How Public Health Took Part in Its Own Downfall - The Atlantic - 0 views
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when the coronavirus pandemic reached the United States, it found a public-health system in disrepair. That system, with its overstretched staff, meager budgets, crumbling buildings, and archaic equipment, could barely cope with sickness as usual, let alone with a new, fast-spreading virus.
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By one telling, public health was a victim of its own success, its value shrouded by the complacency of good health
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By a different account, the competing field of medicine actively suppressed public health, which threatened the financial model of treating illness in (insured) individuals
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In fact, “public health has actively participated in its own marginalization,” Daniel Goldberg, a historian of medicine at the University of Colorado, told me. As the 20th century progressed, the field moved away from the idea that social reforms were a necessary part of preventing disease and willingly silenced its own political voice. By swimming along with the changing currents of American ideology, it drowned many of the qualities that made it most effective.
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Germ theory offered a seductive new vision for defeating disease: Although the old public health “sought the sources of infectious disease in the surroundings of man; the new finds them in man himself,” wrote Hibbert Hill in The New Public health in 1913
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“They didn’t have to think of themselves as activists,” Rosner said. “It was so much easier to identify individual victims of disease and cure them than it was to rebuild a city.”
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As public health moved into the laboratory, a narrow set of professionals associated with new academic schools began to dominate the once-broad field. “It was a way of consolidating power: If you don’t have a degree in public health, you’re not public health,”
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Mastering the new science of bacteriology “became an ideological marker,” sharply differentiating an old generation of amateurs from a new one of scientifically minded professionals,
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Hospitals, meanwhile, were becoming the centerpieces of American health care, and medicine was quickly amassing money and prestige by reorienting toward biomedical research
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Public health began to self-identify as a field of objective, outside observers of society instead of agents of social change. It assumed a narrower set of responsibilities that included data collection, diagnostic services for clinicians, disease tracing, and health education.
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Assuming that its science could speak for itself, the field pulled away from allies such as labor unions, housing reformers, and social-welfare organizations that had supported city-scale sanitation projects, workplace reforms, and other ambitious public-health projects.
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That left public health in a precarious position—still in medicine’s shadow, but without the political base “that had been the source of its power,”
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After World War II, biomedicine lived up to its promise, and American ideology turned strongly toward individualism.
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Seeing poor health as a matter of personal irresponsibility rather than of societal rot became natural.
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Even public health began to treat people as if they lived in a social vacuum. Epidemiologists now searched for “risk factors,” such as inactivity and alcohol consumption, that made individuals more vulnerable to disease and designed health-promotion campaigns that exhorted people to change their behaviors, tying health to willpower in a way that persists today.
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This approach appealed, too, to powerful industries with an interest in highlighting individual failings rather than the dangers of their products.
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“epidemiology isn’t a field of activists saying, ‘God, asbestos is terrible,’ but of scientists calculating the statistical probability of someone’s death being due to this exposure or that one.”
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In 1971, Paul Cornely, then the president of the APHA and the first Black American to earn a Ph.D. in public health, said that “if the health organizations of this country have any concern about the quality of life of its citizens, they would come out of their sterile and scientific atmosphere and jump in the polluted waters of the real world where action is the basis for survival.”
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a new wave of “social epidemiologists” once again turned their attention to racism, poverty, and other structural problems.
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The biomedical view of health still dominates, as evidenced by the Biden administration’s focus on vaccines at the expense of masks, rapid tests, and other “nonpharmaceutical interventions.”
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Public health has often been represented by leaders with backgrounds primarily in clinical medicine, who have repeatedly cast the pandemic in individualist terms: “Your health is in your own hands,” said the CDC’s director, Rochelle Walensky, in May
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the pandemic has proved what public health’s practitioners understood well in the late 19th and early 20th century: how important the social side of health is. People can’t isolate themselves if they work low-income jobs with no paid sick leave, or if they live in crowded housing or prisons.
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Public health is now trapped in an unenviable bind. “If it conceives of itself too narrowly, it will be accused of lacking vision … If it conceives of itself too expansively, it will be accused of overreaching,
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“Public health gains credibility from its adherence to science, and if it strays too far into political advocacy, it may lose the appearance of objectivity,”
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In truth, public health is inescapably political, not least because it “has to make decisions in the face of rapidly evolving and contested evidence,” Fairchild told me. That evidence almost never speaks for itself, which means the decisions that arise from it must be grounded in values.
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Those values, Fairchild said, should include equity and the prevention of harm to others, “but in our history, we lost the ability to claim these ethical principles.”
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“Sick-leave policies, health-insurance coverage, the importance of housing … these things are outside the ability of public health to implement, but we should raise our voices about them,” said Mary Bassett, of Harvard, who was recently appointed as New York’s health commissioner. “I think we can get explicit.”
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The future might lie in reviving the past, and reopening the umbrella of public health to encompass people without a formal degree or a job at a health department.
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What if, instead, we thought of the Black Lives Matter movement as a public-health movement, the American Rescue Plan as a public-health bill, or decarceration, as the APHA recently stated, as a public-health goal? In this way of thinking, too, employers who institute policies that protect the health of their workers are themselves public-health advocates.
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“We need to re-create alliances with others and help them to understand that what they are doing is public health,