To Dr. Benjamin Mazer, a pathologist and medical writer in Baltimore, a paper in the Nov. 24 issue of the New England Journal of Medicine was “the perfect study for Substack.” That’s the online platform where he has just begun a newsletter about, as he puts it, “diagnostics, medical evidence, and the media.”
The paper he was describing was written by public health researchers in Boston. By analyzing data from schools that dropped mask mandates at different times last winter, the scientists determined that in the first 15 weeks after the state allowed the policy change, Boston-area schools without mandates had 45 more COVID cases per 1,000 students and staff than they otherwise would have had. That amounted to 29 percent of the COVID cases in these schools in that time period.
Some critics questioned the validity of comparing case counts across districts, given that other factors — including levels of COVID immunity and testing — were also fluctuating. But Mazer thought the study’s statistical methods seemed solid. What concerned him was the commentary accompanying the data. The researchers wrote that school masking policies should also be considered matters of health equity for “students and staff already made vulnerable by historical and contemporary systems of oppression (e.g., racism, capitalism, xenophobia, and ableism).”
To Mazer, this and other references in the paper to oppression and capitalism crossed a line. “The authors shoot themselves in the foot,” he wrote on Substack. “Public health has already become so politicized during the pandemic. Why would you want to further contribute to that, undermining your own credibility as a scientific actor? . . . A well-designed study might help convince political leaders and regular Americans that mask mandates are effective, but positioning masks as anti-capitalist is going to cancel that right out.”
I relayed Mazer’s criticism to one of the authors of the paper, Natalia Linos, a social epidemiologist who is the executive director of the FXB Center for Health and Human Rights at Harvard. She suggested that Globe Ideas host a conversation between her and Mazer. So I introduced them on a video call in November, and edited and condensed highlights of the discussion follow.
Linos: By definition, COVID policy is political. We wanted to be open about that and also to make clear that COVID policy has a differential impact for different groups. I was very proud that the paper addressed politics, power, and economic inequities. Because the doctors who read the New England Journal of Medicine, who are in the clinic seeing patients, maybe they’re not thinking, “Why am I seeing more patients of color in my clinic with COVID?” Research on public health requires attention to the why. We see these different patterns in COVID rates, not because of genetics or biology but because of structures that we have put in place. And therefore the optimist in me says there’s something we can do about it.
Mazer: I’m kind of the target audience for the New England Journal of Medicine. I’m a medical practitioner who wants to keep up on the big advances of the field. And so I was excited to read this paper specifically because of its high-quality natural experimental methods. I saw this was a really good methodology. And then I get to the discussion section, and I found it both interesting and a little jarring. It didn’t necessarily seem to connect very much to the purpose of the paper, which is to evaluate the impact of a particular social intervention on rates of COVID.
I was really struck by the references to capitalism. Masks don’t really have to do with capitalism. I could tell from the discussion that it was really sincere and erudite, but I think it will end up being provocative. I want politicians to be able to take a step back from some of the political division and say, “Can we use good evidence to guide us in our decisionmaking?” Some Republican governors did that with COVID interventions, and I think that is the kind of person you should be targeting. Because you’re revving up some of these political divisions in the discussion, that message might get lost on people who otherwise would be receptive to it.
Linos: That’s a helpful point, and it’s one that we considered. There’s also the other argument, which is: You get a chance to put something in front of all of these doctors at a moment in time. After George Floyd’s killing, all the world is having these debates of, How are we thinking about racism? And in this country, unfortunately, racism and racial capitalism go hand in hand. It’s not by chance that the vast majority of poor people in our cities are also people of color. And so if you have an opportunity to give doctors and an audience that doesn’t get trained in social epidemiology a flavor of that conversation, the hope isn’t to close down the conversation. I hear your point that at times it could be jarring. I just think that when the COVID pandemic has unequivocally shown that our country does worse than other countries because of structural issues — the way that we don’t give low-wage workers the protection of sick leave, for example — these are debates that doctors should be having. If we’re not having the debates in medical journals, then we miss an entire audience that I’d like to invite into the conversation. And we need to be able to say the word “racism” in order to start dealing with it.
Mazer: In that sense, it’s to be applauded that you brought those issues to the fore, because here we are having this conversation. I think unfortunately you didn’t give yourself the room to really bring people on board and explain it. There are conservative doctors, Republican doctors, there are doctors who maybe don’t understand how a particular word is being used in a particular academic context. There was a focus on capitalism, on racism, on these unequal structures, but there was very little interrogation of our governmental systems, our policy systems. A lot of these inequalities are being produced by our democratic institutions, not by the free market. You guys brought up the very different quality of school infrastructure, classroom size, these kinds of well-known inequalities in education, and that’s a failure of government. I mean, these are government-run public schools.
Linos: Yeah, exactly. When we talk about structural racism, it’s around institutions and policies and government. Should public health be political? My answer is: Of course. Because government has the opportunity to solve a lot of these public health issues. And if we pretend that public health is not political and that scientific knowledge can happen in a neutral way, then we’re not interrogating the status quo, which has allowed the pandemic to have very different impacts on different people.
Mazer: I think the important distinction to make is between being political and being partisan. And I think much of public health has started to be seen as partisan, and I think that’s where public health has lost some people. You lost some trust. And it enabled political partisans to say, “Hey, the science is wrong because they’re just Democratic stooges and they’re not thoughtful, careful scientists.”
The pandemic does bring a lot of these structural inequalities to the forefront, but I think the idea that we were going to have a massive political change maybe pushed people to be more partisan — even on some of the measures where there could have been more agreement.
Ideas: Ben, you’re saying it’s one thing to identify the structural and thus political causes of health disparities, but it’s quite another to go down the road of suggesting policy prescriptions that are overwhelmingly or entirely Democratic policy goals. Natalia, do you think it’s possible for the public health profession to stop short of advocacy while being effective in the way you intend?
Linos: I don’t know if it’s possible. I’m very comfortable talking about issues that are unfortunately seen as partisan, like sick leave or maternity leave, which I don’t think are that controversial. Similarly on climate change, there’s a lot of data now around how fossil fuels and air pollution are bad for health. We can’t stay silent. I think it’s our responsibility to use our data and our institutions to show how different policies could be.
Now, you could accuse people like me of going too far. For example, we had a symposium at the FXB Center that asked: Could reparations close the white-Black health divide? Reparations are being discussed by economists, by historians, by others. A lot of people in public health may think, “This has nothing to do with us.” But part of me wonders, if you’ve dedicated your life to health and you’re seeing these health inequities, you can’t not be part of those conversations. Yes, at this moment in time, that is an issue that is unlikely to be supported by Republicans, but I’m hoping to normalize some of these conversations across different political viewpoints.
Mazer: I think there are two ways you could maintain a political aspect to public health without being seen as partisan.
One is the way policies are packaged. Many different ideas were put forth during the pandemic that started to hit on longtime Democratic goals. Many of which I agree with. But, you know, things like single-payer health care are not necessarily completely related to the pandemic, whereas something like sick leave — I think you would actually find a lot of agreement on finding some way of providing more sick leave to people. You may actually bring some Republicans over, at least at the state level.
And I think the other way public health could be political while being less partisan is to look at the outcome you want to change, some kind of disparity you want to close. Like with paid sick leave — there are different ways in practice to implement that policy along every kind of political philosophy, and they’ve been implemented differently around the world. Same thing with various public health interventions. Perhaps you could have given people a menu of choices and said, “Here’s a more conservative approach. Here’s a classically liberal approach. All working toward this outcome we think is important.”
Doctors are a very powerful political group. They are engaged in massive amounts of lobbying and fundraising and donations to political leaders. They speak out as a group, for important public health and medical issues, and of course for their own self-interest. So I’d like us to be able to use the political power of physicians to promote people’s health. And so I think if you want to better bring doctors into the public health realm as the political force that they can be, then you need to do what you can to remove those partisan signifiers and to find common ground.
Brian Bergstein is the deputy managing editor of Ideas. He can be reached at firstname.lastname@example.org.