Review: Within Reason bySandro Galea

As Covid restrictions hit, bizarrely, my department at Harvard had an idea about the impending massive lockdown well in advance. The institute asked me to refrain from two international trips to academic conferences that had been planned for March and April 2020. Tickets had already been booked by the hosts. After realising that I was unwilling to cancel, the institute director sought a meeting. In a serious tone, he advised me to call off all trips. A week later, the US announced the lockdown. I was grateful since some of my colleagues were stuck outside, and could not return to their families in the US.

As 2020 progressed, Covid deaths mounted. I called my mother, worried about her health. She seemed unperturbed. When she fell sick, once, I requested her to visit a hospital and get herself tested for Covid. She did not. She did not trust the health system or the Covid narrative. She said that it seemed like a regular flu and that if she tested positive, she would be cordoned off. She did not want that.

I asked my cousin, who works for a rationalist, anti superstition movement, to help. He calmly explained that COVID-19 is merely a few days of runny nose and a headache and that they would manage. They did not get themselves tested. I was agitated by what I took to be my family’s right-wing attitude.

This narrative was largely prevalent in the area where they lived. People were afraid to go to hospitals as they were a site of death. They preferred home treatments. The reservation towards hospitals was due to a lack of trust in the medical industry and a history of exploitation done by doctors who prized profits over care.

In Nanded, a general practitioner told me that the prognosis of Covid and the dialogue around it had done more harm than good. His wife, a physiotherapist, was pregnant when she was asked to take the vaccine as a precautionary measure. A couple of months later, they lost the foetus. The doctor examined the Covid system and could find no conclusive evidence to support the vaccine and the state response. Still, since he works in the government health department and had been tasked with administering the vaccine, he felt heavy pressure to justify it to rural folk.

An NHS professional in the UK refused to take the vaccine. When he came to visit me in Oxford, I was wary. I donned protective gear and was irritated by his presence. He told me that nearly all of his colleagues have refused to take the vaccine. He shared a video of NHS physicians confronting the Health Minister of the UK. Nearly half of those in the video said they hadn’t taken the vaccine.

In the Balkans, where I went to attend a Vipassana meditation camp, I discovered many self-professed liberals and progressives who had refused to get vaccinated. Their argument was about being closer to nature; about not wanting to put anything that they were unsure of into their bodies. One retired mathematics teacher told me that nature and the body have their own remedies and she will not disturb that order.

None of these people are rednecks. They are highly educated and sensible. They are smart and are aware of their responsibility as citizens

For a while, all of this put me in a deep ideological flux. But the weight of that memory has been lifted. Sandro Galea, who heads the public health school at Boston University, has somewhat released me from this burden of having to choose between the commitment to an idea and the practice of politics. The two major divides that occurred during Covid times were singularly shaped by the ideological differences of the Right and the Left. Vaccines, economic divides, regional variations, and global catastrophes were all seen and examined through the lens of the Right vs the Left. The public health field, as the author puts it, had not seen such an unprecedented front-chair view of policy and politics.

My Covid story is personal but also social. Let me, for the sake of the current review, focus on the latter.

Dissection of American Public Health

I have been engaging with a crop of extraordinary public health professionals at the Lancet Commission. It was an awakening for me to be in the space of those who advocate such radical politics. It is one thing to see and observe the armchair philosophy of those whose vocation is to teach. It is another thing to see people involved in policy and general health carry this belief. This form of thinking at times causes harm. This is what concerns Sandro Galea. He takes the reader through small, accessible chapters on what happened during Covid to help his discipline recover from the extremities of ideological alignments.

Galea is an advocate of liberal thought, in science and rationalism that emerged from the European Enlightenment. Similar thoughts existed in the Buddhist canon too, and in the enlightenment led by subaltern caste saints and seers of medieval India. And though the concerns that Galea charts out speak largely to his colleagues, there is a message here for general readers as well.

Liberal philosophical thinking needs a revival. Explaining the downward trajectory of the moral grandstanding of health professionals, Galea states that doing the right thing for health is not always “the most popular in the moment”. He proffers many such nuggets of wisdom throughout the book, which is focused on laying bare the complex workings of the health profession by using sophisticated examples that appeal to conscience and logic. He also backs his arguments with credible evidence, facts, data, and analogies.

Telling it with hard facts and ideological supposition

Galea is interested in the question of mistrust, fear and apathy that his field of study has created, in irrationalism and illiberalism. What is illiberalism? What are its core values? Is being illiberal an anti-liberal position? Or is it a philosophical charge against a mandate that does not fit ours? The author poses illiberalism as a counter to liberalism but not as the rational practice of a constituency that find legitimate reasons of defiance.  

Looking back at the recent global catastrophe that has overlaid any preceding memories of global health epidemics, the author is concerned at the hyper-indecisiveness that has divided the quorum leaving many stranded. Given that the story is just a couple of years old, the rhythm to analysing what went wrong and what can be done in the future is a testament to individual choices over government-imposed arbitrary rules. Everything was done on the premise of a common fear. Fear is a space of illogical assumptions and exists among, both, elites and subalterns. But do those from protected backgrounds who have never experienced hunger and fatal episodes of fear overreact in comparison to a subaltern?

The provocations that Galea makes the reader engage with are too interesting to be ignored. His chapters include those that examine the question, ‘What is Left?’ apart from looking at suburban impulses, class, race, bureaucracy, sectarianism, power conflicts, borders, incentivising the narrative, and the attraction of social media, among others. The book is divided into three parts: Foundations, Heresies, Hope and concludes with a promise of liberal public health. He is scathing about his field of practice and the hypocrisies that endure in times of crisis. Covid is a nearer question for Galea, as he demonstrates that public health professionals announced policies based on “incomplete and changing information”. This led to the imposition of unwarranted draconian measures, which fueled tensions between communities and political camps. Naturally, the individual was profoundly impacted.

Galea is not too shy to take positions. He calls for social care for “the marginalized without neglecting the needs of the majority”. This is a position of classical liberal thought. He is able to defend his position by pointing out the nature of the shift of the marginalized to figures like Modi and Trump.

Liberalism, too, has had many pitfalls owing to its shyness to command action. As a result, it has given way to right or left-wing supremacy. At times, the divide betwixt the right and the left looks like the taking of particular positions solely because the other side has taken the opposite ones. Elite liberals want to regulate the social polity without harming their own privileges but by pointing out faults to others. This has created a strong base for the Right or the Left, who each accuse liberals of being in the opposite camp. But liberalism as an order of measured thinking need not be like this. It can have an independent position and ought to serve, in complete honesty, the needs of the poor and the oppressed. 

Galea could as well have written a monograph on political activism but he keeps the focus on public health. He shies away from taking long jumps because he wants to keep reminding the audience and perhaps himself too that he is still a public health professional.

A brave communicator, Galea has the style of a tutor who doesn’t heap his readers with unwarranted show-and-tell sympathy. When it comes to complex issues such as the economy, ideas, inequality, health, technology, policy, and politics, he is there, engaging the audience with parables. It is not difficult to be on board with him.

But the merit of the book also acts as a lacuna. The author does not give the public any prescriptive advice on do’s and don’ts. This is a bit jarring as the field is clouded by an inability to promote healthier food and lifestyles. Part of the problem is the obsessive creed of the American empire and the falsified dreams advocated to preserve the tsars of health – insurance, farming, pharma, and practitioners. Here, the author misses his chance to write a manifesto for the public role of public health.

Perhaps, a call to bring down injustice and structures of oppressive inequality would have been in order. The question to ask is what can taxpayers, the public health field, and activists do together to make life better rather than resign to the tortures of mental and physical violence that individuals undergo in America’s capitalist health system. I hoped to find a free Medicare option, which was primarily a liberal-conservative agenda of the first half of the twentieth century. Alas. To have socialized health care is to attend to the peace and reason that every government hopes to achieve in their tenure.

Suraj Yengde is a Du Bois Fellow at Harvard University and a DPhil scholar at Oxford University. He is the author of the forthcoming Caste A Global Story.