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May 24, 2023
Quarterly Opinion
Sandro Galea
May 1, 2024
Feb 21, 2024
Dec 12, 2023
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Public health aspires to creating a healthier world, one where all can flourish and realize their full human potential. Definitionally, prevention has always been, and should always be, at the core of the public health enterprise. Simply stated, it is far better to have populations that are healthy for as long as possible, than to have disease and treatment cycles shape our lives. The academic evolution of public health has appropriately engaged with prevention over the years, with preventive medicine emerging from clinical medicine in parallel to academic public health structures. Academic journals dedicated to prevention publish papers that are, in tone and content, indistinguishable from those in public health journals, further reinforcing the integration of the two perspectives. With this background in mind, it is then reasonable, at this moment in history, to ask whether we need a reconsideration of how we think about prevention, much as we have started to have a reckoning with the work of public health in the aftermath of the COVID-19 pandemic.
At some level, we failed at prevention during the COVID-19 pandemic. If our metric for success was preventing viral spread, illness, or death, then a pandemic in which the United States was hit harder than any other large country showed us that we fell substantially shorter in prevention than we might have hoped. With this as a motivating impulse, I suggest that we ask two questions: what caused the consequences of COVID-19 to be so devastating in the US? And, understanding that, what would be an intellectual and practical agenda for prevention going forward?
If COVID-19 taught us anything, it is that the consequences of the pandemic were driven as much by circumstances surrounding the virus, as they were by the virus itself. Three conditions were the primary causes of US failures during COVID-19.
First, we as a country had social and economic structures that precluded us from adequately preventing the ravages of a novel virus that asked changes of us that we were ill-prepared to make. Take, by way of illustration, the early need, in March of 2020, to isolate and limit viral spread. This rather obvious need to limit viral transmission resulted in a call, wherever possible, for people to work from home. While a logical effort to interrupt viral transmission, we had ample data in hand before the pandemic that only in the highest quartile of income earners could a majority of workers actually work from home. A minority of persons in the lowest 75% of income earning,1 and a very small minority in the lowest quartile, could work from home and hence prevent viral transmission. This resulted, predictably, in prevention of viral transmission disproportionately among those who could work from home, and not among others. It was therefore construction workers, manufacturing workers, warehouse workers, and bus drivers, by way of example, who were disproportionately represented among those who died from COVID-19. This illustrates a fundamental point—that underlying economic structures, in this case the opportunity to continue working while protecting oneself, did not lend themselves to the changes we needed to make to adequately prevent disease and protect ourselves from a novel pathogen.
Second, our poor health before the pandemic predisposed us to the consequences of COVID-19. We have long, as a country, been less healthy than we should be, with our health indicators falling far short of those of other, comparable, high-income countries.2 This stands in sharp contrast to the amount of money that we spend on health, creating a mismatch between our spending and our achievements on health. This made us enormously vulnerable to a novel pathogen that disproportionately affected people with underlying illness3 with people with underlying illness more than six times as likely as those without to die from COVID-19. The challenge to our national health during the pandemic was that we already were sicker than we needed to be, and that our poor health was unevenly distributed across groups. The virus’s impact was then predictably both worse at the national level than it was in other healthier countries, and also disproportionately borne by the groups who had poorer health to begin with. Hence, the pandemic saw the disproportionate death of minoritized groups like Black Americans and Native Americans, groups that already had worse health than other majority groups in the country.4 In many ways the virus behaved as we knew it would before it ever hit the United States, and the consequences, three years on, followed a pattern pre-written and predicted.
Third, compounding the underlying challenges with social and economic structures that precluded our efforts at prevention, and our poor health that predisposed us to worse outcomes than could have been, was the fact that we were systematically disinvesting from the very public health structures that could have been helpful in prevention. We have been disinvesting in public health for decades, with year-on-year decreases in spending on public health during that time. Most states spent less than $100 per person before the pandemic on public health and prevention. This resulted, also predictably, in ineffective efforts to contain the pandemic essentially across the board. We were slow in implementing widespread testing, systematic test, trace, and isolate procedures, and when the time came, fell behind other high-income countries in penetration of vaccination. All of these are core public health functions. While it is impossible to establish whether a well-funded public health system could have prevented much of what happened during COVID-19, it certainly seems reasonable to wonder whether greater investment in public health infrastructure would not have been warranted in light of the loss of 1.1 million lives and the likely $16 trillion cost incurred by the COVID-19 pandemic.
It is, therefore, a clear understanding of what happened during COVID-19, and centrally why it happened, that should articulate an agenda for prevention going forward. I offer here three areas and approaches that should focus our thinking on a prevention agenda for the rest of the century.
First, the moment calls for a sharper centering of prevention in the concerns of health equity. Health equity has appropriately achieved higher prominence in the public and academic conversations in the aftermath of COVID-19, although one fears that our embrace of the idea remains superficial to the real and deep challenges that face us to genuinely prioritize equity in health decision-making. The challenges highlighted earlier in this commentary around limiting exposure to the virus were real. While the politicization of public health during COVID-19 devolved such questions into simplistic arguments about the utility of lockdowns, the fact remains that limiting interpersonal contact is logically a strategy to limit infectious disease transmission, and yet such an option was not available to the majority of Americans. What then does an equity-centered approach mean in this case? It will require an orientation to all questions relevant to prevention that considers equity first and foremost, and weighs pros and cons not only on overall population health, but also on the ensuing health gaps. And it will require an honest recognition of the often-conflicting demands of health efficiency and health equity. Although in this commentary I am focusing on a US-centric approach to the issues at hand, it is germane here to note that a health equity approach that considers our shared humanity recognizes the enormous health inequities that characterize the global picture, and the issues that arise when one considers an equity-first approach to a rapidly spreading global phenomenon.5 While the public conversation on this front was dominated by questions around vaccine availability globally, it was itself a superficial discussion that omitted much harder questions of global health priorities shaped by decades of inequities and uneven health playing fields.
Second, a forward-looking prevention science needs to be better able to guide decision-making. One of the sentinel challenges of the COVID-19 moment was the gap between what prevention science, broadly writ, was publishing, and how decisions were made that informed the COVID-19 response. While academic frustration about perceived marginalization of the science led to rather trite calls to “follow the science”, this reductionism conveniently forgot to note that the science was often not helpful to the real-time needs of policymaking, dealing with particular contexts that called for data that could grapple with real-world trade-offs and balance.6 This calls for the need for a better prevention science that provides inputs to decision-making not simply about the urgent concerns of the moment—in this case clearly the spread of the COVID-19 pandemic—but also with the important concerns of the long term, including secondary consequences of the pandemic and responses to it like educational losses, increases in opioid overdoses, motor vehicle accidents, and loss of trust in public health authorities that had already resulted in lower vaccination rates from other, previously routine, vaccines. A prevention science that is useful to decision-making must recognize that policies are informed by science and by values, and that it is our responsibility to act on both, and to recognize that there are times when the latter outweigh the former, toward the goal of a healthy world that is not divided, but rather is united, by science.
Third, and building on the above, a re-thought prevention agenda needs to be self-reflective, recognizing that COVID-19 has taught us, perhaps above all, that the realities of prevention are extraordinarily complicated and that there are no simple answers to problems that involve social structures. This should not be a surprise to anyone who has thought of public health as embedded deeply in social and economic structures. And yet, during COVID-19, the general public could have been forgiven for thinking that public health was offering simplistic solutions when it was clear to all that there were none available. This all calls for a prevention science that is self-aware, and particularly so of our biases and perspectives that during COVID-19 uncomfortably enmeshed us with competing political priorities. It is no secret that public health broadly aligns with one political party in the United States, and that is, in and of itself, not a problem given the values of public health. But our alignment with one set of perspectives should not close off communication or engagement with the ideas that are, for better or for worse, embraced by half the country. Therefore, a self-aware prevention agenda needs to make the effort to extend its lens to well beyond our typical constituency, to understand how a whole country thinks. This extends to the biases that are inherent in a public health field that does not, at the moment, represent the population that it serves on a range of identity characteristics. This should occasion extra caution in the policy recommendations we make to ensure that they align with what communities might actually want for themselves, even if that is informed by genuine expertise and experience that prevention science brings to the table.
There is nothing that can redeem a tragedy like the COVID-19 pandemic. And yet, the tragedy is made worse if we do not learn from the moment. This seems then an opportunity to understand clearly what happened during COVID-19, and the implications that it has for a prevention science and practice in coming decades. This stands both to help improve our long-standing poor health, and also to put in place the steps we would need to mitigate a future pandemic.
Sandro Galea, a physician, epidemiologist, and author, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. He has published extensively in the peer-reviewed literature, and is a regular contributor to a range of public media, about the social causes of health, mental health, and the consequences of trauma. He has been listed as one of the most widely cited scholars in the social sciences. He is chair of the board of the Association of Schools and Programs of Public Health and past president of the Society for Epidemiologic Research and of the Interdisciplinary Association for Population Health Science. He is an elected member of the National Academy of Medicine. Galea has received several lifetime achievement awards. Galea holds a medical degree from the University of Toronto, graduate degrees from Harvard University and Columbia University, and an honorary doctorate from the University of Glasgow. His book Within Reason was published by University of Chicago Press on December 1, 2023.
