Legitimacy and Public Health

COVID-19 Public Health

In 1988, the Institute of Medicine (now the Health and Medicine Division of the National Academies of Science, Engineering, and Medicine) defined public health as “what we as a society do collectively to assure the conditions in which people can be healthy.” Much attention in recent years has been focused on the second half of this phrase. Researchers, policymakers, and advocates have worked to better define the conditions for health—not just access to medical care, but also safe environments, good nutrition, quality education, anti-racism, and economic opportunity.  Recently, the COVID-19 pandemic exposed the mortal dangers of the absence of these conditions.

At the same time, the pandemic also highlighted the first words of the Institute of Medicine’s definition, “What we as a society do collectively.”

It has become increasingly difficult for public health agencies and elected leaders to adopt measures to control the spread of a deadly virus. Governors who took decisive action early are finding it difficult to respond to the latest surge in COVID-19 cases. State legislatures across the country are now voting on legislation to limit public health authority to fight infectious disease emergencies and require vaccination. There is a clear danger that a legacy of COVID-19 may be the restriction in many areas of the ability to take needed action to protect health.

The origins of the legitimacy crisis for public health run deep in American history to the tension between individualism and common purpose. This tension has become quite visible during the pandemic. Is the purpose of COVID testing primarily to help people know their status, or also to help people who have COVID connect to social resources for successful contact tracing, isolation, and quarantine? Is it sufficient for people to access testing and care through usual mechanisms, or should the government support new venues for people at highest risk? Is it enough to make vaccines available to people in large vaccination sites, or is there a responsibility to bring vaccines to hard-to-reach populations through mobile services?

Faced with these questions, the answers of many in the field of population health may be broad, but the predominant responses in many parts of the country have been narrow.

Where collective action affected the freedom of movement or the personal behavior of individuals, intense conflict has sometimes resulted. Even as more than 500,000 Americans died from COVID-19, and as many hospitals were overwhelmed with cases, many people rejected effective non-pharmaceutical interventions, such as mask mandates, closures of restaurants and bars, and requirements for social distancing. In many areas, the frustrated and overwhelmed voices of health care workers failed to overcome this opposition. Also of limited impact were the testimonials of people who had denied the existence of COVID-19, fallen ill, and changed their minds.

Nowhere were these conflicts more evident than in the debate over opening schools. The clear path to opening schools was to limit community spread and invest resources in mitigation measures. Yet, many of those eager to see schools open could only go so far as to demand their opening, resisting even basic collaborative efforts to make doing so safer.

In the midst of the most significant public health crisis in a century, the legitimacy of public health has fallen into doubt. Responding to this existential crisis will require a strong case and advocacy for what we, as a society, do collectively.

The first step will be to vocalize the benefits. Public health has long been known as “the dog that doesn’t bark”—the agency, in the words of former Baltimore City Health Commissioner Leana Wen, that “saved your life today—you just didn’t know it.” No longer. When public health stops meningitis outbreaks, or prevents toxic poisonings, or lowers infant mortality, it should be front page news. If lives are lost because state legislatures have limited public health authority, the story should also be broadcast far and wide.

A second step will be for public health agencies to expand their public engagement. Too many actions during the pandemic were simply announced by health officials or elected leaders. Not enough were put forward with opportunities for comment and questions. Agencies should use advisory panels, public meetings, and community input to elicit and surface the broad support that exists for action to protect health based on evidence, rather than confront loud opposition alone.

Third, public health should put forward a coherent vision for supporting individual freedom. How free is someone dying of emphysema after a lifetime of smoking cigarettes? How free is a child poisoned by lead, or a family living in fear of its own water supply? Anyone who has set foot in a public health school knows that the workforce is not full of wannabe “nannies” eager to knock a drink from someone’s hands, but rather people who want to help thousands or millions of people be healthy enough to reach for their dreams.

The debate over the sharing of vaccination status illustrates the opportunity to reframe public health. While objecting to “vaccine passports,” some states are making it more difficult for individuals to provide proof of their COVID vaccination status to others. These actions may make it more difficult for people to assemble safely and for businesses to function, the very opposite of liberty. Public health leaders should make it clear that vaccination—and the responsible sharing of vaccination status—will allow people around the world to resume their lives without fear of severe illness or infecting others.

Three decades ago, the Institute of Medicine recognized that a society’s health depends as much on a population’s ability to work together as it does on the conditions of health. Attention to both dimensions is necessary for the United States and the world to recover from COVID-19 into a healthier future.

Sharfstein, JM. Legitimacy and Public Health. Milbank Quarterly Opinion. April 15, 2021. https://doi.org/10.1599/mqop.2021.0416.

About the Author

Joshua M. Sharfstein is associate dean for public health practice and training at the Johns Hopkins Bloomberg School of Public Health. He served as secretary of the Maryland Department of Health and Mental Hygiene from 2011 to 2014, as principal deputy commissioner of the US Food and Drug Administration from 2009 to 2011, and as the commissioner of health in Baltimore, Maryland, from December 2005 to March 2009. From July 2001 to December 2005, Sharfstein served on the minority staff of the Committee on Government Reform of the US House of Representatives, working for Congressman Henry A. Waxman. He serves on the Board on Population Health and Public Health Practice of the Institute of Medicine and the editorial board of JAMA. He is a 1991 graduate of Harvard College, a 1996 graduate of Harvard Medical School, a 1999 graduate of the combined residency program in pediatrics at Boston Medical Center and Boston Children’s Hospital, and a 2001 graduate of the fellowship program in general pediatrics at the Boston University School of Medicine.

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