Which country did the best at the Tokyo 2020 summer Olympics? The United States led the way with the most medals: 113. China had nearly as many gold medals: 38 to the US’s 39. But are either total number of medals or total number of gold medals the best way to assess Olympic success? Both the US and China are, after all, large countries. As pointed out by The Guardian, San Marino, a country with a population of about 35,000, won three medals or, effectively, eight medals per million people, readily dwarfing the US and China which won 0.3 and 0.06 medals per million respectively. So, who did the best at the Olympics?
All of this is to say that the stories we tell ourselves about our success and failure can be quite different, even in the face of seemingly objective data—in the case of the Olympics, number of medals. This is always also the case in health, as much as in sports. And the same data can lend itself to quite different stories about our health achievement. The US spends far more on healthcare than any of its peer high-income countries. And yet, we have lower life expectancy at birth than our peers. One story of our health that these data tell is that we spend far too much and have less health dividend than we should. But, we also perform better than almost all of these countries for persons over age 75—when healthcare becomes most important. A story can then be told that we value our health throughout the life course, and that we spend accordingly, prolonging life, aligned with our national values.
That data are only part of any story we tell ourselves about our health has perhaps never been more evident than during the Covid-19 pandemic. We struggled initially with what our goalposts should be, whether we considered success primarily a matter of having lower cases or fewer deaths. Our data also told conflicting stories depending on the premium we placed on health equity. Early rapid success in vaccination—the single most effective means to mitigate viral spread—was also accompanied by racial/ethnic gaps in vaccination. In most states, white people received a higher share of vaccinations compared to their share of cases, leading to widening racial gaps in risk of Covid-19. Was that early vaccination achievement then a success, or was it a failure? And the vaccines themselves remained extraordinarily effective even as the more transmissible delta variant swept the country. Among fully vaccinated people, re-infection rate was less than 1%, fewer than 0.004% needed hospitalization, and fewer than 0.001% died from the disease. And yet, concern about the delta variant dramatically changed the public perception of our success in mitigating Covid-19 in the summer of 2021.
All of this teaches us that the same data can become the foundation of quite different stories. And as such, a reliance on the data alone to shape the narratives that guide our policy-making is a mistake. It teaches us that those who do science have a collective responsibility to generate data but also to help mold the stories that shape the public conversation and that ultimately inform politics and policies. Next week we consider how expectations play a sentinel role in that sense-making, in shaping the stories that emerge from the data.
Michael Stein & Sandro Galea
As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.
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