Opinion Public health needs a reset

(Ollie Hirst for The Washington Post)

“Follow the science.”

That has become a mantra in public health policy. Health officials and politicians — including President Biden — invoke it to justify their decisions. Social media partisans hurl it back and forth to bolster their arguments.

The slogan has power because of course science matters, and of course we should follow it. But solely relying on science to guide public health decisions misses the complexity of policy deliberations.

The tragic paradox is that it fuels distrust in the scientific community and undermines the credibility of health officials.

Consider what’s happened in just the past few years, as the United States has grappled with one of the worst public health challenges in its history. A Pew Research Center survey last year found that only 29 percent of adults say they have a great deal of confidence in medical scientists to act in the best interest of the public, down from 40 percent in November 2020. An NBC News poll similarly found that trust in the Centers for Disease and Control and Prevention fell from 69 percent at the beginning of the pandemic to just 44 percent by early 2022.

I’m not here to blame that decline on “follow the science.” My concern is different. I’m worried about the way that we lose people’s trust when we oversimplify the trade-offs and uncertainty of complicated public health policy.

Health officials have seen this erosion of trust firsthand. A study of local health department workers found nearly 1,500 instances of harassment between March 2020 and January 2021. Six percent of respondents said they received threats to their safety. Many left their jobs, depleting a field that was already in need of workers.

I’ve experienced this myself. When I supported lockdowns in March 2020, I was called a fearmonger bent on taking away people’s livelihoods. When I promoted vaccines, anti-vaccine advocates accused me of “mass murder” for pushing “experimental” injections on people. I received hundreds of threatening messages. The FBI arrested two people for threats against me and my family; one pleaded guilty and is serving six months in federal prison.

Later, after I wrote columns agreeing with Biden administration decisions to ease covid mitigation measures, more than 600 people signed a petition labeling me a racist and ableist who promoted eugenics. These advocates called on the American Public Health Association to rescind my invitation to speak at its conference. Eventually, I withdrew because activists were threatening to shout down the panel and even accost me in the bathroom.

Many of those who serve in local and state health departments have similar stories. No matter what they said or did to help constituents navigate covid risks, they were subjected to backlash. And the discord threatened their ability to carry out their duties.

Clearly, public health needs a reset. But what kind? The answer, I’m convinced, isn’t to diminish the role of science but to make clear the role of values alongside it.

A fundamental tension

At its core, public health wrestles with the tension between individual liberty and communal good. People should be able to do what they wish without interference from the government. But if someone’s actions endanger those around them, the need to protect the larger group could outweigh this basic right to self-determination.

But when is that warranted? Science alone can’t provide the answer.

An example of this tension: When I was Baltimore’s health commissioner, a city resident refused treatment for multi-drug resistant tuberculosis (MDTB). This presented a dangerous situation. TB is an airborne illness with a high fatality rate; the World Health Organization reports that without proper treatment, 45 percent of HIV-negative patients and nearly all HIV-positive patients with TB will die. MDTB is resistant to treatment with the most effective medicines, and an outbreak could be catastrophic.

My jurisdiction was among those with statutes empowering health officials to isolate individuals with deadly infectious diseases. After careful deliberation, we took the extraordinary step of arresting the individual and confining them against their will in a treatment facility until they were no longer contagious — which can take up to six months.

I still believe this was the right call. But what if an entire population needed restraining? And what if the disease in question had a much lower fatality rate?

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Such was the case with covid-19 — and China’s initial response was similar to the one we made for that single MDTB case in Baltimore.

For nearly three years, the country was subject to constant lockdowns. Families were padlocked in their apartments and unable to get basic provisions; they were even forbidden to leave during an earthquake and fire. Some workers who were forced to quarantine in factories became so desperate that they fled dozens of miles on foot. Hospitals turned away women in labor and patients suffering heart attacks for fear that they could be infected.

Chinese officials no doubt thought that they were following the science. However, in the United States, where individual liberty is fundamental, most reasonable people would argue that China’s “zero covid” approach — now abandoned — was wildly over the top.

What, then, is the “correct” approach to covid? That’s much harder to answer.

Any policy that requires people to involuntarily change their behavior is fraught. There are always difficult tradeoffs. For instance, governors and mayors who initially shuttered businesses and schools understood there would be negative economic and educational consequences. But they reasoned the fallout would be worth the price of reducing deaths from a novel virus.

Now, with the benefit of hindsight, we can quantify economic and learning losses. We can also estimate how many lives were saved because of early shutdowns. Even so, the same facts presented to different people will lead to different conclusions. Some might say reducing covid transmission is worth any and all measures, given the toll of long covid and the trauma inflicted by the sickness and death of loved ones. Others argue that the upside is outweighed by negative downstream consequences such as widening educational disparities and worsening mental health.

Part of the disconnect occurs because Americans do not agree on how mitigation measures affected individual rights. Some viewed mask and vaccines mandates as a direct encroachment on bodily autonomy. Others preferred them because they helped people feel safer as they resumed daily routines.

Underneath it all is values: Whose rights are paramount? The individual who must give up freedoms, or those around them who want to lower infection risk? Yes, science should guide such debates, but it cannot lead all the way to the answer.

One way to reconcile these questions is to consider context. When people didn’t have tools to protect themselves against severe illness, the onus was on the government to protect the public. When that changed, with vaccines and treatments, the calculus shifted toward individual rights.

How to restore trust

It’s tempting to blame the erosion of trust on the many actors who spread false information. That’s part of the story, but many well-intentioned medical professionals, scientists and political leaders are also at fault.

Restoring trust requires that we curb the instinct to simplify public health policy. Decisions often require policymakers to weigh competing priorities and painful tradeoffs. They should own the challenge and not shy away from communicating nuance and complexity.

This begins with setting the expectation that recommendations change as circumstances evolve. During the height of the initial omicron surge last winter, the CDC changed its isolation guidance for covid from a strict 10 days to five. This prompted much criticism, since research cited in the CDC’s own publication showed that as many as 80 percent of infected people were still testing positive after five days. If the CDC made such a miscalculation, people naturally wondered, what else was it getting wrong?

I think much of this second-guessing could have been avoided if the CDC were upfront that its changing guidance was born out of necessity. There was real fear about not having enough workers to sustain critical infrastructure with a 10-day isolation period. Being clear about their true rationale could have engendered more agreement.

Same goes for the unfortunate attempts to play down or outright ignore natural immunity. I suspect many public health experts feared that if they acknowledged that people have some protection against covid after infection, fewer would get vaccinated. Some might even have tried to contract covid on purpose. There was also the practical difficulty of determining whether prior infections satisfied vaccine requirements.

But health officials largely didn’t acknowledge these nuances. Instead, any expert who even brought up studies supporting natural immunity, myself included, were accused of spreading disinformation.

The public health community must do better. We should display more humility and acknowledge what we don’t know. In the midst of a crisis, decisions need to be made with incomplete information. People intuitively understand this; after all, everyone has had to wrestle with decisions about their own individual risks. Clear-cut answers are hard to find, and it’s okay to say that.

For now, policymakers should seek areas of broad agreement. For months, I’ve been arguing for improving wastewater surveillance, prioritizing boosters for nursing home residents and the elderly, increasing early treatment that prevents progression to severe illness, and investing in better vaccines and treatments to help the immunocompromised. These measures can save lives and reduce the strain on hospitals far more than mask or vaccine requirements could without furthering dividing the populace.

I’d go even further and recommend that public health officials pivot away from covid and refocus on the many other unmet needs, such as the alarming decline in routine childhood immunizations and the worsening opioid epidemic. Before the pandemic, public health was rarely discussed. Now, it has essentially become synonymous with covid, which has real danger: If covid is polarized, then public health becomes polarized, too.

Finally, all of us must create space for civil conversation. Instead of demonizing those we disagree with, we need to approach one another with compassion and engage in productive dialogue. Only by working together can we improve public health and preserve our ability to respond effectively to the next crisis.