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The last sixteen months have been a terrifying crash course in risk calculation. There’s a particular exhaustion that accompanies trying to figure out which activities are safe, particularly when so much of the conversation ends up flattened into a good/bad binary. With roughly half of Americans vaccinated — how are we supposed to think about risk now?
Julia Marcus is an epidemiologist at Harvard Medical School and a contributing writer for The Atlantic. Her background is in HIV prevention, and her extensive research and writing examines how we ought to think about and communicate risk. For me, she has been one of the essential voices throughout the pandemic.
Marcus rarely issues a yes or no ruling on a behavior or scenario. Instead, she offers a framework to think about the hard choices we have to make. Her writing is deeply human and unceasingly realistic. It focuses on the ways that shaming backfires as a public health strategy — as well as the ways we tend to stigmatize and sacrifice pleasure for public health when we don’t need to.
When I messaged Marcus earlier this week, she mentioned that she’d stepped away from public life for the last few months. Like so many health care workers and public health professionals, she was severely burned out and felt overexposed. I asked her if she felt like talking about arriving at that place, and she agreed.
What follows is a lightly edited version of a long conversation about what it’s like to be vaulted into the public square during a dark and difficult moment. We also talked about this weird reentry period that the United States, in particular, is beginning — and how to shed some of the fear and trauma of the pandemic without leaving people behind.
During the pandemic you emerged as an an essential voice on a number of public health issues, informed by your own work on the HIV epidemic. You wrote frequently for The Atlantic and were pretty active on Twitter. But you’ve pulled back. Can you talk about that?
The last year or so took a toll on me. One way to deal with that was to stop writing and doing media interviews and tweeting and hide out a bit. I’ve been doing that and it’s helped. I’m trying to focus now on my usual work and research and less public ways I can be helpful.
Did inserting yourself into the Covid culture wars burn you out, specifically? Or was it a combination of everything? The work you did was so focused on the polarized elements of the pandemic, like masks. I imagine it was taxing. Plus, I think a lot of people forget that on top of going on podcasts and writing magazine stories and tweeting that you also had a full time job.
I think it was all of that and more. I never intended to be a public facing person. It doesn’t suit my personality. It was not something I sought out. I have found it really hard to engage publicly, and that’s been exacerbated by how fraught these issues have been. I think all the suffering and the relentless conflict between scientists, between scientists and the public, among the public — all of it, really, just was quite challenging for me.
Over the last 18 months I watched a number of scientists and epidemiologists and infectious disease experts go through the same process I went through when I started writing online and engaging on Twitter. They got thrown into this media ecosystem with all the algorithmic rewards and all of the risks and exposure and toxicity. And I feel like I watched a lot of public health people struggle to adapt to this. Some fell victim to what we in the media fall victim to and leaned too hard into the engagement. You want to get in there to do the right thing but it’s also addicting and feels a bit like a game and you can lose yourself a bit. How was it for you?
It was an overnight process for me. It was so jarring and surreal. In May of 2020 I tweeted something and an Atlantic editor asked me to write about it. The piece came out and by dinner time I was on Chris Hayes’s MSNBC show. Before that day I hadn’t heard of Chris Hayes. I didn’t have a TV. I’d joined Twitter in 2019 to quietly tweet about HIV, which is my research area. It was all quite unexpected and not necessarily desirable. But I felt a sense of obligation to use my new platform to try to shift narratives, advocate for certain approaches, and do my best to contribute to the pandemic response. I know that I didn’t always get it right. I wish I’d emphasized some things more or less. And, frankly, the stresses of the pandemic have affected my resilience, which may be true for others, too. I feel like the experience of doing public facing work would have been easier if I’d had the social and professional support I normally have. It’s been rewarding and meaningful in many ways, but has also made me feel vulnerable and often quite anxious. The best way for me to cope with that, for better or worse, was to get really quiet.
That’s so painful but I think it’s also a healthy impulse to disconnect. I know what it’s like to get hooked on the feeling of, ‘I have an opinion and this audience and I’m gonna throw it out there and get immediate feedback on the always-on bad faith internet machine.’ There are some medical professionals — I won’t name names — who I look at and say, ‘oh no they can’t log off.’
There’s a lot of conversation right now — some of it around the “lab leak” hypothesis — about this distorted notion of scientific consensus that got created as a result of so many people joining Twitter or being very vocal in the press. There’s an odd thing that happens where well intentioned people were talking about how we need to trust science but there were also moments where false consensus emerged as a result of that. I’m curious how you think about this. As a journalist I felt so hamstrung by wanting to inform people and help build public trust but it can also flatten the discourse so there’s no easy way to dissent.
I wonder how much social media contributed to that flattening. I’m fairly new to Twitter but it’s felt to me that the people who are amplified in news media as experts are often the people who have large followings on Twitter, which creates this feedback loop that can build a false sense of consensus. And that makes it very difficult to put forth alternative perspectives. It’s hard to imagine how the pandemic would’ve played out without social media but it feels to me that social media contributed to an unhelpful polarization of the discussion.
I’ve heard public health people say that before everyone flocked to social media a lot of these scientific discussions were happening on private listservs or messageboards and in those spaces there was room for disagreement or to express a greater spectrum of doubt. It was a safe space. And then the discussion moved into the public and it was distorted. Is that true in your experience?
Twitter rewards certainty. How often do you see a tweet go viral when somebody is unsure about something? And it’s an addictive process. Certainty is rewarded, high emotion is rewarded, especially anger and fear, and it’s a self-perpetuating phenomenon. When the scientific discourse largely moves onto social media it begins to degrade. I think it moved to social media because it was the easiest way to get the word out, and because so many scientists were working at home and social media provided a forum for conversations in their fields. But sometimes it has felt more like a middle school cafeteria than a scientific discussion. And maybe the middle school cafeteria was a happy place for some people but it wasn’t for me!
You wrote a lot about public messaging and a lot of your pieces were a form of service journalism. But a lot of the polarization around the pandemic issues you wrote about didn’t really get better over time — sometimes it got more intense. Did you get discouraged?
I think over the past few months I started to feel that my efforts were more futile than they were last year. Earlier I felt a sense of contribution putting my thoughts out there and saying things based on my research experience that felt semi unique. Eventually, I got to a place where I was questioning everything, and even whether I should be saying anything at all. Maybe that’s simply the burnout talking. Or, again, that lack of resilience I have felt. But I also think that our social patterns and the politicization of the pandemic response felt more cemented over time, and that feeling of futility kicked in.
Which brings us to right now. I’m curious how you’re thinking about this moment where so many people are getting vaccinated and rightfully trying to claw back some parts of their pre-pandemic lives. And then there are people who are (also rightfully) traumatized by the last year and not ready to move on. There are so many feelings out there right now — excitement, exhaustion, fear, resentment and mostly confusion about how to safely live right now. It feels like no one is wrong and everyone is wrong.
This is an awkward moment. People have had vastly different experiences of the past year — from minor inconvenience to full blown trauma, and there are a lot of stressed out people in between. In some ways, nothing’s changed. People are continuing to judge each other’s behavior: they’re either moving on too quickly or not quickly enough. Compassion on all fronts would probably go a long way.
I think, though, that it’s important to differentiate between peoples’ individual behaviors and what policies need to be in place. As a public health person I think about both. The online and media discourse has been so focused on individual behavior — for example, the whole, ‘why are you still wearing [or not wearing] a mask outside?!’ debate. It’s often questions about what individuals are doing. But policy is so different and subject to its own distractions. Take outdoor mask mandates, which have had an outsized focus. There’s this visibility bias, I think. We focus on things we can see and control, while the real risks — in workplaces and households — remain out of sight and largely unaddressed.
I think there’s a very valid concern right now that if some people move on and feel that the pandemic is over, others will be left behind, and that Covid will continue to circulate in the fall and winter, especially in disadvantaged groups who haven’t gotten equitable access to vaccination. Policy-wise, we need to focus on vaccine access and not get complacent. Cases and death rates are going down nationally, and that’s excellent. But when you actually look at what’s going on in some communities, especially Black and Hispanic people, you see lower vaccination rates that are concerning. And that could come back to bite us. I think some of the heated discourse around peoples’ individual behavior comes from the fear that allowing people, especially those with power and privilege, to feel the pandemic is over will result in less urgency around the workplace protections and vaccine equity efforts that are still needed domestically and globally.
That fear resonates for me. But I also feel that there’s some conflating happening. In the end, whether people wear masks outdoors or enjoy post-vaccination freedoms in their personal lives has little to do with whether there are continued efforts to increase access to vaccination. I’m not sure that asking people to hold off on pleasures that cost other people nothing is a winning strategy for engaging them in efforts to advocate for those still in need.
It’s such a difficult needle to thread. We’ve talked all pandemic about how it’s treacherous to craft policy that’s designed to produce a specific behavior in people. It doesn’t always work!
It’s such a difficult balance. Take the CDC’s recent messaging about masking for vaccinated people indoors. They really did try to create evidence based guidance and many people slammed them for it. I critiqued the guidance as well because I felt they hadn’t communicated it in a way that thought through the social ramifications of vaccination-tiered rules in public spaces. Ultimately public health policy is being implemented in the messy reality of human beings lives and social structures. There has to be some anticipation of how people will behave and how policy will affect the most vulnerable groups. But guidance should also be rooted in scientific evidence. It honestly feels like the CDC can’t win right now.
I felt that way writing about Covid issues over the last year. That any good that might come from a piece of service journalism would be countered by people using it as ammunition in the culture war.
I’ve also felt that way when putting things out in the world and watching the response, including the ways my work has been distorted or weaponized in ways that I hadn’t intended. And it’s also true on a policy level. At times, I’ve felt paralyzed in this pandemic about the inevitable tradeoffs involved in every decision. After we moved past the initial stage, when it was clear there was a failure to contain the virus, we were faced with a lot of policy options that were suboptimal. Schools are one example: there are competing risks with every policy choice. Of course we still have to figure out the least bad option and take action, but I personally have had moments where I have felt hesitant to take a stand because every message or policy is inevitably going to leave someone behind.
A lot of your writing around the pandemic as well as your research deals with the effects of stigma. I’m wondering if you have any lessons to share with us as we reach this tricky phase of gentle reentry into society. For example, I have a friend who has spent the last 16 months totally isolated with his family for medical reasons. He’s now vaccinated and told me he felt just an extreme amount of guilt the first time he left his family to be with friends. He knew it was nonsensical but still, he felt like he was betraying them by having fun without them for a few hours. And it felt like one tiny example of the peculiar ways that our trauma will manifest.
This is a major transition time. Half the population is vaccinated. There are a lot of psychological adjustments that need to happen after a year of loss, fear, illness, isolation, and hearing over and over again that being close to other humans is risky, selfish, and irresponsible. Many of the things that bring us joy were risky over the last 15 months, but enjoyment also got somewhat confused with risk. There’s a pre-print study that came out recently showing that people perceived morally good activities as less risky and morally questionable activities as more risky — even if the two activities actually had similar risk. That’s a lot to recover from and unlearn.
As far as lessons from history — there’s the concern I mentioned earlier, that the people with the most privilege will declare the pandemic over at the expense of others. To some extent, that concern became a reality in the HIV epidemic. There’s a perception that HIV isn’t much of a problem anymore, but the CDC estimates that half of black gay men will acquire HIV in their lifetime. So, if you’re saying the pandemic is over...who is it over for?
This is tangential but I’ve been thinking about my friends who are gay men who started using PrEP when it first came out, and the complex emotional and physical experience of having sex without a condom after a lifetime of being told that condomless sex as a gay man is risky and could result in a potentially fatal disease. From what I understood from their stories, there was a lot of guilt and shame and fear and anxiety wrapped up with this euphoric experience of freedom. I’ve been thinking about that a lot with the transition from masks and distancing to vaccination. The initial response to PrEP was, ‘you can’t do anything differently in your lives.’ Just concern, caution, and fears about irresponsible behavior instead of celebrating this amazing new intervention. Initially, the response to Covid vaccines was the same: don’t do anything differently. Fortunately, the discussion evolved on vaccines and there now seems to be an understanding that people need to be able to change their behavior, as long as that doesn’t put unvaccinated people at risk. Unfortunately, the CDC has not evolved as much in terms of PrEP. I was on a webinar yesterday to give the CDC feedback on their new draft PrEP guidelines and they still use the old playbook, saying that PrEP users must continue to use condoms because PrEP is only 99% effective. It’s been 7 years since their first guidelines, and they still feel so detached from the reality of why many people want PrEP.
Ultimately, I think puritanism contributes to a lot of poor public health messaging and policy. There’s a sense that it’s unimportant or even wrong to want to have pleasure for the sake of pleasure, when it’s actually a human universal and can be critical for health and well-being. I think that contributed to some of what we saw during Covid, too.
I wanted to ask you about the reputation of public health post-Covid. Publicly and privately I’ve had officials tell me they are concerned that people will emerge from the pandemic with less trust in public health officials and institutions than when they started. What’s your take on that?
I’m a bit worried about it. I think public health professionals by and large have done their absolute best and worked their asses off and tried to contribute as much as they could. That includes government workers, clinicians, academics, and everyone in between. There are unquestionably things we’ve gotten wrong and lessons that will need to be learned. And there are ways that the lack of public health infrastructure and funding limited what could be done. But there were also politicians making decisions about public health policy that weren’t always based on public health advice.
I think some of those decisions really hurt trust in public health. I see this all the time on social media and in op-eds. People talk about policy decisions as if they are coming from Big Public Health, whatever that is. The decisions they’re talking about were likely informed to some extent by public health, but they were also made for political reasons and shaped by structural factors, including capitalism and racism. So there will be some warranted loss of trust and some unwarranted loss of trust that will take time and effort to repair.
Before we end, how are you feeling about the summer. How will you take time to build back that resiliency you say you lost this year?
I have two little kids, so my overarching feeling this year was of being both extremely isolated and never alone. My dream — the ultimate thing I want — is to be in a crowd but not tending to anyone’s needs. I’m fully vaccinated as of today so I’m just embarking on this new phase. Human beings need to be close to other humans. I’ve been so fortunate to have the company of my wonderful family, but I really need to be around other people, too.