Our Institutions Have Long Covid with David Wallace-Wells

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The Supreme Court issues a series of blockbuster rulings with huge implications for reproductive rights, environmental justice, the regulatory state, indigent health care, and the overdose epidemic. And the Surgeon General declares gun violence a public health issue. This is America Dissected. I'm your host, Dr. Abdul-El-Sayed.

Friends, I missed you last week. It's good to be back. And before I get to the meat of today's episode about the ways that the pandemic has changed the very fabric of American life, I've got to speak plainly to the elephant in the room. We're still reeling from a presidential debate of epic proportions, and it was one of the most disappointing displays of public leadership I've ever seen. We talk a lot here about the interplay between society and the ways it gets under our skin to shape the function of our organs, our tissues, and our cells.

If public health is about communities coming together to take action that promotes our health, then democracy itself is the foundation of meaningful public health action. And after the presidential debate we all watched on Thursday, it's hard to have a lot of faith in the choices our democracy is offering us right now, and what that means for our future. This isn't a politics podcast, so I'm going to leave the horse race to others that are. But as someone who believes deeply in the vital need for our democracy, we simply should not be forced to choose between one man who is lying to all of us and another who is lying to himself. We shouldn't be held hostage to the ego of a well-meaning, if self-deluded, president, lest we find ourselves at the mercy of the ego of a craven would-be autocrat.

Which gets us back to our subject today. Because last Thursday wasn't the first time Joe Biden and Donald Trump debated. The first time was four years ago, when we were heading into the worst pandemic in modern history. One that would ultimately take the lives of over a million Americans and indelibly change life for the rest of us. And the fact that we're watching the same two dudes duke it out again, in this case about golf, in some respects is a reflection of our inability to move past the bizarre world that the pandemic has created.

One of the most important features of my childhood, as a third-culture kid, growing up in the U.

S. with a summer toehold in my family's homeland of Egypt, is that I was given a split-screen of sorts. Having the opportunity to compare and contrast life in America with life in Egypt. That split-screen offers a perspective on what makes America what it is. It's easy to attribute the quality of life that Americans enjoy to the wealth and power this country wields.

But there's something more that was always so obvious. Something that most Americans, though, take for granted. And that's the quality of our institutions. Whether a Little League baseball team, a small business, a trade union, or a Fortune 500 corporation, Americans invest in institutions. In building them, maintaining them, and holding them accountable.

And it's nothing new. Back in 1835, de Tocqueville wrote about the Americans' peculiar, quote, spirit of association, which he tied to the democratic ethos he observed here. He said, and I quote, When citizens can associate only in certain cases, they regard associations as a rare and singular process, and they hardly think of it. When you allow them to associate freely in everything, they end up seeing in association, the universal, and, so to speak, unique means that men can use to attain the various ends that they propose. Each new need immediately awakens the idea of association.

The art of association then becomes, as I said, above, the mother science. Everyone studies it and applies it. Now me talking. That spirit of association has eroded, and the pandemic had a lot to do with it. While the SARS-CoV-2 virus itself infected people's bodies, the pandemic infected our institutions, giving them a form of long COVID that continues to ail them.

The symptoms of that institutional long COVID have hobbled everything from our workplaces to our media to, very clearly, our politics. David Wallace-Wells is a columnist and staff writer at the New York Times, where he's been writing on the post-pandemic reality in which we find ourselves. I was particularly intrigued by two recent columns he's written on, quote, medical libertarianism and teen mental health. While the two seem unrelated at first, both speak to the long tail of the pandemic, mistrust in the medical establishment and the isolation and retreat into our virtual worlds, respectively. And I wanted to have him on the show to talk about these topics and the erosion of our institutions in this moment.

writ large. Here's my conversation with David Wallace-Wells. Okay, can you introduce yourself at the table?

We'll talk a little bit about tech and teen depression as well. But you coined this term, a new age of medical libertarianism, which I just thought was really apropos of this moment. Can you tell us what that is and what that means to you, and then give us some examples of how that works?

And then in the pandemic, there were certain things that illustrated that. And then, I also think, actually certain things that undermine that critique. But the country as a whole, I think, came out of the pandemic for some reasonable reasons and some unreasonable reasons, frustrated with the rule of the American public health establishment, the perspective of our public health leaders. And, you know, as a result, in the aftermath of this, I think we have more and more people wondering whether they should trust an organization like the FDA at all. And particularly among sort of wealthy self, you know, they're not self educated, in the sense that they didn't go to college themselves, but they, in their professional lives, are also educating themselves about lots of new stuff on the Internet.

Feeling empowered to sort of decide, on their own behalf and even on the behalf of the people that follow them online, what might be worth experimenting with or what might not be experimenting with. And the piece that I wrote was focused on an experimental sort of vaccine that was billed as for cavities. And we could talk about the particular details of that treatment and reasons. it may be good to be skeptical of its promises. But basically, there was a kind of Silicon Valley investor who bought a genetically engineered strain of bacteria that a researcher had developed a generation or two ago and had failed to get through meaningful clinical trials for this purpose.

Bought it, set it up as a company in a charter city that didn't have any medical oversight in Central America, and then marketed it to his own friends in Silicon Valley, as like, this is the cure for cavities. So it had not gone through a successful clinical trial. It had not been approved by any by the FDA or any other American regulatory body. And it was being sold through a kind of a loophole that it was a health supplement as opposed to a treatment, even though all of the marketing material was like this will cure you of ever having getting cavities ever again. And I saw in the space of just a few weeks, this sort of frenetic, almost feeding frenzy of excitement among a particular subset of, they call themselves rationalists, but community around Silicon Valley, who take seriously, you know, statistical reasoning and are really trying to like outthink the rest of the world.

This incredible enthusiasm for this medicine, and then a huge number of them took it. And I just thought, you know, this may not be the most dangerous thing in the world, like maybe a few of them are going to get diarrhea, and that's bad, but it's probably not a catastrophic medical, you know, self-sabotage. On the other hand, it's really quite concerning to see so many well-informed, intelligent, well-connected, well-educated, well-networked people who were basically deciding that they weren't going to even wait for any American regulatory agency to weigh in. They were going to take medicine that nobody had tested, nobody had trialed, and just take it on faith.

And that was the prompt for the column. But the broader context, I think, as you're highlighting, is just as important, which is that in the aftermath of the pandemic, even though there are a lot of things we got right, I think to some degree, the country is not acknowledging all the many things that we did do well during the pandemic.

The country as a whole has emerged from that experience, really, really skeptical, really, really unwilling to take direction on medical issues from anyone. And even, in many cases, making it illegal for public health authorities to give direction. So in the aftermath of the pandemic, we've had more than half of American states have passed laws prohibiting state public health authorities from offering restrictions in the face of future pandemics. We just had a week or two ago, there's a bill going through North Carolina where they're trying to ban mask wearing, not ban mask mandates, which would be problematic on its own level, but ban mask wearing. So if you are an immunocompromised person, and you are still worried about the circulation of COVID or other diseases, and you want to wear a mask when you go into the supermarket, that would be banned.

And, as you know, same sort of news cycle, as we've been thinking about following the possibility of the threat of a H5N1 bird flu outbreak, you know, there's been a massive outbreak in American dairy cows, but it's only infected a couple of humans. to this point, we're worried it might jump, but it hasn't really jumped into humans. yet. The FDA, you know, put out a statement saying, you know, you may have heard, there's all this milk in American supermarkets that has fragments of this disease, but all pasteurized milk, we can very safely, very confidently say, you can drink, but don't buy or drink unpasteurized milk, we can't vouch for that, and it might be dangerous. And in the wake of that announcement, sales of raw milk, unpasteurized milk, spiked.

And it's interesting, because the tech curriculum, right, the implicit curriculum of technology, which is really around engineering, which is about identifying what does work, sometimes doesn't really apply when it comes to medicine, because there's rigorous approaches, because everything you put in your body has some adverse or can have some adverse consequence. And so we pay a lot more attention to what doesn't work. But what's interesting in the inverse, and like this, is the next level, which is the institutions built around science, right, and whether or not you give them credibility to be the correct or the interpreters on record of what science says, does work or doesn't work. And then there's a final piece here, which is around, who gets access to those institutions and who doesn't. And you raise this really important point about the pandemic and the vaccines, which to me is just crazy, because we develop these vaccines in a moment where we fundamentally need them to save lives.

And they come out in record time. And so many of the same voices we hear trying to engage in this medical libertarianism, poo-poo the outcomes of the vaccine trials and say, we just don't know enough. And then the same folks, right, will brush their teeth with a genetically modified bacteria, right, to address a problem. that is, you know, and dental caries and cavities are a problem, but like they're not imminently deadly in the same way that COVID was, and they're not spreading rapidly, they've kind of just spread at the level that they are. And we'll introduce this without any actual science.

And I guess the frustration that folks like me have, take away the institutional hats that I wear, is this is pick and choose, right? This is cherry picking science, which is not science at all. And a lot of these folks do this in the name of what they think of as science, which tends to be this like hacky version, which is like, I can get there faster. I don't need your fancy bells and whistles. And I guess my question to you is, as you've talked to some of these folks, how do they justify that, right?

Because if you're cherry picking the outcomes that you want, that's just not science at all. That's just cherry picking information. That's as good as anecdotes to me.

Judgment that's superior to the institutions and regulatory bodies that have managed these questions on behalf of the country as a whole for a very long time. And as I said at the outset, you know, or suggested at the outset, it's not as though these people have no legitimate complaints with the regulatory bodies that we have. There are drugs that have been approved that shouldn't have been approved. There are drugs that probably should have been approved that didn't get approved. And, you know, at the beginning of the pandemic, there was a real bottleneck with testing, in part because the FDA was insistent that they approve themselves or manufacture themselves.

Every test that was being put out, almost certainly that fed us back significantly in those early months. You know, there are reasons to think that the process for producing and rolling out the vaccines may have been also a little slower than was necessary. You know, it's possible that we could have avoided some of that initial winter surge, 2020-21, if we had gotten the vaccines out, say, six weeks earlier, which I think is doable and may have saved, you know, tens of thousands of American lives as a result if we had moved faster. So it's not as though I want to say the FDA is a perfect institution. I just think those are reasons to reform the bodies that we have, rather than say, screw it, I'm going to read a few blog posts online, I'm going to poke around a few academic papers that are not even in my field of expertise or specialty, and I'm going to decide myself what is good and just and safe.

For me, yes, but also for, like, the people to whom I'm communicating and advising. And I think that, yeah, I mean, I think it's quite concerning. In the case of the cavity, you know, the cavity vaccine, probably not, as you say, deadly, probably not, you know, consequential at great scale. But where it points is quite alarming and worrying. And it does suggest to me, you know, that we're heading to a place of really fundamental distrust and discord in which a great many people who should know better are in fact, turning their back on the wisdom of, you know, the wisdom of institutions.

And I say that, you know, even as someone who looks back on the pandemic and thinks, as I said a few minutes ago, there are a fair amount of things that we did relatively well there. I do think that Operation Warp Speed was kind of a miracle. It saved probably a few million American lives. It probably saved 10s of millions of lives elsewhere in the world. And though we have reasons to lament the vaccine rollout, you know, I always think it's important to remind people.

by the end of 2021, which is to say within the calendar year of the initial rollout of the vaccines, we had 95% of American seniors vaccinated and the vast majority of COVID risk, at least mortality risk, was concentrated in those seniors.

We would have done better, we would have had fewer deaths in the years that followed. But on some basic, you know, like, just sit you down in a room and ask you, you know, if someone had sat you down in a room and said, you know, in the spring of 2020, okay, we're going to get vaccines in six months. And like, at the end of a year, after that, 95% of seniors are going to be vaccinated, you'd be like, that's a pretty good deal. That's a pretty good performance. And that's where we ended up.

So I don't think that, like the pandemic itself was, like the public health disaster, that, narratively, we seem to have come to believe that it was. And that's one of the things that really worries me is that, as we move forward, not just fringe libertarian types in Silicon Valley, but a lot of good liberals that I know in New York, you know, a lot of good progressives came away from the pandemic, really distrusting Anthony Fauci, really distrusting the FDA and the CDC, and really reluctant, in the face of even hypothetical scenarios of a future pandemic, to do as much as we did the last time to protect one another. And that's especially tragic, because when I think about this history, I'm, like, you know, we, there are a lot of things we bungled, there are a lot of. there was a lot of trauma, there was a lot of death, and a lot of unfortunate political disarray, and they came out of the pandemic. But I think back on those first three, six months, and I think there was an enormous amount of human compassion exhibited by almost all Americans, and indeed, almost all people all around the world, changing their lives, upending their lives out of concern for their own well being and the well being around them.

And I want to remember that value, that set of those set of values and that behavior, because I want to recreate it in other areas. Unfortunately, I think the pandemic sort of has made us try to forget or pretend that never happened. And that, among other things, is a real, a real tragic outcome of this whole experience.

And I wonder, how much of this do you feel like is just a function of that curriculum that's been taught to us by social media, that, you know, rather than trust the institutions that have been out there, you really need to read this one guy who's been right about one or two things, or who did a great job calling out that major institution. Ergo, is right about everything. And they've got the true, true, right? Everybody else is just kind of playing to the incentives of the system. How much do you think that plays?

And what role do you think that has in shaping this, you know, this moment, as we watch, not just, you know, the medical establishment and institutions losing credibility, but institutions of all types in media and politics, in, you know, the universities, government, of course, what role do you feel like that has?

They've overstated that case, but there was some effort to suppress it. And yet they became out as like, they were, the big winners of audience over the course of the pandemic. These are the people who the American public seem to turn to more than the establishment voices who are available to them. And, you know, I don't want to say like, it's one side winning or the other, you know, we have, we have a lot of information disarray over this period. And there certainly are trustworthy sources who built large platforms for themselves too.

But it does seem to me, I think, as you're suggesting as well, that over the course of this period, we have a remarkable rise of contrarianism, which tends to be politically sort of center-right, or at least anti-left in its perspective. And that seemed, as recently as five or six years ago, to be an intellectually significant movement, but not a mass movement. And over the course of the pandemic, it's somewhat became a mass movement. And I think that on both sides of the equation, you know, you have people responding to that audience and, you know, and trying to serve them with, you know, messages they think they'll like. But you also have an audience that's becoming more and more eager to hear that the people who told you what to do those last couple of years got it all wrong.

And there, I think that there's a psychological phenomenon at play that isn't just about anti-institutionalism. It's not just about the particular criticisms of pandemic guidance or public health messaging over the course of COVID. And it's not just about cloud chasing. I think, as a country, we are really reluctant to see our experience of the pandemic. clearly.

We know we suffered. But we don't want to believe that that suffering was appropriate, because we don't want to believe that we would have to endure it again, if faced with the same set of challenges. And so we sort of want to pin the blame for the pandemic as a whole, on some authority or other, who we can, in theory, fire or replace, or some ideology or other, which we can, in theory, revise or sort of suppress. Rather than acknowledging that, like, the reason that we all had a tough 2020, that we were lonely and socially isolated, and anxious, and in some, in many cases, caring for very sick people, dying people. The reason that that happened was not because, you know, Tony Fauci cracked his whip and told everybody that if they stepped outside their apartments, they'd get arrested.

That actually didn't happen. It's because we were all scared and worried. And we behaved that way out of that fear and concern. But now, looking back on it, we don't want to acknowledge that we participated in that experience. We don't want to acknowledge that it was a reasonable response to the disease itself.

We want to pretend that it was not necessary, and that the people who suggested that we might do it are ultimately the ones to blame. And I think that there's a complicated, but really important psychological dynamic that's playing out now in America. Again, not just on the libertarian, right? Not just on, you know, in the Tucker Carlson world. But among a lot of people who five years ago, would have said, like, some public health official tells me what to do, I'm going to do it.

And now they think, I'm really not going to listen to those people anymore.

And Eric Kleinberg makes this argument that we really haven't dealt with 2020 in any real way. And it's like, rather than actually deal with the reality of the lack of agency that we, you know, in 2020, 2024, have over nature, right? And the ability for a virus you didn't even know existed to upend everything you knew. That, instead of dealing with that, we try to find some level of agency by knocking down the very thing we think failed. And what's interesting about this, though, is that I don't think it just starts with 2020..

I actually think that one of the reasons there is so much frustration with medical institutions and the medical establishment more generally, is the fact that people have found it lacking in the micro experiences that they've had with it. You know, no matter who you are, you're probably paying way too much every two weeks or every month for your health insurance. And then, when you need it, now, you're hit with a deductible, thousands of dollars to get the thing that you know you need. And then all of a sudden, some public health official says, well, you need this vaccine. And you're like, well, I'm feeling perfectly fine.

And when I needed my insulin, or I needed my you name the medication, y'all weren't there for me. Now you want to give me this for free. And I think that there is some aspect of the way that the financial incentives of this particular institution has almost set us up for this moment where people say, you know, I could do it better by myself. And I'm gonna go find that guy who's giving me the real, real advice, because clearly, this isn't working. And clearly, they're trying to fleece me.

of lack of, or one of the biggest predictors of, the probability of getting vaccinated early on was whether or not you were insured. And, and I think we have to deal with that. And those incentives, you talk about that a little bit in your piece on on GLP one agonists, and I'd love your thoughts on, you know, what it looks like to try and win back that trust in the context of economic incentives that have run wild.

And in many ways, they're not great, because the other side of it is that we've impoverished a lot of those provisions over the course of decades. We have let so many of the social determinants of health really collapse, so that we've embraced as a culture, a model of medical treatment, which is like the heroic doctor saving the millionaire from terminal four cancer. And we haven't embraced either at a funding level, at a mythology level, or at an individual experience level, we haven't really supported the things that make the health of everyday Americans better in a systematic way. And I think that almost everyone can see the injustice of that system, but also what it tells us about our own responsibility, how much responsibility we have over navigating the system ourselves. I think that's another thing that's contributing to a lot of these dynamics, making us feel like we have to make assessments of our own health and the risks and benefits of a particular treatment on our own, making it seem like we can buy our way to better care, rather than just, you know, the best thing you can do is listen to the doctor you have.

All of these things are, I think, quite, quite corrosive, and to some extent, mirrored, even in countries that have more extensive health care, you know, national health care or something similar, because there's so much of this sort of, you know, so much of the heroism of the individual doctor saving someone's life, and much less focus on, you know, securing the basic social determinants of health that we all know are so much more important. In the case of, you know, of obesity, and, you know, the Ozempic and its cousins, you know, I think this is a really interesting moment sociologically, in the sense that we have had for a long time, as you know well, you know, an incredible, expanding obesity epidemic in the United States. It's one of the main reasons why American health outcomes are so much worse than many of our peer countries. We don't even have an especially good handle on what's causing it. You know, when I was first reading about this, there was the simple answer was it's sugar, but our sugar consumption has dropped off dramatically, and obesity keeps going up.

You know, and, and we know that it's making almost every health problem that we have in this country worse. And now we have some drugs that seem to be quite promising in treating those treating that underlying condition much more effective, at least in clinical trials, than anything that's come before. But they're very expensive. They're basically not yet covered by any major insurance company. And in fact, it's not clear that insurance can cover them, because they're so expensive.

There are also other problems, you know, people seem reluctant to stay on them for a long time, even to get the benefit that we think we think they might they might offer. There are, you know, we're not totally clear about the long term side effects. So I don't want to sell them as a pure, pure miracle drug. But we have had this, this major, major problem, which is a huge part, you know, I'm sure most of your listeners know, America's health outcomes are considerably worse than you would expect, based on our, on our wealth and spending on healthcare. But just to put a few numbers on that, I've been speaking recently to some researchers who are, you know, just do this very basic math of comparing American mortality rates to rates across the other wealthy countries in the world, and saying how many more Americans are dying in any given year than would if we just had an average mortality rate for for the rich countries in the world.

And that number before the pandemic was over 500,000 Americans a year, which means 500,000 Americans were dying every year, that wouldn't have if we just had rich world average mortality rates. And now it's up over 2020 and 2021, we're, we're about a million. But now, even in the sort of post emergency phase of the pandemic, we're up in the 700-800,000 Americans a year dying that would not have otherwise needed to die if we had had mortality rates to match our peers. And a big part of that is obesity, it's not all of it, but it's, you know, it's one of the major, major factors. And we've been living with this, we've been confused by it, we've been unable to really address it medically or behaviorally over the course of 50 years, it just keeps getting worse as a problem.

And now along come these drugs, and they seem, like, you know, more promising than anything we've ever had before to deal with this issue. And yet we are in no position to provide them to the vast majority of people who need them most, which is to say, working people, you know, the less well off who are nevertheless struggling with serious obesity.

And you set up a really helpful framework that, you know, folks in epidemiology think through all the time. Is what we're seeing a function of a difference in the way we're measuring, or is it a function of something happening in the world? And, of course, that thing happening in the world that everybody, led largely by a psychologist named Jonathan Haidt, is arguing is the advent of mobile enabled social media. And I happen to agree with that hypothesis. But you make a pretty compelling argument about the notion that this might just be what we call ascertainment bias, or the fact that we're just measuring differently and therefore getting different outcomes that can't be compared to past moments when we were measuring in the previous way.

Can you give us the argument on both sides and sort of give us a sense of where you fall on it?

And, you know, I think that the fact that we are seeing more teenagers report depression and anxiety in a lot of parts of the world is genuinely concerning.

And my question is, exactly what does this tell us?

And I just have a lot of open questions about this. I don't want to say that, you know, there is no mental health crisis among teenagers around the world. And I don't even want to say that there's no relationship to the arrival of the phone. But I think that we've gotten into a place as a kind of a pundit class, you know, the group of people to whom I'm a part, of just sort of like chalking this up almost like monocosmally to the arrival of the phone. And I think that we know from our experience of the world, our, you know, our assessments of previous episodes of, you know, of suicide, of drug use, of, you know, when we see changes in social behavior, particularly among teens, over the decades.

And we rarely look back on those moments and say, oh, there was a huge spike in teen suicide in the late 80s, early 90s, because of this single driving factor. And we don't look back and say, you know, the overdose crisis that we're dealing with right now, which is really quite enormous, is down to a single, you know, a single cause. That there's, it's a complicated story. We may want to, you know, fault the pharma companies for rolling out OxyContin. That's totally legitimate.

But, you know, there are a lot of things going on that are making so many Americans addicted to drugs and making them ultimately die. of them. I mean, one, you know, including just the arrival of fentanyl and how it succeeded other synthetic opioids over the last decade. But when I spoke to researchers who study this, and so when I spoke to researchers who studied this material most closely, which is to say how teens are doing all around the world, they did not believe what had become completely conventional wisdom among the pundits and among, you know, other parents I know who are worried about the social media use of their teens. And they said, look, all of these global surveys show something about a flat trend in teen well-being.

Now, it's true that you're seeing some worsening well-being in northern Europe and the United States. And it's offset by improvements in well-being among teens in, say, South Asia and sub-Saharan Africa. And so you could say that there's, you know, there's a notable problem here, especially in the richest parts of the world. But that in and of itself starts to undermine the idea that we are seeing something that is so powerfully caused by phones, because everybody in the world has smartphones and everybody in the world now has social media. That wasn't true five years ago, but it is now, or 10 years ago, but it is now.

And if we're not seeing these trends everywhere, then maybe the story is a bit more complicated than just that. phones are driving teens to horrible depression. And the most reliable measure of well-being that researchers point to is not measures of depression or anxiety, as registered by physicians or in surveys, but the suicide rate. This is in the same way that crime researchers say you can't really trust burglary numbers because sometimes people don't report burglaries. Sometimes the police cook the numbers for their own funding reasons.

You know, the definition of rape has changed over time. So the number of rapes also reflects the changing culture of reporting. You know, all these kinds of things, you know, different crimes are reliable to different degrees. But murder is something that's like if there's a dead body, the police are going to pick up on it. They're going to register it.

And those are not perfect, but they're pretty close to perfectly reliable as a measure of violent crime, at least. And they say the same about suicide when it comes to mental health, that, you know, ultimately there may be sub suicidal problems that populations are dealing with. But if we're looking for a real distress signal, presumably we would see that it's the best objective metric that we have. Yeah. Yeah.

And in the U.

S.

, American teens are committing suicide more than they were a generation ago. There's been a pretty steady increase over the last decade. It is concerning. It is significant, but it actually is not any larger than the increase in suicide that we've seen across the population as a whole in the U.S., which is to say, there is a bit of a suicide epidemic in this country. It is distributed almost equally across demographic groups.

And teenagers, female teenagers, male teenagers, are not unusual in that respect. So they are committing suicide more than they used to, but they are not. The growth is not unusual to teenagers. And when you look around the world, actually, you don't even see that. You see almost nowhere else in the world are teenagers committing suicide more than they used to.

Almost everywhere you look, they're committing suicide less than they used to. And so if we're seeing smartphones driving a real epidemic of of of Christ, of meant really driving a mental health crisis, you know, in the sense that if anyone picked up a cell phone, they would be suffering as a result. Presumably you would be seeing this in the suicide data in Sweden and the Netherlands and the UK, and in Italy. And in fact, those international comparisons are helpful when it comes to the lesser measures, too, because while it is, I would say, more common than not in the rich countries, the world that we're seeing a growth in report reporting of depression and anxiety. There are plenty of outliers there, too, that where that is not the case.

In South Korea, for instance, they've their depression rates among teen girls have fallen in half over the last decade. And what the researchers told me, and what seemed completely credible and plausible to me, is that, you know, a big part of this story is that we have become much more attuned to the well-being, to questions of mental health and the well-being of teenagers. That's happened at a cultural level, which probably all of your listeners can, you know, they can they have experienced within their own lives or the lives of those around them, that people that, you know, a generation ago might have been ashamed or might not have been so eager to get attention from a, from a psychiatrist or psychologist. Psychologists are now getting that support. in institutions like schools.

You have much more proactive efforts to identify kids who are struggling and try to get them some medical help if necessary. And there's also been some sort of institutional changes along the way. So, you know, there was a change in when Obamacare was rolled out. It actually sort of recommended for the first time that primary care physicians screen teenage girls for depression for the first time every year. And that means that almost certainly there were more of those screenings and almost certainly, as a result, more people were diagnosed with depression than would have been before.

There were also some changes in the way that hospitals do their coding, so that even when people showed up at the hospital for accidents that were probably self-harm, a suicide attempt, it used to be the case that you would code that by saying, you know, here's the injury. You know, there's a, there's a cut on their arm, or it's a drug overdose, or whatever the injury was. And then, secondarily, you had the option of saying whether you thought that this was accidental or intentional. And many times the people processing that data just left that second column blank. And when they changed the coding protocols in 2011,, you saw at the national level, literally overnight, a doubling in the rate of self-harm in hospitals.

And so, for all these reasons, I think I come to this question with a fair amount of skepticism. I'm a phone user. I hate my phone. I think it's deforming my own life, my own emotional and intellectual life. When I see my daughters playing with my phone, I get really angry when I see my friends looking at their phones rather than talking to one another.

That frustrates me, too. I think this is obviously and arguably a major intervention in our social and emotional lives. I just don't think that the data is really clear for us to say at this point that we know that it's causing a mental health crisis, especially among among teenagers. And that's not to say I think we should hand a 12 year old, every 12 year old, a phone and say, go spend eight hours a day in your room. But even that example, I think, illustrates that what we're really saying is something much more complicated about social dynamics, about the way we, the way we spend our lives, who we're spending our lives with.

What are the tradeoffs involved in spending an extra hour a day on social media, as opposed to playing video games or as opposed to playing basketball, or whatever the case may be?

So, you know, I think about, like, you know, when I travel abroad, I look at people, obviously, they all have phones in their pockets. But when you're out at a restaurant or you're out walking, the number of people who are just sitting and looking at their phone versus engaged in a conversation is strikingly different here versus there. And I think you're right, right? It's not a monocausal argument, but it is about the context in which this thing hit us and the degree to which the companies who created the thing and are driving the thing are interested in pushing the thing on us. I mean, we are the most lucrative social media market.

And because of that, right, the amount of effort to fully saturate us is pretty big. And you talked about your kids. To me, like where the rubber hits the road is? I got two daughters. And I think about, right, it's like, what are going to be my rules of the road on cell phones?

And, you know, Sarah, my wife, who's a psychiatrist, and I basically have said that, like, it's going to be zero phones until you're like 16.

. And if that means that you're like the not cool kid who doesn't have a cell phone and you're like hankering to look at your other friend's cell phones, fine. But, like, I am a lot more interested in making sure that, whatever the danger may be, I have done my part to protect you from, right, versus being able to engage.

And then part of it is also, like, the way that it – I don't think, you know, you go back to theorist postman. And our minds aren't created to be able to handle all the worst news all the time. And, you know, I think about the way that I'm consuming the Gaza conflict, for example, right, and the suffering of children who look like my children in Gaza. And that is awful. And I think it's really critical in the sense that we all know what's happening.

And for the first time, you're seeing very clearly the imagery coming out. But I also think that it is having a profound impact on my mental health and the mental health of so many other people around me. Because we are not good at being able to leverage or change our engagement with something relative to our agency. And so that failure of saying I'm literally watching children be slaughtered in my face and I can do nothing about it day in and day out, I think, creates a space that is very difficult to occupy. And social media does that to us all the time, right.

I mean this is a particular, unique example of it. But, you know, I think about all of us who consumed the post-Trump news, right, all day and all night of, like, all the things we wanted to stop from happening and couldn't. And so, you know, it's those two things that I think are the most profound. But to your point, like to the point that we were talking about, maybe the most important thing I or you or any of us can do to protect our kids from the potential danger, whatever it may be, of it, is to build a compelling social environment for them to grow up in, right. Like I think about, you know, one of the most important things we do is, like, try and eat dinner together every night, right.

And I work really hard to get home for dinner because I want them to have that experience of, you know, talking about issues in a safe space and being able to know that they're loved and engaged with. And so those rituals that say real human contact is so important and valuable, and you should fight for it in your life, right, I actually think is probably the antidote, right. Because I want my kids, frankly, more than anything else, to look at a phone and be like, ah, this sucks, it's boring. Let me go, like, find somebody and actually engage with them in real life. And I think that's the place of control where most of us forget.

It's like, yeah, take the phone away, fine. But if you don't have something that's compelling and the phone is the most compelling thing, then that's where people are going to find themselves. And I actually think the challenge for us is that we have created a society where there's nothing that really competes. And, you know, and then people fall into their phones and then fall into all these traps and then don't have an alternative to be able to go to.

it feels in many ways like, yeah, we're a country that's very vulnerable to many of these challenges. And it probably shouldn't surprise us that if there were something being triggered by social media use and phones, we'd see it most dramatically in the U.S. In the same way that it shouldn't surprise us that among the rich countries of the world, our COVID outcomes were so poor.

Among those dissenting was Justice Katanji Brown-Jackson, a liberal justice, who dissented in part because the court refused to take up the case on substance. Arguing in her dissent that the Idaho ban clearly violated federal law, allowing the court to, quote, avoid issues that it does not wish to decide. On similar but somewhat opposite grounds, Justice Alito also argued that the court should have taken up the case on its merits, predictably arguing that the, quote, patient that the federal law should protect is the, quote, unborn child. I agree with Justice Jackson here. I worry that in this case, just like the case involving Miffy-Pristone before it, the court is rather conspicuously leaving the door open for less complicated cases.

In the Miffy-Pristone case, the judges again failed to rule on the substance, instead arguing that the plaintiffs lacked the standing to bring the case in the first place. So while this may be a victory for abortion rights today, it leaves space for a stinging loss tomorrow. In another case, the court ruled against an EPA rule intended to reduce emissions that cross state lines, making it harder for some states to meet clean air standards. Here's a case in point. New York Solicitor General Judith Vale argued that up to 65% of smog pollution comes from outside the state.

The rule was challenged by three states, Ohio, Indiana, and West Virginia. And the Supreme Court put a hold on the rule, pending other legal challenges, through a 6-3 conservative majority. In doing so, they built upon their precedent of eroding EPA powers, including a previous 2022 ruling limiting the EPA ability to regulate CO2 emissions. So what does this mean for everyday folks? The EPA's rule simply can't be enforced.

So if you live on the other side of a border of a high-polluting state, you're left breathing the consequences. Beyond this ruling curtailing the EPA's authority, the court took a sledgehammer to rulemaking powers of federal agencies. more broadly. In another 6-3 ruling down ideological lines, the court reversed a 40-year-old precedent known as Chevron deference, named that way because it arose out of a 1984 case brought by Chevron Corporation. This precedent had required courts to give federal agencies wide leeway in their interpretation of laws passed by Congress, provided, of course, they were, quote, reasonable.

Eliminating Chevron has been a longtime goal of the conservative legal movement, as it vastly curtails a regulatory power of the administrative state. So why does this matter for health? So many of the health regulations that protect our air, our water, our workplaces, and our communities in ways we see and ways we don't are founded in rules promulgated by experts sitting in these agencies. This ruling opens those rules up to judicial review by courts packed by politicians elected with the money of the same corporations those rules regulate. And that means that the true impact of the ruling will have a long tail, which we'll only really understand in the fullness of time.

In a fourth ruling with big implications for health, the Supreme Court blocked civil immunity for the Sackler family, owners of Purdue Pharmaceutical, the company that created OxyContin and sits at the root of the ongoing opioid epidemic in this country. As we've discussed before, Purdue had reached an intricate settlement for billions of dollars in exchange for immunity from further civil liability. In a 5-4 decision, including Justices Clarence Thomas, Sam Alito, Amy Corny Barrett, and Katenji Brown-Jackson, the Justices argued that the deal violated a basic premise of bankruptcy law, which is that the Sacklers haven't laid all their assets on the table to creditors. On the premise of the argument, I agree with the ruling. The Sacklers, whose knowing malfeasance kicked off an overdose crisis that has taken hundreds of thousands of lives, would have gotten away without much personal consequence for their actions.

This ruling opens them back up to the kind of personal liability they deserve. On the other hand, I can't help but agree with the dissenting opinion that this decision may ultimately harm those suffering the consequences of the opioid epidemic by delaying, if not completely interrupting, the flow of funds intended to tackle the crisis. And the final ruling we'll discuss can only be surmised as being anti-poor. In a 6-3 vote, down ideological lines, the court upheld a ban on unhoused people sleeping outdoors, as if that would stop the combination of poverty and a limited supply of housing that is driving homelessness. And make no mistake, this has huge implications for public health, as I worry that it will eliminate so many of the incentives that municipalities have to ensure shelter for unhoused folks in their communities.

In Justice Sotomayor's words, quote,

Finally, U.

S. Surgeon General Vivek Murthy declared this,

If gun violence is not a public health crisis, then public health has no coherent meaning. So yes, of course it is. The question now is what happens next. Our current moment, so dominated by memes and zeitgeist, sometimes leaves us believing that words are themselves action. And so, while this declaration is really important, it's only as important as it drives meaningful action, which the 32-page advisory outlines, funding for gun violence research and more structured data collection, analysis, policy that limits access to firearms, scrutiny over gun manufacturers and the ways they peddle their wares to young people and normalize the violence their products create.

There is some promising motion here. The CDC is resuming funding, if limited, for gun violence research. And as this framing continues to build, I do have hope that it will normalize the space for meaningful policy action. Meanwhile, the scourge of the public health issue of gun violence continues to claim innocent lives. That's it for today.

Thank you so much to David Wallace-Wells for joining us. And if you have guest recommendations for the show, share them with us at info at incisionmedia.co. On your way out, please don't forget to rate and review the show. It really does go a long way. America Dissected is also on YouTube.

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America Dissected is a product of Incision Media. Our producer is Andy Gardner-Bernstein. Video editing by Nar Melkonian. Our theme song is by Otakar Sazawa and Alex Uguiera. Sales and marketing by Joel Fowler and Nick Freeman at Big Little Media.

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This show is for general information and entertainment purposes only. It's not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veteran Services.