdown. Johnson’s government wanted to limit the economic consequences of a complete lockdown. And in places that faced tighter restrictions under the tiered system, such as Manchester, leaders pushed back.

The SAGE group watched the political inertia with dismay. They had seen this happen in February and March. They knew the consequences of letting the virus spread unchecked through the population and feeling like the science was ignored. At the start, even the scientists could not predict the impact of a countrywide lockdown, but now they had robust models about the pandemic. “We didn’t want to make those same mistakes again. And, unfortunately, we [collectively] did,” says Edmunds.

Farrar says it should have been clear: Follow the data. “The tragedy was having that brilliant data in July, August, September [of 2020] and seeing the wave developing, infections increasing day after day after day, and then not making a policy decision on the basis of data,” he says.

It wasn’t until November 5 that the government finally imposed a four-week lockdown across the whole of England (schools excepted) in order to prevent what Johnson would call a “medical and moral disaster” for the NHS. Less than a month later, on December 2, UK regulators approved a Covid vaccine. The country returned to the three-tiered restrictions within days. 

Unfortunately, sequencing data from COG-UK had identified a new, highly transmissible mutation of Covid, the Alpha variant (also called the Kent variant, after the part of the UK where it was first seen). Cases soared in early January 2021. This time, Johnson’s government was quick to announce a third full lockdown, including schools, across England (Wales, Northern Ireland, and most of Scotland were also in lockdown).

As the vaccine rolled out across the country, data was capturing its effectiveness at preventing infection. Policymakers were able to use the data included in the dashboard to inform an easing of the lockdowns by July 2021.

Takeaways

The extent of any missteps could take until 2026 to be determined, as the inquiry will ultimately report on nine aspects of the UK’s Covid response, from the impact on young people to vaccines and therapeutics. Farrar says years of fiscal austerity meant the UK had neglected its public health infrastructure, leaving it without the capacity it needed to deal with a pandemic. The first report on preparedness, published in July, affirmed this point, finding that the UK was ill-equipped to deal with any catastrophic emergency. It also said the UK had planned for the wrong pandemic—a mild one. This meant it had not developed guidelines about using lockdowns in a pandemic, and politicians had to use the untested policy in the heat of the moment.

Despite criticism of the timing of the original lockdown in March 2020, Johnson told the inquiry the lockdown was data-driven and timed correctly. (Johnson tested positive for Covid soon after the first lockdown, winding up in intensive care before recovering.)

Even Johnson acknowledged that what happened in September 2020 was a mistake. He told the inquiry the one thing future leaders should do differently would be to focus on a UK-wide approach rather than a tiered policy.

The data effort drew praise. Edmunds calls gathering the data and expertise so quickly “amazing.” He says it showed “what you can do with political will, with money. It was absolutely transformative.”

The challenge for scientists came when they faced the unknown. He says scientists may have been too timid in pushing for lockdowns because they were so extreme. Hancock says the UK now knows lockdowns belong in the toolkit for fighting future pandemics, and politicians and scientists need to have agreements in principle on timing them. “As soon as you can see that the cost of action is going to be smaller than the cost of inaction, you must act,” he says. Separately, having an operational response ready to go is key for dealing with any future pandemic. This should include standing test capacity, contact tracing infrastructure, and the ability to set up clinical trials and vaccine challenge studies at pace, he says.

Hindsight is only so helpful, though. Edmunds says he still ruminates on the delays. “It’s a horrible thing. How much I am to blame versus other people further up the chain, I don’t know, but you feel it.”

The post Even great data couldn’t solve the UK’s COVID woes appeared first on Harvard Public Health Magazine.

A National Institutes of Health (NIH) study found that long-term marijuana use increases the likelihood of mental health disorders, including schizophrenia, in people who are genetically predisposed. Daily users are five times more likely to develop psychosis than non-users. Marijuana-related emergency room visits have surged, particularly among adolescents and young adults, in states with legalized recreational use. And although many people use marijuana without problems, some become addicted.

Today’s cannabis products can contain levels of THC—tetrahydrocannabinol, the compound that makes users high—as high as 90 percent, a staggering leap from the two to three percent THC concentrations typical of the 1970s. This isn’t just a nostalgic nod to simpler times; it’s a public health alarm.

Yet we continue to treat marijuana use as a footnote in the conversation about drugs. There’s no consistent national policy to address these risks, leaving public health at the mercy of state politics. Twenty-four states have made marijuana legal for recreational use.

Now there’s a narrow but significant opportunity for the federal government to create a more consistent policy. The Biden administration has begun the process of rescheduling cannabis under the Controlled Substances Act, and Robert F. Kennedy Jr., President-elect Donald Trump’s nominee to run the Department of Health and Human Services, has suggested he’ll continue the push.

The process would downgrade marijuana from Schedule I—where it’s grouped with heroin and LSD—to Schedule III, allowing more research. But it would also give the federal government a chance to regulate marijuana use.

Standardized labeling is critical. Currently, THC products often fail to disclose potency clearly, leaving consumers to guess at a product’s strength. It’s like buying a bottle labeled “alcohol” without knowing if it’s beer or rum. Just as alcohol is labeled with its alcohol by volume (ABV) percentage, and tobacco products carry prominent warnings, THC products need transparent, federally mandated labels.

A “Cannabis Facts Panel”—like the nutrition labels on all food—could indicate not just THC potency, but also as well as potential effects and risks. The National Cannabis Industry Association (NCIA) has already proposed this type of standardization, arguing that clear labeling empowers consumers to make informed choices.

Canada offers a roadmap for addressing these concerns. Federal regulations there include THC potency caps of 10mg per serving and 1,000mg per package, standardized labeling, and a clear age minimum for purchase. These measures haven’t stifled the cannabis industry; instead, they’ve created a safer and more predictable market. The U.S. can and should follow suit, adapting similar strategies to fit its own regulatory landscape.

Federal guidelines must include caps on THC potency to mitigate the risks of these hyper-concentrated products. Health providers and public health campaigns should focus on increasing awareness of the risks of high-potency THC, especially for younger users. By learning from Canada’s successes and applying the lessons from our regulation of tobacco and alcohol, we can safeguard public health without reversing legalization.

Marijuana’s evolution has outpaced our regulatory systems. Ironically, marijuana is often touted as a way to reduce anxiety, but regular use of high-potency THC can amplify anxiety. This paradox underscores a fundamental misunderstanding about the risks of today’s cannabis products. It’s the public health equivalent of throwing water on a grease fire—good intentions gone horribly wrong. This misalignment leaves consumers, especially young adults, vulnerable to its unintended consequences. And yet, marketing strategies, particularly on social media, glamorize these high-strength options, targeting younger consumers.

Federal oversight is overdue. Clear, standardized labeling of THC products must become the norm. We have the data, the science, and the tools to act. Let’s not wait for this issue to spiral further out of control. It’s time to prioritize public health and ensure a safer, smarter approach to marijuana in America.

Image: Mary Delaware / Source images: Adobe Stock

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One of Arulampalam’s very first acts after taking office January 1, 2024 was creating an Office of Community Violence Intervention to coordinate between the city and several hospital-based programs. Arulampalam has made several moves to boost other social determinants of health, something he thinks mayors are uniquely positioned to do. And he aims to get the city its first supermarket, a goal that has eluded previous administrations.

The 39-year-old, who was born in Zimbabwe to Sri Lankan refugees and moved to the United States before he was two, graduated from Emory University and then law school at Quinnipiac University. Before running for office, he was CEO of the Hartford Land Bank, which works to reduce blight in the city. He talked with Michael F. Fitzgerald, the editor in chief of Harvard Public Health, about why mayors should care about public health even though it rarely leads to press conferences about achievements. The interview has been condensed and edited.

Harvard Public Health: I met you in the context of my reporting on the North Hartford Triple Aim Collaborative, which is trying to broadly address social drivers of health. You talked about housing, gun violence, recreation, and education—four big social drivers. They’re all valid issues on their own. What’s different about putting them in a health context?

Arulampalam: I have an inch-deep knowledge in public health—[in college] I did a minor in public health. What was amazing to me is that the biggest gains we made in public health—poverty eradication, nutrition, major diseases—most individuals didn’t recognize there were lives that were saved; people didn’t connect [those gains] to the public health interventions that were made.

To have a [public health] mindset you’ve got to be comfortable with doing the non-sexy stuff, doing the things that will actually move the needle for communities and not worrying about the credit that you get from it. One of the things that’s difficult in politics broadly and for mayors specifically is, to be successful, you’ve got to articulate visions. You’ve got to make gains in those visions. And then help the public connect the dots between the gains and the promises.

HPH: Are there places in Hartford that made especially noteworthy gains?

Arulampalam: North Hartford is a really good example. Depending on where you live in North Hartford, your life expectancy could be 16 years lower than the life expectancy of someone in West Hartford, just over a mile down the road. The vast majority of causality for that are the social determinants of health. Take access to food. The clear win for this administration would be to get a grocery store in the north end of Hartford. And we are working on that. We have an $8.5 million RFP [request for proposal] out right now.

We’re looking at turning some of our vacant lots into urban farms, working with a cohort of urban farmers who came out of the Keney Park Sustainability Project. I went and door-knocked with them and talked to the residents in that neighborhood, to make sure the residents understood what they were doing. They would ask things like, you know, for folks who are from Puerto Rico or one of the West Indian countries, what are some foods that you had growing up that you don’t find here in Hartford? We do the research to figure out if they could grow here.

[Keney Park] worked with every corner store and bodega in the neighborhood and said, “Hey, if we grow some lettuce, would you sell it? If we grew some kale, would you sell it?” Those sorts of small interventions don’t warrant a press conference. But they will have an actual impact on the social determinants that are [currently] leading to shorter lives for our residents.

HPH: If you’re trying to change life expectancy, you don’t see those numbers change really in one term.

Arulampalam: We’ve got to create an ecosystem, right? That requires a little bit of faith. If you do the right thing, even if you don’t get the credit for it up front, people will feel better about their city working.

Politicians try to understand public health through a politician’s lens: You weigh the political costs and the financial costs against the value it brings. You’re likely to underestimate the value of innovative solutions to public safety, violence prevention—to housing, certainly. And then we get into these crisis moments like the one we’re in now [with housing]. And then you tend to fight for shorter-term solutions that might deliver political results. But they don’t really move the needle for the communities you’re serving.

Residents, actually, are very astute, especially residents in the neighborhoods that feel this pain, when it comes to identifying whether proposed solutions are going to get them closer to where they want to go or whether they’re just, you know, fluff, a political trick. I don’t believe the residents are looking to see if the metrics change. I think they’re looking for a really viable plan that will eventually lead to a change in metrics.

HPH: I saw that there was a drop in murders and shootings in your first year. One of the very first things you did was create an Office of Violence Prevention. Can you point to this office to say it has helped with this?

Arulampalam: I think the office is still a little new for that. Our metrics around public safety actually have really shifted. Our police department has gotten smarter in policing, in many ways, deploying the same kind of public health-based techniques that you would for addressing disease: targeting those who are most likely to commit acts of crime [and] monitoring and trying to interrupt gang activity before the summer hits when there’s usually a spike in crime. We moved 15 additional cops on patrol, so the response time to crime has shortened.

From the year before [I took office], murders are down 55 percent; shootings are down 28 percent. That’s what grabbed the headlines. To me, the most telling statistic is that group and gang violence was 1.6 percent of shootings. That tells me that there wasn’t continual retaliation between gangs. The hospital-based violence intervention programs, which are coordinated by this new office of ours, [are] really working [so] that as soon as somebody got to the hospital with a gunshot wound, every service that we could give them as a city was provided at their fingertips. We opened up night gyms this summer, a thousand kids in night gyms. That was incredibly successful in giving kids a safe place to be.

HPH: I’m curious about the dynamic that you think mayors and public health directors should have.

Arulampalam: Our public health department is very focused on things like infectious disease and chronic disease. [Ebony Shaheed-Jackson, its director] has done great work. She has created this mobile health clinic, got funding for it. But things like developing housing, ensuring that that housing is up to code, the impact of education systems, don’t neatly fit into [public health] goals. And yet all of those components have to work together in order to create healthier communities. The greatest authority and power mayors can have in many places is the power of the convener. If you reach out to the heads of your major [institutions] and ask them to come to your table, they will do that.

HPH: Where do the tradeoffs come when you’re trying to [make] public health decisions?

Arulampalam: We’re a city of less than 19 square miles, half of which is untaxable. We’ve got about 120,000 people, but we’re the center of a metro area of 1.2 million people. We’ve got 93 percent of the homeless shelter beds for that larger region. We’ve got all the methadone clinics. And that means the city is consistently under-resourced for the size and scope of challenges that we are addressing. If you go into our homeless shelters, it’ll be a small minority of people in those shelters who are from Hartford. The case that I’m trying to make to my surrounding mayors is that if we don’t work together, it’s not just to the detriment of the city of Hartford, it’s a detriment to the entire region.

HPH: Let’s just say that you’re going to run for reelection. What would you like to be able to say about the public’s health?

Arulampalam: My hope is that we have made actionable and sustainable gains in public safety. That there is a vastly improved infrastructure of access to healthy foods in the city. And that all of the partners in that health effort from the large hospitals to the community health clinics to the on-the-ground efforts are all in alignment. I hope we’ll be working off [of] a consistent set of data towards a consistent set of goals. I don’t know if that’ll all come together in 1,150 days. But my hope is that we’ve made progress on that.

Top photo: City of Hartford

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