Tuesday, October 26, 2021

Public Health is Public

North Western Fever and Smallpox Hopsital, Hampstead, 1871, via UK National Archives

 Piece at The Atlantic by the extraordinary Ed Yong putting the concept of "public health" in its US historical context in the Progressive era, with the realization that poverty, inequity, and exploitation were literally making people sick:

A mixed group of physicians, scientists, industrialists, and social activists all saw themselves “as part of this giant social-reform effort that was going to transform the health of the nation,” David Rosner, a public-health historian at Columbia University, told me. They were united by a simple yet radical notion: that some people were more susceptible to disease because of social problems. And they worked to address those foundational ills—dilapidated neighborhoods, crowded housing, unsafe working conditions, poor sanitation—with a “moral certainty regarding the need to act,” Rosner and his colleagues wrote in a 2010 paper.
Providing the slumdwellers with fresh air, clean water, and light protects everybody from tuberculosis, cholera, and typhoid, even us upstanding citizens on the right side of the railroad tracks. 

This is such a nice communitarian picture, of something that really existed in our country at one time, through it existed, of course, at the same time as the rapacity and cruelty of the Gilded Age, and the real power was generally wielded by the robber barons who were responsible for the poverty and inequity and exploitation—government being largely their obedient servant, the "management committee of the bourgeoisie" as Marx called it. 

Theodore Roosevelt is a kind of epitome of the whole arrangement, since it was vast wealth (but old Knickerbocker money, not vulgar railroad or steel money—the Roosevelts got rich in colonial New York, refining sugar from cane cut by armies of slaves in the Caribbean) that enabled him to give his life to community activism and a political career that began with his service as New York City's police commissioner, working to clean up the city with all the other activists (the subject of Caleb Carr's enjoyable Alienist series), but inherited racism that, in the end, poisoned the good intentions of his politics, in my opinion.

Nevertheless, that's not what poisoned the public health movement, as Yong tells the story; that began with the hostility of the medical profession, whose business model, based on the treatment of individuals, was threatened by the idea of preventing illness through the community as a whole. Then there was their own success, in the furnishing of cities with plumbing, street cleaning, sewage treatment, reliable water supplies and public parks, which rendered the movement less necessary; and when science came to understand that the diseases public health was mainly concerned with were caused not by bad air (mal'aria) and miasmas but microorganisms, the focus of public health shifted from the environment to the lab, and the attack on bacteria and virus. Which really was necessary: the science was right, and antibiotics and vaccines and recently antiviral drugs have saved countless lives, but something has been lost all the same in the disappearance of the holistic model of people with different focuses working together, and its democratic underpinnings:

Many practitioners no longer felt compelled to deal with sticky, sweeping problems such as poverty, inequity, and racial segregation (or to consider their own role in maintaining the status quo). “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.” Public-health leaders even mocked their predecessors’ efforts at social reform, which they saw as inefficient and misguided. Some dismissively billed the impressive work of the sanitarian movement, which had essentially plumbed entire cities, as “a matter of pipes.”

Public health became a profession, and a bureaucracy that didn't necessarily get along all that well with the public, and everybody lost from that, not least public health, which no longer inspired the same kind of trust, or the same kind of volunteerism.

Meanwhile, in the conservative ascendancy in the US after World War II, community action itself became an object of suspicion—isn't that a little like Communism?—and a sort of  Calvinist tendency arose to blame individuals for their own diseases, as a kind of outward sign of lack of inward grace, caused by personal irresponsibility:

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.

You can see all this social pathology in the Trumpy response to the Covid pandemic, in the conservative belief from the beginning that only the weak and self-indulgent were really in danger, the fat and the diabetic—by which they clearly secretly meant members of minority communities, knowing the numbers but refusing to see that the real danger was in being forced to go out to work, in grocery stores and nursing homes, in the jobs white people no longer do in big American cities, and it was going to be different when the virus arrived in less populated and more white areas, as we now see in devastating detail in South Dakota and Iowa. But Yong forces us to notice that it applies to Democrats too:

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.” 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, after announcing that the vaccinated could abandon indoor masking. “Human behavior in this pandemic hasn’t served us very well,” she said this month.

(Yes, if you abandoned indoor masking last May, it was probably too early, and she's blaming you for following her advice.)

The doctors' and scientists' and civil servants' revenge is that they've finally taken over public health themselves, with spectacular results in the development of individual responses, especially the vaccines, but an overall approach that really hasn't worked well enough, abandoning the essential masking and test-and-trace, as if they hadn't heard that vaccines normally aren't even close to 100% effective.

We're now coming to thinking back on public health (as Yong doesn't specifically note, we're finally getting to my own contribution) as a really important perspective on social problems: on gun violence over the past 10 or 15 years, for example, and on opiate abuse as almost everybody acknowledges, and on systemic racism especially since the advent of the pandemic and the killing of George Floyd. And it doesn't seem as if the public health establishment is really ready. I'm finding myself understanding a kind of Republican point, gods forgive me a kind of David Brooks point, about the general thoughtlessness of the intelligentsiya when it comes—not to selling smart policy to the public, but to coming to a smart policy program that deserves to be sold; knowing so much about what the public needs that they don't ask the public.

That is, in the case of Covid, a bad political appraisal may have led to a bad policy stance, of total reliance on vaccines and neglect of the other vital elements of a response, and it may be at least in part a consequence of the continually increasing professionalization of public health. Brooks would call it "meritocracy" because everybody in the profession got good exam results, as if that was a bad thing, but the bad thing is really something else: that the intelligentsiya doesn't have contact with all those other people, professional and amateur, the grassroots activists and the charitable gentry, who may have a sense of what's going on.

The Republican version of this issue (government must yield to the local gentry) is certainly stupid, but the general idea isn't; public health really needs to get back to the public part of the discussion, if the professionals want to have any impact.  I don't know how that's supposed to get done, but it needs to start from an understanding that public health is public, and the public is personally involved.

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