The Importance of Saying “Not in the Name of Public Health”

One frequently overheard phrase in our field is “in the name of public health” or some equivalent like “in the interest of public health.” This phrase is often applied to the interventions we promote with an eye toward shaping better health for all. Such initiatives can vary in expense, complexity, duration, and the demands they make on the public. Sometimes the “ask” they make is minor, as in the case of handwashing. Sometimes they demand more of the public, policymakers, and our collective investment in health.

We have been able to make these asks secure in the knowledge that they are in support of something which, for most people, is worth a high level of effort: health. We all desire health—for ourselves, for our family and friends, and for our communities. Without health, we have nothing. So, when we say we are doing something “in the name of public health,” there can be few greater motivations. This is why public health has been able to ask so much of the public over the years and generally enjoy a high level of cooperation.

A critical factor to maintain public support

There is, however, one factor on which this cooperation depends, without which it is difficult to maintain widespread support for our efforts: trust. The public must be able to trust that, when we say something is done in the name of health, it really is necessary for supporting the health of populations. They must be able to believe that we will not subject them to interventions that are half-baked or that constrain civil liberties any more than is absolutely necessary in the context of a crisis. The public must also be able to believe that when we in public health see individuals or institutions claiming to act on behalf of health when they are in fact doing something authoritarian or otherwise harmful, we will say, as a field, “No. Not in the name of public health.”

Do we always do this? The pandemic moment may have helped provide an answer to this difficult question. During COVID-19, much was done by many in the name of public health. Actions were taken by the government, the private sector, and public health toward the goal of keeping populations safe. Some of these actions were minor, despite the arguably disproportionate pushback they received—I am thinking, particularly, of masking. Others were less easy to take in stride, straining physical and mental wellbeing. Some countries took a lighter touch with what they did in the name of public health, trying to balance preventing the spread of disease with supporting the full range of other factors which generate health. Then, there was the handful of countries that embraced an approach that was truly authoritarian, working to contain or eliminate the disease by dispensing with any pretense of upholding civil liberties.

The authoritarian response to COVID-19

Perhaps the most high-profile example of an authoritarian response to COVID-19 has been that of China, which leveraged its powers of mass surveillance and political control toward a zero-COVID policy of eliminating all traces of the virus in the country. These measures have become increasingly repressive, as illustrated in this recent piece in The New York Times. Even as COVID-19 itself has become more manageable, the Chinese government has tightened its grip on the lives of its citizens, all in the name of fighting the disease—in the name of public health.

Our field has been by no means united in its critique of an authoritarian approach to COVID-19. While few in public health would endorse dictatorships seizing greater power in the name of public health, if we are honest with ourselves, we in public health have leaned into the heavy hand of what the political philosopher Thomas Hobbes called “the Leviathan”—the active, powerful, undivided state, working towards its ends with all the authoritarian capacities such a state can wield. This arguably informed public health’s increased politicization during the pandemic, as we partnered with state actors to help use the Leviathan in pursuit of our goals—for both good and ill.

The importance of a social contract

It is noteworthy that while Hobbes made the case for the utility of a strong, authoritative state, he also argued that the basis for its power should be a social contract between the government and the governed. He felt the state of nature for humans is so violent and uncertain that it is in our collective best interest to enter into a kind of trust with the Leviathan, accepting its checks on our liberty in the name of stability and safety. Without this social contract, Hobbes’s model reflects mere despotism.

The work of public health, too, depends on a social contract. It is a contract that frequently goes unspoken, but which is nevertheless core to the effective work of our field. It stipulates that we will not take steps in the name of public health unless the health of the public truly demands that we do so. When our actions align with this contract, we have the moral standing to criticize others when they take steps in the name of public health that, in fact, harm populations. When our actions do not align with this contract, when we even tacitly endorse certain actions taken in the name of public health that are authoritarian or illiberal in nature, the contract breaks down and we are left with the powers of the Leviathan, wielded without the public buy-in that keeps us from verging on the authoritarian.

This speaks to the importance not just of saying “not in the name of public health” when the moment calls on us to do so, but of embracing a liberal vision of public health so that we can take these stands without risk of hypocrisy. Public health needs to be grounded in the social contract, using its powers to support the public. It is a vision in which authority is tempered by humility, a willingness to learn, and to self-correct. It is a vision to which we should return, and we can start by saying to our own illiberal tendencies, “No. Not in the name of public health.”

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This piece also appears on Substack.