This piece was first posted on Substack. To comment, please go there.

In last week’s column, I introduced my new book, The Contagion Next Time, in advance of its November 1 release. In that column, I wrote about why I felt compelled to write a book about a pandemic during a pandemic. I have since had a chance to engage with friends and colleagues who are in the process of reading the book and engaging with its ideas. This has long been a favorite part of the writing process. The aim of writing has always been, for me, to sharpen my thinking, with the goal of informing a broader conversation about the issues that matter most for health. Once a piece is out in the world, engaging with readers—in addition to being simply fun—helps sharpen my thinking still further. This has been the case in the days since the launch of The Contagion Next Time. It has been a joy to be able to speak with readers, to hear their reflections.

In a way, these conversations have been consistent with the spirit in which the book was written. While the act of writing is a solitary endeavor, producing a book—shaping its ideas and thinking through its structure—is a collaborative process. The thoughts in The Contagion Next Time emerged from countless conversations with friends and colleagues, from reading the work of authors and journalists I admire, and from the unique academic setting in which I am privileged to work. Academia is a discipline founded on rigorous debate, on the airing of ideas in the public conversation. I was deeply influenced by this context in writing The Contagion Next Time.

Owning in no small part to this engagement, a book emerged which tries to tackle what we got wrong during COVID-19, why these failures were less about what we did in the moment and more about our longstanding neglect of the foundational forces that shape health, and how we can apply the hard lessons of COVID-19 to shaping a healthier world. The book starts with a section about the world we live in now; how it is both the healthiest time to be alive and a period of history characterized by deep inequities. The next section looks at the conditions that create health in our society. In particular, it explores how health is shaped by where we live, work, and play, and by the influence of politics, power, and money. It both examines the historical roots of these forces, and looks at how they shaped health during COVID-19.

The book’s third section makes the case for the values that should inform how we address these foundational forces, towards the aim of shaping a healthier world. Chief among these values are compassion, concern for social, racial, and economic justice, and a willingness to pursue health as a public good. These values point us towards what matters most for health and help us see the urgency of addressing these issues, so we can create a society where contagion cannot take hold. The book’s final section articulates a science for better health. For our science to most effectively support a healthier world, it must maintain a focus on what matters most—the social determinants of health that were so central to our experience of COVID-19. As we maintain this focus, however, we often find ourselves working in a context of complexity and doubt. In the book, I argue that this is not always a bad place to be, and that we should cultivate a comfort with complexity and embrace the doubts that stop us from being overconfident in what we know. This suggests the core importance of humility in guiding both our science and the public conversation about health. Humility keeps us mindful of what we do not know, and of the extent to which what we do know is contingent and subject to the influence of new information. It also helps us to resist the temptation to think we can protect ourselves from contagion through treatment and medical know-how alone. The fundamental message of The Contagion Next Time is that these tools, important as they are, are not enough to prevent pandemics. What prevents pandemics is values-driven engagement with the foundational forces that shape health.

Now that the book is out, I have much enjoyed starting to discuss these ideas in a range of settings, towards the goal of informing the conversation about health. As I have talked with readers, three key themes have emerged which are worth sharing, I think, for their intersection with the broader aims of The Contagion Next Time

First, my experience of writing The Contagion Next Time and engaging with readers has made me even firmer in my belief that the world is a fundamentally good place. This may seem strange to say, given what we went through during COVID-19. It may seem even stranger to say given that The Contagion Next Time is, in large part, a tour of the many ways we fell short in our response to the pandemic. Yet the pandemic moment also revealed our enormous capacity for coming together to care for each other, and for making dramatic changes to our world in the name of health. I have long argued that we need to make deep, structural progress in order to create a healthier world. When I make this case, I occasionally encounter the objection that such progress would be too hard to implement, that we are incapable of making changes at a scale necessary for building the kind of world we wish to see. The COVID-19 moment showed that this is not the case. Once we understood that our health was threatened, we changed the world, seemingly overnight. This suggests the power of health as a universal aspiration capable of bringing us together in shared endeavor. This is indeed to the good. It is now up to us to understand that our health remains at stake, that the structures that allowed COVID-19 to take hold remain in place. Once we realize this, we can follow through on the work we began during the pandemic and truly shape a world where contagion cannot take hold. It has been encouraging to see how many readers of The Contagion Next Time share this view, and are receptive to a message that calls on us to double down on what is good about the world, to make it even better.    

Second, the things we got wrong during the pandemic were things that we should have fixed before contagion struck. COVID-19 was a novel threat, unprecedented in our lifetimes. Yet the conditions that allowed it to take hold were familiar, long known to us. They were the conditions that characterized a broken status quo around health in our society. Racism, poverty, economic inequality, deepening political divides—these were fuel to COVID-19’s fire, and none of them are new. They are all challenges we should have addressed years ago. Yet we allowed them to become tolerable, even acceptable. We dragged our feet until finally a contagion came and exploited our failure, to catastrophic effect. We cannot afford to let this happen again. Just as our vulnerabilities were not hidden before the pandemic, they are not hidden now—because they are the same. Our response to them, however, must not be the same. This has been a core takeaway from speaking with those who have been engaged in the work of trying to address fundamental challenges to our health. Long before COVID-19, they saw what needed to be done and how far we were from doing it. Speaking to them both before and after the launch of The Contagion Next Time has only sharpened in my mind the urgency of engaging with the foundational drivers of health, while there is still time.  

Finally, COVID-19 showed us that our science can do better. We have at times let our justifiable pride in scientific advances like vaccines distract us from investing in improving the foundational drivers of health. A healthier state of affairs would be for science to work in tandem with this broader engagement, informing a more comprehensive approach to health. Doing so will take humility and an understanding that no scientific advance, no matter how sophisticated, has more influence on health than the larger forces discussed in The Contagion Next Time. Science has an important role to play in shoring up the foundations of health, but it can only do so when it has fully accepted the importance of these forces, and engages with them with an eye toward supporting health. Hearing the personal stories of those who lived through the pandemic—family, friends, colleagues, and readers—was a reminder of the degree to which health is shaped by the context of our lives. It is about the world around us, all of it, and whether or not that world is maximized for health. Science is part of that world, but it is not the whole world, and it is by realizing this that science can maximize its own influence on our collective wellbeing.   

These preliminary reflections mark the start, I hope, of an ongoing conversation around the core themes of The Contagion Next Time. I look forward to hearing from many of you in the weeks and months to come. Thank you for your continued engagement with ideas that shape a healthier world. It is a privilege to connect with you, to learn from you.  


  • Sandro Galea is Dean and Robert A. Knox Professor at the Boston University School of Public Health. He has been named an "epidemiology innovator" by Time and one of the "World's Most Influential Scientific Minds" by Thomson Reuters. A native of Malta, he has served as a field physician for Doctors Without Borders and held academic positions at Columbia University, University of Michigan, and the New York Academy of Medicine. His new book, The Contagion Next Time, was published in fall 2021, and is available to order here:

    Subscribe to his weekly newsletter, The Healthiest Goldfish, or follow him on Twitter: @sandrogalea