Abstract
While the SARS-CoV-2 pandemic has exacerbated known and long-standing challenges to the nation’s public health system, including a neglected infrastructure and inadequate funding, new actions to limit the authority of public health in an environment of mistrust and disregard for public health science, public health measures, and public health officials add to the complexity of challenges we are facing. The ability to determine whether public health measures are needed to address issues that pose significant risks to the health and well-being of communities has been dramatically limited or reassigned to elected officials without any requisite knowledge of science or public health. Public health professionals who have promoted and worked to implement evidence-informed public health measures have been contradicted or ignored by elected officials and others while being harassed or threatened for doing their work. A significant number of professionals have been fired, have retired early, or have terminated their employment as a result of fear for themselves and their families, an inability to protect the communities they have served, exhaustion, and a bleak forward-looking picture. Public health’s mission to ensure conditions in which all people can be healthy has been overshadowed, eclipsed, and minimized by assorted national, state, and local policymakers and community residents. Public health’s future rests on our work to understand and address these challenges, to strengthen systems that are lacking, and to be innovative in looking forward and implementing what is needed to carry out our mission to protect the health of the public we serve.
Relationship to Existing APHA Policy Statements
- APHA Policy Statement LB20-03: COVID-19 and the Education Sector: Early Lessons from the Pandemic
- APHA Policy Statement 20171: Supporting Research and Evidence-Based Public Health Practice in State and Local Health
- APHA Policy Statement 201511: Impact of Preemptive Laws on Public Health
- APHA Policy Statement 201015: Securing the Long-Term Sustainability of State and Local Health Departments
- APHA Policy Statement 200911: Public Health’s Critical Role in Health Reform in the United States
- APHA Policy Statement 20063: Preparing for Pandemic Influenza
- APHA Policy Statement 20034: Protecting Essential Public Health Functions Amidst State Economic Downturns
- APHA Policy Statement 200023: The Need for Continued and Strengthened Support for Immunization Programs
Problem Statement
While the SARS-CoV-2 pandemic has exacerbated known and long-lasting challenges facing the country’s public health system, such as neglected infrastructure and inadequate funding, new actions to limit the authority of public health in an environment of mistrust and disregard for public health science, public health actions, and public health officials add further concerns and complexity.[1]
Recent dramatic increases in legislative actions to limit the power of public health have been reported by the Network for Public Health Law and the National Association of County and City Health Officials (NACCHO).[2] As of mid-September 2021, more than half of U.S. states had passed legislation that limits public health authority, and bills limiting public health authority have been introduced in the remainder of the states. Idaho now allows county commissioners to override countywide public health orders.[3] At least nine states now have laws that ban or limit mask mandates (Florida, Texas, Arkansas, Arizona, Iowa, Oklahoma, South Carolina, Utah, Montana), and five states have executive orders or court rulings that limit mask requirements.[4] In at least 16 states, the power of public health officials to order mask mandates, quarantines, or isolation has been limited. Many governors have opted not to implement mask mandates and are relying on local public health agencies to determine whether mandates are needed and to implement them. Seventeen states have passed laws banning COVID vaccine mandates or vaccine passports or have made it easier to get around vaccine requirements.[2]
Other state-level policies include limiting public health’s ability to close businesses to prevent the spread of disease (Kansas), banning the use of quarantine (Montana), stripping authority from local health departments and local governments to respond to local emergency conditions (Texas), blocking state universities from requiring vaccinations for students and employees (Arizona, Georgia), prohibiting hospitals from requiring employees to be vaccinated (Arizona), setting arbitrary time limits for emergency orders (Florida), and shifting power from state and local public health agencies to legislatures (Ohio, Indiana). Lawsuits have been filed in a number of states including California, Kentucky, Louisiana, and Virginia claiming that state or local restrictions on religious gatherings are in violation of the First Amendment right to free exercise of religion. Some states have classified religious gatherings as “essential” to elude public health recommendations.[5] On a national level, at least 24 governors are threatening to sue President Biden over his vaccine mandates, as the governors perceive the mandates to be overreaching.[6,7]
The judicial branch has typically upheld delegations of authority under public health powers. The U.S. Supreme Court, in the 1905 Jacobson v. Massachusetts case, ruled in favor of the state to require that Reverend Henning Jacobson be vaccinated for smallpox or pay the required $5 fine, recognizing that the public good outweighed the rights of the individual.[8] Over the years, the courts have continued to grant public health agencies substantial deference in imposing requirements to control preventable diseases, for example by requiring childhood vaccinations for school entrance. In using the power from the Jacobson court ruling, public health authorities should not merely be reasonable and transparent in their actions but should also “adopt the least restrictive alternative that will meet the public health goal.”[9]
Opposition to science-based public health measures that have been utilized during the pandemic has taken a number of forms. In some locales, public health agencies have gone to court to ensure enforcement of public health orders, as these agencies do not have other ways of enforcing compliance. For example, Dr. Dawn Comstock, executive director of Jefferson County Public Health (Colorado), issued a public health order to require masks in schools. Three private schools in the county did not comply with the order, nor did they allow Jefferson County Public Health to enter the school buildings unannounced to determine whether the order was being followed. A court hearing was held in September 2021. The judge decided to allow the order to stand temporarily. The cost of the court hearing was borne by Jefferson County (personal communication between Dawn Comstock, PhD, and Linda Degutis, DrPH, September 2021).
Another difficulty that health departments face with respect to public health orders is that in many situations the agency, in its efforts to enforce an order, has a single option for action if the order is violated. For example, if there is a mandate for mask wearing in schools and there is a report to the health department that a school is violating the public health order, the health department will investigate to document compliance or noncompliance. If the school is found to be noncompliant, the only choice that may be available to the health department is to shut the school down, thereby preventing the children attending that school from participating in in-person learning. This differs from the types of actions that might be undertaken in restaurant inspections, in which the department inspects a restaurant and identifies levels of compliance with food safety regulations. The restaurant will receive a score, and, if the score is below a specified level, the restaurant will be given a warning and will be reinspected within a short time frame. If its score remains low, the restaurant may be fined, and continued noncompliance may result in closure. This stepwise process provides an opportunity to take corrective measures that help to ensure that patrons of the restaurant are not at risk of illness because of food storage, preparation, and service.
Actions to strip public health of its ability to take measures to protect the public have included harassing and threatening public health officials and limiting or restricting the release of data related to the pandemic by public health officials.[10] News accounts report on a substantial number of personnel who have voluntarily left their positions or been fired at local and state levels. NACCHO has tracked more than 250 public health officials who have left their positions.[11]
Attacks have come not just from elected officials but from the public in the form of physical threats directed at public health workers and their families. Vitriolic postings on social media, radio attack ads, armed protesters, suspicious packages left on door steps, vandalized cars, and demonstrations at clinic sites have exacted a toll as documented by a Centers for Disease Control and Prevention summer 2021 survey of mental health among state, tribal, local, and territorial public health workers. The results document self-reported symptoms of depression, anxiety, posttraumatic stress disorder, and suicidal ideation.[12] In addition, a systematic review and meta-analysis linked psychological stress at work to mental health symptoms and increased absenteeism, high turnover, lower productivity, and lower morale.[13]
A Boots on the Ground post[14] suggests that public health borrow the concept of “moral injury” from combat medicine to describe the psychological, behavioral, social, and/or spiritual distress experienced by an overworked and undervalued public health workforce.
The disappearance of experienced public health professionals through resignation or dismissal results in the loss of institutional memory, expertise, and experience. The Association of State and Territorial Health Officers (ASTHO) determined that 33% of the state health officer turnover that had occurred as of August 2020 could be attributed to conflicts with elected officials and/or threats of physical harm and harassment from the public.[15] The already short tenure of state health officers has been exacerbated by COVID-19 and warrants serious consideration as the country emerges from the pandemic.
Assuming that new leaders can be found, having to replace leadership is an unwanted, unnecessary detraction. Recruitment of new personnel is a daunting task when the last office holder’s home was the staging ground for gun-toting protesters, as was the case for one state health commissioner.[16] There are particular challenges to recruitment of new leaders and personnel in rural and remote areas.
Collaborators have lost trusted colleagues. The community’s trust in public health and public administrators has eroded.[17] Observers suggest that public health learn from consumer product research that emphasizes the importance of transparency in sharing known and unknown risks. When made, errors should be acknowledged.[18] Distrust was amplified when, rather than attempting to provide an understanding of a new, evolving virus, early statements were used to reinforce a message of not being truthful, of incompetence, or of politicization of the pandemic.
People’s view of public health and the pandemic was also shaped by the data they received. Initial data terms were confusing[19] and left the public unsure of data’s value. Policymakers needed public health data. Jurisdictions across the country had data gaps and inadequate and inconsistent data definitions. Reporting timetables varied, as did access to data, and in some jurisdictions data were underreported or not reported at all.[20]
Disparate systems at state and local levels continue to challenge data’s usability and accuracy. During the pandemic, data systems struggled with disaggregation by key characteristics. COVID laid bare the patchwork of U.S. mortality tracking systems, including issues related to accuracy, completeness, and timeliness.[21] Challenges with data exchange between hospitals and public health agencies included both technology and workforce shortfalls.[22] The public health system, out of necessity, engaged academics as well as private sector consultants in assisting with data analysis and visualization, but valuable time was lost and lack of coordination across states led to varying case definitions and methods of measuring COVID-19-related deaths.[23] International comparisons were hampered by inconsistencies across countries. The pandemic has provided an incentive to develop a dynamic data system, a system called for in a 1995 report in Science.[24]
The pandemic has also elevated the need to rethink public health services and systems. We need to take a critical look at current activities and priorities and examine what we can do better, do differently, or stop doing. While public health continues its mission of protecting the health of the public, the system might benefit from a reexamination of structure and function and apply lessons learned during the pandemic. Organizations that serve to support state, regional, tribal, and local health departments and their leaders and staff can collaborate to identify model structures and functions that will contribute to the redesign and evolution of the public health system.
Evidence-Based Strategies to Address the Problem
The best means of communicating public health messages is an area of research across the country. Recently, Cornell researchers tested strategies to increase source credibility through strategic message design in the context of vaccine hesitancy.[25] Research has established that there are three core components of source credibility: expertise, trustworthiness, and caring/goodwill. The authors found that messages designed to convey source expertise produced greater perceived trustworthiness and reduced vaccine hesitancy. Observing that perceptions of credibility of sources differed, they called for more research on how strategic messaging might serve to increase the credibility of a specific source. The researchers noted that while perceptions of caring/goodwill may be of particular importance for those who distrust institutional science, this is an underresearched area.[25] Only relatively late in the pandemic has there been a focus on seeking recommendations from one’s trusted health care provider.
The APHA Code of Ethics provides a framework for analyzing public health actions and speaks to, among other points, the need to enforce public health laws: “While coercive legal measures limiting behavior can be ethically justified in certain circumstances, overall the effective and ethical practice of public health depends upon social and cultural conditions of respect for personal autonomy, self-determination, privacy, and the absence of domination in its many interpersonal and institutional forms. Contemporary public health respects and helps sustain those social and cultural conditions.”[26] This code provides a foundation for engaging in public health actions to create and sustain healthy communities and for designing the future of public health that updates structure and function.
In public health, evidence has a number of different audiences: practitioners; local, state, regional, tribal, national, and international policymakers; nongovernmental stakeholders whose mission is to improve health; researchers/academics; and the public.[27] Evidence should inform our policies, programs, and systems. The systematic development and synthesis of evidence for these audiences has been ongoing, but there is much yet to learn coming out of this pandemic, particularly about the interface of evidence with policymakers and the public. The public’s lack of understanding or recognition of the progression of science regarding the SARS-CoV-2 virus has interfered with acceptance of changing “facts.” Some policymakers and members of the public are dismissive of accumulating science and evidence. How we deal with those with hardened positions going forward warrants careful study. McKinlay and Marceau maintain that public health workers, motivated by humanism and utilitarianism, deserve to get somewhere by design, not just by perseverance.[28] Just what is that design?
Opposing Arguments/Evidence
Opposing views or arguments essentially consist of a dominant concern for oneself rather than others, reliance on readily available misinformation, locus of control regarding promulgation of public health measures, a pattern of distrust in government, politicization of a public health issue, and perceptions of overreach in the implementation of public health measures.
Much of the legal basis for public health measures, orders, and emergency orders resides within the authority of states. As definitions and assignments of authority lack uniformity across states, policies and practice also differ from one state to another. Decisions about what strategies are appropriate in order to prevent or mitigate a public health emergency are dependent upon the designated decision maker’s knowledge and understanding of the issue at hand. If the decision maker lacks the background or knowledge of public health and health issues and does not have a knowledgeable and reliable set of advisors on the issue (or may not heed the advice of knowledgeable public health advisors and leaders), decisions may be based on factors or outcomes that, although having an impact on the community, are not health outcomes. The outcomes that may be of concern to the decision maker may be economic, social, or community related. When public health experts are prohibited from exercising their authority to construct science-based public health orders and initiatives, the health of the community may be threatened and undervalued as other aspects of society are prioritized at the expense of the health of the public.
A prime example of the denigration of public health, as well as the inadequate response by some public health leaders, occurred at the beginning of the pandemic, when the White House set the stage for an unprecedented circumvention of public health agencies. Politicians rather than public health officials communicated with the public about the pandemic and the associated health risks. There were repeated denials of the potential severity of illness and risk of death as politicians continued their communications. Heads of federal agencies that focus on public health and health research—the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health—were not called upon to present the evidence for effective mitigation measures. Politicians promoted “cures” and treatments that were not only unproven but dangerous (e.g., hydroxychloroquine, bleach).
Early criticism from the White House of the CDC’s guidance made it appear politicized, eroding public trust in both the organization and its messages. Four former CDC heads penned an editorial appearing in the Washington Post titled “We Ran the CDC. No President Ever Politicized Its Science the Way Trump Has.” They noted that over their collective tenure at the CDC, spanning both Democratic and Republican administrations, they could not recall a single instance when political pressure resulted in a change in the interpretation of scientific evidence.[29] The secretary of the Department of Education described CDC guidelines for reopening schools as an impediment rather than characterizing them as actions to protect the safety of children and staff.[30]
According to Brown, public health interventions often stir controversies about the legitimate role of the state vis-à-vis individual autonomy and liberty and about the scope of personal versus social responsibility.[31] Public health measures implemented during the pandemic have relied on collective action to derive the most benefit, but a portion of society has a deep-seated belief that individual freedom trumps such actions. The breadth of the government’s action angered this population, as evidenced by their behavior toward public health officials and policymakers.[5,32–34]
During the pandemic, some political leaders decided to trust that their constituents would make the best decisions about protecting their health and the health of their community, regardless of their understanding of the evolving science of the pandemic and the efforts being made to end it. In addition, various sectors, including political groups, the media, and social networks, promulgated statements and theories that reinforced opposition to evidence-based public health measures and the continued erosion of public health authorities.
The pandemic catapulted public health experts to the forefront of what was viewed as political decision-making with polarizing reactions. Little is known about what citizens think of expert involvement in political decision-making. A study conducted in Europe showed that citizens prefer independent experts over national elected representatives in the policy change and implementation stages but that such acceptance is linked to specific issues.[35]
Opposition has also been built on the massive amounts of misinformation available on social media platforms and discussions with others with similar views. Messaging about the pandemic changed in real time as more was learned about SARS-CoV-2. Acknowledgment of uncertainty related to lack of available data was viewed as a negative rather than an understanding of the legitimacy of evolving science.
Action Steps
System
APHA calls for Congress, governors, mayors, tribal leaders, local leaders, and boards of health to form and support a comprehensive, nonpartisan, multisector commission to assess public health actions taken at the federal, state, tribal, regional, and local levels during the pandemic to control the spread of COVID-19.
APHA calls on policymakers at all levels to:
- Defend existing statutes that allow public health officials to implement public health measures that will aid in protecting the community from the impact of public health emergencies.
- Reinstate authority to public health officials to control outbreaks and manage other emergent and ongoing threats to the public’s health.
Funding
APHA calls for Congress and state, tribal, and local governments to fund:
- Transformation of the nation’s public health infrastructure at a level that allows the system to provide essential public health services to all.
- Development of dynamic data systems that are timely, accurate, and relevant; involve analyses that can be formatted for distribution to stakeholders and members of the community in a range of formats; and include interoperability for monitoring public health issues, emerging issues, and public health actions.
- A distinct, parallel public health Health Resources and Services Administration education and training program while including basic core public health training in all health professional programs.
Workforce Threats
APHA calls on Congress to require a reporting system of threats and harassment against public health workers in the performance of their official duties to the CDC and the CDC to build a database to better understand these occurrences.
APHA calls on groups such as the National Council of State Legislators, the National Governors Association, ASTHO, and NACCHO to develop model legislation and advocate for all state governors and legislative bodies to endorse a policy condemning harassment of or threats against public health officials (e.g., Colorado’s governor signed a law making it a misdemeanor to threaten public health officials or their families and California’s governor instituted an executive order protecting the privacy of public health officials) and implement legislation to protect public health officials.
Research
APHA calls on the National Institutes of Health, the CDC, the Department of Defense, the Department of Homeland Security, and foundations to increase funding for research addressing public health crisis interventions with options for just-in-time funding to prospectively study actions during public health emergencies.
Education
APHA calls on the Council on Education for Public Health to consider a mandatory requirement for inclusion of public health communication coursework to ensure that people who complete public health degrees are familiar with communication technology options and limitations, evidence-based communication strategies, crisis communication, communication with population subgroups, and communication with policymakers so that they can better understand and use evidence-based public health measures.
References
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