Rebuilding Public Health

The past two years have reinforced the Public Health truth that the lives of human beings are globally inter-related. The SARS-COV2 pandemic was always going to be a challenge for the United States because Public Health–doing what is best for the individual by doing what is best for the group–is anathema to the American ethos. However, Public Health interventions can succeed, especially when protection is built so seamlessly into our lives that we are unaware that we are being protected. When Public Health works best, no one notices. When it fails, it is front page news, as it should be.

For example, I was protected from waterborne disease this morning when I turned the tap to get a drink–I could boil my water each day for protection, and many people around the World must still do so, but Public Health would have protected me even if I remained unaware. The past two years have seen numerous failures intermingled with scientific advancements. We have struggled to assimilate the Public Health evidence base around basic policy questions such as when should schools close and, how important are masks versus ventilation? A person wanting to follow the evidence may find themselves lost in a bewildering stream of information, while others have tuned out due to political reasons.

Outside of the horrible human toll of the pandemic shown via morbidity, mortality and the overwhelming of health care systems around the World, the loss of confidence in Public Health and Public Health guidance has been the worst outcome of the pandemic. Some of this has resulted from politically motivated distrust fueled by mis-information, but not all of it. There have been numerous missteps and errors by our Public Health agencies, and these are certainly multi-factorial but many flow from a paternalistic impulse of not trusting people to assimilate evidence into their own lives that often shadows Public Health. A top to bottom reconsideration of how we develop, assimilate, and communicate Public Health evidence is needed both in the United States and globally.

There are 3 overarching challenges that Global Public Health/Health Policy must address if we are to live up to our potential to improve human flourishing in the World today and in the future.

• Rebuild trust in Public Health guidance and evidence production, by
focusing on communicating uncertainty and normalizing the updating of
guidance. Uncertainty and updating are hallmarks of science, and it will take an interdisciplinary effort to communicate this reality. Being clear about uncertainty is the route to more trust.
• Embracing the cross-cutting question “how much evidence is good enough
to decide to make a policy change or decision?” in order to create a more productive use of data
to inform decisions of all types. Our world is data rich, information poor, and
evidentiary standards to anchor decisions have not kept pace with data availability. Different decisions and decisionmakers will have different standards, we simply need clarity that is informed by the risks and rewards of different domains. Policy failures and errors of policy assessment due to the suboptimal use of data should be viewed as as Public Health problem, and policy improvements as harm reduction.
• We should catalyze movement beyond describing the effects of Racism on Public
Health, to testing interventions that can reduce harm (morbidity and mortality) in
populations that experience Racism. There was a period of increased understanding of the impact of Racism on the lives of those exposed, that was spurred by the confluence of the differential burden of COVID19 in the pre-vaccine period of the pandemic on Black and Latina/o persons, and the beginnings of a reckoning that seemed to be accelerated by a series of events encapsulated by the murder of George Floyd. However, much of the momentum that seemed afoot has been lost, replaced both by apathy and the rhythm of push back. The United States will either lean into this difficult challenge and make progress, or turn away and fail.

Much can and should be said about these three issues, and I will be writing about them in the weeks, months and years ahead.

Don Taylor