Debating tradeoffs, sharing ideas

Some thoughts, informed by recent conversations, about the role of public health in the present moment.

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. We argued that public health should shift away from the all-or-nothing dynamic that characterized many pandemic-era debates (over masking, lockdowns, school closures, etc.), recognizing that the local context in which decisions are made can involve a level of nuance often lost in the broader public debate. It is up to us to provide data-informed guidance to policymakers as they weigh this nuance and consider the tradeoffs inherent in choices about health policy. In doing so, we should continue to be guided, always, by our core values: the pursuit of healthy populations, with special concern for the marginalized and vulnerable.

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 towards continuing the conversation, to help get us closer to the best possible version of our field.   

First, some notes on the origins of the ideas in the NEJM piece. Our piece builds on work I have published over a decade. Professor Dupont led us on this paper, and this work emerged from a conversation the two of us started having six months ago. However, I have long written work that reflected the evolution of my thinking on these issues. The core subject here—tradeoffs—is not new to my writing. In my book Population Health Science, published more than five years ago, with my colleague Dr. Kerry Keyes, a full chapter is dedicated to tradeoffs between health equity and the pragmatic pursuit of a healthier world, and I returned to this theme in writing for AJPH and in other places. But, and this seems to me critical to the arguments raised in the NEJM piece, acknowledging that there are and should be tradeoffs does not in any way weaken the values that underpin what we do in public health, and I have also previously written of the responsibilities of the population health scientist to keep these values front and center. An acknowledgement of tradeoffs is simply an acknowledgement of reality, of a world where progress towards a vision of a better future is often incremental. This is not to compromise in any way on our vision for a healthier future, a vision which is necessarily radical, calling as it does for a fundamental restructuring of society. This vision functions as a kind of North Star for our efforts, but to get there we must be able to navigate the messy realities of the journey. At core, recognizing the importance of tradeoffs simply positions public health as one piece of the broader architecture of building a better world, with health being a means—but not the end—of our work together, of our progress towards a shared radical vision. 

Coming back to the specifics of the piece, it is 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 which 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, to have lower incomes, or to 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.

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 towards 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, 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?

Sometimes the moment calls for us to make choices about health that do not garner immediate praise from our in-group. We all say that we are on the side of health, and I do believe that all of us in public health believe that our own opinions on the correct course of action during the pandemic are centered in promoting health. But there is danger in the absolutism that is appearing in these conversations. There is danger when we in public health will not engage with the very real contexts of the world that we live in. If we do not engage in these conversations about the tradeoffs that we as a society are making, at the national and local levels, our efforts to build a healthier world will come up short. And we will have no one to blame but ourselves.

It is also important to note—and this point was core to the NEJM piece—that paying greater attention to tradeoffs better positions us to see how these challenges might factor into the choices with which policymakers engage. 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 level, engaging with respect for the nuance and tradeoffs inherent in these decisions. This will not just lead to better decisions, but to the preservation of public health’s long-term influence, as we are seen as pragmatic, reasonable actors to be listened to, rather than as ideologues to be ignored. I note that there are, in my assessment, substantial downsides to public health not engaging in this pragmatic decision-making. Simply put: populations will stop listening to public health, and we have much more to lose in the long-term. I write of these challenges out of a deep commitment to the efficacy of public health in that very long-term.

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. This means being willing to take political positions without becoming, as a field, politicized—a distinction we have arguably lost in recent years, to the detriment of our efforts. A politicized public health is one which trades long-term public trust and influence for short-term power that ebbs and flows with each election cycle, as we find ourselves hostage to the fortunes of whichever political party we have chosen to embrace.  

Accepting this, the question then becomes: how can we be most effective in the political arena? How can we balance advocacy informed by our values with our engagement with data and the clear-eyed realism that supports the often frustratingly slow advance of political progress? I have spent much of my career arguing for a consequentialist public health that embraces a muscular engagement with the political process, guided by our core values. This means prioritizing steps that will have a maximum real-world effect, with emphasis on caring for those whose health has been left behind. At the heart of this is a vision of the world not as it is, but as it could, and should, be. Sometimes, it is prudent to lead with this vision, leaning into advocacy to shift the Overton window towards the policies that will help create the world we wish to see. Other times, it is necessary to acknowledge tradeoffs, to tune our ears to the nuance of a situation, to pick the “least-worst” option, even as our vision for a healthier world remains at the heart of all we do. 

Politics, particularly in a democracy, always entails a measure of constraint on what decision makers can do in a context of competing interests. Often, success in this context is a matter of balance—when each choice involves a tradeoff, have we managed to advance a vision of health within the parameters of the possible? This question is best answered by the populations we serve, by listening to their voices, which is why it is necessary, always, to make decisions in a context of transparency and debate.

This means supporting a culture of robust and open conversation within public health institutions, where a multitude of good-faith perspectives can be heard. We need to welcome perspectives which may go against the grain of prevailing opinion and to bring into the process voices of the communities most affected by the policies under consideration. Such conversations can help public health institutions generate the data that can assist policymakers in doing right by health as they weigh tradeoffs and aim to make the best possible choices. To my thinking, this conversation about the NEJM piece is an example of just the sort of debate we should be having about the issues that matter most to health. Thank you to everyone who has engaged with this debate, with particular thanks to Dr. Dupont for leading the article. While I am writing this Goldfish piece in the first person, largely because it leans on my prior writing, it is through collaboration with valued colleagues that my thinking has evolved, just as discussions such as these help me carefully think through ideas to the end of learning how to think better.

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.