Engaging With Tradeoffs in Pursuit of Health

Last month, Dr. Sarah Dupont and I published a paper in The New England Journal of Medicine on science, competing values, and tradeoffs in public health decision-making. We looked at these issues through the lens of masking during the COVID-19 pandemic. The piece was animated by a concern for balancing the core values of public health with the pragmatic demands of advising policymakers in a context of incomplete or evolving information.

The piece has since generated a fair bit of discussion over the role of public health during a crisis like COVID-19, and, more broadly, over how we can best engage with the work of supporting health in a world of tradeoffs, compromises, and “least-worst” options. It has been good to see this conversation unfold, as a reflection of the kind of discussions we should be having to shape a better future for our field and a healthier world for ourselves and for generations to come. With this in mind, I would like to take a moment here to revisit the NEJM piece, with an eye toward continuing the conversation to help get us closer to the best possible version of our field.

A world of health haves and have-nots

It feels appropriate to start by saying what the piece is not. It is not an argument for public health’s withdrawal from the work of shaping a more equitable world, nor does it call for us to stop prioritizing the needs of the marginalized and vulnerable. A public health that abdicated this responsibility would not, as far as I am concerned, be public health. Engaging with tradeoffs does not imply neutrality—neither political neutrality nor neutrality with respect to whose side we are on. We are on the side of the marginalized, always, full stop. Core to our mission is our duty to address the inequities that have created a world of health haves and have-nots. When we do not address these inequities, we are complicit in the continued poor health of vulnerable populations, as I have previously written. This means engaging with the socioeconomic forces that keep health out of reach for many. These inequities should be at the heart of all our choices about health, including how we think about tradeoffs. In the piece, we raise the example of masking in grocery stores. We note that for the average healthy customer, a mask mandate might not be necessary in a context of low COVID-19 community spread. We then noted that the risk calculus may change when it comes to the cashiers and other essential workers in stores, who are likelier to be Black or Latine, have lower incomes or live with someone who is 65+. These socioeconomic factors shape pockets of vulnerability in what would otherwise be a relatively safe environment, a classic example of inequity and the structural forces that shape it.

Tradeoffs in public health decision-making

These inequities also reflect why we have a responsibility to engage with tradeoffs in public health decision-making. Just as essential workers can face disproportionate risk from the virus, they can also face disproportionate risk from the hardships of school closures and lockdowns. It is easy for those of us who work in public health, many of whom come from backgrounds of comparative privilege, to argue that a continued state of pandemic emergency is the clear path toward addressing these inequities. But are we so sure that populations who carry a greater burden of marginalization would agree with our assessment of the risk? Are we so sure that we all agree that the possibility of getting COVID outweighs concern about losing work, about childcare, and about maintaining the social connections that sustain health? Does everyone share our absolutism, or see it as an expression of the very privilege we are so quick to acknowledge but are so slow to relinquish?

It is the job of public health to provide the data that can help clarify risks and tradeoffs, so policymakers can make choices that best support the health of populations, with special concern for the marginalized and vulnerable. It is not our job, however, to advocate for one-size-fits-all solutions, sticking dogmatically to our positions despite changes to the data and heedless of the nuance of specific contexts. I would argue public health has, at times, been guilty of this, and that this has undermined our capacity to pursue our work, including the vital work of supporting equity. The solution is public health’s continued, active involvement in the decision-making process, together with partners at the local, state, and federal levels, engaging with respect for the nuance and tradeoffs inherent in these decisions.

The piece is also not an argument for public health’s withdrawal from the political process. I have long agreed with Rudolf Virchow's statement, "Medicine is a social science and politics is nothing else but medicine on a large scale," substituting “health” for “medicine.” In fundamental ways, public health is politics. Politics is centrally concerned with the distribution of the resources that support health—tangible resources like money, security, infrastructure, and a clean environment, and less-tangible but no less important factors like justice, equity, and the compassionate application of the law. Public health cannot separate itself from the process that engages with these foundational forces. We have always been political, and always will be.

An effective, engaged public health

Having said what the piece is not, I will close with what it is: a call for an effective, engaged public health, one that is not afraid to roll up its sleeves and address the messy realities of shaping a healthier world. It calls for a revival of the pragmatic, data-driven work that has advanced much progress within our field. In recent years, it has been possible to see this approach upstaged by a public health that embraces moralistic rhetoric which, while satisfying for us to say, does little to move forward a constructive engagement with the challenges we face. At times, this approach can even hinder our work, when it becomes dogmatic or distracts us from the data. Building a better future means returning to what has worked in our past—pragmatism, diversity of thought and opinion, really listening to the populations we serve and maintaining our commitment to our core values, with emphasis on supporting the health of the marginalized. Such a vision of public health, it seems to me, is one on which we can all agree.

This piece also appears on Substack.