Systems Are the Solution
Connecting the dots between culture, policy, and public health failure
The last patient I saw in clinic on Friday afternoon was high on methamphetamine. He admitted it at the start of the visit. And over the course of the next 20 minutes, our conversation ricocheted everywhere: rent, fentanyl-laced speed, a neighbor controlling his mind, missed ARVs, loneliness, weight loss, a pustule on his buttocks. No through line. It felt like talking to a pinball machine; our conversation bouncing from one topic to the next. If I’m honest, my own mental landscape doesn’t always feel that different right now. So here goes:
Over the weekend, I listened to Tucker Carlson in conversation with The New York Times. Much of what he said was just plane bonkers. But every now and then he said something incisive that was hard to dismiss. His critique of generational selfishness, for one, was sharper than I expected. You don’t have to buy his worldview to recognize the diagnosis: there is something off about the way American society is organized right now; an economy and culture increasingly shaped around the preferences of those who already have the most (according to Carlson, ‘the boomer generation’), paired with a slow erosion of any real obligation to people at the margins.
Then I watched Outcome, the new film with Keanu Reeves and Jonah Hill. And in a strange way, it felt like a perfect illustration of that same critique. A self-referential story about movie stars, told by movie stars, for movie stars; a closed loop that never connects to anything outside itself. It’s billed as a comedy, but plays more like end-stage narcissism. Presumably written by screenwriters with their heads up their own arses (or the arses of the Hollywood celebs who produced and directed this nonsense). I wasted 90 minutes of my life. Don’t do the same.
Meanwhile, something actually real and tragically awful. There’s a major HIV outbreak unfolding in rural Maine right now. In Penobscot to be exact. Cases have increased roughly twenty-fold. (Check out Dr Koss giving UCSF HIV Grand Rounds for a great synopsis from minute 22 onwards).
This is exactly the kind of signal that used to trigger an immediate, coordinated public health response. During the Indiana outbreak in 2014, federal and state authorities moved quickly: syringe access expanded, testing surged, treatment scaled. It wasn’t perfect, but it was decisive.
That’s not what’s happening now. The response in Maine is, by all accounts, slow, fragmented, and under-resourced. But perhaps that shouldn’t surprise us. When prevention programs are stripped back, when the populations most at risk are excluded from basic health services, and when the public health system loses its capacity to act quickly, this is exactly what follows.
It’s also a reminder that global health isn’t “over there.” The same dynamics I worry about in places like Zambia, shrinking resources, weakened outreach, delayed detection, are playing out in rural America.
Zooming out. At the very moment we are struggling to mount a basic public health response in Maine, we are also deploying some of the most powerful HIV prevention tools ever developed (both domestically and globally) at scale. Lenacapavir now. MK-8527 soon. These tools could fundamentally change the trajectory of the HIV epidemic. They are worth getting excited about. But they can’t deliver impact on their own. Without functioning public health systems, lenacapavir is, quite literally, a very expensive shot in the dark.
TDLR: New tools don’t end epidemics. Systems do. Testing, outreach, linkage; these are the unglamorous, cost-effective strategies that determine whether innovation reaches people, or doesn’t.
And I guess, that’s the real through-line here. Tucker called it generational selfishness. Reeves’ movie was the embodiment of it. And US health policies increasingly reflect it. Decisions shaped less by need than greed, leaving those on the margins excluded and the tools that could help them effectively irrelevant.
