The Future of Public Health

Most readers of this blog know that this Spirited Reasoner bagged a law career after 17 years to enter graduate school in the field of public health policy and administration. After earning my PhD in 1998, I spent a year as a postdoctoral researcher at the CDC in Atlanta. I then faced a career choice: stay at the CDC for a career in public health research or accept a job as a university professor. I chose the latter, ultimately winding my way through the ranks of university administration on four campuses. I retired in 2017. Now, after watching the nations of the world choose a wide variety of policy approaches in their attempts—mostly unsuccessful—to address COVID-19, I confess to being thankful that I do not find myself in the public health trenches these days.

In one of the first courses I took in the UNC School of Public Health, students debated the seeming contradiction between various public health policies, such as enforced quarantines, and America’s tradition of personal liberty. Our professor asked us what rationale we would use, consistent with U. S. Constitutional Law, to justify requiring those suffering from contagious diseases to remain under what amounted to house arrest. Our responses, amazingly naïve in retrospect, were mostly based on the notion that the vast majority of Americans would agree to such quarantines if sufficiently convinced of the dangers to life and health in the absence of public health measures.

Little did we students imagine the legal and logistical difficulties that would be posed by COVID-19!

Having had time to reflect on those, Spirited Reasoners can observe at least three major lessons that can assist in guiding public health policymakers in the future.

First: There is no way a majority of Americans will be okay with any sort of enforced mandate that substantially affects their personal freedoms in the absence of effective disease testing. In our graduate school hypothetical, we blithely assumed that officials could know with 100% certainty which individuals were contagious and which were not, and that the only real question was what to do with those who were. In this nation’s actual experience with COVID-19, however, we quickly learned that no one was ever quite sure who was contagious and who wasn’t.

Second: Policymakers must assume that a substantial minority of Americans will always refuse to be vaccinated regardless of what scientific evidence exists concerning the safety and efficacy of the vaccination. We’re talking religion here. Although health education might shrink the number of anti-vaxxers to some degree, policymakers should always assume that the numbers of such folks and their political clout will remain substantial.

Third: Given the fact that no amount of public intervention on any measure—whether it be seat belts, smoking, or a healthy diet—can ever reduce the risk of disease or serious injury to zero, policymakers must be willing to adopt policies that are less than 100% effective. For example, what if those willing to be vaccinated had been given the carrot of being allowed to walk around in public without masks? And what if we had only required masks (as a stick) those who refused vaccination? Some sort of vaccination badge would have been necessary, which might have been less than optimal. But might it have been a politically workable carrot + stick approach? Schools of public health will be debating these measures for generations to come. Meanwhile, this Spirited Reasoner will remain happy to watch, listen, and pontificate a bit from the sidelines.