These days, everything is said to be a public health issue: gun violence, disinformation, and climate change. An ongoing opioid epidemic, an epidemic of loneliness, and an “epidemic of hate.” Kids are “addicted” to social media and that, too, is a public health issue.
But what exactly is “public health,” supposedly the only hope for our sick culture? Since the mid-1800s, the term has been used to describe interventions intended to benefit the health of the greatest possible number of people, ideally without relying on individuals to change on their own. Such an approach led to urban sewers to stop the spread of waterborne diseases, mass vaccination campaigns to curtail smallpox and polio, and seat belt legislation to reduce road deaths. Today it covers a growing number of distinct and even conflicting philosophies, from “disease detectives” who track down outbreaks to “harm reduction” specialists who get clean needles to people who use intravenous drugs.
Unlike historical efforts, which focused on collective action and policy change, contemporary strategies can often seem small, fragmented, and reactionary. While consumerist concepts like “wellness” have never been more prominent, the American public health apparatus has faltered—hamstrung, like so many progressive visions, by regulatory retreat and declining trust in institutions. “We treat public health as a series of individual health problems,” says Sean Valles, director of the Center for Bioethics and Social Justice at Michigan State University. The result? “Our public health is god-awful,” he says. Americans spend more than any other nation on health, yet we have the highest maternal mortality rate, the highest rate of drug-related deaths, and the highest Covid deaths per capita among developed countries.
The future looks just as bleak. The American imagination has atrophied such that many people no longer know what a big swing in the name of public health would look like. This has been clear in the matter of the ongoing Covid-19 pandemic. A temporary surge in government support for workers, the unemployed, and low-income children reduced poverty across the country—but congressional aid has since expired. Mask mandates are gone, widespread vaccine mandates were never really on the table, and the future of booster uptake remains an open question. Leaders, instead of overhauling the ventilation systems in schools, businesses, and public spaces to manage airborne viruses, have left constituents to individually opt in to a few free nasal swabs. When people do test positive, they are at the mercy of their employer, many of whom don’t offer paid sick leave.
Similar shortcomings plague other so-called public health crises, too. Take disinformation: It’s clear the problem can only be addressed with substantial changes to the news ecosystem. The government could task social media platforms with developing better ways to remove misinformation before it spreads, and public interest campaigns could effectively defund Fox News. But the most popular tactic, even among ostensible public health experts, is to promote news or health literacy in hopes it will inoculate individuals from bad ideas.
Compared to other responses to pressing social issues like the call for “law and order,” a public health response at least implies the need to gather evidence and employ empathy. But “it doesn’t take us far enough,” says Dennis Raphael, a professor in the school of health policy and management at York University in Canada. In the end, the invocation of public health often has the stink of other stock phrases like “structural issue” or “community solutions”—both of which are just more erudite ways to say, “This is hard.”
Perhaps no single public health method is more prevalsent than epidemiology, which uses shoe-leather data collection and statistics to analyze the incidence and distribution of disease between populations. Epidemiology can be an incredibly powerful tool; it’s what experts used to identify the first cases of Covid-19 community spread in the United States. However, it also reveals the downsides of a public health approach that sees itself as all science, no politics.
The epidemiological approach is too often “characterized by a focus on factors considered in isolation from their context,” wrote the late epidemiologist Steve Wing. He noticed that his colleagues often focused on identifying a handful of discrete “risk factors” that could be manipulated to improve health. But Wing argued that this logic often had terrible consequences. It’s been used to pin lung cancer on an individual’s smoking behavior (instead of the tobacco industry) and to blame worse health outcomes among people of color on their behavior, like what they eat or how they seek medical care, instead of racial stress or poverty.
Then, in the late 1990s, researchers formulated the “social determinants of health” to emphasize the importance of confounding factors, including one’s access to education, quality healthcare, and a safe environment, to the health of communities. Yet 20 years on, the social determinants revolution has not arrived. While the benefits of steady employment, fresh food, and a good neighborhood—in short, the benefits of wealth—are more readily acknowledged, remarkably little has been done in the US to reduce inequality. Instead, Americans double down on personal responsibility—the very antithesis of the “public health thinking” so often invoked.
The problem is not that public health officials want to turn their field to studying individual health. Rather, it’s that public health officials do not hold the purse strings and, even when they do wield some power over their communities, some refuse to use it for fear of backlash. As a result, our response to collective crises has become narrowly focused on what can be done, with little attention to what should be done. And what should be done, Raphael says, is the hardest thing of all: redistribute power in our society.
A progressive stance on public health—one that doesn’t ask people to solve their own problems but builds equitable systems that enable them to live better lives—is still at work in some parts of the globe. Notably, these ideas flourish in nations with conservative or social democratic welfare states, as seen in central and northern Europe. None of these public health bureaucracies are perfect; among other limitations, they are often still capitalist to their core. But some local and national governments are at least willing to intervene on behalf of citizens.
This was once true in the United States as well, says Richard Hofrichter, the former senior director of health equity for the National Association of County and City Health Officials. In the early 20th century, the country witnessed a dramatic leap in life expectancies. While these improvements are attributed, for good reason, to public health interventions like investing in sewage infrastructure, Hofricher says the transformations were only possible because of larger progressive social movements. Reformers of this era also reorganized society by abolishing child labor, establishing factory and housing codes, creating food safety inspection programs, and more. Boons to health followed, though the benefits were still not distributed equally as racism remained entrenched.
This radical potential feels remote to many Americans today. The United States and other liberal welfare states believe that the best path to equality and prosperity is one driven by the market, free from government intervention—with disastrous results. While countries like Norway or Finland are idealized, there’s no reason to think their policymakers “are a lot smarter than our policymakers,” Raphael has said. “They just have different values than we might have.” Radically reconsidering our priorities is the only way to build a healthier society.
The question of how to reform a liberal welfare state is almost too big to answer, which is precisely why vague calls to “systemic solutions” are so appealing. But flimsy sloganeering won’t get the job done. Instead, we must reclaim the political sphere itself. While the term “politics” may conjure sociopaths and swamps, it is nothing more and nothing less than the means by which we fight for what we believe in. Constantly calling on the presumed powers of public health instead of taking back this other, more comprehensive p-word only serves to obscure the interconnected nature of the challenges we face.
It may be tempting to say that the US is too far gone—that all we can do now is reduce harm from the disastrous policies, crumbling infrastructure, corporate interference, and the inherent tensions of pluralism. But without broader reforms, mitigation will only become more and more difficult to achieve. In other words, we need both: to minimize present suffering using public health approaches, and to dream up the big swings that build a better future. If equity is our ultimate goal, we must also be up for a more foundational fight.
