Just a quick note about something I’ve been thinking about… saving the Big One (my manifesto, if you will) that gets into similar topics in a lot more depth for tomorrow. Or perhaps later in the week — just depends on how productive I can be.

For anybody that doesn’t know (I do have some readers outside the US, weirdly enough), the US does have two “public” insurers, Medicare which primarily covers people over 65 and Medicaid which covers very low-income people. The Medicare Advantage program, which began in 1999 — although it wasn’t named Medicare Advantage until 2003 — essentially amounts to a privatization of Medicare. Medicare Advantage allows private insurers to offer all the same benefits that traditional Medicare offers, as well as some other stuff that isn’t covered by the core components of traditional Medicare. Enrollment in Medicare Advantage plans really started to take off after the passage of the Affordable Care Act in 2010, and has been growing especially quickly in the last few years. By 2018, the share of Medicare beneficiaries enrolled in Medicare Advantage private plans had risen to 37%, to 48% in 2022, and finally to 54% of all Medicare beneficiaries in 2024, some 33 million people.

The Medicare Advantage “space” is dominated by a small number of private insurers, with Humana and United Healthcare insuring nearly half (47%) of all Medicare Advantage enrollees in the country. I am going to write more about the behemoth that is United Health Group (which has an insurer, United Health Care, and another business unit, Optum, which aggregates a number of different businesses under its aegis), but briefly: United Health Group has grown via aggressive acquisitions over the past 10-20 years to make up a huge portion of the health care industry itself, and its profitability depends in large part on paying itself via deals between its different business subunits, a practice euphemistically termed “flywheeling” in the business press. More on this later — again, perhaps tomorrow. For now, I’m going to focus on the insurance side and Medicare Advantage.

The majority of enrollment in United Health Care has come from Medicare Advantage in the last 10 years, and Medicare Advantage is extremely profitable. According to this post, United Health Care “now takes in nearly twice as much revenue from the 7.8 million people enrolled in that program as it does from the 29.6 million enrolled in its commercial insurance plans in the United States.”

On the urging of a close friend I’ve been listening to and really enjoying the TrueAnon podcast. This past weekend I listened to an episode from Back in April (sorry the embedding is so weird here, I can’t just link it):

with Erik Davis, author of High Weirdness: Drugs, Esoterica, and Visionary Experiences in the Seventies and the Blotter: The Untold Story of an Acid Medium. It’s actually a two-parter but I think the second part may be paywalled.

Since Trump’s election and the appointment of his anti-science MAHA cabinet, there’s a Carl Sagan quotation I’ve been seeing floating around the internet in meme format:

One of the saddest lessons of history is this: If we’ve been bamboozled long enough, we tend to reject any evidence of the bamboozle. We’re no longer interested in finding out the truth. The bamboozle has captured us. It’s simply too painful to acknowledge, even to ourselves, that we’ve been taken. Once you give a charlatan power over you, you almost never get it back.

This is from Sagan’s 1995 book The Demon-Haunted World: Science as a Candle in the Dark. Sagan was writing in the middle of a specific New Age moment in the mid-1990s. His book reads like a tart episode-by-episode rebuttal of Art Bell’s Coast to Coast AM from the same year – topics addressed and dispatched as pseudoscientific or “baloney” (to use Sagan’s word) include UFOs, witchcraft, extra-sensory perception, angels, channeling, and so-called “recovered memories” (which featured heavily in that decade’s Satanic Panic). The core of Sagan’s argument is fashioned into what he calls a “baloney-detection kit,” essentially a popularized Scientific Method that readers can use to distinguish real science from pseudoscience and woo, to use logic to defang superstition, and ultimately, to widen the small pool of light, cast by reason, against the oppressive, encroaching darkness of ignorance and delusion.

It sure does seem like we need Sagan’s baloney-detection kit more than ever now. I’ve written extensively about the MAHA cabinet on this newsletter, and about the issues they’re concerned with, like anti-fluoridation and raw milk, from a very debunk-ey perspective that jives with Sagan’s project. I definitely intend to continue – anybody interested in whatever the hell is really up with seed oils? But even as I’m doing this, I’m doubting myself. I’ve been on this tip since the early 2000s, when I was rattling off facts about thimerosal, the preservative in vaccines that the now-retracted cornerstone paper of the anti-vaccine movement spuriously linked to an increase in autism spectrum diagnoses, about the need for preservatives in multi-dose vaccine vials, about how vaccines themselves work, to anyone who would listen. What did all this accomplish? Not shit.

Last week, Trump announced the appointment of Jay Bhattacharya to head the NIH — we all knew it was coming. I didn’t have any kind of plan or destination in mind when I started writing this a few hours ago; it’s not heavily considered, chewed-over, or edited, just some general thoughts about where I’m at today. Read in that spirit.

I don’t know what to say about Bhattacharya that I haven’t already said. Way back on October 11, 2020, Justin Feldman and I published a deep dive into the now-infamous Great Barrington Declaration, of which Bhattacharya was one of the three fringe authors — joke’s on us now, I suppose. I’ve done some smaller-scale investigations into Bhattacharya’s discredited COVID “seroprevalence study” (discredited and also corrupt — remember how a JetBlue executive funded it? to show that COVID was already widespread, mostly asymptomatic, and not very deadly, and thereby undercut the case for nonpharmaceutical interventions?) of Santa Clara County, CA. I could note that the scientific arguments characteristic of Bhattacharya’s COVID career explicitly contradict some of his earlier research, such as this 2010 NBER influenza modeling study that highlights the effectiveness of early adoption of “avoidance measures,” a.k.a. nonpharmaceutical interventions. If anyone reading this would be interested in a deep dive analysis of Bhattacharya’s scientific publications, email me. I’m happy to do it if people would find it useful. I’m not sure I find it useful for myself at this point.

I’ve talked about COVID as a political defeat. This is it. I’m so glad I didn’t become a professor of epidemiology. Don’t get me wrong — what I really want to be doing is teaching and writing. I’m still trying to figure out a way to do that; being a professor of epidemiology would not have helped. While teaching and writing are what professors in most disciplines do, it’s not the case in epidemiology. What professors in epidemiology do is write grant applications to the NIH to fund their own salaries and their universities. (As an aside, I think this contributes to the structural tendency of epidemiology programs to produce astoundingly ignorant graduates and to the structural tendency of the discipline as a whole towards irrationality, ignorance, and myopia. Since grant writing is the only metric of success, no one is trained or hired for their ability to think, write, or teach, only for their “demonstrated track record of securing extramural funding,” to use the tired stock phrase of every academic job description.)

Bhattacharya is about (to try, anyway) to take an axe to the NIH, which means that a lot of people’s careers are about to get a lot more precarious. It’s way more than just long COVID research that will be affected if Bhattacharya and the interests he was appointed to represent get their way — my intuition tells me infectious disease research, particularly of a population/epidemiologic bent, is possibly in big trouble. The experiences of the past several years have made me a bit of a nihilist about the science the institutions produce as well as about the institutions themselves. But this is really pretty bad. My guess is that a lot of academics who maybe signed the John Snow Memorandum out of some vague sense of wounded expert authority are going to suck up to Bhattacharya and reconfigure their research agendas to be more attractive to Bhattacharya’s NIH, once it becomes clear what the funding priorities of the institution will be under him. It’s understandable, but it’s sad.

Trump appointed Marty Makary as head of the FDA. Marty Makary is one of the peripheral D-list conservative baddies of the COVID era, kind of a Trump administration gadfly who came out hard against vaccine mandates especially. Here’s how PBS describes him:

Makary gained prominence on Fox News and other conservative outlets for his contrarian views during the COVID-19 pandemic. He questioned the need for masking and, though not opposed to the COVID-19 vaccine, had concerns about booster vaccinations in young children. He was part of a vocal group of physicians calling for greater emphasis on herd immunity to stop the virus, or the idea that mass infections would quickly lead to population-level protection.

The Centers for Disease Control and Prevention estimated that COVID-19 vaccinations prevented more than 686,000 U.S. deaths in 2020 and 2021 alone. While children faced much lower rates of hospitalization and death from the virus, medical societies including the American Academy of Pediatrics concluded that vaccinations significantly reduced severe disease in the age group.

Before surfing the COVID waves to minor Fox news celebrity, Makary was most famous as the first author of a 2016 “study” purporting to show that medical errors are “the third leading cause of death in the US.”

What is in Makary’s paper? I put “study” in scare quotes above because it is not, in fact, a study. The authors (Makary and someone named Michael Daniel) neither collected nor analyzed any data. They did not systematically review any literature, either quantitatively (pooling the data from each selected paper and analyzing it as in a meta-analysis) or qualitatively (as in a narrative review of the existing literature, its strengths or weaknesses). None of that shit. The paper is a two page — literally, two page — overview of four other papers on medical error.

Pour one out for Raw Farm and CEO Mark McAfee, whose business and livelihood depend on making people wretchedly ill with his company’s raw milk products. Santa Clara, CA county public health officials just detected H5N1 (bird flu) in a retail sample of Raw Farm raw milk taken from a Fresno. It’s nearly 9 PM where I am, so I am going to keep this brief, but: this is very bad. Perhaps I will do a longer post soon explaining in more detail just why this is bad. For now, suffice it to say, this indicates tangibly increased risk of a so-called spillover event. Right now, H5N1 isn’t very good at infecting humans, and the people that have been infected have been (overwhelmingly but not totally) people who work very closely with infected animals. Viruses, as we have seen with COVID, increase their “fitness” to infect humans (and spread human-to-human) with increased transmission; one critical driver of this is the rate at which the virus’s genetic material mutates. (Mutation = variability, and variability is what the process of natural selection works on.) Not awesome news for us, influenza mutates very fast and very often. It’s a probabilistic game: any given individual mutation is unlikely to turn the virus into an airborne superbug, but every transmission — from bird to bird, bird to cattle, cattle to human — is an explosion of roulette spins, new opportunities for the virus to mutate. The risk gets higher and higher, the more the virus circulates, that one (or more) highly unlikely things might happen.

This is a huge reason why factory farming of chickens is the worst idea ever. It basically creates a crucible for breeding ever-more pathogenic strains of bird flu. Mike Davis (Z”L) wrote an entire book about this back in 2003 (it’s called The Monster At Our Door and it is quite good, maybe I’ll review it on here). Factory farming in general creates optimally hellish conditions for sparking off an influenza pandemic by concentrating different species of animals together in abject close quarters — influenza loves to recombine in nasty ways in pigs in particular. Conditions for human laborers on factory farms are nearly as dangerous and atrocious as the conditions for the animals — it’s an educated guess that there’s not a lot of PPE for these workers that would help confine any animal infections to the animals. (And American news has the gall to sniff about “wet markets” in Asia. Get a fucking GRIP.) Then, on top of this, in the dumbest possible timeline, we are getting dragged over the event horizon of another terrifying pandemic by scientifically illiterate kundalini cult Erewhon girlies who want to shit their brains out 24/7, the closer we are to Gwyneth, amen.

Pour one out for Emily Oster, who just last week wrote a New York Times article dismissing concerns about bird flu in commercially available milk. You know what would have killed the bird flu in this sample of Raw Farm milk? Pasteurization. Fucking dipshit. Pour one out for Jennifer Nuzzo, public health mediocrity (even by public health standards) and COVID waffler now at the helm of “The Pandemic Center” at Brown who is quoted in the LA Times article downplaying the risks of drinking raw milk but impelled by… some glimmer of conscience, maybe? (are you there, Gwyneth?) to say that “I personally would avoid drinking it.” Ya don’t say. (Nuzzo: “This isn’t surprising, given how quickly H5N1 seems to be spreading among farms in California and given the fact that these outbreaks on farms are being discovered in large part due to bulk testing of raw milk from farms.” How else would you propose we discover it, Jennifer? Might you put on, I dunno, your “pandemic preparedness” cap to think about this?)

Lmfao. I’ll let Mark McAfee — we NEED a deep dive into this dude and his whole deal, can anyone point me in the right direction? — have the second-to-last word here.

In my youth I was a punk and I especially loved the Dead Kennedys. The Dead Kennedys’ arguably most famous song is California Über Alles, a sendup of Jerry Brown’s (first) hippie-rightwing tenure as California governor from 1975-83 (“your kids will meditate in school,” Jello Biafra, in character as Brown, threatens in his warbly singing voice as the song reaches the chorus, “YOUR KIDS WILL MEDITATE IN SCHOOL!”). After Reagan’s election, the band recorded an updated version of California Über Alles for their 1981 In God We Trust, Inc., inserting some jazzy, louche, lounge-singing interludes between the blasts of power chords (waiting for Bon Appétit to release a recipe for the “Tricky Dicky Screwdriver,” which Biafra entreats the listener to enjoy: one part Jack Daniels, two parts purple Kool-Aid, and “a jigger of formaldehyde from the jar with Hitler’s brain in it”) and revising the lyrics to skewer the Great Communicator himself. The song also gets a new title: We’ve Got A Bigger Problem Now.

Well, folks, here I stand at The Limits of Rhetoric thinking to myself… we’ve got a bigger problem now. For years, I’ve been writing and speaking about what I see and believe in as “leftist” public health, a complicated, difficult story about public health and what it’s doing in the world, historically and in the present. I’ve been complicating the narrative to death, interrogating flashlight-in-face style the faulty assumptions of public health and biomedicine, arguing in an increasingly shrill and angry voice for a collectivist idea of public health that is regulatory, precautionary, organized around something other than the “valorization of value” (aka the profit motive) at the heart of the capitalist logic of everything. And I’ll be brutally honest, I didn’t really see MAHA coming, I didn’t take it seriously enough, I just ascribed it to more of the same in our fucked up economy of health.

Which, it kind of is, but with a sinister new twist. I have another post coming and mostly drafted about what it would mean to actually take this shit seriously rather than dismissing it out of hand as for a) crackpots, b) losers, c) stupid people, d) health economics-brained liberals. There’s a lot in there about science and science communication, but I’ll save that for later. Right now I think I’m going to try to back the fucking truck up and see clearly where we’re actually at now that RFK Jr. is in charge of HHS, Dr. Oz is in charge of CMS, and so on.

I’ve been investigating the Means siblings, Calley and Casey means, brother-sister team of health entrepreneurs that are some of the most visible proponents of the MAHA movement. (That’s Make America Healthy Again, for anybody that doesn’t know.) Apparently Calley is launching a newsletter on 12/19 which I will absolutely be signing up for. In looking at Calley’s webiste, I was really struck by something, though. Even though I know this dude is just an alternative health grifter, here’s how he summarizes what he has learned on his “journey”:

I promised a post about fluoridation. This is it. This may be the first of several; I won’t pretend to be familiar with any of the literature on this, whether on the health effects (detrimental or beneficial) of water fluoridation or on how fluoridation fears are an entry-level conspiracy theory. (Although, I have some anecdotal evidence — long ago I lived in Austin, TX and thought the Alex Jones/Infowars people who camped out in front of city hall protesting fluoridation were kind of campy and funny. Little did I know where we were headed.)

Leana Wen and Emily Oster both wrote about fluoridation last week, Oster in her New York Times piece and Wen for Amazon house rag The Washington Post. Their points are almost identical, which should alert you to the level of effort these brown-nosers are putting into their public intellectual output.

Both mention that European countries stopped recommending fluoridation. Hmm, can we think of anything that is different between European countries and the US of A? Here’s one: nationalized health care. In the US, dental insurance is separate from health insurance, and both are private. (Fun fact, I got two wisdom teeth extracted with nothin’ but shots of Novocain because I had no dental insurance — paid out of pocket for the extraction — and my crappy health insurance didn’t cover nitrous oxide.) Dental care is a crisis in the US, and if the legislative panels convened to worry over it don’t convince you, may I point you in the direction of the huge repository of memes about teeth as “luxury bones”? In this context, where kids go to bed suckling on bottles of Mountain Dew (is RFK gonna do anything about those Big Ag corn subsidies or are we just gonna get some kind of funky MAHA remix of the soda tax?) and many can’t go to the dentist at all, might the value of something like public water fluoridation be evident?

Anyhow, this post isn’t going to focus on that. This post is going to focus on how to read a study. Both Oster and Wen cite the same study, from JAMA Pediatrics (scoffing here because people think JAMA is some kind of prestigious journal when in reality the statistical review is shit-tier and the journal publishes mostly dreck from unqualified clinical personnel under tremendous pressure to churn out research, no matter what it says, in order to move up the rungs of competitive medical training), purporting to show an association between prenatal “fluoride exposure” (this is, I will state up top, not what the study measured) and child IQ.

Sorry! Insomnia brain still whirring. One more thing that I want to note: the elision Oster makes of the distinction between individual-level and population level constructs of “risk.” Here, again, is what she says in the article:

“There is no good evidence of any health benefits associated with raw milk. But the overall picture here is of a slightly elevated risk, and one that is in the range of other risks people take, especially for healthy individuals.”

BZZZZZT! Wrong! The population-level incidence of illness linked to raw milk is not an index of the individual-level likelihood of becoming sick from drinking raw milk. If you drink 100 bottles of raw milk and 99 of them are uncontaminated (or uncontaminated with a sufficient number of pathogens to make you sick), you won’t get sick. You might conclude from this that raw milk is basically safe because 99/100 is pretty good. The risks are low, on par with others we take in normal life!!! (or whatever horseshit she’s serving, it’s always an argument like that). But if the 100th is contaminated with E. coli 0157:H7, you will get very sick and you might get hemolytic uremic syndrome and/or kidney failure. It’s spinning a roulette wheel, but you have even less information than you do about a roulette wheel. A roulette wheel has 37 or 38 numbers. The combinatorial mathematics can get complicated, but you can work them out. You have no idea what is in a given batch of raw milk. There are very good reasons to suspect that it might be something really nasty. There are also very good reasons to suspect that with RFK Jr. in charge of the FDA, regulations on the productions and sale of raw milk are about to get much more lax. More spins of the wheel, more potential for bad bets.

Do not be fooled by the Freakonomics parenting lady scowling in the fugly MM Lafleur. She does not know what the fuck she’s talking about.

A minor personal update, I have been sober for just over a month (it’s less serious than it sounds) and this, my first un-self-medicated menstrual cycle in a long time, is kicking my fucking ass with insomnia. I’m a lifelong insomniac and this is rough even for me. That’s why this is coming to you at 2:20 AM EST. I wrote this earlier today, before it was reported that Trump is appointing RFK Jr. to head HHS after all. Haha. All is well with me, this too shall pass, the way out is through, etc., but the world is pretty completely fucked. Nevertheless, I’ve still gotta work tomorrow, and you probably do too. After I send this I’m gonna make myself a lemon balm and valerian root tea (have you tried this shit? In normal, non-insomniac times it totally knocks me out) and restart my bedtime routine* over again for the third time tonight. Wish me luck, or don’t; whatever the case, I hope you enjoy.

We’re barely a week out from the election and Tweedle-Dee and Tweedle-Dum of the early pandemic, Leana Wen and Emily Oster, are back again. Both are in large national publications this week, doing exactly what they did with COVID: laundering fringe bullshit for respectable liberal audiences through the language of data. They shot their shot with Biden, bit the dust pretty hard, lost credibility, and now they’re trying again with Trump. Best of luck to these ladies!

About a year ago, I was working with a friend and colleague on a vague idea for a piece along the lines of "abortion is health care... and health care sucks!" I gave a guest lecture on some of the themes we were exploring, we both got busy, the piece (God do I hate the word "piece") never developed further. Well, now here we are, sitting with the "puzzling" result that ballot measures protecting abortion at the state level did well while Kamala Harris bit the fucking dust in the presidential race. What could explain this? I don't expect the Democrats to do any reflection on this, but here on Closed Form we can say and do whatever we want.

A few years ago I wrote a profile of Leana Wen (she's baaaaaaaack!). I didn't have much as much space as I would have ideally liked to go into a detailed critique of her tenure as president of Planned Parenthood, but I came to take major issue with her "abortion is health care" campaign. Here's what I wrote then:

In 2018, Wen left Baltimore to accept a new job as the sixth president of Planned Parenthood — the first Asian-American woman and the second doctor to ever hold the role. Less than a year later, Wen was dismissed from the position, with a flurry of news reports describing differences in vision and strategy for the organization. The most insurmountable differences derived, in part, from her center-aisle approach to business; Wen’s vision, in her telling, was to depoliticize abortion by rebranding Planned Parenthood as a general health-care provider. In Lifelines [Wen’s memoir], this is framed as a concession to sensible moderates, based on her previous interactions with some Title X grant recipients who were leery of attending meetings where Planned Parenthood would be present. “If Planned Parenthood was seen as too controversial,” Wen writes, “then reproductive health was at risk of becoming even more cut off from the rest of health care.”

Wen’s goal was to resituate abortion within the spectrum of “regular” health care, but she confused cause and consequence: abortion is siloed off from other health care precisely because it is so politicized, and it is politicized because of fundamental values conflict over reproductive autonomy. Thus, with longstanding political conflicts increasingly placing reproductive rights at jeopardy, the head of the single largest provider of reproductive health services in the nation was busy placating a phantom constituency of moderates.

Good morning to everyone out there in internet-land. I am having some nice strong coffee and listening to jazz, enjoying the golden sunshine of a daylight savings morning. I hope your Saturday is treating you at least as well.

In general, I really want to move away from writing about Covid, because it feels completely purposeless at this point in time – just inviting pain and judgment and hatred, which I already have plenty of. I certainly don’t want to write about the election; I’m no longer enough of a left-wing narcissist to think that my “analysis” is something anyone needs any of. But today I’m going to write about both, because there’s something going on that I think is interesting.

In the days since the election result was announced, I have seen a thread by a familiar Covid grifter circulating all over the internet. The thread is an evidence-less argument that pandemics lead to fascism. The examples in support of this are: the Great Depression, and hyperinflation in Weimar Germany* (only one of those things led to fascism, but whatever?) came after the 1918 influenza pandemic, and Donald Trump’s reelection in 2024 after the pandemic began in 2020 (Trump was already elected once before, pre-Covid, in 2016, but whatever?). The mechanism proposed for how these things happened is that they “brought eugenics into the mainstream” or some such. Obviously, this is not true. Eugenics long predates, and was mainstream long prior to, 1918. The ideology and movement first coalesced in the 1880s; the US state of Indiana passed the world’s first compulsory sterilization law for the “unfit” in 1907. In 1911, the Carnegie Institution – hardly a fringe outfit – released a report proposing several methods for removing the genetically unfit from the general population, including euthanasia by gas chamber. The connection between eugenics and fascist ideology is clear. What I’m saying is that this connection predates, and is only remotely and tenuously connected to, the influenza of 1918 or the Covid-19 of 2020.

I could take a weathered desire path here and argue that these analyses are politically dangerous in addition to being ignorant; that they misidentify the culprits, misunderstand the problems, point people galvanized to “get involved” down dead-end paths. Someone else can make those arguments. I want to talk about something weirder: the funky thread of esotericism running through the beautiful tapestry of the Covid grifter community and through its associated epistemological stance. I read a really fun paper by Susannah Crockford yesterday that reviews the “sociology of secrecy” in an analysis of esotericism, neoliberalism, and the Goop jade vaginal egg (my essay about Goop Lab, which covers some of the same ground, is here). The relationship between esotericism and what we now call science is long, complicated, and fuzzy, but for our purposes, some simple definitions will suffice.

Verso books, man. Why are they like this?

I picked up a copy of Justin Joque's 2022 book Revolutionary Mathematics: Artificial Intelligence, Statistics, and the Logic of Capitalism -- sounds promising, right? Wrong.

I wanted to like it. Obviously! This book is way up my alley, judging from the title alone -- in fact, at first glance I was worried that it had sort of scooped the idea for my own (glacially progressing) book project. But the book is simply, where the thread of argument is briefly intelligible, like a dark street illuminated by a flash of lightning, wrong. At least, this is my take on it about three turgid chapters (of eight) in. I've read three chapters, and I still have absolutely no fucking clue what this book is trying to argue about statistics and its relationship to capitalism. A few of my stray thoughts are below.

Joque describes a "revolution" in statististical inference which seems to refer to... a move to Bayesian inference? This is hardly a revolution. For one thing, the move to Bayesian inference techniques over the more familiar midcentury frequentist techniques is far from total. I guess many so-called AI models (which are really "machine learning," which is to say, statistical learning models) use some kind of Bayesian methodology, but if you look around, frequentist statistics are very much the norm (hah hah) in many other fields. I work as a statistician facilitating (really subpar) clinical research; I reside in, have my mail forwarded to, frequentist-land. I spend my days arguing with pompous surgeons about why a p-value doesn't mean what they think it means (I do not want to be doing this, so please, if you've got any job leads, or are looking for writers or book reviewers for hire, please reach out).

The 2019 version of me would have been shocked and horrified at what I’m about to say: Nancy Krieger is incredibly fucking tedious to read. I’m so over it. I’m particularly tired today (and particularly exhausted lately), but today is not the problem. I’ve been incubating an idea for this essay for months at this point — a take on Krieger’s arid 50-page 2012 paper “Who and what is a ‘population’? Historical debates, current controversies, and implications for understanding ‘population health’ and rectifying health inequities.” I haven’t published anything yet because I simply can’t get through the fucking thing. Even trying to say the title out loud is tiresome to the jaw muscles, like trying to break down a Tootsie pop. Not that I don’t have a high tolerance for boring text. (I’m a Marxist, after all. Ask me how many yards of linen to make a coat.)

I can barely even even bring myself to open the document again, honestly. It’s not even really necessary. Like all Krieger papers, the “argument,” if we can call it that, is an extremely pedestrian non-point buried under a sludge of dictionary definitions. (Literally. And if that’s not annoying enough, she archly close-reads dictionary entries for “population” according to a completely arbitrary and occult set of criteria — Miriam-Webster defines population this way, but they don’t specify exactly what a population is, that kind of grating vibe.) Here’s a quote from the paper: “Consequently, apart from specifying that entities comprising a population individually possess some attribute qualifying them to be a member of that population, none of the conventional definitions offers systematic criteria by which to decide, in theoretical or practical terms, who and what is a population, let alone whether and, if so, why their mean value or rate (or any statistical parameter) might have any substantive meaning.” Okay? What I want to get into here is… what are the epistemic assumptions, or the system of thought, behind the idea that having “systematic criteria” to decide “who and what is a population” is something that we really need.

At issue is the concept of population, “core to epidemiology” (as Krieger says) or some such nonsense, and a rather interesting story.

Have you ever thought much about what an average really is? It’s kind of a funny joke about the “average American” with 2.5 kids, which of course corresponds to no actual person, living or dead. The joke, which makes fractional children possible, is that the average is an abstraction, a reified statistical object, that we nevertheless endow with some kind of meaning or authority as a representation of a group of things. How did we get here?

Numbers have a qualitative dimension. Or, the same number doesn’t always mean the same thing. If we had COVID-19 transmission numbers (we don’t, and beware grifters trying to tell you we do), they would not mean the same thing today as they did this time in 2020. The population of the US has changed, the virus itself has undergone several transformations, we have vaccines and therapeutics now that we didn’t have in 2020. This makes the medical (versus the social) end of a pandemic highly ambiguous.

We saw some outlines of this with the fruitless “epidemic or endemic?” arguments that have circulated in the COVID discourse, less and less frequently in recent years. I’ve done some public-facing work around this and given a couple of interviews, the upshot of which is that epidemic vs. endemic is a qualitative rather than a quantitative distinction. By this I mean that there is no threshold of infection or transmission below which an epidemic disease becomes and endemic one. Diseases are rendered as endemic via a complex socio-ecological process — adaptations are installed or not, pandemic income supports go away, the business of life, for those of us still here, must go on somehow.

Other examples I can think of. COVID cases are certainly much more numerous than cases of locally-acquired dengue in the US, but the dengue is more concerning to me as an epidemiologist. At this point, COVID is the devil everyone knows; one dark cloud on the horizon, for me, is the recrudescence of mosquito-borne illness in the USA. (Another one is pandemic influenza… although the COVID grifters are trying to latch on to it, it’s mercifully not an emergency; not yet, anyway.)

Or, to use a non-infectious-disease example, pregnancy-related mortality. The numbers tell a jarring story: Black and Indigenous people are unnervingly more likely to die in pregnancy or childbirth than their white counterparts. These numbers have a qualitative dimension that is expressed in quantitative terms as “relative” or “absolute” rates of mortality. Relative to white people, Black and Indigenous people have extremely high risk. In absolute terms, though, even the demographic groups with the most social privilege (white people) have alarming rates of pregnancy-related death. Which is to say, Black and Indigenous people bear the brunt, but the picture is not good even for white people. What to make of this?

Good day, freaks — and my apologies for a lack of content over the last few weeks. I have several things I want to publish here in the works and I keep getting mired in perfectionism (which I do have the power to change) and life stress (which I don’t). So, thanks for hanging in there with me.

This is just to alert you all that both parts of the episode of Last Born in the Wilderness I recorded recently are now available. You can find the Soundcloud links to both parts at this page here.

To my chagrin, I didn’t know about this podcast until the host reached out to me to appear on it. It is fantastic — I’ve been catching up on past episodes over the last few weeks, and I highly recommend subscribing to the show on Patreon if you have a couple bucks to spare.

More of substance from me soon, I promise!

Quick note here. I wrote this a few months ago and am still kind of workshopping it. But I was revisiting it today and I think this fragment is sufficiently developed to send out.

A little while ago, I wrote some posts about Goran Therborn and ideology: here and here.

As I was reading Therborn’s book, and writing those posts, I (Carrie Bradshaw voice) couldn’t help but wonder: what is the ideology of public health? (In the interest of limited time, I am not going to rehash Therborn’s analysis in depth here. You can go back and read my posts if you’d like to, but basically, following Althusser, Therborn argues that ideology “interpellates” different kinds of human subjects; ideology is a process that subjectifies you and also qualifies you for certain kinds of social roles and responsibilities.)

Who does public health “subject and qualify”? What kind(s) of subject(s) does it interpellate? Immediately, I think there are already two distinct ways to talk about this: the ideological processes of public health interpellate 1.) public health professionals and also interpellate 2.) “the public” that public health is addressed to. Bringing Therborn back in, he argues that ideology interpellates human subjects according to: ontology (what is), possibility (what could be), and normativity (what is good or desirable).

Good morning, everyone. This is just a quick bulletin to let you know that my new radio show, A COURSE IN MIRACLES, starts today. It will be this evening (and every subsequent Sunday evening) from 5-7 PM, Eastern time. You can stream it at www.wrct.org. If your heart is tender or heavy then I hope you find the show as therapeutic to listen to as I do to put it together.

Till next time!

Though this isn’t its most vernacular meaning, “embodiment” has a second life as a term of art in a marginal subdiscipline of epidemiology, so-called “social” epidemiology. Depending on the day and my mood, I could articulate social epidemiology as the heir to some kind of real public health, before molecular medicine got in the way, or as the part of epidemiology that traffics the most cynically and shamefully in trauma questionnaires and DEI ambulance-chasing. It is supposed to be, I guess, the part of epidemiology that deals with social conditions and gives them primacy over individual factors like genotype or health behaviors. Social conditions are a hugely important aspect of population health and this is (or at least can be) a hugely powerful line of inquiry — look into any public health problem that is formulated as such (to be a public health problem is to be a technical problem amenable to technical manipulation) and there is a sense of vertigo as one realizes how deeply the roots of the technical problem reach into social organization and history. The concept of “embodiment” (in overwrought language about how “bodies tell stories”) is basically The Body Keeps the Score for the population health scientist — we in-corp-orate, quite literally, the social conditions in which we live. I, for example, embody the thick fug of particulate air pollution constantly lying over my neighborhood, which is a historically redlined one… you get the picture.

But, I have soured a little bit on social epidemiology in recent years. One reason is pretty obvious — this shit is not original. It might be compelling, but it’s not original. It might have been original for Rudolf Virchow in 1848, but it’s absolutely no longer in 2024, though people make interminable, monotonously prolific careers out of announcing over and over again that social conditions matter. Yes, I am subtweeting Nancy Krieger, the person who coined the term “embodiment” in its epidemiological application. I used to really love and admire Krieger’s work, but am coming to view it as quite unsatisfying. This is connected to another of my objections to social epidemiology as such right now, that there’s not really much “there” there. True that everything is connected to everything else. True that we are not isolated laboratory subjects. So what? What are we supposed to do with this information? How to actually link the insights derived from thinking about epidemiology through embodiment with actual practice of public health? It’s not clear, and the practice of social epidemiology seems to be little more than an endless iteration and explication of a familiar parade of social ills: capitalism, racism, environmental destruction, and so on. (Wouldn’t you know? All bad for your health!)

The last reason I will mention and the one I want to focus on is: the very existence of social epidemiology effects the same artificial severance of living individuals from social context that social epidemiology is (at least ostensibly) meant to mend. Are history and “social conditions” external to the human beings that constitute them? Is there any place for experience in public health? A very familiar reference point for me is Lewontin’s Gene, Environment, Organism — tl;dr, all three actively constitute and “make” each other, all the time. A very new and unfamiliar reference point for thinking about this stuff (for me) is Maurice Merleau-Ponty’s Phenomenology of Perception.

Merleau-Ponty makes use of embodiment in a different sense and to a different end, but one that I think is generative for thinking about stale public health concepts. His concern was a philosophical treatment of perception, and as far as I understand it, in Phenomenology of Perception he is trying to argue against both “empiricist” notions of perception (perception is a causal process of sense-experience or stimulus-response, for example, light of a certain wavelength striking certain receptors in my eyes and giving my brain the perception of the color red; unidirectional influence of world on mind) and “intellectualist” notions (my mind synthesizes different objects in the world into a perception of the color red; unidirectional influence of mind on world) in favor of a secret third thing, something like gestalt theory. From the Stanford Encyclopedia of Philosophy entry:

A couple of weeks ago, the Pandemic Mitigation Collaborative rolled out some updates to their models, which I’ve posted about before: here and here. Since then, I’ve seen Eric Topol, director of the Scripps Research Translational Institute and member of the National Academy of Medicine, cite the “one million cases per day” pseudo-statistic on PBS Newshour, which sucks. I’ve seen the figures from this model cited all over the news — in the absence of real information, grifters like Hoerger fill the void, and with the sorry state of media today, nobody is any the wiser and his bullshit claims get spun up and amplified into synthetic truths. It’s really awful to watch. I am critiquing these models as a PhD epidemiologist. This is exactly my lane, this is exactly my expertise, and people like me and our insights are being completely marginalized as the pandemic grifters crowd us out with fake data, hyperbole, truly horrendous and stigmatizing claims about “airborne AIDS,” and all other manner of dog shit.

The PMC published a “technical appendix” about the updates to their models. I reviewed the technical appendix and it is one of the most bizarre documents I’ve ever laid eyes on. So, in today’s bonus edition of this newsletter, let’s close-read it — or at least some of it (I will get to anything I don’t cover today, a Friday evening, at a later time). The TL;DR: Dr. Hoerger definitely read my previous posts (LOL) but doesn’t really have a response to any of the critiques in them, and the technical appendix doesn’t go far enough in elucidating exactly what their modeling methodology is or how accurate it is. I am repeating my call for the PMC to publicly share the code they use to run these models (this can be done easily on GitHub and is in fact common practice among working scientists, at least in epidemiology) and will reiterate it at the end.

I’m going to take it by sections as they appear in the appendix, with heading titles italicized and bolded and direct quotes of text from the appendix italicized. My commentary will appear below any text quoted, not italicized.

What’s new?