“You’re On Your Own”: How the U.S. response to COVID revealed the flaws in the public health system

 This piece is a guest essay/book review by Ken Rosenberg, MD 

 

“The Premonition: A Pandemic Story” is Michael Lewis’ love letter to local health officers who are trying to do an impossible job. It is also a compelling analysis of why the U.S. public health system is not capable of effectively responding to a rapidly moving pandemic.

In 2018, Michael Lewis published “The Fifth Risk” in which he described the Obama administrative staff preparing detailed briefings for the incoming Trump administrators and finding that no one from the incoming Trump administration showed up to get briefed. When COVID quickly got out of hand, Lewis assumed that Trump and his fellow anti-government conservatives were at fault. But once Lewis started looking into the U.S. government’s COVID response he discovered a set of problems that was more complex and much more disturbing. 

Dr. Charity Dean, the Santa Barbara (CA) County health officer, was passionate in trying to prevent communicable diseases. She had sought help from the Centers for Disease Control and Prevention (CDC) in controlling outbreaks of tuberculosis, hepatitis, meningococcal disease and H1N1 influenza before COVID. She had found that CDC was risk-averse: they would not recommend a course of action. They hid behind the argument that nothing should be done unless there was sufficient data to support a decision. “She never had all the data she wanted or needed when making her decisions…People were far less likely to blame a health officer for what she didn’t do than what she did. Sins of commission get you fired. Sins of omission you could get away with, but they left people dead.” CDC’s mantra was “That decision is not supported by the data.” But Charity Dean knew that there was no data. Her mantra became “You’re On Your Own.”

 

[cartoon Hillary Fitzgerald Campbell, the New Yorker]

Similarly, everywhere he looked, Michael Lewis found a dysfunctional public health system where local public health officers were on their own with little support from the federal government. CDC, once run by infectious disease experts, had become a risk-averse academic bureaucracy run by political appointees. Their expertise had become the study of past events more than advice to health departments on what they should do in a crisis. And government agencies outside CDC, like FEMA, refused to take leadership in pandemic planning. In the end, a few individuals, both inside and outside the federal government, did what they could to craft a pandemic response -- without telling their bosses.

The U.S. public health system is relatively good at handling the prevention of chronic diseases – when it is adequately funded. (It is mostly not adequately funded.) But Michael Lewis found that it was not good at providing support for local health departments in how to handle epidemics. Bureaucracies do not do well working across silos. CDC is not structured to take leadership in a fast-moving prevention situation and its funding for emergency preparedness shrank by about half in the past ten years.(1)

“The Premonition” has two significant weaknesses:

(1) Although “The Premonition” purports to be a critique of the U.S. public health system, it is mostly about our inability to handle epidemics, especially fast-moving epidemics.

(2) “The Premonition” does not explore why there is a gap between the needs of local health officers and the federal public health agencies that are supposed to be supporting them. Much of the gap is due to changes in the field of epidemiology in the past 40 years. With the development of commercial data analysis software, epidemiology has largely changed from the practical work of public health to the analysis of risk factors. Academic public health currently spends much of its energy promoting evidence-based public health decision-making although local public health practitioners spend most of their time making decisions without the benefit of sufficient evidence. Currently both academics and CDC focus on promoting evidence-based decision-making while denigrating decisions that are not supported by evidence-based epidemiologic methods. By focusing primarily on evidence-based science, CDC has failed to explore and promote information that would help local health departments do their job in the absence of adequate information.

There are three main lessons of “The Premonition.” The first is that the U.S. public health system needs to be restructured so that 1500 local health officers are not forced to reach their own conclusions (often based on insufficient evidence) on how to save lives in an epidemic. Federal (and state) governments need to find a way to support the work of local health departments in epidemic times.

The second lesson is that public health needs increased stable funding. We continue to fund public health “in response to particular threats and then let our interest lapse when the immediate crisis seems to be over….[W]e should not allow ideological shifts and inevitable economic cycles to deflect us from maintaining appropriate public and governmental responsibility for the health of the community.”(2)

The third, and perhaps the most important lesson, is that public health must return to its origins in advocacy to eliminate social inequalities and what we now call the “social determinants of health.”(3) In the late nineteenth and early twentieth centuries, American public health’s mission was social reform, identifying itself with housing, sanitation, and labor reform efforts. “[P]ublic health professionals have, over the course of a century, defined their mandate ever more narrowly….For many decades, the field has…avoided engagement with those who challenge complacency and existing power relationships….Forsaking its early ideology, commitments, and crusading spirit, public health became unwilling or uncertain about how to use science to challenge powerful corporate interests, deeply entrenched moral beliefs, or profound social inequalities linked to gender, race, and class.”(4)

Public health needs to return to its advocacy roots – by reconnecting with labor, housing, transportation and other insurgents – “to deal with the problems that truly define the public’s health.”(5)

FOOTNOTES:

1. Trust for America’s Health. The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2021. At: https://www.tfah.org/report-details/pandemic-proved-underinvesting-in-public-health-lives-livelihoods-risk/

2. Elizabeth Fee, Theodore M Brown. The unfulfilled promise of public health: déjà vu all over again. Health Aff (Millwood). Nov-Dec 2002;21(6):31-43

3. https://en.wikipedia.org/wiki/Social_determinants_of_health

4. Amy L. Fairchild, David Rosner, James Colgrove, Ronald Bayer, and Linda P. Fried. American Journal of Public Health. January 2010, Vol 100, No. 154, pages 54-63

5. Ed Yong, “How Public Health Took Part in Its Own Downfall,” The Atlantic – Oct 23, 2021. At:  

https://www.theatlantic.com/health/archive/2021/10/how-public-health-took-part-its-own-downfall/620457/

 

Kenneth D. Rosenberg, MD, MPH, is a public health epidemiologist. He worked for many years for the New York City Department of Health and the Oregon Public Health Division.

 

Thanks to Kendall Belmont and Patrick Lemmon for their editorial assistance.