Dr. Monica Gandhi Visits PWR's Notation in Science Communication
In October, Monica Gandhi, MD, MPH, and professor of medicine at the University of California, San Francisco, visited Stanford PWR to speak with Notation in Science Communication students and our broader community. As a professor of infectious diseases, Gandhi became very active in COVID communication. Reflecting back on the pandemic, she argues for fresh emphasis on individual agency and public empowerment in public health communication and asks us to dwell a little longer on the recent history to prepare for the next viral threat. Even though we came out of the pandemic with remarkable new vaccines, trust in medical science was damaged. A recent survey of patients in the UCSF system revealed that only 39% trust their doctors. Dr. Gandhi implored her audience to consider the causes for this low level of trust and how it might be rebuilt.
Co-organized by Dr. Kevin Moore and Dr. Emily Polk, the public event took place in a lecture hall at Lane History Corner. “I first became aware of Dr. Gandhi in Winter 2021, when a friend posted to social media one of her interviews on the promise of the vaccines and the possibility of the pandemic’s end,” said Dr. Moore. “I remember, at the time, how struck I was by a public health expert speaking in this tone, when so much of the messaging remained fear-based. I think it was the first thing that gave me real hope that we might eventually emerge from the crisis. It also became apparent to me that Dr. Gandhi understood the challenges of encouraging vaccine uptake, as well as the importance of providing reassurance, hope, and agency as part of that messaging. I began following her work and appearances as they played out over the next year, during which Dr. Gandhi continued to publish extensively. I really admire her awareness that science is rhetorical, and her courage to speak out as well as to adapt her messaging in response to new treatments and evidence.”
In Summer 2023, Dr. Gandhi published her book Endemic: A Post-Pandemic Playbook (Mayo Clinic Press), which reflects on her experience and proposes strategies for future pandemics. She gave a reading at Green Apple Books in San Francisco in July 2023, where Dr. Moore had a chance to meet the physician, after which they began the correspondence that led to her PWR visit.
At her talk, Gandhi read from Endemic before taking questions. She explained that her views on COVID were shaped by the population she works with– the “publicly insured”--who helped her see mistakes in the public response. But first she needed to go back a bit further in time to help us understand how she came to her worldview: in 1981, she knew she wanted to be an infectious disease specialist, the same year that HIV was first described. As a young physician, she quickly observed the disparities that drove the HIV pandemic, and her HIV patients “taught her everything that she needed to know to respond to COVID.” As she explained, these patients responded best to tenets of “harm reduction.” Any successful treatment for HIV could not just aim to treat the virus without considering the consequences of the treatment; it also had to consider patient mental health and ways to build individual and community resilience. Due to stigma, HIV was not acknowledged until 1985, a time when public science communication campaigns preached abstinence to solve social problems related to pleasure seeking. But public health people knew that “just say no” – a response to recreational drugs popular among conservatives at the time – wouldn’t help to contain HIV either.
Like HIV, SARS-COV2 cannot be eradicated and all infectious diseases specialists knew it (only smallpox has been eliminated). It would continue to circulate and evolve; hence the worldwide effort to slow the spread of the novel virus, whether through mandatory shutdowns, mask mandates, or vaccination campaigns. While Dr. Gandhi supported the early round of quarantines, once the vulnerable, especially the elderly, were vaccinated, she observed many political narratives in the US ignored the harms of the public health response. Put differently, the medicine caused further injury. In particular, Dr. Gandhi called out long term school closures, prohibiting families from visiting loved ones in the hospital, and the suspension of much screening for other diseases (a lot of cancer and heart disease diagnoses were missed that ended up causing terrible injury). By contrast, in Scandinavia, Dr. Gandhi pointed out, once the vaccine came out, people got back to regular life, including to life without masks. Because, as she said, “social life matters too.” “We need faces.”
Gandhi was also surprised when people who were infected with covid were diminished by the rhetoric of the leaders in government. As she observed wryly, they got infected because they were human. In public health, in her view, there is no room for a shame based approach, which, again, likely caused further harm. Now we all have to be screened for anxiety. Dr Gandhi thinks high levels of mental distress are the result of the fear-based messaging during the pandemic. When the next infectious disease emerges, she wants us to see, yes we need infection control, but we also need greater sensitivity to harm control.
Dr. Gandhi is an Indian American living in the US, though she has also worked in India and Africa. Through her work she has consistently observed that the poor are disproportionately impacted by disease. Moreover, poverty intensified worldwide due to the COVID response, especially among children, another harm that has not been well enough articulated. As she said, “I’m really interested in poverty,” calling for universal healthcare coverage and the recognition of health as a right. Ghandi says she is sensitive to the stigma against the poor and sexual minorities due to her experience growing up as a brown woman, which she couldn’t change, like LGBTQ+ people.
HIV was the last great pandemic before COVID, and we should see it as a “prophet and teacher,” Gandhi maintains. But we didn’t listen. Why not? Politics was the first factor. In both pandemics, in Gandhi's view, messaging from public health authorities was largely fear based. Second, the American media had and has negative bias in reporting on disease, which amplifies the fear based messaging. Third, messaging largely seeks to increase compliance, whether around condom use or mask wearing. What’s more effective, Gandhi convincingly argued, is information and tools to help people stay safe from a pathogen. People need agency, and the job of medicine is to reassure people they are capable of exercising it.
From these hard-earned lessons of two pandemics, Gandhi has crafted a playbook for the next pandemic response. As she says, the duty of public health is to pursue equity, social justice, and participation. And public health authorities must collect data as well as foster dialogue to keep the public’s trust. Public health experts must speak truth to power and say what they believe should happen: in Gandhi’s view, stalwart resistance to the stigma of infection and to SES-drive inequities through harm reduction policies. These include lifting patents to help make vaccines available to all around the world.
Finally, to increase trust in public health, we need to acknowledge mistakes in our COVID response. Many other countries have established national commissions to assess their pandemic responses. The US and China are exceptions with politicians refusing to admit errors. Unfortunately, in Gandhi’s provocative view, the public health establishment is now also behaving that way in this country and now 30% of Americans distrust the CDC. In closing, Gandhi returned to an error in the pandemic response that she found particularly egregious and offered an explanation for it: she suggested that the older age of infectious disease leaders may have contributed to their fear response and shut downs (since COVID infections were more deadly among seniors). In her view, Trump was actually right to try to open schools, but the public health community was reactionary since they disagreed with his other politics.
Gandhi wrote her book because she had learned valuable lessons in harm reduction from those living with HIV, which gave her courage to articulate unpopular policies. While many other physicians agreed with her, they didn’t speak up because it’s terrible to be labeled a right winger if you’re a medical doctor. Gandhi’s rich and consequential experience in science communication made students aware of the intricate interrelations of rhetorical and ethical choices in public health. The social context of disease cannot be ignored; pragmatism and activism are required of physicians.