Where is the “Public” in American Public Health? Moving from individual responsibility to collective action

Abstract

American individualism continues to prove incommensurate to the public health challenge of COVID-19. Where the previous US Administration silenced public health science, neglected rising inequalities, and undermined global solidarity in the early pandemic response, the Biden Administration has sought to take action to respond to the ongoing pandemic. However, the Administration's overwhelming focus on individual responsibility over population-level policy stands in sharp contrast to fundamental tenets of public health that emphasize “what we, as a society, do collectively to assure the conditions for people to be healthy”.1Institute of Medicine Committee for the Study of the Future of Public HealthThe Future of Public Health. National Academy Press, Washington, DC1988Google Scholar When this misalignment of individual responsibility and public health initially became clear with the removal of mask guidance for vaccinated individuals in May 2021, we decried the CDC Director's public admonition: “Your health is in your hands.”2Tomori C. Ahmed A. Evans D.P. Meier B.M. Nair A. Your health is in your hands? US CDC COVID-19 mask guidance reveals the moral foundations of public health.EClinicalMedicine. 2021; 38101071Google Scholar We argued that such statements – coupled with the label of “the pandemic of the unvaccinated” – represent a moral failing of US policy because they “undermine the fundamental notion that all people are equal in dignity and rights2Tomori C. Ahmed A. Evans D.P. Meier B.M. Nair A. Your health is in your hands? US CDC COVID-19 mask guidance reveals the moral foundations of public health.EClinicalMedicine. 2021; 38101071Google Scholar” and implicitly shift blame to individuals for systemic failures. This turn towards an individualised approach by US leaders has continued amid a series of new variants and a vaccination-focused response. With the Biden Administration claiming that variants were unpredictable,3CNN. Harris Says Biden administration 'didn't see' Delta or Omicron coming. 2021.https://www.cnn.com/2021/12/18/politics/kamala-harris-biden-administraton-delta-omicron-variant/index.html. Accessed 14 February 2022.Google Scholar and that people are responsible for their own protection by getting vaccinated,4The White House. Press briefing by White House COVID-⁠19 Response team and public health officials, December 17, 2021. 2021. https://www.whitehouse.gov/briefing-room/press-briefings/2021/12/17/press-briefing-by-white-house-covid-19-response-team-and-public-health-officials-74/. Accessed 16 February 2022.Google Scholar this neglect amid the Delta and Omicron waves led to an additional 318,000 deaths in seven months, accounting for over a third of all US COVID deaths to date.5Centers for Disease Control and Prevention. COVID data tracker. February 14, 2022 2022. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Accessed 14 February 2022).Google Scholar By increasingly framing the escalating transmission and continued deaths as a “pandemic of the unvaccinated,” the Administration has overlooked systemic inequities in vaccination (resulting from housing or immigration status, income and insurance, unequal access to information and systemic racism) while ignoring the plight of those ineligible for vaccination (children younger than 5 years) and those who remain at risk even after vaccination (e.g., people who are elderly, disabled or immunocompromised). The Administration promised “no disruptions” for the vaccinated while the unvaccinated were left susceptible to a “winter of severe illness and death”4The White House. Press briefing by White House COVID-⁠19 Response team and public health officials, December 17, 2021. 2021. https://www.whitehouse.gov/briefing-room/press-briefings/2021/12/17/press-briefing-by-white-house-covid-19-response-team-and-public-health-officials-74/. Accessed 16 February 2022.Google Scholar — further deepening divisions and neglecting fundamental human rights. Where vaccine mandates were a central pillar of the pandemic response, the Supreme Court's rejection of vaccine mandates for employers outside health-care settings has undermined even this pillar, leaving an even more extreme, libertarian, and individualistic approach and ignoring the need for structural solutions. Beyond vaccinations, few federal public health policies have been enacted to contain transmission of recent variants, letting the virus spread virtually unmitigated in a country where only 65% have received two doses of the vaccine5Centers for Disease Control and Prevention. COVID data tracker. February 14, 2022 2022. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Accessed 14 February 2022).Google Scholar (as of February 14, 2022) —among the lowest vaccination rates of any high-income country. Prompted by public pressure, the Biden Administration belatedly acknowledged the need to provide additional public health protections in January 2022 – setting up a website for ordering four free rapid tests per household and distributing free N95 masks – but these efforts have been slow and remain inadequate, with little attention to inequities in access. Framing the Omicron variant as “mild” – shifting focus from spiking cases and “long COVID” to hospitalisations and deaths, both lagging indicators – has only compounded these failures. As hospitalisations reached and exceeded January 2021 levels,5Centers for Disease Control and Prevention. COVID data tracker. February 14, 2022 2022. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Accessed 14 February 2022).Google Scholar reports from overwhelmed hospital staff negotiating crisis standards began to reveal the consequences of this individualistic approach, leaving weak health systems and essential supply chains at the verge of collapse. Despite the constant evolution of SARS-CoV-2 variants and the unprecedented health burden of the COVID-19 crisis, the solution to the pandemic response remains strikingly simple—a return to foundational principles of public health and human rights. Three principles must drive all US policy actions: population health as the primary focus for collective action, the prioritisation of those groups at greatest risk, and equitable access to COVID-19 prevention and treatment—both inside and outside of the United States. The public health response to the pandemic must prioritise population health. Populations have a collective right to public health, meriting the restriction of individual liberties where necessary and proportionate to protecting public health.6Meier B.M. Advancing health rights in a globalized world: responding to globalization through a collective human right to public health.J Law Med Ethics. 2007; 35: 545-555Google Scholar A multi-layered approach to COVID-19 prevention and response is foundational to a successful population health response.7Ngô T. To slow the spread of COVID-19, we need to bring back the Swiss Cheese Model of pandemic response.Health Aff. 2021; Google Scholar This response includes access to vaccination, high-quality masks, ventilation, physical distancing, testing, and treatments – coupled with supportive social policies and regulations. In these equitable measures to promote the public's health, special consideration must be given to ensuring the rights of those who are at higher risk for SARS-CoV-2 infection and more severe health outcomes as a result of COVID-19. These groups include children, older people (especially those in nursing homes), people who are disabled or immunocompromised, pregnant and postpartum people, those in carceral and other institutionalised settings, insecurely housed people, and workers such as teachers, essential, and low-wage workers.5Centers for Disease Control and Prevention. COVID data tracker. February 14, 2022 2022. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Accessed 14 February 2022).Google Scholar,8Michaels D, Barab J. OSHA can do more to protect Americans from Covid-19. The New York Times. 2022 January 14, 2022.Google Scholar These groups’ risks are further compounded by a history of policies motivated by structural racism, with the effect of undermining the health of racial and ethnic minorities. Comprehensive action is necessary not only to prevent avoidable illness, hospitalisation, and death but also to prevent other chronic complications of COVID-19 such as diabetes,9Barrett C.E. Koyama A.K. Alvarez P. et al.Risk for Newly diagnosed diabetes>30 days after SARS-CoV-2 infection among persons aged< 18 years—United States, March 1, 2020–June 28, 2021.Morb Mortal Wkly Rep. 2022; 71: 59Google Scholar negative cardiovascular outcomes10Xie Y. Xu E. Bowe B. Al-Aly Z. Long-term cardiovascular outcomes of COVID-19.Nat Med. 2022; Google Scholar and “long COVID”, which are still poorly understood and are estimated to affect millions of Americans. Finally, the United States should not only take positive steps toward remedying the policy response at the national level; it must do so on the global stage. The disproportionate focus on individualism in domestic policy has been mirrored by nationalism in foreign policy. In abandoning the global community, nationalism continues to undermine international cooperation in facing a common health threat. Without efforts to ensure increased equity to COVID-19 testing, vaccination, and therapeutics across nations, variants will continue to emerge, undermining individual country efforts. It is only through global solidarity that we can achieve the collective action across nations that is necessary to advance public health in the pandemic response. The authors conceived, drafted, and revised this commentary for publication jointly. All authors participated in each step of the process. The authors wish it to be known that, in their opinion all authors should be regarded as joint first authors. The authors have no conflicts of interest to declare.

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