The director of New Zealand’s Covid-19 response reviews Within Reason: A Liberal Public Health for an Illiberal Time by Sandro Galea.

The US and Aotearoa/New Zealand are both open democratic societies, yet their fundamental organising principle is quite different. In the US, freedom and liberty are central, while here in Aotearoa fairness (or equity) is the focus.

These contrasting organising principles are reflected in each country’s health system. In the US, the free market reigns; most health care is delivered privately and access to health services remains a major challenge for parts of the population, including the most vulnerable. New Zealand’s health care system is largely publicly funded and provided, with equity of access and outcomes a significant focus (and work in progress).

This historical context framed my reading of Sandro Galea’s Within Reason. This recent book, by an epidemiologist and dean of Boston University School of Public Health, is not about health care per se; rather it focuses on public health and the way that discipline responded during the Covid-19 pandemic. Central to the ideas put forward in this book is that public health is, and should remain, based on liberal values. These are defined by the author as those with “…roots in the European Enlightenment, a time when societies began to organize around reason, free speech, the pursuit of truth, and the preservation of liberty. Out of these values emerged liberal democracy and modern science.”

The author’s chief concern about the public health response to the pandemic is that many public health practitioners, especially those in positions of influence, “lost their way” during the pandemic, at times eschewing the discipline’s liberal roots that firmly anchor it in scientific inquiry. The book is arranged in a series of short, well-referenced chapters that build the case for a liberal foundation of public health, challenge the “heresies” that threaten to undermine this foundation, and chart a way forward to a more hopeful future that learns the lessons of the pandemic. 

I agree with the author that public health, like all scientific disciplines, is not a “values free” zone, and we need to be explicit about our values and why they are important. If liberal thinking is defined as thinking based on scientific inquiry and the generation of new knowledge that helps people live long and health lives, then it is indeed an important underpinning value for public health.

But equity, which is rarely mentioned in the book, is an equally an important and widely accepted public health value. At times, these values are in conflict – as they were during the pandemic when some actions (such as lockdowns or vaccine mandates) impinged on people’s liberty in part to protect vulnerable groups in the population. In many countries, including our own, the vast majority of the population understood the rationale for such measures, sometimes in the absence of a strong scientific underpinning, and accepted them with great grace and kindness. 

The almost exclusive focus on the US is a key limitation of this book. The response to the pandemic in the US became heavily politicised and communication to the public was visibly inconsistent and often confusing, which worked to undermine rather than build trust. This was clearly not the experience in some other countries, including our own, where there was a focus on open and consistent communication about the science and key decisions, including what was and wasn’t known. During the first lockdown in New Zealand, public trust in the government’s response was measured weekly and over 90% of people trusted the response. Between 2020 and 2021, trust in government increased in New Zealand, uniquely among Western democracies.

In my reading, the author tends to conflate the loss of trust in public health (and scientific) advice in the US with the way that advice was politicised. This politicisation occurred in many countries, at times including our own, but was a particular problem in the US where sound scientific advice was often questioned and sometimes frankly rejected. Post-pandemic surveys show that trust in scientists has not declined, including here in New Zealand, and they remain among the most trusted professional groups in society. However, I concur with the author’s warning: “If we are not making a good faith effort to follow the data, if we seem to suppress information because it is politically inconvenient, if we appear to wield power for its own sake, we diminish our field.” And, of course, we would quickly lose the trust of the public.

I also thought the author underplayed somewhat the extenuating circumstances during the pandemic: the fact it was the largest global security challenge since WWII, the need for sometimes drastic decisions despite huge uncertainty and limited evidence, the high levels of fear in the early days as we watched health systems become overwhelmed and large numbers of people dying each day. Even in less extreme times, political decision-making is not a linear process and scientific knowledge is just one of the inputs into it; values apply at all points in the process.

That being said, I thoroughly enjoyed this book; it is erudite, well written and thought provoking. I agree with much of what the author argues. I will be coming back to large sections of it to inform my own practice and teaching in public health. I would also love to have a discussion with the author to debate the ideas in his book, comparing and contrasting the experience of the pandemic in the US and New Zealand to see whether his arguments would hold or whether they could be strengthened. His ideas may make a great deal of sense in a society that values liberty über alles, but do they hold where equity is the main organising principle? Such a discussion would, I am sure, assist public health practitioners in their “pursuit of truth, and the preservation of liberty”.

Finally, many of the ideas put forward by Professor Galea contain wisdom for the VUCA world we live in – volatile, uncertain, complex and ambiguous. Uncertainty and chance are daily realities in all our lives. We would do well to grant our political decision-makers and those who advise them a little leeway in this regard before describing anything that doesn’t go perfectly to plan as a “failure” and every challenging situation as a “crisis”. As the author reminds us:

“The emergence of Covid was a reminder that uncertainty is always present. For this reason, a bias toward accepting uncertainty can help us to create a healthier world not only when navigating crises, but also when times are good. Uncertainty calls to mind our shared vulnerability, a vulnerability that persists at all times and in all places.” 

Within Reason: A Liberal Public Health for an Illiberal Time by Sandro Galea is published by Chicago University Press.