The replacement of guards in US public health is imminent. This is a chance to revitalize unstable areas. Anthony Fauci is retiring in the shadow of the worst preventable disaster in history, and President Biden is moving to make new appointments. Established Permanent White House Office for Pandemic Preparedness and Response Policy. In doing so, Biden and his advisers must confront the fact that public health corruption is structural. Building a decent national health infrastructure will require confronting pervasive public health distortions and reinventing the system of leadership appointments that has made America’s public health agency a prisoner of partisan interests.
Part of what makes public health vulnerable and a toy of partisan politics is Gradual medicalizationFor example, consider the history of the most important public health agency in the United States. Since 1953, all directors of the Centers for Disease Control and Prevention (CDC) have earned a Doctor of Medicine (MD) degree as their primary qualification, with secondary degrees used primarily as resume adornments. I’m here. Given that medical intervention is a component of Only 10-20% of modifiable factors Affecting health, the background reflected in CDC’s leadership, and likewise most state and local public health agencies, is narrow, at the expense of other areas that represent the remaining 80-90% of relevant knowledge. Notable for consistently prioritizing biomedical expertise. to formulate public health policies;
Physician and Public Health Scientist Milton Roemer one time Observed For public health work, “most medical education is irrelevant.” But neither physicians’ irrelevant medical knowledge nor their relative ignorance of important areas such as labor history, social anthropology, political economy, epidemiology, and environmental science are among the most troublesome for physicians in managing public health. not the sides. Rather, it is a lack of epistemological humility, an inability to recognize the limitations and dangers of clinical reasoning that medical training often imbues them with. Not just not. It’s often the exact opposite.
Danger of clinicalism
When we treat patients, doctors try to properly care for the patient in front of them. We generally recognize that we cannot change their living circumstances. For example, economic and housing conditions, employer demands, student and medical debt, neighborhood violence, and social isolation. existing constraints.
Public health, by contrast, is about treating populations. Like medicine, the goal of public health is to break free from health restrictions that limit an individual’s ability to live as they please. But public health pursues this in a very different way. Work is not about helping individuals adjust to oppressive social or work situations. Instead, use the power of government to change the conditions that limit people’s freedom. The core tools of public health are therefore not only vaccines and laboratory tests, but also corporate regulations and policies regarding consumer safety standards. labor protection; public jobs and housing programs; investment Community Health Workers, Decriminalization, and Jailbreaks. and civil rights litigation.
Public health does not meet where people are. Changing the environment to encourage risk-reducing behaviors, such as taking time off work and staying home when sick, without fear of loss of income, allows people to move freely. It’s not about individual risk tolerance, it’s about government’s use of population-level tools. pretty air and water— to reduce the level of risk to which individuals are exposed by living in society. To do this effectively, public health prioritizes the protection of those whose freedoms are most hindered by the current situation. migrant agricultural workers; people of color; and those who are particularly at risk. Public health needs to do this because it recognizes that harm can be done and not simply out of altruism. vulnerable group It will eventually return something like Double offense for society. So public health needs to see the world.”from below,” not through the eyes of banker, economistagain opinion writer in a national newspaper.
Different from clinical medicine, public health requires different modes of analysis. for example, twisted incentives Overtreatment is rampant in US medicine and causing harm. But simply translating these concerns into a public health scenario, without adequately accounting for population-level dynamics, may sound sensible to physicians’ ears, but is in fact fundamentally erroneous. Arguments against masking and Covid-19 vaccination recommendations for individuals at relatively low risk of serious consequences, such as school and university students, are often led by young people, teachers, It fails to address being an inevitable part of an epidemiological network involving conservation staff and parents. Parents, grandparents, and other more vulnerable groups. Similarly, precautionary principleIt underscores that scientific uncertainty must not be used as a reason for delaying the implementation of preventive measures in cases of serious threats to public health, and is a clear pillar of responsible health policy. But it can be confusing for clinicians trained to think on a smaller scale and follow reactive rather than preventive treatment protocols.
Today, clinical reasoning predominates, degrading the health status of individual patients while normalizing them. social situation— what I call “clinicalism” — the movement around public health is stronger than ever. Clinicalism is so pervasive that not only the physician’s perspective on public health, but also the largely decorative microwave “Master’s Degree in Public Health” that many physicians seeking leadership roles acquire. It forms much of what goes into public health education, such as academic degrees. This is because the individualist paradigm of biomedicine fits so well with the economic philosophies of her two major political parties in the United States.
privatized public health
Since the 1990s, when Bill Clinton endorsed “welfare reform,” Democratic and Republican leaders have embraced privatization, deregulation, and “free markets.” This economic agenda calls for government withdrawal from public service provision in order to maximize opportunities for private benefits. This not only exacerbates inequality. It also erodes the material basis of trust in governments and each other, The plague of public mistrust We are currently undermining the vaccination campaign.
This anti-public system paradigm only gained momentum during Covid-19. For example, his Covid-19 response coordinator for Biden, Dr. Ashish Jha, said:Product commercializationCovid-19 tests, vaccines and treatments. He explained that the government should no longer get involved as people can buy these for themselves.
It is fundamentally contradictory that Jha, Fauci, CDC director Rochelle Walensky, and other officials are tasked with carrying out. Privatized public health is not really a defensible policy. But because the president appoints the most powerful public health officials in the country, economic priorities that serve partisan electoral interests supplant actual public health politics, turning public health agencies into partisan pawns. changing.
Rather than highlighting the population-level health benefits of addressing structural defects such as loose labor protectionepidemic amplification imprisonment systemunregulated The greed of the pharmaceutical industry,Exclusive for-profit health care system, and economic inequalitypublic health figureheads are instead forced to seek ways to strengthen the existing unequal system and cast their political bosses in the most flattering light. If they refuse, they can be expected to be dismissed quickly and replaced by a more obedient doctor from among the many waiting eagerly in the wings.
Public health should be political, but not partisan
Health officials take mandates from politicians, but what we need is federal scientific agencies such as the CDC, NIH, EPA, and Occupational Safety and Health Administration to publish recommendations for executive and legislative action. to be a nonpartisan body that tells lawmakers what to do by presenting To enable this, their leadership should be selected by a process that is as non-partisan as possible. National Academy of Sciences, Engineering and Medicine (NASEM), Established The agency that advised the federal government on matters of science and art in 1863 could be the ideal agency to guide such a process. For example, delegating to NASEM the power to appoint the leaders of federal scientific agencies for subsequent congressional approval would allow those agencies to operate more independently of partisan interference and serve the public more effectively. It may become like this.
Whatever approach is taken, it is important to acknowledge that public health agencies are political in nature. When public health leaders shy away from politics, their jobs are worse than useless. But for the inherently political work of public health to be effective, it cannot be allowed to continue to be conflated with partisan loyalties. To challenge politicians and oligarchs regardless of party affiliation, and to be trusted by the public while doing so, public health officials: isolated from partisan power.
Persons such as Jha, Walensky, and Fauci now have very general profiles that could help accelerate needed change. Each of them has faced harsh public criticism and has been repeatedly defended by public health colleagues. In doing so, they can ask the president and Congress to address the policy structures that have created the partisan clutches to which public health officials have been restricted under Trump and Biden.
It’s only a matter of time before the far-right anti-science agenda returns to power. The Biden administration needs to recognize that and reshape appointment structures that align with both the long-term interests of public health leaders and the interests of the public they are meant to serve.
Achieving structural restructuring of public health in the United States is a tall order. But if ever there was a time when public health agencies needed to be transformed, this is it. We must use all our resources to try to achieve change, but the window of possibility remains wider than usual amidst undeniable waves of failure still rippling.