10 minutes

How to Lose a Century of Progress

When caring for two toddlers during the pandemic felt impossible, I took solace in knowing that raising children used to be considerably more difficult. During the early 20th century, infectious organisms in tainted food or fetid water exacted a frightening toll on children; in some places, up to 30 percent died before their first birthday. In those days, there was often little more to offer children suffering from dehydration and diarrhea than milk teeming with harmful bacteria or so-called soothing syrups laced with morphine and alcohol.

Since then, deaths during childhood went from commonplace to rare. Partly as a result, the average human life span doubled, granting us, on average, the equivalent of a whole extra life to live. The field of public health is primarily responsible for this exceptional achievement.

Medicine revolves around the care of individual patients; public health, by contrast, works to protect and improve the health of entire populations, whether small communities or large countries. This encompasses researching how to prevent injuries, developing policies to address health disparities, and, of course, tackling disease outbreaks.

George Whipple, a co-founder of the Harvard School of Public Health, proclaimed in 1914 in The Atlantic that “one of the greatest events of the dawning twentieth century is the triumph of man over his microscopic foes.” Even he’d likely be shocked by the success of public health over the past century.

But as the coronavirus pandemic wanes, the field of public health has come under a barrage of criticism. Some are calling to curtail the field’s power. Even many of public health’s strongest proponents are disappointed with how the profession navigated the pandemic.

While it is essential to learn from mistakes of the recent past, such rhetoric could have awful consequences. Our public-health workforce is already burdened by massive attrition. Simultaneously, a growing body of legislation and litigation is chipping away at public health’s ability to address current and future health threats. Politicians have accused health experts of being “wrong about almost everything” during the pandemic. Senator Rand Paul of Kentucky, a Republican who fundraised his reelection bid with “#FireFauci” ads, introduced a bill to eliminate the position that Anthony Fauci recently left at the National Institutes of Health and to split the agency in three.

Public health wasn’t perfect during the pandemic; it never has been. But its remarkable track record–on the provision of clean water, prevention of childhood lead poisoning, tobacco-cessation programs, vaccine development and promotion, and much more–has driven unprecedented gains in better health and life expectancy worldwide. Public health saves lives, and is an essential component of protecting and improving our collective health.

Exacting revenge on the field following a devastating pandemic may feel satisfying to some people, but curtailing public health’s programs, credibility, and funding will not help anyone. What it will do is put a century of progress at risk.

I understand why the backlash has been so intense. There were errors at many steps. The CDC botched testing for SARS-CoV-2 early in 2020, delaying our ability to track the virus from day one. Much of the communication about masks and vaccines from public-health officials was unclear and unhelpful. We too often failed to put our best public-health knowledge to use in schools to keep kids learning while reducing spread, leading to closures that went on far longer than necessary; at bars and restaurants down the block, meanwhile, life continued as normal. The full extent of the damage done to a generation of students will not be known for years to come.

But at the same time, while critics love to talk about everything public health got wrong throughout the pandemic, they rarely stop to recognize all that it got right–and under truly challenging circumstances. For example, when asked to reflect on the COVID-19-vaccine rollout, many will note the confusion about eligibility or countless hours spent frantically clicking “Refresh” on appointment sites. But the fact is that in just six months, almost half of the U.S. population got vaccinated. As a health-care provider, I can say that the effects were dramatic: We quickly saw fewer and fewer patients arriving with severe illness. The phenomenal achievement of the vaccination rollout–coordinated by federal, state, and local public-health agencies–averted millions of deaths from COVID-19 to date and serves as a blueprint for how to mobilize mass-vaccination campaigns in the future.

Rapid antigen testing feels routine now, but consider how widespread and accessible it became, and how quickly. For the first time, people are able to easily diagnose a respiratory infection at home without a doctor, helping prevent spread and avoiding unnecessary office visits. At the outset of the pandemic, we relied on time-consuming, expensive, and severely limited PCR tests. Within months, at-home tests were approved, and now hundreds of millions have been produced, shipped, and used across the country. This helped improve timely access to antivirals such as Paxlovid, which saved more lives yet. And the lessons learned from using rapid tests in this pandemic will help bolster preparedness and response in future disease outbreaks. Additionally, at-home rapid tests for other respiratory pathogens, such as influenza and respiratory syncytial virus, are on the immediate horizon.

The tendency to focus on public health’s slipups rather than its successes is not new. Americans have long undervalued public health: We almost never have to question if the food we consume or the medicines we’re prescribed will inadvertently sicken us and send us to the hospital. This disconnect between what we value and what truly benefits us becomes clearer when we compare public health with the field of medicine.

Throughout the pandemic, while public-health officials were met with pitchforks–forced out of their job or taunted with death threats–health-care providers (like myself) were applauded with pots and pans, in recognition of the challenges we faced on COVID’s front lines.

This is a classically American pattern. Public health is focused on the health of communities; medicine, on individuals. Almost all of the more than $4 trillion spent on health care annually supports individual patient care, with only 4 percent of funding going to public health. This is strikingly inefficient and helps explain why the U.S. has one of the lowest life expectancies and the highest rates of maternal and infant mortality among high-income nations.

Armed with a growing array of treatments and diagnostic tools, medicine has gotten much better at treating infections. But it can still do very little to stop a novel pandemic, and in March 2020, its ability to save lives from COVID wasn’t markedly better than during the 1918 influenza pandemic. America needs a robust field of public health to do what medicine cannot: keep people safe from emerging pathogens, environmental toxins, and gun violence. Medicine can treat people who are sick, but only public health can preserve their health in the first place.

It’s easy to assume that progress in public health is linear, and that over time the world’s population will only get healthier. But we’re witnessing profound challenges that may turn back the field’s achievements.

In 1972, the Noble-laureate immunologist Macfarlane Burnet predicted, “The most likely forecast about the future of infectious disease is that it will be very dull.” His optimism seemed justified in 1980, when the World Health Organization declared smallpox eradicated.

But the triumph over microbes was short-lived. In 1981, a CDC Morbidity and Mortality Weekly Report outlined the first five cases of what would eventually be called HIV/AIDs, a global pandemic that has since killed 40 million people worldwide. More recently, outbreaks of measles, polio, and other diseases most of us know only from playing Oregon Trail pose new threats and challenges. Syphilis cases in the U.S. are at their highest level in 70 years.

The anger directed at public health following the pandemic could further weaken the field, accelerating this backslide. Dozens of states have implemented restrictions on public-health powers, intended to limit what politicians regard as the field’s overreach during the pandemic. This means greater gatekeeping and restrictions on the role of public-health authorities by politicians, a flawed and problematic setup in the midst of crises.

The problem isn’t coming only from politicians. A judge recently overturned the FDA’s approval of mifepristone, the first time a judicial appointee overruled the national authority on drug safety, which could open a challenge to all medications, vaccines, foods, and other products regulated by the FDA. Before the 1906 Pure Food and Drugs Act–the progenitor of our FDA–there was virtually no regulation of patented medicines or other “treatments” sold for a variety of illnesses. Many contained toxic chemicals and addictive substances, or were dangerously misbranded.

And another judge recently struck down a mandate that required private-health insurers to provide free preventive services. (Earlier this month, the Department of Justice reached a tentative deal to preserve preventive services while the legal case proceeds.) Such rulings would threaten access to mammograms, pre-exposure prophylaxis for HIV, and other basic health care for nearly 150 million Americans. The U.S. is already last in preventable deaths among 16 high-income nations, and the loss of preventive services will only make an already dismal situation worse.

If what we desire is a better response to future outbreaks and health threats, we must all–adversaries and advocates alike–push for a stronger, bolder, and better-resourced field of public health. In denouncing the failed policies of U.S. pandemic response, critics frequently point to Sweden as an exemplar of success during the COVID pandemic. Rarely do they point out that its public health-care system is one of the most robust and well resourced in the world.

In 1903 C.-E. A. Winslow–who created the standard definition of public health and founded what would become the Yale School of Public Health–wrote in The Atlantic that “immunity from certain diseases is accepted, like the sun-shine, without thought, by a generation which has not felt their incidence; and this condition has its dangerous side, for it leads often to a neglect of the pre-cautions necessary to retain the advan-tages won.”

The same sentiment can be applied to how public health more broadly is appreciated–or rather underappreciatedtoday.

You don’t need to recognize everything public health does for you in the background; it is used to being ignored. The President’s Emergency Plan for AIDS Relief, one of the greatest global public-health initiatives since smallpox eradication, just celebrated its 20th anniversary with almost no public recognition, despite saving tens of millions of lives around the globe.

But Americans must make sure that public health keeps working, even if it remains unnoticed. It’s how you know that the cauliflower at the supermarket isn’t crawling with Cyclospora or that the water from your faucet won’t keep your children from seeing their first birthday. We’re lucky we haven’t had to think about it, but that doesn’t mean we can take it for granted.

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