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Democrats need to build a bigger tent to be competitive. But building a bigger political tent means compromising—and that compromise usually means making someone inside your tent angry.

Take, for instance, Colorado Governor Jared Polis, who surprised many and angered some by announcing that he was “excited” by the nomination of Robert F. Kennedy Jr. to lead the Department of Health and Human Services. Asking people to hold off on mocking or disagreeing with RFK Jr., Polis pointed to issues like pharmaceutical reform, nutrition policy, and the use of pesticides. After facing backlash, Polis clarified that he was pro-vaccines, but it left me thinking: What might it look like to open the Democratic tent to vaccine-skeptical Americans, of which there are a growing number?

Today’s episode of Good on Paper is with Dr. Rachael Bedard, a practicing physician who writes publicly about her work, including a recent op-ed arguing RFK Jr.’s critics need to acknowledge the “seeds of truth” to some of his critiques and sit with the fact that many Americans are skeptical of our public-health institutions.

“The pandemic provided this entrée into politics for a kind of person where the combination of sort of the fear of the moment and the trauma of the moment and this sense that people’s bodily autonomy was being violated in some ways by government incursion,” Bedard argues. “There are people who reacted really badly to that, and it changed the dynamics of this conversation.”

The following is a transcript of the episode:

[Music]

Jerusalem Demsas: Robert F. Kennedy Jr. has said “there’s no vaccine that is safe and effective” and has argued that vaccines cause autism. His nomination to run the Department of Health and Human Services has spurred opposition from some physician groups and Nobel laureates in various scientific fields.

So it was surprising to come across a New York Times essay by a pro-vaccine, left-leaning physician arguing that instead of spending “four years simply fighting his agenda” opponents should seek to find common ground with RFK Jr.

The author of that piece, Dr. Rachael Bedard, is not just your run-of-the-mill doctor. She’s one with experience treating patients of very diverse backgrounds. The first time I learned about her work was when she wrote an essay about being a physician on Rikers Island during the COVID-19 pandemic.

Bedard’s argument is not just one about the political necessity of compromising with people you disagree with. It’s also a warning that, in their zeal to oppose RFK Jr.’s false claims about vaccine safety, opponents risk dismissing and alienating people who have a healthy skepticism of Big Pharma, overmedicalization, and just a generalized distrust of the medical system.

[Music]

My name is Jerusalem Demsas. I’m a staff writer at The Atlantic, and this is Good on Paper, a policy show that questions what we really know about popular narratives.

Today’s episode is rooted in Rachael’s own experiences as a doctor, and it contains some controversial advice for public-health officials and political activists worried about RFK Jr.’s rise.

Rachael, welcome to the show!

Rachael Bedard: Thank you. Thank you for having me.

Demsas: I am so excited to have this conversation because you are an actual doctor, so I don’t just get to rant with someone who doesn’t have real, lived experience.

Bedard: I am an actual doctor.

Demsas: (Laughs.) So I think most college-educated liberal people have a sort of knee-jerk reaction to RFK Jr. and his arguments about everything from vaccines to fluoride, and sort of his orientation towards science and public health. And I think that reaction is a combination of fear and dismissiveness. I mean, you’re a doctor who’s worked with a variety of populations, and, you know, you’re supportive of vaccines and public health, and yet you wrote an article that I think might surprise some people.

In the Times, you wrote about how people should react to RFK at HHS, and you wrote that you think that there’s common ground between people like yourself—medical researchers and scientists and clinicians—and Kennedy. So what are those areas of common ground?

Bedard: There are a few assumptions in what you said, which I do think is sort of the conventional wisdom around this topic, that might be wrong or deserve to be unpacked. One of them is the idea that most liberals have this knee-jerk reaction to Kennedy.

And what I think is really important to recognize is: Really until the pandemic, a lot of what Kennedy talks about—the idea that government and Big Pharma are in cahoots with one another, and that we’re overprescribing medications to ourselves, especially to our kids; the idea that we’re poisoning the environment with toxins; the idea that food companies are tempting kids with high-sugar, high-fructose, dyed products that then are contributing to a childhood-obesity epidemic—all of those things, I think, coded as liberal critiques of the medical establishment until very recently.

The other thing is the really specific sort of point of dissent between liberals and conservatives in this conversation now, which is around vaccines. Until the pandemic, who did you think of as being sort of anti-vaccine?

Demsas: The crunchy mom who sends her kids to Montessori.

Bedard: Right. And specifically, what color is that mom? That mom’s white—so high-socioeconomic-status, white women who had anxieties about not putting poisons into their children’s body, who didn’t feel themselves to be vulnerable to infectious diseases and didn’t see themselves as sort of responsible to the commons to protect others.

What’s really interesting is that Kennedy was on the same team as those folks until fairly recently. And then what happened in the pandemic is: The pandemic provided this entrée into politics, I think, for a kind of person where the combination of sort of the fear of the moment and the trauma of the moment and this sense that people’s bodily autonomy was being violated in some ways by government incursion—whether or not that’s valid, whether it’s valid to say being told you had to wear a mask in the airport was some kind of huge violation of your civil rights—there are people who reacted really badly to that, and it changed the dynamics of this conversation so that there was this flip.

So instead of being sort of the crunchy mom, it’s now very bro-coded, I think, to be an RFK guy, right? But it’s all the same kind of body-purity politics. So the first thing I would just say is: RFK is who he’s always been, in some ways. And what’s changed a lot is the partisanship of who agrees with him.

Demsas: I think what I would ask you then is: How do you think about how liberals should now engage with this, given that it used to be there was this small fraction of, like, white moms who are kind of preventing their kids from getting some, if not all, childhood vaccines. And now it’s, like, this broader skepticism of public health in general. So what’s your argument then to how Democrats should respond to an RFK?

Bedard: There are sort of two levels in thinking about how you answer that. First of all, there’s a really important distinction to be made between public health and medicine, right? Public health is the creation of policy and intervention meant to apply to groups of people or universally across a population in the interest of the many. Medicine is the practice of helping people improve their own health that’s practiced individually with the patient in front of you.

What we should be doing at the public-health level is not the same thing as what I think we should be doing at the doctor level, necessarily. But some of what best practice looks like at the doctor level ought to be adopted at the public-health level.

Demsas: Can you talk about that more specifically? Like, what does that look like?

Bedard: Yeah, so vaccine mandates work. They’re really important. They’re the only thing that has been shown to work to get meaningful vaccine uptake in a population.

Without them—so for example, the flu vaccine, right? The flu vaccine is not mandated for adults. Forty-four percent of American adults got the flu vaccine last year. That’s not enough to achieve herd immunity, right? We don’t mandate it, because we’ve decided that it’s not worth the hassle.

So we’re pretty choosy about what we mandate. But the things that we choose to mandate, we mandate because we think they’re really contagious, and the consequences of infection are high. And mandates are the only things that help ensure that enough people acquire immunity to something that you’re going to diminish the population burden of that infection, right?

So I don’t think the Democrats should be doing anything different at the mandate level. And that’s a place where I really differ from, say, Jared Polis, the governor of Colorado, who’s been tweeting in support of RFK with this kind of, like, bizarre zeal and who I think has sort of overstepped where he maybe wants to be. I think he wants to sort of express some understanding of where the folks of Colorado are, where there’s a really growing, pervasive anti-vax sentiment. That’s actually not—it’s bad public policy. It’s a recipe for disease outbreak.

But in communicating with individual patients about vaccines, you don’t tell them that they have to get it, or they can’t come and see you again. That’s not a persuasive way to interact with people, right? At the individual level, when I’m talking to patients, I engage in shared decision making about this. And that starts with offering people the intervention but then really listening to their reactions to it and listening to their fears around it.

Demsas: What sorts of things do you hear when people say they’re scared about getting a vaccine? Is this mostly COVID or other sorts of things?

Bedard: Well, I take care of adults and not kids, right? So I don’t hear people talk about autism and then the MMR vaccine, for example. I talk to adults about the flu vaccine, the COVID vaccine. It’s different, vaccine to vaccine.

So overall, I think one of the things is that people have had the experience themselves of getting the vaccine and then feeling crappy for the next 24 to 48 hours. And they don’t want to do that. The most pervasive thing you hear is, The flu vaccine makes me sick.

Demsas: Yeah. And that’s real. It does make you feel sick.

Bedard: And it’s real. And so one of the most important things to do is to say, Yeah, you’re going to feel bad. We expect that. That’s normal. And if you don’t want to take it today, because you have to go, you know, do something tomorrow, that’s okay. You can do it at your next visit. It’s really, really important with folks to do expectation setting, and then it’s also very, very important to not play down their own experiences or the information that they’re bringing to you.

There’s a great piece that was written by a guy that I work with now, Sudhakar Nuti, who wrote about the phenomena of lay epidemiology. Lay epidemiology is, like, the sort of informal information gathering that people do around how the people in their community and in their lives experience a vaccine. So if you have a brother who got the flu vaccine and got Guillain-Barré syndrome afterwards—

Demsas: And can you say what that is?

Bedard: Yeah, totally. It is a known, very rare complication where—it’s a neurologic complication, but it’s pretty serious, where—people experience sort of temporary paralysis.

Demsas: Wow. That’s bad.

Bedard: It’s bad. It’s a bad thing to have happen. It’s very rare. If it happens, you never get the flu shot again. But if your brother got it or your friend got it, then your sense of danger and your ability to sort of evaluate your personal risk changes a lot.

So people make this decision a lot because of the lay epidemiology in their lives, which is, What have they heard about it? What do they know about it? And around some things, like the COVID vaccine, there was tons of either real or sort of misinformation reporting about people who got the vaccine and then got sick afterwards, had consequences afterwards, right?

The sort of—people thought that Damar Hamlin, the football player, when his heart stopped on the field, right? They attributed that to having received the COVID vaccine. That’s not what did that. But there was all of this fear around myocarditis—inflammation of the heart—especially in teenage boys.

Demsas: But it’s funny. I don’t view the—at least from my perspective, and I’m not a public-health researcher. I don’t view, like, the orientation of public-health institutions as having been like, We’re going to give everyone the information, so they can make the decision for themselves. I view it much more as, like, I’m going to tell you it’s safe because I’ve done the calculation but refuse to explain to you what safe means.

So I do think that in some cases it’s maybe both. It’s like, Yes, you need to engage with that emotional side, but also just say, like—I mean, my own personal experience with this is: I remember when I was trying to get an IUD for the first time, and I went to a women’s health clinic. And I just said, like, Hey. I’ve heard some stuff about birth control and cancer risk. Like, I was young. I didn’t know anything, and I just, like, read something online, and I was just asking for some support.

This is, like, a women’s-health clinic. It’s a place where, you know, you’re supposed to—it felt very progressive and open. And the doctor just kind of looked at me and was just, like, No, that’s fine. Don’t worry about that. And that didn’t make me feel safer. That didn’t make me feel like—

Bedard: Totally.

Demsas: I got the IUD, but I was also just, like, It’s not really clear to me that I feel like you’ve listened to me. I didn’t go back there when the IUD didn’t work. I ended up, like, you know—I went on the pill instead and never went back to that. You know what I mean? So it’s all these things where I’m not really clear, you know?

Bedard: Well, so the thing that I would say about that, Jerusalem, is that’s really—what you’re talking about is an experience that’s really specific to who you are. Right? So you’re a “facts maxer.” You want the info.

Demsas: I’ve never heard that before in my life. (Laughs.)

Bedard: You want the information, right? And you’re a person who spends a lot of your day digesting and synthesizing huge amounts of information—primary research a lot, right? It’s your preferred way of understanding things, is getting lots and lots of facts and reading lots of different interpretations, and then making your own judgment about it.

So if you were my patient, and you expressed hesitancy about getting the IUD, the thing that—and I should say, you know, the reason. I have a really different orientation than lots of doctors, and that’s because my training is actually in palliative care, right? And palliative care is caring for people with serious illness or people who have life-limiting disease. And it’s very much attuned to and preoccupied with not just physical suffering but also existential distress. And because you are working with people who are sick in ways where the sort of calculus about what’s important changes a little bit, we do a lot of shared decision making. And I am trained in sitting with people and trying to decide what’s important to them, and given the options and sort of the constraints of reality, what can we do to meet their goals, right?

So that’s to say that my approach with you, if you were to ask me about getting an IUD and expressed hesitation, would be to delve deeper about, What are your concerns? Where did you read that? Where did you hear it? Do you know anybody in your life for whom that’s been an issue? Try to get really to the bottom of the thing that’s worrying you, and then also try to say, Well, what would make you feel better about it? And what would help you make this decision?

And then, for you, I think it’s probably true that the right thing for us to do would be to turn the computer screen towards you and look it up together, right? And then talk that through.

Demsas: I mean, I agree with you. I am now going to use “facts maxer” as part of my bio.

But I don’t know. I feel like I hear a lot from other people who I think maybe spend less time on econ working-paper sites—I hear a lot from them that they’re like, I just want the facts. I want someone to give me the facts. And I think that I’ve seen a lot of the same stuff that you have about, like, people have a difficult time hearing odds. I mean, I don’t think I’m particularly great at this. Like, one in 1,000 and one in 10,000—like, do you emotionally understand the differences between those numbers? Or does it just seem small but, like, there? Like, I know a thousand people, you know. Like, That’s a person.

And do you hear that the same way when you hear, like, There’s a one-in-a-thousand risk you have cancer, versus, There’s a one-in-a-thousand risk that you’ve just won $1,000? Like, do you understand those things in the same way? So I think all those things are true, but do you think that when people are saying, I want more information, they’re not actually asking for that?

Bedard: I think you have to—this is what I’m saying about, sort of: It’s different to be a doctor with a person in front of you, where I think the task is to try to explore that. Is this a person who genuinely needs more information? It would be clarifying to Jerusalem Demsas if I said to her, Actually, that study has been disproven by this subsequent study. That might be something that for you would be reassuring.

Demsas: That would work.

Bedard: It would do it, right? But I will give you the example of the patients that I took care of on Rikers. So I was a doctor on Rikers for six years. I worked in the jail system. I was there during COVID. The public-health agency that I worked for, that provided health care in the jail system, worked very hard to advocate for our patients—for people who are incarcerated on Rikers—to be among the early groups of folks who would receive the vaccine in 2021.

Demsas: I mean, the outbreaks in jails were astronomical.

Bedard: There was a period where Rikers had the highest prevalence rate in the country, at the very beginning. Jails have the worst possible conditions for airborne viral spread. So it made lots of sense to advocate for this. And also, it really felt like this important equity issue that we were saying, like, Look—these people’s lives matter, and their risk is incredibly high, and they should be prioritized.

New York City also, relatively early on in the vaccination rollout to incentivize people to get the vaccine, was offering people $100 if they got their shot. That was true in the community. We advocated hard to have something commensurate offered to people in jail—that if you accepted the vaccine, like any other New Yorker, you would be compensated with some money put into your commissary account. I don’t think it was $100. I can’t remember exactly what it was.

I walked around the jails offering vaccination to folks with one of our head nurses and one of our head physician’s assistants, both excellent communicators and people who had really great trust with our patients. And we would approach guys and say, Do you want to get the vaccine? And they would say, Hell no. And then we’d say, No, it’s really important. We would give them our spiel. And we would say, And we’ll put—whatever it was—$50 into your commissary. And almost to a man, the guys said, Now I’m definitely not getting it. The government’s never paid me to put anything in my body before.

Demsas: (Laughs.) Wow.

Bedard: And that wasn’t a situation where if I had said, No, no. Let me explain to you why this is happening. No, no. Let’s explore the facts around RNA vaccine safety, that was going to change hearts and minds, right?

That was a situation where I was encountering a resistance that was born from entirely different experience than the experience you’re describing, and with entirely different concerns. It was a low-trust environment. To respond to that, often I would joke back and be like, Well, then you should take it the first time that they do, right? And, like—

Demsas: Did that work?

Bedard: Sometimes. You know, mostly what worked was, like, sparring with dudes in a jokey way, in a way that helped them feel grounded in the idea that I, or my colleagues, were not going to try to hurt them. So in other words, their resistance was born out of low trust, and the right strategy was to try to increase trust between us and the folks we were trying to help.

And that’s just to say that there are lots of different reasons that people are vaccine hesitant. Vaccine hesitancy is not the same thing as being anti-vax, and most people are not strongly anti-vaccine. Most people who are in this RFK universe are vaccine hesitant, which means that they’re in this state of sort of vulnerable ambivalence about it.

And what you want to do, as an individual doctor, is sit with someone and try to explore where that ambivalence comes from and then address the source of that ambivalence. That’s really hard to do at the public-health level, right? It’s very different to do that at the policy level. At the policy level, mandates work. And so what you want to do is sort of, I think, have the mandate in place but think about how your communication makes it easier for people to live with those mandates and accept those mandates and feel aligned with them.

Demsas: So you brought us back to RFK and to mandates. And another part of your op-ed is that—and I don’t want this to just be about vaccines—but you say that “there are seeds of truth to some of what Mr. Kennedy says.” And I want you to overview. I mean, you’ve mentioned the mandates here, and you’ve talked a little bit about kind of some of the nutrition stuff, but what are these seeds of truth that you think we should be seeing in what he’s talking about?

Bedard: You know, I think the concerns about the relationship between pharma and government and drug regulation are really valid. They’re concerns that any liberal doctor would tell you they agree with, up to a point.

So when I say that there’s seeds of truth, common ground—the common ground stops at some point, where it’s not like Anthony Fauci traveled to China in order to engineer the COVID vaccine himself or whatever. Like, that’s just absolutely not true. But the idea that there is too cozy a relationship between pharma, pharma-sponsored patient-advocacy groups, the FDA, and the committees that provide drug approvals, and then provider associations—like, that’s definitely true. And there are lots of recent examples of that.

There’s, you know, sort of famously: In 2021, there was a really controversial, high-profile case of approval for a drug for Alzheimer’s that had just been shown not to work, basically. And Alzheimer’s—very common disease, incredibly devastating to families. People are desperate to believe that there is something that they can do for folks. We don’t really have good treatments right now. This was the sort of treatment that had received a lot of hype in advance.

The data was just not supportive of the idea that it was effective. And, in fact, it did obviously cause harm in some small number of patients. It got pushed through the FDA approval process anyway, largely, in part, due to pressure from the Alzheimer’s Association, which was receiving money from the drug company. That is a perfect-storm setup for an RFK-type critique. And it’s true. And at the time, I wrote an op-ed criticizing that process. So that’s a place where he and I totally agree.

There is a lot of truth, I think, in questioning the balance in terms of how much we’re thinking about treating diseases versus preventing them. He talks a lot about prevention. He talks a lot about lifestyle. He talks a lot about working on things upstream before they develop into sort of full-blown organ failure, right? So tackling childhood obesity by changing the food environment and encouraging exercise—it’s pretty hard to disagree with that, right?

Whether that means that, you know, I am a huge booster of the GLP-1 drugs, of Ozempic and its brethren, RFK is not, right? And that’s a place of disagreement. But it’s not a place of disagreement because I think that his premise is necessarily wrong. I think it’s a different idea about what’s realistic in terms of addressing a current prevalent issue.

[Music]

Demsas: After the break: How I learned to be skeptical of fluoride in children’s toothpaste.

[Break]

Demsas: I think my Oh my gosh—there’s a seed of truth in something he’s saying moment was when I was reading an article from the Atlantic by our fantastic science reporter Sarah Zhang about fluoride. And the article is titled Why I Buy German Toothpaste Now.

And it’s about how, you know, she buys German fluoride-free toothpaste for her daughter. And it’s because at very high levels, fluoride can lead to fluorosis, which is when your teeth become mottled or structurally weak, but also that high levels of fluoride have been linked to lower IQ in children. And toothpaste contains, you know, 1,000 times more fluoride than recommended in drinking water, and you know, young kids don’t spit that out reliably.

And she talked to a researcher recommended to her from the American Dental Association, which is obviously a pro-fluoride group. And she told her that she would also choose fluoride-free toothpaste for her children. I also learned from that article that Canada recommends holding off on fluoride for most kids under age 3.

And it’s just this moment of just realizing, like: I’m not saying that we should all listen to RFK, but I think it’s strange that that’s the only space where I’m hearing anyone question some of these things. And so then it raises this problem of, like, Oh, is this tamped down? But then, you know, it’s also a weird reaction for me to have that, because I just read this in an article in The Atlantic. So is it being tamped down at all?

So I wonder why you think that dynamic happens, where sometimes, you know, the public is talking about it? Like, these are people who are parts of the public-health establishment who are talking to journalists. Journalists are reporting that. They’re giving people facts. And yet, it feels like the only truth tellers are RFK Jr. and people on these bro podcasts. Like, what is that coming from?

Bedard: I think the operative word is question, right? It’s not necessarily that you feel definitively after reading Sarah’s article—that you understand, with total certainty, what the deal is with fluoride. What you took away from that article was, There’s more uncertainty around this intervention than I initially appreciated.

And what feels difficult is that to learn that, then subsequently makes you feel betrayed, right? That that uncertainty had never been introduced to you before and, in fact, that you had sort of felt, perhaps—I’m projecting, but I think this is probably true—sort of encouraged to assume that anybody questioning fluoride was coming from an anti-science place, was a crank, right? And then you think, I don’t want to be sort of blindly following things that there isn’t good evidence for.

It’s really, really hard for public health to effectively communicate around uncertainty. The pandemic was an incredible example of this. This has been discussed ad nauseam. Lots of mistakes were made, right? Initially, we didn’t appreciate that it was airborne, right? Initially—but even before that, we told people that they didn’t actually need to wear masks, and then we said, Actually, you need to wear a mask all the time, and you can never take your mask off, and you have to wear your mask even when you’re jogging in the park. Then we said, Don’t worry—you’ll get the vaccine, and nobody will get COVID after we have the vaccine. And then we vaccinated everyone, and the Delta wave happened, like, six weeks later.

The way that the public experiences that is as a series of reversals that feel like betrayals, I think. What I think we should do differently, regardless of whether it’s Kennedy or somebody else in charge, is communicate with the public differently about uncertainty—do different kinds of expectation setting.

Another good example is: At the beginning of the pandemic, when people went into what we’re calling lockdown—although lockdown was never really lockdown in the U.S., the way it was in some other places—initially, people sort of said, right, Go in for two weeks, and we’ll flatten the curve. Or, Go in for a couple of weeks, and we’ll flatten the curve.

And actually, we didn’t know what it was going to take, right? We didn’t know how long it was going to take to make a difference or to be safe. We didn’t totally really know what go inside had to mean. Did it mean that you couldn’t go outside at all? There were certainly people who did that. Did it mean that schools shouldn’t open for two years? Did it mean that once we sort of had enough epidemiologic data about average risk of serious illness in kids, we would make a different decision about schools?

There was very little transparency around that decision making. And essentially, there was very little transparency around the uncertainty around that decision making, right? There was a real feeling and sense that the public had to hear clear messaging: You have to wear a mask or it’s unsafe. But actually, everything is sort of a risk-benefit calculus, right? And once some of the things that people were initially told turned out not to be true, they experienced those reversals as a betrayal, and then they were pissed, and they didn’t trust anything going forward.

And that’s what I think sort of your fluoride experience is like a microcosm of, which is this sense of, like, I’ve been duped—and not because you’re convinced now that fluoride is, for sure, bad but more because you think, I thought this was settled matter, because you guys told me it was, and now I realize it’s not, and it makes me wonder what else I should be questioning.

Demsas: I think a lot of, you know, public-health folks have felt really attacked, maybe, post-COVID or even during a lot of the COVID experience. And one pushback I imagine that they would raise to our conversation, and to conversations like this happening everywhere, is that they actually do debate a lot the ethics and need for vaccine mandates all the time.

There’s one study I came across when researching for this episode in the Journal of Medical Ethics, and it was asking whether universities should mandate third-dose COVID-19 boosters. And they estimate that to prevent one hospitalization over a six-month period, you’d have to vaccinate between, roughly, 31,000 to 42,000 young adults. In order to do that, you’re getting a handful of adverse events and up to 5,000 adverse reactions that would “interfere with daily activities.” And as a result of that, they conclude that university booster mandates are unethical because they don’t take into account the low risk this group faces with Omicron, which was the wave at the time, and they’re just not proportionate, among other reasons.

And that’s the exact sort of balancing that I think that a lot of people feel like, I wish public health was like this. And I myself did not know that this was a way that bioethicists were interacting with this question. And so I guess part of that makes me feel like it’s a bit hopeless. Like, is this a problem of whether it’s social media? But also, just the way that you’re kind of describing the scientific iterative process reads as a series of betrayals rather than just, you know, a scientific iterative process, where you’re learning and changing your mind and updating. How optimistic are you that this balance is even possible?

Bedard: A few things. One thing is that I think what you’re describing there, in terms of the really painstaking decision-making process that goes into things like vaccine mandates—that’s the standard, right? And that’s how everything works, with the obvious caveat that in emergency situations where you’re dealing with a circumstance where there’s a ton of uncertainty and unsettled evidence, you have to make decisions anyway that are your best guess in the moment, right?

And so the pandemic, I think, was a little bit of an outlier situation—compared to, say, the way that we think about vaccine mandates for a childhood vaccination—where, in March of 2020, the U.S. government had to make a lot of decisions really quickly with imperfect information. And they had to do that without being able to do all of the modeling you just described, right?

And so, again, what I wish we had done differently then is been more transparent about that uncertainty and talked about how we would then potentially revise that decision making in the future as more information came out. So, This is what we’re saying you should do today based on what we know. As we learn more, this guidance may change. Here’s what we’ll tell you that will help you feel like that change makes sense. If we are wrong, there are potential consequences, and we might do something differently sooner than we’re saying, right? Like, you can sort of—there’s no character limit, right? You can say it all.

Demsas: You can only tweet your public-health pronouncements, and you can’t get premium. (Laughs.)

Bedard: Yeah. Exactly. There was and often is, I think, this sort of mistaken sense that the public needs to hear short, clear, decisive messaging, even when the circumstance that you’re in necessitates a totally different kind of communication. So that’s the caveat case, I think, is that there are lots of times when you don’t have that information that you just sort of described around—by the time Omicron came around, we had tons of information about what the real risk was to 22-year-olds, right? We didn’t have that at the beginning.

But for childhood vaccination, for example, we do have that information. The childhood vaccine schedule is something that has been created with a ton of thought and a ton of data, and a ton of thought and data that’s balancing lots of different considerations—not just safety and efficacy of the vaccines themselves, but information about how often people are willing to come to the doctor, right?

There was a really great piece written in 2009 by Danielle Ofri, who’s a doctor at Bellevue, here in New York. And 2009 was when the H1N1 swine flu outbreak happened. And she wrote this piece about what she calls the “emotional epidemiology of the H1N1 influenza vaccine.” Her patients—patients who generally did not accept the flu vaccine—when H1N1 first broke out began calling her office, being like, When is the vaccine going to be available? When is the vaccine going to be available? And she was surprised because they were generally folks who had not accepted the seasonal flu vaccine in the past.

It took a little while—and by a little while, I really mean months, not a year, right—for an H1N1 vaccine to become available to her patients. In those intervening months, many of those patients who initially had this sense of urgency lost it and, in fact, changed their minds and ultimately didn’t want the vaccine once it became available. And she talks about—I just want to read this quote that she has in here: “Emotional epidemiology does not remain static. As autumn rolled around,” which is when the vaccine became available, “I sensed a peeved expectation from my patients that this swine flu problem should have been solved already. The fact that it wasn’t ‘solved,’ that the medical profession seemed somehow to be dithering, created an uneasy void. Not knowing whether to succumb to panic or to indifference, patients instead grew suspicious. No amount of rational explanation—about the natural variety of influenza strains, about the simple issue of outbreak timing that necessitates a separate H1N1 vaccine—could allay this wariness.”

I think that this void that Ofri is identifying is really important. When you aren’t communicating consistently with the public in a way that makes the work that you’re doing transparent to them, the thinking that you’re doing transparent to them, and in a way that is in some ways responsive to their feelings, then it feels as though there is a void, and into that void people project all sorts of things and end up relying on information from other sources and changing their mind or deciding that they don’t trust you anymore.

Demsas: So I think it’s an interesting kind of tension, though. Because, you know, I wrote this article in 2022, and the headline was, “Is the FDA Too Cautious?” And part of what the article talks about is that the FDA is way too conservative when assessing clinical trials for therapies of, quote, “terminal illnesses with no existing therapies such as pancreatic cancer.” So these are areas where you would want the FDA to be overly willing to approve therapeutics, because the risk of death and disability are already high for the individual patients.

And there’s this anecdote from Henry Miller, a former FDA physician, that I’m going to read quickly. He says, “In the early 1980s, when I headed the team at the FDA that was reviewing the NDA [New Drug Application] for insulin … we were ready to recommend approval a mere four months after the application was submitted. With quintessential bureaucratic reasoning, my supervisor refused to sign off on the approval—even though he agreed that the data provided compelling evidence of the drug’s safety and effectiveness. ‘If anything goes wrong,’ he argued, ‘think how bad it will look that we approved the drug so quickly.’”

So earlier in our conversation, you mentioned the Alzheimer’s drug, which I think, universally, everyone was kind of condemning as being a situation where the FDA had rushed something through approvals, even though there was not good evidence that it was going to be beneficial for people who needed that drug.

And then when I wrote this article, there were a lot of people who were like, Yes, it’s so important. There were scientists, outside individuals, public-health researchers from the outside who were like, Yes, it’s really a problem that the FDA doesn’t behave this way. There’s tension that we have in this conversation that I can imagine is very frustrating for people in government, where they’re being told, Hey. Why won’t you approve these tests quickly? Even though you’re not sure that they’re good, why won’t you act with greater degree of concern for people who need something right now, rather than trying to get the perfect thing later?

And on their end, they’re saying, We need to increase trust. And trust means provide people things when they’re ready, provide people things when we can actually defend them clearly. And on the other hand, they’re being told and criticized for not doing that. And there’s, obviously, this dynamic here, where you get blamed for things that go wrong much more than you get blamed for things that you don’t do, because people often don’t see those sorts of things.

And so I guess I ask you: You’re, obviously, trying to get to a point where there’s a lot more of this democracy, openness, talking about these individual problems, but it seems to also open up a lot of these institutions to kind of daily critique about how they’re not actually getting things right on a day-to-day basis. Like, Well, yesterday you said this, and now you’re saying this. So I mean, how do you think about that problem?

Bedard: So the first thing I would say is: The science actually matters a lot here. So there are examples, like the one that you just gave, where there are things—there are discoveries, breakthroughs, drugs, whatever—where the evidence is just sort of incontrovertible right out the gate, right? Like, way before sort of a study’s expected end point, it’s very clear the benefit is there, and people are tolerating it well enough, and the condition is serious enough that we should try to expedite it.

Expedited approval really came to the fore during the AIDS crisis, when this was a huge issue, right—where AIDS patients, understandably, were like, We’re dying today, so it doesn’t make sense for us that you have to go through this bureaucratic approvals process. We’re willing to try therapies that are promising, that may not work, even that may have risks, now because—

Demsas: We’re dying.

Bedard: We’re dying. The natural course of our disease is such that we don’t have the time to wait for your process. That’s clearly reasonable, and Anthony Fauci, in response to those very complaints, adjusted the clinical-trials approval process to have a fast-track option. There’s compassionate-use-case approvals, where for diseases that are rapidly terminal, seriously debilitating, etcetera, the threshold to be able to let people try something that’s in development is much lower.

There’s also always the possibility of enrolling in clinical trials, right, as a way to try therapy. And that’s an example of sort of just—there’s both sort of a rigorous system around deciding whether or not somebody is eligible for something, but there are opportunities before something has been proven safe, or not 100 percent, to let people try it. The flip side is that there are lots of things that pharma is working on that don’t work that well, that are for problems that aren’t that debilitating, right, and where rushing approval for those things doesn’t make any sense, because the risk even of sort of minor adverse effects way outweighs the sort of tepid benefit that they might offer.

And so, to me, the challenge for the agency is less about whether they look good or bad, and more about trying to sort out those types of problems, right? When does it make sense for us to err on the side of being as conservative as possible in approving something? Versus, when does it make sense for us to err on the side of being as open to risk as possible because the alternative of continuing to live in an environment without treatment is so devastating to people?

The way that the FDA and other public-health agencies—the NIH, etcetera—have tried to get at this issue that you’re talking about is by having patients involved at sort of every step of the drug-approval process, the research process, etcetera, etcetera. That doesn’t work all that well, I don’t think, because there’s a little bit of an elite-capture problem there, which is that: Any patient who ends up sitting on the committee for drug approval stops actually being a representative of that patient population, knows too much, is sort of influenced by lots of other factors, etcetera, etcetera. And I don’t think just involving patients along the way really sort of solves the problem that you’re talking about, but it’s the way that the agencies try to do it now.

Demsas: So I can imagine that there are people who are very afraid of RFK’s ascent and, like, kind of the increase in skepticism around basic public-health measures that are listening to the conversation and just going, I feel like you’re just sane-washing. People who are serious trust the science people or public-health researchers, or if you’re serious about preventing long-term disability from COVID reinfections—I mean, if you really care about those things, then what you should do is just constantly sort of oppose that.

And so how do you think about the risk of sane-washing, instead of just going, like, Hey—we’re just saying we agree that sometimes Big Pharma is way too involved in the regulatory process. That doesn’t mean we think that X conspiracy theory is true. So like, what is the balance there? Who’s responsible for making it?

Bedard: So I’m a little bit different, I think, than lots of doctors because of my background and my practice experience. One thing is about being a palliative-care doctor. The other thing is that I have always worked with marginalized populations where there’s a high prevalence of substance-use issues. And because of that, I’m very sort of seeped in the harm-reduction approach to problems.

And I don’t think that advocacy from the public-health community or doctors is going to be what prevents RFK from getting through the Senate and being approved to become an HHS secretary. I think he’s gonna end up getting the job. And I also think—because of the sort of way that he is ensconced in Trump World and the fact that he comes with his own constituency that Trump sort of needs—in the outcome where, like, a couple brave senators stand up and decide that they’re not going to vote for him, I think he gets made health czar or something like that. Like, I don’t think he just goes away.

So part of the harm-reduction ethos is just about being real about what the challenges are. And to me, the fact that I don’t want RFK to be anywhere near in charge of the federal government’s health apparatus, it doesn’t make it not so. And my sort of principled opposition to that doesn’t feel like an intervention that has a lot of juice.

That’s really different, I will say, than I felt in 2016 with the first Trump administration, where I sort of felt like there was lots of reason to believe that resistance was the path. I don’t feel that way, and I don’t think we’re seeing that, generally, now, right? Like, we’re seeing a lot less sort of resistance stuff and a lot more trying to figure out how to make the reality of this situation less harmful.

I don’t think it’s sane-washing him to say, Look—if this guy’s gonna be in charge, what does it look like for us to recognize who he is and where he’s coming from, recognize that he has a growing movement of people behind him, who aren’t just going to go away because we yell at them? What does it look like to try to achieve something that doesn’t even have to be consensus but is understanding between us so that the entire sort of public-health apparatus doesn’t just get dismantled?

Demsas: That seems a perfect place to ask our last question, which is: What is something that you once thought was a good idea but ended up only being good on paper?

Bedard: Okay, I have two answers to this.

Demsas: Okay.

Bedard: I thought about it a lot.

Demsas: Lots of “good on paper” problems in your life. (Laughs.)

Bedard: And they were, like—these are not necessarily good on paper just to me. I think that there are two things that I think. The first is the Manhattan Project.

Demsas: What?

Bedard: It’s hard for me to think of anything cooler in the world than taking the best scientists in the country—like, the best scientists from around the world, basically—and bringing them all to the desert and being like, Figure out the hardest scientific problem of the moment, and we’ll give you unlimited resources to do it. Unbelievably sexy proposition. Turned out really bad. You know what I mean?

If I think about the Manhattan Project still, I’m very seduced—maybe you’re not at all, but I’m very seduced by it. It’s also like: You think you’re beating the Germans. It feels really important.

Demsas: Yeah.

Bedard: The other thing that I was going to say is: small plates. (Laughs.)

Demsas: So Manhattan Project and small plates.

Bedard: Manhattan Project and small plates.

So I think one of the major millennial failures is the invention and then rollout of small plates to, like, every yuppie restaurant in every city in the country—which is like: You go. You sit down. There’s, like, this menu of items that are all very expensive and very tiny, and they’re supposed to be for sharing, but they’re not big enough to share.

And then the waiter comes and, like, does this whole explanation, like, Have you ever been here before? Let me explain to you how the menu works. Things at the top are small, and things at the bottom are bigger. And then the menu proceeds from, like, $18 for four anchovies to, like, eventually you get to, like, a whole fish. You know what I mean?

And, like, (1) it’s insane. Like, you can’t—

Demsas: The sharing part is the most annoying part, where there’s, like, three things, and there’s five people at the table, and so you’re cutting each one—

Bedard: Of course! If the concept is you should be sharing, so you can try lots of things, then everything has to be family style. It should be big, not small. Big plates is what you need!

Demsas: Big plates. Wow. This is very attractive to me as an Eritrean because our food is the biggest of plates. It is one big, shared plate. So you know what? Sure.

Bedard: That’s the right approach!

Demsas: Yeah. Not the tapas way—the Eritrean way.

Bedard: Tapas was never meant to be a meal. Tapas is, like, an hors d’oeuvre situation. It’s not supposed to be that, like, it’s 7 p.m., and I’m starving. I’m sitting down with another couple, and we’re, you know, gingerly ripping apart one piece of sourdough between us.

Demsas: You know what? You’ve convinced me. I’m going to launch a tirade against this next time I’m at a restaurant to a poor, unsuspecting waiter. Well, Rachael, thank you so much for coming on the show. This was fantastic.

Bedard: Thank you, Jerusalem.

[Music]

Demsas: Good on Paper is produced by Rosie Hughes. It was edited by Dave Shaw, fact-checked by Ena Alvarado, and engineered by Erica Huang. Our theme music is composed by Rob Smierciak. Claudine Ebeid is the executive producer of Atlantic audio. Andrea Valdez is our managing editor.

And hey, if you like what you’re hearing, please leave us a rating and review on Apple Podcasts. I’m Jerusalem Demsas, and we’ll see you next week.

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I could have been a tech entrepreneur, but my parents let me go to sleepovers. I could have been a billionaire, but I used to watch Saturday-morning cartoons. I could have been Vivek Ramaswamy, if not for the ways I’ve been corrupted by the mediocrity of American culture. I’m sad when I contemplate my lazy, pathetic, non-Ramaswamy life.

These ruminations were triggered by a statement that Ramaswamy, the noted cultural critic, made on X on Thursday. He was explaining why tech companies prefer to hire foreign-born and first-generation engineers instead of native-born American ones: It has to do with the utter mediocrity of American culture.

“A culture that celebrates the prom queen over the math Olympiad champ, or the jock over the Valedictorian, will not produce the best engineers,” he observed. Then he laid out his vision of how America needs to change: “More movies like Whiplash, fewer reruns of ‘Friends.’ More math tutoring, fewer sleepovers. More weekend science competitions, fewer Saturday morning cartoons. More books, less TV. More creating, less ‘chillin.’ More extracurriculars, less ‘hanging out at the mall.’”

In other words, Ramaswamy has decided to use the reelection of Donald Trump as an occasion to tiger-mom the hell out of us. No, you may not finish studying before midnight! Put that violin back under your chin this instant! No, a score of 1540 on your SATs is not good enough!

That sound you hear is immigrant parents all across America cheering and applauding.

Maybe Ramaswamy’s missive hit me so hard because I grew up in that kind of household. My grandfather, who went to the tuition-free City College of New York and made it in America as a lawyer, imbued me with that hustling-immigrant mindset. We may be outsiders, he told me, but we’re going to grind, we’re going to work, we’re going to climb that greasy pole.

And yet it never happened for me. I have never written a line of code. Unlike Ramaswamy, I have never founded an unprofitable biotech firm. What can I say? I got sucked into the whole sleepover lifestyle—the pillow fights, the long conversations about guitar solos with my fellow ninth graders. I thought those Saturday-morning Bugs Bunny cartoons were harmless, but soon I was into the hard stuff: Road Runner, Scooby-Doo, and worse, far worse.

As the days have gone by, though, I have had some further thoughts about Ramaswamy’s little sermon. It occurred to me that he may not be quite right about everything. For example, he describes a nation awash in lazy mediocrity, yet America has the strongest economy in the world. American workers are among the most productive, and over the past few years American productivity has been surging. In the past decade, American workers have steadily shifted from low-skill to higher-skill jobs. Apparently, our mediocrity shows up everywhere except in the economic data.

Then I began to wonder if our culture is really as hostile to nerdy kids as he implies. This is a culture that puts The Big Bang Theory on our TV screens and The Social Network in the movie theaters. Haven’t we spent many years lionizing Steve Jobs, Bill Gates, and Sam Altman? These days, millions of young men orient their lives around the Joe Rogan–Lex Friedman–Andrew Huberman social ideal—bright and curious tech bros who talk a lot about how much protein they ingest and look like they just swallowed a weight machine. When we think about the chief failing of American culture, is it really that we don’t spend enough time valorizing Stanford computer-science majors?

Then I had even deeper doubts about Ramaswamy’s argument. First, maybe he doesn’t understand what thinking is. He seems to believe that the only kind of thinking that matters is solving math problem sets. But one of the reasons we evolved these big brains of ours is so we can live in groups and navigate social landscapes. The hardest intellectual challenges usually involve understanding other people. If Ramaswamy wants a young person to do something cognitively demanding, he shouldn’t send her to a math tutor; he should send her to a sleepover with a bunch of other 12-year-old girls. That’s cognitively demanding.

Second, it could be that Ramaswamy doesn’t understand what makes America great. We are not going to out-compete China by rote learning and obsessive test taking. We don’t thrive only because of those first-generation strivers who keep their nose to the 70-hour-a-week grindstone and build a life for their family. We also thrive because of all the generations that come after, who live in a culture of pluralism and audacity. America is the place where people from all over the world get jammed together into one fractious mess. America was settled by people willing to take a venture into the unknown, willing to work in spaces where the rules hadn’t been written yet. As COVID revealed yet again, we are not adept at compliance and rule following, but we have a flair for dynamism, creativity, and innovation.

Third, I’m not sure Ramaswamy understands what propelled Trump to office. Trump was elected largely by non–college graduates whose highest abilities manifest in largely nonacademic ways—fixing an engine, raising crops, caring for the dying. Maybe Ramaswamy could celebrate the skills of people who didn’t join him at Harvard and Yale instead of dumping on them as a bunch of lard-butts. What part of the word populism does he not understand?

Most important, maybe Ramaswamy doesn’t understand how to motivate people. He seems to think you produce ambitious people by acting like a drill sergeant: Be tough. Impose rules. Offer carrots when they achieve and smash them with sticks when they fail.

But as Daniel Pink writes in his book Drive, these systems of extrinsic reward are effective motivational techniques only when the tasks in front of people are boring, routine, and technical. When creativity and initiative are required, the best way to motivate people is to help them find the thing they intrinsically love to do and then empower them to do that thing obsessively. Systems of extrinsic rewards don’t tend to arouse intrinsic motivations; they tend to smother them.

Don’t grind your kids until they become worker drones; help them become really good at leisure.

Today, when we hear the word leisure, we tend to think of relaxation. We live in an atmosphere of what the theologian Josef Pieper called “total work.” We define leisure as time spent not working. It’s the pause in our lives that helps us recharge so we can get back to what really matters—work.

But for many centuries, people thought about leisure in a very different way: We spend part of our lives in idleness, they believed, doing nothing. We spend part of our lives on amusements, enjoying small pleasures that divert us. We spend part of our lives on work, doing the unpleasant things we need to do to make a living. But then we spend part of our time on leisure.

Leisure, properly conceived, is a state of mind. It’s doing the things we love doing. For you it could be gardening, or writing, or coding, or learning. It’s driven by enthusiasm, wonder, enjoyment, natural interest—all the intrinsic motivators. When we say something is a labor of love, that’s leisure. When we see somebody in a flow state, that’s leisure. The word school comes from schole, which is Greek for “leisure.” School was supposed to be home to leisure, the most intense kind of human activity, the passionate and enjoyable pursuit of understanding.

The kind of nose-to-the-grindstone culture Ramaswamy endorses eviscerates leisure. It takes a lot of free time to discover that thing we really love to do. We usually stumble across it when we’re just fooling around, curious, during those moments when nobody is telling us what to do. The tiger-mom mentality sees free time as a waste of time—as “hanging out at the mall.”

A life of leisure requires a lot of autonomy. People are most engaged when they are leading their own learning journey. You can’t build a life of leisure when your mental energies are consumed by a thousand assignments and hoops to jump through.

A life of leisure also requires mental play. Sure, we use a valuable form of cognition when we’re solving problem sets or filling out HR forms. But many moments of creative breakthrough involve a looser form of cognition—those moments when you’re just following your intuition and making strange associations, when your mind is free enough to see things in new ways. Ninety-nine percent of our thinking is unconscious; leisure is the dance between conscious and unconscious processes.

The story Ramaswamy tells is of hungry immigrants and lazy natives. That story resonates. The vitality of America has been fueled by waves of immigration, and there are some signs that America is becoming less mobile, less dynamic. But upon reflection, I think he’s mostly wrong about how to fix American culture. And he’s definitely not getting invited to my next sleepover.

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This episode, from our first season, called How to Build a Happy Life, features host Arthur Brooks in conversation with the psychotherapist and Atlantic contributing writer Lori Gottlieb about how the first step in making room for more joy in your life is learning how to identify it.

The following is a transcript of the episode:

[Music]

Megan Garber: Hey, it’s Megan Garber, one of the co-hosts of How to Know What’s Real. We’re excited to share with you a special series drawn from past seasons of the How To series. Over the past few weeks, we’ve been revisiting episodes around the theme of winding down. This episode is from our very first season, How to Build a Happy Life, and is called “How to Identify What You Enjoy.” It first published in 2021 during the pandemic, even though that was a really challenging time. This is still one of my favorite episodes to this day. Host Arthur Brooks explores how the first step in making room for more joy in your life is learning how to identify it.

[Music]

Brooks: This is How to Build a Happy Life, The Atlantic’s podcast on all things happiness. I’m Arthur Brooks, Harvard professor and happiness correspondent at The Atlantic. In this special bonus episode of the How to Build a Happy Life series, I sat down with The Atlantic’s own Lori Gottlieb. We reviewed a lot of what we’ve covered in this series, from enjoyment and emotional management to the practical ways to apply the science of happiness to our daily lives. Enjoy!

Hi, everybody, and welcome to The Atlantic Festival. I’m really delighted because this episode of the podcast, it features one of the top psychotherapists in America today, The Atlantic’s Lori Gottlieb. We’re going to talk through some of the how-tos of navigating the natural ups and downs in life. And later in the episode, we’re going to feature some of my very favorite guest stars, which is you, our listeners.

So let’s start by saying hi to Lori. Welcome to How to Build a Happy Life, Lori.

Lori Gottlieb: Well, thank you so much. It’s great to be here.

Brooks: Yeah, it’s wonderful to have you here.

I’ve been looking forward to working with you in some way for the longest time. I teach a class at Harvard Business School called Leadership and Happiness, and on the first day of class, I define happiness. Now, most of my students think happiness is a feeling. That’s wrong. I mean, happiness has a lot of feelings attached to it, and feelings are really important. But it’s not a feeling per se. I describe happiness as more of the way that you would take apart a meal.

Happiness is like a banquet. And you can define it in a lot of different ways, in terms of the ingredients; you can define it in terms of the dishes. But I like to start with the macronutrients of any meal. Now, if you’re eating a, literally, a meal, the three macronutrients are protein, carbohydrates, and fat. And I say that, similarly, there are three macronutrients to happiness. They are enjoyment, satisfaction, and purpose. People who are truly happy about their lives, they have all three. And they have them in abundance, and they have them in balance. And people who are out of balance [with] enjoyment, satisfaction, and purpose tend to define themselves as unhappy. They know that something is wrong with their happiness.

And so when I’m talking to somebody who says “I’m really unhappy,” I start digging in on one of those dimensions. So that’s where I want to start. And I want to start with the first of those, which is enjoyment. I define enjoyment as pleasure plus elevation. When you learn something about the sources of your pleasures, it turns into authentic enjoyment, which is a part of a happy life. Do you agree with that?

Gottlieb: I do. I would say that enjoyment plus connection. I really feel like connection—

Brooks: Connection with people?

Gottlieb: Right, right. Well, there are certain solitary enjoyments. You know, let’s say that you’re an artist or let’s say that you’re a musician or let’s say you’re reading a book. You know that’s enjoyable to you, depending on who you are. But I think that when you talk about the ingredients, I think connection really has to be in there. And what I see in the therapy room is that when you look at those ingredients of happiness, if you don’t have connection added to those ingredients, it’s going to be hard. And I love the way that you are talking about happiness—not as a feeling, because I think that happiness as a byproduct of living our lives in a meaningful way is what we all aspire to. But happiness as a goal in and of itself often is a recipe for disaster, because they’re not looking at the ingredients that you’re talking about.

Brooks: Mm. Yeah, for sure. And this is completely consistent with the findings of, you know, Bob Waldinger and George Vaillant and all those guys who have done all that longitudinal work that shows that the happiest people in their 70s and 80s are people who established the most human connections in their 20s and 30s. They got really, really good at love. They’ve got good love chops, is the bottom line. And so this is the No. 1 ingredient probably, in enjoyment, satisfaction, and purpose, is human connection.

Gottlieb: Well, right, and I think that the question that people ask themselves, I think that we all ask ourselves, when it comes to happiness is: How can I love and be loved? I think that is the essential question. And that’s where the enjoyment, I think, comes from too: What does it mean to not only love someone and be loved, but how do you love yourself too? And so often we don’t know how to do that. We can make ourselves incredibly unhappy by being unloving to ourselves.

Brooks: I want to talk about the specific macronutrient of enjoyment here for a second. One of the characteristics of people who present with clinical depression is a syndrome called anhedonia, which is the inability to experience pleasure and enjoyment. Even if you’re not clinically depressed, clearly if you’re having a hard time enjoying things, you’re going to be unhappy. As we just talked about a minute ago, and even better, if you’re enjoying things in connection, in communion with other people, because that actually creates the most fulfillment.

Do you see patients who because of whatever is going on in their lives—because of an over-sense of discipline or because they’re excessively stoic or for whatever reason—that they have insufficient enjoyment of their lives? And if so, what do you tell them? How can I enjoy my life more?

Gottlieb: Well, this is kind of like a chicken-or-the-egg thing. So anhedonia is when people are depressed; they literally cannot experience joy in the things that would normally bring them joy if they were not depressed. So it’s not that they don’t know how to enjoy things. It’s that because of depression, they aren’t enjoying activities that would normally be pleasurable to them.

But yes, I think that there are people who don’t know how to separate from that. There are people who don’t know how to have fun. I think that we think somehow in our culture today of ambition and moving forward—you know, all sorts of pressures—that people think that fun is frivolous. They don’t realize that it’s actually essential. So when you talk about enjoyment, people think, Well, that’s optional. You know, like if I have time. And then, of course, they don’t make the time because they think that it’s something that’s not necessary, and it absolutely is.

Brooks: So what’s an example of somebody who would come to you and they’re not enjoying their lives. They’re not taking time to have fun. What’s the assignment that you give them? Because, you know, in your show, you give somebody an assignment and then you see how it’s going. So if I came to you and I said, “I just don’t know how to have fun. I work and I work and I work all the time, and I’m not very happy.” And you say, “Arthur, do these three things.” You know: What’s the kind of thing that you would tell me? What’s the assignment?

Gottlieb: Well, actually, on the Dear Therapist podcast, we do a therapy session with people. And then, as you said, we give them a homework assignment that they have a week to do, and they report back to us. We had this 16-year-old who presented this exact issue. She said, “I am just trying to get into college, I’m doing all of these things. I never have any fun.” And so we gave her an assignment where we wanted her to have more balance in her life, and we gave her a specific assignment. This is the Libby episode in season one.

And she was somebody who was very reluctant to do this, because she thought that it would somehow hold her back, that it would somehow make her less competitive for college, that it would affect her in a way. Because nobody around her was having fun, by the way. Everybody was pretending to have fun.

You know, on social media it looks like everybody’s having just a great time. But in reality, everybody was really stressed out, and nobody was making time for fun. And so she did that. And she found that when she made time for fun she not only enjoyed her life more, but she found that actually it made her more productive. It actually helped her to get ahead. And so it was interesting, because I think that we have this idea that, you know, having fun is going to hold us back somehow. And in theory, we want to have fun, but we don’t actually say, “I’m going to put that on my calendar. I’m going to make that a priority.” And I think we really need to.

Brooks: That’s pretty interesting in our hyper-scheduled and and highly schematicized life that certain people have to actually put it in their Outlook: for 45 minutes, have fun. It seems like fun would be the most natural and spontaneous thing that people could have or do. And yet for people who are so scheduled all the way up into the tree, they actually need to treat it like anything else and take time for it, right? Is that what you’re saying?

Gottlieb: I think it needs to be specific too, not just “have fun.” It’s getting in touch with how you have fun. A lot of people don’t even know how they have fun anymore. As adults, they grow up. They forget what fun looks like, because they’re so busy with all of their responsibilities and then all of the things they think they need to be doing. And they don’t realize, first of all, how they’re spending their time.

So many people say, “I don’t have time for this kind of thing.” And yet if they actually do a 24-hour diary—which is what I will prescribe in therapy a lot—where they have to write down everything that they’re doing for 24 hours and sometimes 48 hours. And when they realize that, they’re like, “Oh my gosh, I spent like an hour and a half mindlessly scrolling through the internet.” And that actually dampened their mood. It wasn’t a pleasurable activity for them. It was like, “Oh, I’m so behind; look at what everybody else is doing.” Or “Look at that person. They went to Hawaii, and I don’t get to go to Hawaii.” Or whatever it is.

So it wasn’t even a pleasurable activity. That hour and a half could have been spent doing something that would have actually brought them joy. And I want to use the word joy here when we talk about happiness. You’re right—happiness is not an emotion. Joy is an emotion, right? And so what brings you joy? And so specifically, people don’t know. They’re like, If I had the time, what would fun even look like? I don’t even know what that looks like. And so really, being able to identify, how do you have fun? What does fun look like for you? So that when you schedule time to have fun or make time so that it becomes not a thing that you schedule after a while, but just something that’s a natural part of your existence. What does that look like? People don’t even know sometimes. If you said to them, “How do you have fun?,” they look at me like, Fun? What’s that?

Brooks: It’s interesting that people don’t know how to have fun. And maybe they used to, and maybe they’ve forgotten. So if they present to Lori Gottlieb and say, “I’m not having any fun” or “I don’t have enough enjoyment in life,” the first assignment is not to have fun. The first assignment you’re going to give them is Think about the last time that you had fun—what were you doing—so that you can remember how to have fun in the first place. Is that right?

Gottlieb: Yeah, and a good way to figure out what is fun for you is to look at your envy. People don’t like to feel envy. They feel like it’s kind of like a taboo. They don’t want to feel that. They think that they’re a bad person for feeling that. But actually, envy is very instructive, and envy tells us something about desire. And so I always say to people: Follow your envy. It tells you what you want. And so when you are envious of someone or something or some experience, that’s a clue to what might be enjoyable for you. We are so hesitant to look at our desire. We don’t want to give space for desire. We’re so much about the shoulds, as opposed to the “What do I want? What does desire look like for me?” We feel like it’s almost a selfish act.

Brooks: That’s really interesting, because one of the things that I talk about an awful lot in the study of discernment—which is a part of every philosophical and major religious tradition, from Buddhism to Judaism to Christianity and even stoicism—is that discernment is actually not about “What should I do?” Discernment is about “What do I want?” It’s finding the nature of your own desire. And so that is as old as the hills. And yet it somehow escapes us again and again and again. And when I talk to young people, a lot of my students, they think they’re trying to figure out what they want to do. And actually, they should be thinking about trying to figure out what they want. That’s what they really don’t know: what they want. And that’s what you’re trying to get at, right, Lori?

Gottlieb: Yeah, absolutely. And I think that there’s so much noise out there where sometimes people can’t hear themselves. So they conflate what society wants them to want, what their parents want them to want, what the culture tells them they should want versus what they inherently want. And if it goes against some of those things—like some of those culturally accepted things of what we should want—it’s very hard for them to even acknowledge that that’s something that they want.

Brooks: Let’s move on to the second pillar, the second macronutrient of a happy life, which is satisfaction. Now this is a killer. Satisfaction is really tough. I mean, Mick Jagger saying “I can’t get no satisfaction.” The truth is you can get satisfaction. The problem is you can’t keep satisfaction. Satisfaction is the reward when you meet a goal. It’s the reward for a job well done. It’s a promotion. It’s the race that you get. It’s the little burst of joy that you get from meeting one of your own personal goals. And the big problem that people have is that they get a little burst of this joy, perhaps—but then it goes away, and then they’re running, running, running, running again.

And there’s a whole lot of neurobiology about homeostasis that helps us understand this, and there’s the metaphor of the hedonic treadmill that shows us why we keep running and running and running, which is really good because it shows that after a little while, you’re mostly running out of fear because if you stop on a treadmill, you know, it’s going to happen.

But the real question then becomes, How do we deal with that? You do need satisfaction to be a happy person, but you can’t keep it. So what do you tell people who are workaholics and are addicted to success—and they’re just trying and trying and trying, as Mick Jagger sang, to get satisfaction, and they’re not getting it? The result is that they’re missing something from their lives. When somebody presents with the dissatisfaction dilemma, what do you tell them?

Gottlieb: Well, as you were talking, I was thinking about the people who present almost like a colander instead of a bowl. So it’s kind of like, you know, something goes in and it doesn’t stay there. The satisfaction gets there, and then, like, it just goes through the holes. It doesn’t stay, like in a bowl, right? And I think that the people who are happiest when we talk about people—and I would maybe use the word contentment—the people who are most content, who feel most full and fulfilled in their lives, are people who are what are called satisficers. And this is Barry Schwartz from The Paradox of Choice. And he talks about the difference between satisficers and maximizers. Satisficers are those people who, let’s say: You’re trying to buy a sweater, and you go into a store and you find a sweater that fits you. It looks good. It’s the right price. You buy it, you’re happy, you’re done. Right? It meets all of your criteria.

The maximizer will see that sweater and kind of put it under another sweater, so nobody will buy it. And just in case, go to the next store. And keep looking, because maybe they’ll find something a little bit cheaper or a little bit more attractive or, you know, whatever it is, right? Just something that’s a little bit better in some dimension. And they keep looking, and then maybe they find it. Maybe they don’t. But if they do find it, they tend not to be as happy with that purchase as if they had just bought the original sweater. And if they don’t find it, then they regret that they didn’t get the original one. And the problem is, even if they buy that first one that met all their criteria, the maximizer might be happy for about a week—and then the next week, they’re walking by a store and they see something else in the window and they think, Oh, that one would have been better. And so they’re just never satisfied.

And you see this in relationships. People do this in relationships all the time, too. It’s not just with things like sweaters. It’s with people, it’s with jobs, it’s with everything. So it’s kind of almost like a personality type, like: Are you a satisficer, or are you a maximizer? Even when you’re shopping on Amazon and you’re trying to decide Which set of cookware should I buy?, you know? And it’s like, the people who will spend like an hour going through all the different options instead of 10 minutes going, Oh, this is good. Let me just get this. And it really takes up your emotional energy in a big way, because it’s almost like it’s a perfectionism type of thing. And it really gets in the way, because it takes up all of your time. And then you’re never satisfied with what you have anyway.

Brooks: That’s really interesting. And you know, what you’re saying sounds kind of like a Western version of what His Holiness the Dalai Lama always says—which is the secret to enduring satisfaction is not to have what you want, but to want what you have. The satisficer is one who wants what she has, and the maximizer is the one who is always chasing, trying to have what he wants.

And another way of thinking about this, that actually works in the literature on the science of satisfaction, is that you shouldn’t think of your satisfaction as a function of what you have, but rather what you have, divided by what you want. And if you can actually devise a “wants management strategy,” the denominator of that fraction is going to decrease and your satisfaction is actually going to rise.

So when a patient presents with a satisfaction deficit, what assignment do you give them on your show? This is somebody who’s unsatisfied. Or if you have a patient who says, “It’s just, nothing’s good, Lori. Nothing’s good.” What do you tell them to do specifically, starting today?

Gottlieb: I think this is the difference between what a friend would say to this person and what a therapist would say to this person. Because what the friend tends to do is to say, “Look at all the wonderful things you have in your life,” which is not helpful at all because they can’t see it anyway. You know it’s very funny when you look at the difference between how we talk to our friends and how a therapist might approach this. Because I think that people would expect the therapist to say, “Well, look at all these things that you’re not seeing.” But no. In fact, what I would probably do is I would agree with them and say, “Yeah, you know, I can see that you’re really not satisfied.”

And then what happens for them is the more that you kind of go into their mindset that they start to see something new, that they start to say, “Well, actually, I have this really great partner, and I have this really great job.” But then there are a lot of buts with that. And then they start to sort of change their mindset when you’re not arguing with them about whether they should be satisfied or not. You can’t convince someone to be satisfied with what they have. They have to come to it on their own. And I think that a lot of people have very low tolerance for people like this, because they feel like, Well, you have so much, how can you complain? But I think it speaks to something in our culture—which is that we don’t really value what’s important. We don’t really value what’s going to bring us happiness. And so people tend to take for granted all of the things that they do have that would normally bring a person happiness.

Brooks: Hmm, that’s really interesting. And it actually leads—which we’ll touch on briefly before we go to our, before we go to our listeners—about the last macronutrient of happiness, which is maybe the hardest of all, which is purpose or meaning. And the reason that this is really hard is because it’s the most counterintuitive when it comes to the science of happiness. You know, when I ask in surveys—you know, large-scale surveys or experiments using human subjects—“What brings happiness and purpose to life?,” people always talk about the most painful parts of their lives. They never talk about, you know, “that week in Ibiza with my friends”; they never say “That’s when I actually found out my life’s meaning.” You know, they always talk about that divorce, that ugly breakup, when they got fired, that bankruptcy, when their kid had to go to rehab. That’s when they talk about, you know, the stuff that they were made of, and when they really understood the nature of their own souls.

And yet back when you and I were little kids and the hippies were running around in the ’60s and ’70s and the Woodstock generation said, If it feels good, do it, right? But now young people on either side of us—bookended by people like you and me—their mantra seems to be, If it feels bad, make it stop. Paradoxically, if we don’t suffer—if we don’t have pain, if we don’t come to terms with having a life that’s fully alive with the good and the bad—we can’t actually get enough meaning and purpose in our life, right?

Gottlieb: Well, that’s right. And I think that’s why we assign negative and positive connotations to feelings. Even though feelings are neutral, they don’t have a positive or negative connotation. So people say, “Joy is a positive feeling, and anger or anxiety or sadness are negative feelings,” and that’s just not true. All of our feelings are positive in the sense that they tell us what we want. Our feelings are like a compass. They tell us what direction to go in.

And if you don’t access your feelings, you’re kind of walking around with a faulty GPS. You don’t know what direction to go in. And people think that if they kind of numb their feelings —like, Oh, it’s not a big deal because I have a roof over my head and food on the table—that the sadness, the anxiety, this insomnia, whatever it is, is okay. Because, you know, it seems very trivial to them. But it’s not. It’s actually a message. It’s telling you something about your life. It’s telling you about something that needs to change.

And so people feel like numbness is nothingness. It’s not the absence of feelings. Numbness is actually a sense of being overwhelmed by too many feelings. And then they come out in other ways, like too much food, too much wine, an inability to sleep, a short-temperedness, a lack of focus. You see how the feelings are there. They’re just presenting differently.

And so I think it’s really important for people to notice their feelings and to really welcome their feelings and embrace their feelings, because the feelings give them information about if they’re sad, what is not working. If you’re anxious, what is causing the anxiety? If you’re angry, are there some boundaries that maybe you need to set? Right? Is there something you need to change in your life? What is going on? So I think that that’s really important. And when we talk about meaning and purpose, if you don’t listen to your feelings, they’re going to direct you in the direction of meaning and purpose, they’re going to tell you what is important.

Brooks: It’s interesting, you know. Most of the great sages and saints throughout history have talked about the sacredness of suffering, and some pretty wise and interesting people today do too. I mean, there was a famous interview of Stephen Colbert by Anderson Cooper, where Stephen Colbert talks about the most painful time in his life, when his father and one of his siblings were killed in a plane crash. And he talks about how grateful he is even for that experience, because of the sacredness of every moment of his life, including the pain. He says, “Look, if you’re going to be fully alive, if you’re going to have a life, if you’re going to enjoy life per se, you’ve got to take it all.” If you’re thankful for life, you’ve got to be thankful for all of life, because that’s the fabric of your set of experiences. And it seems to me that that is the essence of how you find your meaning and the essence of how you understand who you are as a person according to what you just told me, right?

Gottlieb: I don’t think that you need to suffer tragedy to feel gratitude. I think that sometimes it awakens us to feeling gratitude when you have some kind of tragedy in your life. But I don’t think that you need to have some kind of tragedy. But I do think that you don’t get through life without suffering in some way, so it doesn’t need to be that a relative dies in a plane crash. I think that just being human inherently means that there are going to be times that you struggle.

And I think if you look at the world today, if you look at—you know, there’s so much suffering that we hear about every day in the world, but then what are we told? If you look at social media, for example, or you’re at a dinner party, you know, you don’t—nobody talks about that. Nobody wants to talk about that. It’s all like, Let’s pretend everything’s great. And I think it’s both. And if we don’t make room for the both, then you’re right that we don’t see the beauty.

We don’t appreciate the beauty in life. It’s almost like you can’t—you know, people always say, like, “I want to mute the the sadness” or “I want to mute the pain,” and it’s like: You can’t mute the pain and then also feel joy. If you mute one aspect of your emotional experience, you’re going to mute all of that. There’s like one mute button. So, if you mute the pain, you mute the joy. And so I think that that speaks to what you’re saying.

Brooks: And there’s one clarification you made that’s incredibly important that I want to underline for everybody listening. Remember: Lori Gottlieb just said that you don’t have to go out looking for suffering. Don’t worry. Suffering will find you, and that’s adequate, too, for us to find purpose in our lives.

Gottlieb: There’s a difference between pain and suffering, too. We all experience pain. You know: You go through a breakup, you go through a divorce, somebody gets ill, something happens with your job. Whatever it is, right? We all experience pain of some sort, but suffering is something that sometimes we do to ourselves.

So you go through a divorce, and then you’re like, looking on social media at your ex and you see them with their new partner, right? You don’t need to do that. That’s suffering. You’re creating your own suffering. So people do that all the time. And so we’re all going to experience pain in some way or another. But sometimes we are creating our own suffering. And in therapy, that’s a big topic of conversation. How are we creating our own suffering? Even though, of course, pain is inevitable.

Brooks: I want to go now to some of our listeners. I put out a call at the end of my column asking people to tell me the last time they were happy, and what we got back was just pure gold. They were so interesting and so moving. And I wanted to play just three clips of people telling me about the last time that they were happy and get your reaction to what they’re saying and, you know, what it says to you. I could analyze this from [my perspective as] the social-science guy, but I’m a lot more interested in what you’d tell these people if they were coming to see you for help.

Let’s bring up audio clip No. 1, who is one of our listeners: Karl from North Carolina.

Listener Submission 1: The last time I felt truly happy was yesterday. I am a high-school English teacher, and we’re now back in person. We’re lucky enough to be in a school where we wear masks. I was able to actually see their—if not their faces—their eyes light up when they figured out something or they got the point of my lesson. And just seeing their eyes light up and getting to exercise that teaching muscle that I haven’t really got to exercise in over a year and a half. Getting to be in front of the students again makes me feel truly like myself again, something that I really haven’t felt in a long time. So, yeah, teaching makes me happy.

Brooks: Isn’t that beautiful, Lori? And it seems to me that he made your point. It’s connection—that’s the secret! Happiness is love, right?

Gottlieb: Right. Well, it’s meaning and purpose and connection all rolled into one—that was so beautiful. We had someone on our Dear Therapist podcast during the pandemic, a teacher also, and she was talking about this, you know, like, wanting to reach her students and how she was. They said to her, like, “The best part of my day is when I get to connect with you.” Right? And so I think that we learned a lot during COVID about meaning and purpose and connection. Many people think it has to be this big epic thing. It can be, you know, I had this moment with my child and we had this great five minutes together. Or just like with Karl, you know, I had this experience with my students and I saw their eyes light up when they got the lesson. That right there is meaning and purpose, and it doesn’t need to be this grand thing. It’s like it’s the dailiness of it. It’s having lots of bursts of meaning and purpose throughout your day.

Brooks: And that actually speaks to what you talked about with satisfaction. Because satisfaction—if you’re looking for it in one big thing—it’s probably going to disappoint you. But if you’re looking at the little things that happen over the course of a day and over the course of life regularly, you’ve got a shot. That’s important, too.

Gottlieb: Often I will give people this assignment in therapy and even on the podcast, which is: I want you to write down the different moments of the day when you feel something positive. And often there are these moments of meaning, these moments of connection. And there are so many during the day that they didn’t even realize, even if it’s like: “I went to Starbucks, and I saw this barista who’s been there for five years and we used to talk every day, and I missed that during COVID. And it was so great to see each other again. And I realized this is meaningful to me.” You know, it’s like those little moments throughout the day that you don’t even pay attention to. And all of a sudden you say, Wait, those are really important to me.

Brooks: Let’s go to clip No. 2: Kristen in New York.

Listener Submission 2: The last time I remember being truly happy was in the summer of 2019. I had just ended my first year of grad school. I was living in Japan and Tokyo. I’d already been there for five years, so I became quite accustomed to living there and found myself in a great group of friends … And looking back from there, it kind of feels like everything has just been this slow and then sudden descent. Because I got back to Japan, and my friends began to graduate and move away. And then the pandemic came. And like many people, I spent months alone in my apartment, so it was just really lonely. And then my visa was expiring, so I had to leave my community that I had spent six years building into this period of great uncertainty. And then my mother died, suddenly and unexpectedly. And since then, I’ve been living in the after. And I feel like I will never experience that kind of happiness again—like I did that summer. Being so devastated by grief and loss, it just feels like whatever way joy manages to find its way back into my life will always be different.

Brooks: What do you say, Lori?

Gottlieb: Wow. Just so much loss and grief, and what she’s experiencing is so common. Because we think that when we’re in the throes of that, we feel like we will never experience joy again. We will never experience happiness again in the same way. And actually, in my book, in Maybe You Should Talk to Someone, there’s one client that I write about. He was talking about how his son was killed in a car accident. And within a week of that, where he was devastated and he thought My life is over, I will never be the same again, he was with his daughter. And they were playing a game, and he laughed. And he said, “I couldn’t believe that. I laughed. I couldn’t believe that I actually could laugh. Like, what was that part of me that could do that, even though the rest of me felt dead and like I would never come alive again?” And so I think what she’s feeling is extremely common, and that’s what grief looks like. And, you know, she’s going to have a lot of grieving to do. And it’s unfortunate that her mother died in the middle of COVID when she was so isolated and she had lost her community, and all of these other things had happened. So she’s experiencing multiple layers of loss. And I hope that she allows herself the space to really grieve all that she has lost, so that she can then start to emerge again.

Brooks: And I think a really important part of your message, Lori—and what you just said and I think that I want people to remember from this and what [I want] Kristen to remember—is that happiness is going to come again. That this isn’t the end. It feels like the end, because that’s how it always feels when you’re in a period of grief. And there’s all kinds of reasons for that. But happiness is going to come again. It just is, right?

Gottlieb: Well, it reminds me of when people are depressed, they feel like they will never be happy. And so I always say to people who are in the middle of a clinical depression You are not the best person to talk to you about you right now. Because their thinking is so distorted in that moment because they can’t see it. They can’t imagine a time when they would experience joy again. And the same thing, I think, when people have experienced a devastating loss, they cannot imagine experiencing joy.

And yet what happens later, just like the man in the book—people go to weddings and they go grocery shopping and they go on Twitter, and their lives move on. There’s this expression like people say, “Well, why haven’t you moved on?” Moved on is not quite right. It’s, you move forward. The loss stays with you, but you move forward and you’re still grieving. You will always grieve that loss. And I think that the grief is a sign of how much love there was with the person who is no longer there, right?

And then loss of the community. She loved those people. So that’s going to be there, but it feels different. It has a different flavor over time. It has a different resonance. And there will be times when you’re standing in an elevator and some song comes on and it’s the song that meant something with that person and you just start bawling in the elevator or whatever it is. You know, that’s what grief looks like, even decades later. So I think that’s part of the human experience and what you were talking about earlier, Arthur—about this idea of meaning and struggle and how they’re somehow intertwined in some way.

Brooks: One of the things that’s so interesting when you talk to older people who are happy and well—when you talk to those people, what you find is that they suffered a lot. It’s weird, you know, for young people, people in their 20s, who want to find out how to have a happy life and want to avoid as much suffering as possible. So in their 80s, they’ll be really happy. That’s actually wrong. In the same way, something that’s a really delicious dessert actually has salt in it.

And the afternoon of your life requires that the morning have had a certain number of challenges. And so you find that the happiest people have been fully alive all throughout their lives, and they’ve grieved, and they’ve recovered. And when bad things are happening, they never thought they’d feel better. And guess what—they did. They did! And they allowed themselves to be sad. And that’s one of the secrets, right?

Gottlieb: Right. And I think that the reason that they’ve been through so much is because they engaged in life. So the people who want to protect themselves from pain or discomfort are the people who never really engage in life because they’re so busy protecting themselves to make sure that they’re not going to experience anything that feels bad, right? And so then they never put themselves out there. They never take any risks.

And when you take risks, sometimes, you know, there’s going to be pain involved. And sometimes there’s going to be great joy involved. But if you are protecting yourself the whole time you didn’t really live; you’re not fully alive. And so maybe you think you protected yourself, but you end up feeling very unsatisfied, very kind of empty and lonely.

Brooks: If you’re going to live your life like an adventure, you’re going to have to take some chances. Let’s go to the last audio clip to finish this out, Lori.

Listener Submission 3: Hi. My name is Joel Marsh, and I own Marsh Painting Inc. in Park City, Utah. [I’ve] been painting homes in Park City for over 20 years. And I’m a fourth-generation painter. What I’ve learned is that Arthur Brooks is correct in this column when he states that what matters is not so much the weight of a job—more the “who” and the “why.” One day, as we were staining a home, we took a 10-minute break and hit golf balls onto the adjoining driving range. With the homeowner’s permission, of course. Our work painting houses is hard and boring much of the time. I tell new recruits that more often than not, when you have good music going, some good Mexican food for lunch, and you get into a rhythm with the rest of the guys, our job can feel a little Zen-like.

Brooks: We’re pretty much near the end of the time, so let’s have this be kind of the last word. What’s your big takeaway? And what’s the big lesson that people should get from this incredibly encouraging message from Joel in Park City?

Gottlieb: Yeah, that was really beautiful. I was thinking about how, before COVID, people used to say co-workers are overrated. You know, people are like, “I really want to work from home,” or whatever it is. Co-workers are not overrated. I think that if we’ve learned anything, it’s those small moments like he was talking about—those spontaneous moments of like, Hey, let’s hit the golf balls, right?

The things that you don’t expect, those moments of connection that happen when you’re in the same space with other people and you have a shared experience. And I think that that’s what we need to look for in general these days. No matter whether it’s at work or in our families or in our social circles or whatever it is. How can we show up? When you show up, those moments of connection happen.

Brooks: Well, the practice of enjoyment and satisfaction and purpose through pain and through love and all the experience—that is the beautiful thing that we call life, courtesy of Lori Gottlieb.

Lori Gottlieb is the author of the best-selling book Maybe You Should Talk to Someone,; of the wonderful, wonderful column, Dear Therapist; my colleague at The Atlantic. What a privilege, what a joy it’s been to be with you during this time. Thank you for joining all of us on How to Build a Happy Life.

Gottlieb: Oh, my pleasure.Thanks so much for the conversation.

[Music]

Garber: If you enjoyed this episode, take a listen to our first season, How to Build a Happy Life. You can find all seven episodes wherever you get your podcasts. Our next episode will be the last installment in our Best of How To series. We’ll look at the art of small talk and what tools are available to help reduce social anxiety.

Julie Beck: So do you think that you’ve gotten more comfortable with socializing over time, or do you just feel like you’ve learned strategies?

Ty Tashiro: I think it’s that I’ve learned strategies first, and then the social comfort came after that.

The twinkling of lit-up trees and festive displays in store windows have come to mean two things: The holidays are upon us, and so is COVID. Since the pandemic began, the week between Christmas and New Year’s has coincided with the dreaded “winter wave.” During that dark period, cases have reliably surged after rising throughout the fall. The holiday season in 2020 and 2021 marked the two biggest COVID peaks to date, with major spikes in infections that also led to hospitalizations and deaths.

But something weird is happening this year. From September through November, levels of the virus in wastewater, one of the most reliable metrics now that cases are no longer tracked, were unusually low. At various points over that span, hospitalizations and deaths also neared all-time lows.

That’s not to say we are in for a COVID-less Christmas. CDC data released over the past two weeks show a sharp increase of viral activity in wastewater. Whether this is the start of a winter wave still remains unclear, but even if so, the timing is all off. Last year, the winter wave was nearing its peak at Christmas. This time around, the wave—if there is one—is only just getting started. America is in for the most unpredictable COVID holiday season yet.

An optimistic view is that the uptick in wastewater levels reflects the spread that happened over the Thanksgiving holiday and will fall quickly, Michael Hoerger, a Tulane University professor who runs the Pandemic Mitigation Collaborative, a COVID-forecasting dashboard, told me. This is a possibility because the CDC posts wastewater data about a week after they’re collected; the most recent data represent the two weeks after the holiday, which would give people who were infected over the break some time to show symptoms. The worst-case scenario is that low transmission throughout autumn was sheer luck, and over the next few weeks the virus will rapidly play catch-up. Hoerger expects transmission to steadily increase over the next couple of weeks, potentially reaching a zenith around January 7, though a marked increase or decrease remains “plausible,” he said. Even if a wave is around the corner, “it likely will not be anywhere close to any of the peaks we had during the pandemic,” Michael Osterholm, an epidemiologist at the University of Minnesota, told me.

The confusion about how the virus will behave over the holidays reflects a bigger COVID uncertainty: Even after four straight winter waves, experts are torn on whether we should continue to expect them. Caitlin Rivers, an epidemiologist at Johns Hopkins, told me it would be “very unusual” if a wave didn’t happen, given that the virus has generally followed a reliable pattern of peaking in the summer and winter. But Osterholm rejects the idea that the virus follows predictable patterns. The nine peaks that have occurred since COVID emerged “were not predicted at all by season,” he told me. Winter waves have less to do with winter, Osterholm said, and more to do with the unpredictable emergence of new variants overlaid on waning immunity.

Squaring the notion that COVID doesn’t follow seasonal patterns with its recent track record of ruining the holidays is not easy. Part of the confusion stems from the expectation that the virus should behave like other respiratory-season bugs: The flu and respiratory syncytial virus, or RSV, typically spike in the winter, which is why shots are offered in the fall. But as my colleague Katherine J. Wu has written, SARS-CoV-2 is not a typical respiratory-season virus, even though updated COVID vaccines are recommended in advance of the winter virus season. As expected, flu and RSV are currently on the rise. In a way, COVID’s weird timing this year is fortuitous because it means the “peak season will likely be out of sync with flu,” reducing the burden on hospitals, Rivers said.

After nearly five years of living with this virus, you might expect that its behavior would be easier to predict. But in scientific terms, five years is not a long time. COVID may turn out to spike every winter, but it is too early to tell. “The only thing that makes this virus seasonal is that it occurs in all seasons,” Osterholm said. Any patterns that have emerged in that period could be rendered obsolete as more data are collected. In time, the ebbs and flows that have been interpreted as trends may yet prove to be irregularities in a completely different pattern—something “funky,” like having two small waves and a big one each year, Hoerger said.

Try as we might, predicting COVID is a guessing game at best. As the holidays draw near, the present reality offers both a warning and a reason for hope. Another wave could be upon us, but things seem unlikely to unfold the same way they have in years past—when the virus spiked at what should be the most festive time of the year. This won’t be a COVID-free Christmas, but it’s still something to be grateful for.

Yesterday, America had one of its worst days of bird flu to date. For starters, the CDC confirmed the country’s first severe case of human bird-flu infection. The patient, a Louisiana resident who is over the age of 65 and has underlying medical conditions, is in the hospital with severe respiratory illness and is in critical condition. This is the first time transmission has been traced back to exposure to sick and dead birds in backyard flocks. Meanwhile, California Governor Gavin Newsom declared a state of emergency after weeks of rising infections among dairy herds and people. In Los Angeles, public-health officials confirmed that two cats died after consuming raw milk that had been recalled due to a risk of bird-flu contamination.

Since March, the virus has spread among livestock and to the humans who handle them. The CDC has maintained that the public-health risk is low because no evidence has shown that the virus can spread among people, and illness in humans has mostly been mild. Of the 61 people who have so far fallen ill, the majority have recovered after experiencing eye infections and flu-like symptoms. But severe illness has always been a possibility—indeed, given how widely bird flu has spread among animals, it was arguably an inevitability.

The case in Louisiana reveals little new information about the virus: H5N1 has always had the capacity to make individuals very sick. The more birds, cows, and other animals exposed people to the virus, and the more people got sick, the greater the chance that one of those cases would look like this. That an infected teenager in British Columbia was hospitalized with respiratory distress last month only emphasized that not every human case would be mild. Now here we are, with a severe case in the United States a little over a month later.

Although worrying, the new case doesn’t change much about the predicted trajectory of bird flu. For months, experts have warned that bird flu would continue spreading among livestock and the people who work with them but that transmission among people was unlikely. And the CDC still says the public-health risk is low. “Everyday Americans should not be panicked by this news,” but they need to stay vigilant about bird flu, Peter Chin-Hong, an infectious-diseases expert at UC San Francisco, told me.

There are a few reasons the latest news shouldn’t cause alarm. The virus hasn’t found a way to efficiently infect humans; its receptors prefer animal hosts. This means the virus doesn’t enter the body at high levels. “It’s kind of forcing its entry using a jackhammer right now, so cases have generally been mild,” Chin-Hong told me. Higher levels of virus generally make people sicker. The Louisiana patient was infected with a strain of the virus related to the one that sickened the Canadian teen but different from the one spreading among dairy herds, poultry, and farmworkers. The mutations in this strain “represent the ability of the virus to cause serious disease, but these instances should be isolated in humans for the time being,” Chin-Hong said.

But just because America is in the same place of steady precarity that it has been in for months doesn’t mean that’s a good place to be in. As I wrote in September, we are in an awkward state of in-between, in which experts are on high alert for concerning mutations but the public has no reason to worry—yet. “Right now, I agree that the risk to the general public is low, but we know avian influenza mutates quickly,” Anne Rimoin, an epidemiology professor at UCLA, told me. The more transmissions among animals—in particular from birds to mammals—the more chances the virus has to mutate to become more threatening to the public. The longer the virus persists in the environment, “the greater potential to mutate, resort, and become more infectious and virulent to humans,” Maurice Pitesky, an animal-infectious-diseases expert at UC Davis, told me.

America is giving the virus a lot of chances to infect people. Although efforts to control the virus, such as regular testing of herds and bulk testing of raw milk, are under way, they have clearly not been enough. The spread of the virus geographically and across mammalian species is unprecedented, Pitesky said. He believes that more efforts should be directed toward shifting waterfowl—ducks, geese, and other wild birds responsible for spreading H5N1—away from commercial farms, where the virus is most likely to be transmitted to humans. A shot for bird flu exists, and experts have urged the government to vaccinate farmworkers. “Farmers need help,” Pitesky said. As of this month, the Biden administration has no plans to authorize a human vaccine, making it likely that that choice will fall under the purview of Donald Trump.

Just as a severe case in America was inevitable, continued mutation is a given too. At this rate, the virus will adapt to infect human hosts, cause more serious disease, and result in human-to-human transmission “at some point,” Chin-Hong said. Earlier this month, a study published in Science by researchers at the Scripps Research Institute showed that a single mutation in the virus strain spreading among dairy herds could switch its preference from bird to human receptors. “In nature, the occurrence of this single mutation could be an indicator of human pandemic risk,” the paper’s editor wrote.

Throughout the bird-flu outbreak, the main concern has been its potential to cause the next pandemic. That outcome is unlikely so long as bird flu remains unable to spread among people. Yet even if it does develop that ability, the world is more prepared for it than it was for COVID, which was caused by an unfamiliar virus. The H5N1 virus that causes bird flu has been known for nearly three decades; vaccine candidates, four influenza drugs, and a diagnostic test are already in existence. “We are not starting from scratch,” Chin-Hong said. Still, to not have to start at all would be preferable.

But right now, the future trajectory of bird flu points to the real possibility that the U.S. will have to weather the virus’s spread among people, with leadership that’s shown little interest in addressing it. Trump has not said anything about his plans, but he has picked Robert F. Kennedy, a vaccine skeptic and raw-milk enthusiast, to lead the country’s health agencies. In the absence of more stringent controls, the public can take steps to prevent the situation from worsening: avoiding raw milk and dead birds, for starters. Getting a regular flu shot decreases the chances of getting infected simultaneously with human and bird flu, which would create conditions for the viruses to combine into a virus that prefers humans. But what America needs is a plan, Pitesky said. The previous four flu pandemics had their origins in avian influenza. There is still time to prevent the next one.

A scientific study on the use of hydroxychloroquine to treat COVID-19 has been retracted.

Americans are unusually likely to die young compared with citizens of other developed countries. The U.S. has more fatalities from gun violence, drug overdoses, and auto accidents than just about any other similarly rich nation, and its obesity rate is about 50 percent higher than the European average. Put this all together and the U.S. is rightly considered a “rich death trap” for its young and middle-aged citizens, whose premature death is the leading reason for America’s unusually short lifespans.

But without much media fanfare, the U.S. has recently experienced a boomlet in good health news. In May 2024, the U.S. government reported that drug-overdose deaths fell 3 percent from 2022 to 2023, a rare bright spot in a century of escalating drug deaths. In June, the National Highway Traffic Safety Administration reported that traffic fatalities continued to decline after a huge rise in 2020 and 2021—and that this happened despite a rise in total vehicle miles traveled. In September, the U.S. government announced that the adult-obesity rate had declined in its most recent count, which ended in August 2023. Also in September, FBI analysis confirmed a double-digit decline in the national murder rate.

[Read: America fails the civilization test]

How rare is this inside straight of good news? Some government estimates—such as rates of obesity and overdose deaths—have reporting lags of one to two years, meaning that these causes of mortality are not necessarily all currently declining. Still, by my count, this year marks the first time in the 21st century that obesity, overdose deaths, traffic fatalities, and murders all declined in the official data analysis. The level of premature death in the U.S. is still unacceptably high. But progress isn’t just about where you are; it’s also about what direction you’re going in. And by the latter definition, 2024 was arguably the best year for American health reports in decades.

It would be convenient—for both efficient punditry and public-policy clarity—if a small number of factors explained all of these trends. After all, if we could isolate a handful of lessons, we could carry them forward and unleash a golden age of American health. Unfortunately, reality is messy and does not always comport with our preference for simple explanations.

Take, for example, the decrease in overdose deaths, which might be the most surprising news of the bunch. “This is the largest decline we’ve seen in recent data, going back at least back to 1999, which is remarkable because overdoses have been going up so steadily,” Charles Fain Lehman, a fellow at the Manhattan Institute, told me. But the exact cause of the decline is mysterious. “I could tell you a policy story,” he said, “such as the fact that we’ve made it easier for people to access drug-addiction treatment and we’ve significantly expanded the availability of Narcan”—an opioid antagonist that rapidly reverses the effects of overdose.

[Read: An anti-overdose drug is getting stronger. Maybe that’s a bad thing?]

But Lehman said he’s not convinced that these policy changes explain all—or even most—of the decline in overdose deaths. “Most of the evidence suggests that the effect size of these interventions should be small and universal across states,” he said. “But instead the U.S. is seeing a decline in overdose deaths that is both large and geographically concentrated in the East, where the overdose crisis started.”

According to Lehman, these facts point to other explanations. Maybe the overdose surge is burning out on its own. Drug waves tend to crest and fall in the absence of a coordinated policy response, because the people mostly likely to get hooked on any one generation of deadly drugs can’t remain indefinitely addicted—they either recover, seek treatment, or die. Or maybe a surge in suicides in 2021 created an unusual and unsustained spike in mortality. “This is grim, but for lack of a better phrase, folks who died during the pandemic can’t die later, and so maybe we should have always expected overdose deaths to decline” after the COVID crisis, he said.

Another possibility is that the fentanyl available on the street became weaker because of relatively lax immigration enforcement under the Biden administration. “There’s an idea known as the ‘iron law of prohibition,’ which says that the more intensive the law enforcement, the more intense the drug,” Lehman said. Perhaps as the risk of contraband confiscation at the border declined, cartels adjusted by moving more units of narcotics across the border while switching to a less concentrated product on a per-unit basis.

The frequency of maybes and perhapses in the above paragraphs makes my point. The decline in overdose deaths was either the direct result of good policy, the ironic result of bad policy, the mathematically inevitable result of lots of addicts dying during the peak pandemic years, or some combination of all three. Celebrating a nice-looking chart is much easier than understanding exactly what is making the line change direction.

A similar theme of uncertainty holds for the obesity story. This fall, the National Health and Nutrition Examination reported that the prevalence of obesity among U.S. adults declined from 41.9 percent to 40.3 percent in its latest sample of several thousand individuals. “Obesity prevalence is potentially plateauing in the United States,” one CDC official told The Washington Post. “We may have passed peak obesity,” the Financial Times’ John Burn-Murdoch wrote of the news.

[Read: The ‘peak obesity’ illusion]

Obesity has declined before by the government’s count, only to continue rising within a few years. One reason to think that this time is different is the rise of GLP-1 drugs, such as Ozempic and Mounjaro, which are remarkably adept at reducing appetite, leading to weight loss. Roughly one in eight Americans has taken a GLP-1 drug, and one in 16 is currently doing so, according to a survey by the health nonprofit KFF. It seems inevitable that as more Americans take therapies that put a lid on their appetite, obesity should mechanically decline.

Another possibility is that the developed world might be running up against a natural limit in overall obesity. In 2023, a team of Greek researchers wrote that obesity rates might stabilize in developed countries in the next few years, as “obesity has reached a biological limit … [or] a saturation threshold for the proportion of people who can become obese.” In fact, international evidence suggests that obesity has already “stabilized in children and adolescents of most economically advanced countries since 2000,” they wrote. (They also conceded that “the trends in adults are mixed and ambiguous and do not unequivocally support the obesity plateau hypothesis.”)

Finally, there’s the sudden decline in violent crime in the past few years—by some accounts, one of the fastest declines in homicide rates since the 1960s. One explanation is that the early 2020s marked the second time in a decade when the U.S. experienced the double whiplash of what some sociologists call the “Ferguson effect.” This theory holds that public outrage about police shootings reduces police activity and leads to an increase in violent crime. Adherents of this theory argue that in 2014, the death of Michael Brown created a backlash against policing, and in 2020, the death of George Floyd created another; in both cases, a high-profile killing created social unrest, which, they argue, may also have reduced police activity, possibly causing an overall increase in violent crime. As the health emergency wound down, policing picked up, and the spell of violence broke.

Another related explanation is that violent crime surged when lockdowns and other social disruptions unmoored young men from their routines in 2020 and 2021. But in the “great normalization” of 2022, young people returned to their pre-COVID schedules, and violent behavior quickly reverted to its pre-COVID rates. As John Roman, the director of the Center on Public Safety and Justice at NORC at the University of Chicago, told The Atlantic’s Rogé Karma, the beginning of the decline in violent crime coincided with the beginning of the 2022–23 school year, when pre-pandemic norms resumed for America’s teenagers.

This theory—that the pandemic created a brief bubble of abnormal and deadly behavior—would also explain why the U.S. saw an increase in auto fatalities during the first years of the pandemic. In March 2022, The Atlantic’s Olga Khazan summarized the berserk sociology of the moment pithily: “Everyone is acting so weird!” But, with time, people acted a little less weird. They resumed, among other things, their pre-pandemic manners of driving—that is to say, normally reckless, rather than completely out-of-control reckless.

[Read: The murder rate is suddenly falling]

Public policy may have played a small but meaningful role in declining crime and auto fatalities too. One creative explanation, from Bloomberg’s Justin Fox, is that Joe Biden’s American Rescue Plan sent hundreds of billions of dollars to governors and mayors, which allowed them to increase law-enforcement spending to crack down on both violent criminals and out-of-control drivers. In fact, state and local government spending increased in 2022 by nearly 8 percent, its largest annual increase since the Great Recession. This coincided with a voter push toward tougher policing standards, as “Minneapolis voters rejected a plan to replace the city’s police department,” “San Franciscans threw out their progressive district attorney,” and “New Yorkers elected a former cop as mayor,” Fox wrote.

At the heights of government power, there is currently a “rift” in the debate over “how to make America healthier,” as Gina Kolata of The New York Times recently pointed out. On one side are techno-optimists such as Elon Musk, who trust in science and technology. “Nothing would do more to improve the health, lifespan and quality of life for Americans than making GLP inhibitors super low cost to the public,” he posted on X. On the other side, Robert F. Kennedy Jr. is deeply skeptical of technology—as varied as nuclear power plants and the polio vaccine—and he has stressed that “lifestyle” is the more important determinant of health.

Kennedy gets this much right: Our lifespans are shaped as much by our behavior as they are medically determined by the health-care system. But rather than scaremongering about effective vaccines, we should be laser-focused on the truly scary causes of premature death in America and what it really takes to eliminate them—and on figuring out what’s gone right in the past few years.