Not in the name of public health

When the goals of public health are used to justify authoritarian overreach, we have a responsibility as a field to say “No.”

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 towards shaping better health for all. Through the years, we have done much in the name of public health. We have promoted handwashing at a time when the practice was still novel and distrusted. We have argued for better sanitation systems and city design to slow the spread of disease in urban spaces. And we have urged greater focus on engaging with the socioeconomic drivers of health as a means of creating a healthier society and preventing disease from taking hold. The range of this work illustrates the breadth of the initiatives we can pursue in the name of public health. 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, of policymakers, and of 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.

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 which 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.” Our willingness—our responsibility—to say this is inextricable from the roots of our field, in which telling the truth is core to our capacity to work effectively towards a healthier world. When we see public health used as an excuse for abuses, we have a duty to call this what it is, to draw a line between the work of our field and those who would exploit it to harm others.  

Do we always do this? It is important that we engage with this question. If we have seen abuses or overreach committed “in the name of public health” and fallen short in our responsibility to say “No,” this reflects a dysfunction in our field we must address. An effective public health is one that does not let its moral authority be coopted by those seeking to launder actions that harm the health of populations. The question is: are we such a public health? 

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 government, the private sector, and public health towards 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. Others took a stricter approach, while still working within the bounds of a liberal system of democratic accountability. Then there were the handful of countries which embraced an approach that was truly authoritarian, working to contain or eliminate the disease by dispensing with any pretense of upholding civil liberties.

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 towards 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.

China is not alone in taking a draconian approach. Uganda, for example, imposed the world’s longest COVID-19 school closure, shuttering schools for nearly two years. This measure caused deep harms to the students who had to endure this disruption. In addition to the many challenges caused by such a sustained gap in in-person learning—the effects of which we are only beginning to understand—the country also saw a rise in teen pregnancy and will likely see a significant rise in the dropout rate, with Uganda's National Planning Authority projecting 4.5 million young people will probably not return to school. We also saw an authoritarian approach taken in the name of public health in Hungary, where the country’s parliament voted to give Prime Minister Viktor Orbán power to rule by decree indefinitely in response to the crisis.

These examples reflect areas where actions taken in the name of public health clearly overstepped the bounds of what is actually in the interest of the public’s health. Reasonable people can disagree with the value of school closures, but a nearly two-year closure that drives up the teen pregnancy rate and causes millions of dropouts is neither reasonable nor liberal. Neither is using the pandemic as an excuse to seize personal political power, as Orbán did, or to lock down, and spy on, citizens without any regard for their civil liberties, as in the case of China. When such actions are taken in the name of public health, it is up to us to speak with one voice and say, “Not in the name of public health.”

To be fair, this is what many in public health have done. But the 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.

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 which 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. I would argue that we neglected this social contract during COVID-19. In moments when we should have said, “No. Not in the name of public health,” we said, “Whatever it takes in the name of public health.” This left us morally stranded, without the standing necessary to make a liberal case for an engagement with health founded on a properly functioning social contract. 

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.”