You Can't Have Public Health Without the Public
The Atlantic recently published an article entitled “Where I Live, No One Cares About COVID.” In it, the author described how many people in his community in southwestern Michigan “are living their lives as if COVID is over.”
The article landed with a splash. HuffPost reporter Michael Hobbes wrote that it was perhaps “the most smug and condescending thing [he’d] ever read.” David Roberts, a clean energy reporter, described it as “sociopathy.” Josh Barocas, an infectious disease physician called it “garbage” that has “completely invalidated” the work of him and other healthcare professionals who have put their lives on the line over the past two years.
But others saw the piece as simply describing the reality on the ground outside of major metropolitan areas:
CNBC anchor Brian Sullivan wrote: “I’ve been been to/through 20+ states since pandemic began & this article resonated. It’s what I’ve tried to explain to many in northeast. That I have friends in south and Midwest who don’t really talk about Covid. Kids never missed in person school.”
New York Times science desk editor Virginia Hughes chimed in with: “100% my experience visiting MI this weekend.”
This also aligns with my own experience of visiting family in rural communities during the pandemic. And indeed, I think the angry responses to the article from critics were so intense not because the author’s claim that many Americans are living as if COVID is a matter of the past rings false, but because it rings true.
This poses a critical challenge for our public health response: many Americans prefer to behave as if the pandemic is over despite the fact that it very much is not. How should public health experts proceed in light of resistance from communities over disruptive pandemic response measures?
One source of guidance comes from the American Public Health Association’s “12 Principles of the Ethical Practice of Public Health.” The document was developed back in 2002 and is intended for “public and other institutions in the United States that have an explicit public health mission.” I’ve pulled out half of the principles, which I believe to be relevant, and bolded certain sections for emphasis:
Public health should achieve community health in a way that respects the rights of individuals in the community.
Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.
Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.
Public health institutions should act in a timely manner on the information they have within the resources and mandate given to them by the public.
Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.
Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.
The message here is extremely clear: public health must meet people where they are. Fully half of the 12 principles hit on this theme in one way or another.
This makes perfect sense. First, as a matter of principle, it’s not clear that overriding the desires of a community on the basis of values and preferences that they do not share actually furthers the mission of improving public health, which APHA describes as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.”
But more importantly, the idea of working in concert with a community’s values rather than against them is simply pragmatic. Trying to overrule the community’s preferences with your own is a surefire way generate conflict, hostility, and mistrust. Valuable time will be spent trying to persuade the community to adopt your values rather than operating within theirs, often to little success.
This value of working with - rather than against - people’s values is even more pronounced when there are a wide variety of means available to combat the public health risk, as is precisely the case with respect to combatting COVID in the United States. Our overall COVID response has been so poor that we have room to improve on nearly all fronts. Not only on vaccines and masking, but also on education and public communication, distribution of high quality PPE, availability of rapid tests, availability and timeliness of PCR tests, improving air filtration and ventilation, conducting more clinical trials for therapeutics, speedy approval of therapeutics, and so on.
I’ll give a recent concrete example of this from my own life. I have conservative family members who are dead set against the vaccine. But they have no objection to rapid tests! Just before Thanksgiving, one of these family members woke up with a sore throat and tested positive on a rapid test that they happened to have in their home. We’d recently been with them and so, after we were notified of the positive result, we decided not to attend a large Thanksgiving family gathering with the other side of our family. Ultimately, we did end up coming down with COVID but, because we knew we’d been exposed, avoided attending a large event while infectious and likely prevented infecting other people.
The above story is far from an unmitigated success. Several of these anti-vaxx family members had fairly serious cases (likely due to not being vaccinated). One was briefly hospitalized and came down with COVID pneumonia. And myself, my wife, and our three children were all also infected. Nonetheless, a chain of transmission was interrupted by the rapid test just ahead of a large gathering. That’s important, and it happened by virtue of these family members happening to have purchased some rapid tests.
Is it frustrating that these family members are opposed to vaccines and masks? Yes! But the fact remains that they are, as are many other members of their community. The public health principles outlined above would suggest that the proper move here is to pivot to measures that they would be amenable to, such as rapid tests, ventilation, air filtration, and holding gatherings outdoors as opposed to indoors. While these family members happened to have rapid tests in their home, many do not, either due to cost, lack of availability, or lack of awareness. My view is that a concerted effort to make rapid tests widely available and a familiar tool would not only help reduce transmission, but demonstrate to these communities that public health officials and institutions respect their values and preferences and earn some credibility along the way.
But hey, that’s just my view. What strategies are the actual public health experts pushing?
Well, this week more than 300 public health and related experts signed an open letter calling on the Biden administration and CDC to issue “federal guidance” on state and local mask “policies,” by which they mean laws that require the use of masks in certain contexts.
On the one hand, I completely understand the impulse to move in this direction. Masks are cheap, widely available, and, in the grand scheme of things, not terribly invasive. If you’re a public health expert whose career is oriented towards combatting public health threats, and you’re seeing the extreme public health cost of the pandemic, masks seem like a no brainer. Sure, they may be minorly annoying, but isn’t it worth it to reduce the spread of the virus? It certainly is to these public health officials.
But this brings us back to last week’s article in The Atlantic, “Where I Live, No One Cares About COVID.” What if a substantial portion of the country simply doesn’t share this view of the cost-benefit of masking? What if some individuals and communities place a premium on normalcy over masking, even at the cost of increased spread of the disease?
In theory, the Principles for the Ethical Practice of Public Health would suggest that public health experts should work very hard to meet the community where they’re at and attempt to work within, rather than override, their preferences.
In practice, public health experts seem to be quite fond of calling for federally-driven mask mandates. This is far from a ground up practice of public health that seriously accounts for the different values of various communities. Instead, it represents nearly the polar opposite: going right to the federal government to lobby for laws across the country that will mandate individual actions.
I understand the arguments ostensibly in favor of federal mask policies here. This is an emergency. Thousands of Americans are dying every week. It’s an infectious disease and one individual’s personal behavior may harm others.
But to paraphrase APHA’s own stated principles, you can’t have public health without the public. And the dire nature of the pandemic shouldn’t cause us to abandon these principles, but to double down on them. Having another protracted fight over mask mandates, even if it eventually results in new policies being issued, is unlikely to lead to substantial changes on the ground where masks are disregarded in the first place. That time should instead be spent vigorously pursuing alternatives that will actually be embraced by these communities.