Earlier this month, the CDC announced that fully vaccinated people need no longer wear a mask or physically distance to prevent the spread of COVID-19 (with the exception of places where such measures remain required by law). There are undoubtedly a large number of factors—from the political to the scientific—that informed and influenced this decision. But, leaving aside etiology for the moment, the unexpected announcement does present an opportunity to interrogate why we have done what we have done during the pandemic, and what we want, or perhaps should want, to guide our decision-making during these times.
There seems little question that implicit in the CDC announcement is a greater tolerance of some risk; a move away from saying that we are doing everything possible to reduce all risk, to accepting that some risk is acceptable—maybe desirable—as we move to more freely engage with those we have missed this past year. At the same time, I am also aware that the trauma of the pandemic has made it difficult for some to immediately embrace a future without the protective measures we have all become used to, with some amount of risk, even as these measures become less necessary. This is understandable, and those who are processing these feelings deserve compassion and time to adjust. It is clear that returning to something like “normal” will be a journey rather than a single step. So, as we embark, collectively, on this path, I wanted to reflect today on a first principle that informs much about what we have done this past year and will do going forward: why health? Why does it matter that we spend so much time working to generate health? Come to think of it, what is health anyways, at its core? What is it for? Perhaps in better understanding these questions we can better think how to factor in the risks we are, or are not, willing to take, to better address the steps necessary for getting to health; and to think better about the tradeoffs inherent in any decision about the health of populations—now and in the post-COVID future.
I will begin by tackling the question: what is health for? I will do so by sharing an idea first developed by my colleague, George Annas. It is the idea of a “human zoo.” Imagine this zoo as a lovely place where everything is provided for its inhabitants. The people living there have food, space to roam, and the safety that comes with being kept from the potential hazards that lie beyond its walls. The zoo was designed as a place where its inhabitants can thrive, where they can be healthy because everything that could make them sick or cause them injury has been kept at bay. And it works. They are healthy, living out their days free from disease and risk. There is, however, a catch. They can never leave. If they did, they would immediately face all the perils of an ordinary life in the real world.
Over the last year, much of the country participated in what amounted to similar experiences.
Facing the danger of COVID-19, we were rightly afraid, and worked to minimize risk. Yet through it all, the break-glass-in-case-of-emergency option existed—not for everyone, but for many—to essentially eliminate all risk by sealing ourselves in our rooms, our own personal human zoos, indefinitely.
Our behavior during COVID was, in a sense, an answer to the question: what is health for? Before COVID, many of us might have said health is exclusively the avoidance of sickness and death. Yet, during COVID-19, we realized that, for most, the enduring isolation was painful to bear, and even knowing that sickness and death were literally at our door, this still was not enough to keep all of us from venturing outside. This suggests health is, at core, a means rather than an end. It is a means to everything we were reluctant to give up during the pandemic: travel, time with friends, the pursuit of romance, furthering our education in classrooms and on campuses, peaceably assembling to advocate for social change, taking our kids to the playground, going out to eat. In short, health is a means to being able to do everything that makes for a rich, full life. We can forgo this richness in favor of the well-manicured human zoo, and this might indeed help keep us alive. But few would argue this existence would truly be living, as it is properly understood.
I realize suggesting health is a means, rather than an end, may seem, to some, like a radical rewrite of the nature of health. The conflation of health with the absence of sickness is in some ways intuitive. Yet no less a body than the World Health Organization defines health as, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition reflects a long evolution in how we think of health. Hippocrates, for example, regarded health as an equilibrium between the four humors—blood, yellow bile, black bile, and phlegm—which were thought to regulate physical and emotional wellbeing. This early definition bears little resemblance to the view of health as a means to the end of a full life, save for one important detail: both definitions prize equilibrium as the defining feature of health. To Hippocrates, this meant a balance between the physical substances that make up a body, in which no single humor predominates. To the philosophy of health embraced by the WHO, equilibrium means a balance of the material resources necessary to enable the complete well-being of a rich, full life. Core to this vision is a definition of health which accepts the risk inherent in living such a life, while rejecting the conditions that can make such risk undue. For example, there will likely always be some risk involved in driving in a car, and that is fine—that is life. But it is only fine if we have taken reasonable steps to mitigate risk, via seatbelts, road safety campaigns, drunk driving laws, and the like. The alternative path to safety would be to never drive. This would keep us safe, but it would also mean never going anywhere. An embrace of road safety creates an equilibrium which allows us to live neither ultra-safe in our bubbles nor facing needless risks we have the power to mitigate.
Public health does not always do a good job of factoring this impulse into what it says and does; it is necessary that we improve at doing so, if we are to engage with health on a level that does not conflict with our essential nature as humans. When we have asked populations to accept restrictions on their daily autonomy, implicit in our guidance has been the belief that the pursuit of health is an end in itself, rather than a means to a fully-realized life. We have often pursued a goal of near-total safety rather than reasonable safety as a means of supporting living fully, with all the risks involved.
Consider, for example, the issues surrounding the care of older adults at this stage of the pandemic. As vaccination rates rise, many nursing homes and long-term care facilities are continuing to isolate the older adults who live in these places, even when these residents have been vaccinated. The choice to do so is understandable. These facilities have been the frontline of the pandemic for a year; after such trauma, it is no surprise decision-makers would want to be extra cautious about reopening. Yet it is also true that, if the tradeoff between living fully and being healthy is difficult for most people to accept, it is even more difficult for older adults, for whom time is particularly precious. The experience of older adults during the latter stages of the pandemic throws into sharp relief the question: just what are we staying healthy for? Is it to live for as long as we can in a human zoo? Or is it to take the risks inherent in living a full life?
I realize that any conversation such as this one is always modified by assets, and reflective of the historical opportunities afforded to, or not afforded to different groups, and that one of our core responsibilities is always to make sure that resources are justly distributed so that all can fully live. It is also worth noting that to take risks does not mean condoning recklessness; there is a balance to be struck between recklessness and acceptable risk. It is striking this balance that is key for supporting the effective pursuit of health, for all.
COVID-19 confronted us with the question which engages directly with this issue of tradeoffs and balance: what are we willing to give up in order to get to health? How we answer depends on how we define health. If health is the absence of disease and nothing else—if the pursuit of health means doing everything we can to drive risk of disease down to zero—then what is asked for is the willingness to give up much of what makes life worth living. As we have seen, few are willing to pay such a high price for the feeling of total safety, even in the midst of a pandemic. However, if health is defined as an equilibrium, a balancing of risk mitigation with the reasonable risk inherent in the pursuit of a full life, with health seen as a means to living such a life, the price for health becomes something more of us are willing to pay.
When we ask ourselves “what is health for?” and answer that it is for enabling us to live rich, full lives, we are halfway to answering the even more fundamental question: why health? Why does our engagement with the forces that shape health matter? Health matters because love matters, because connection matters, because working with valued colleagues matters, because tasting food matters, because going for a swim matters, because traveling abroad matters, because watching your daughter graduate from college matters, because writing a book matters, because living a rich, full life matters—which we cannot do unless we are healthy. To see health as an end in itself is too limiting to support the creation of a healthier world. It denies all else that goes into shaping a full life, even as it undercuts the work of public health by leading us to make demands of the public they may struggle to fulfill. The root of much discontent during COVID arose from the impression that health was being pursued at the expense of the conditions that allow us to truly live. A more moderate approach, which recognizes health as a means to this end, could well go farther towards supporting health. If we truly believe health matters, our pursuit of it should reflect the understanding that we do not live to be healthy—we aspire to be healthy so we can live.
__ __ __
In this week’s The Turning Point, Michael Stein and I discuss the centrality of the public sector to any conversation about health, and how ever clearer that has become in the time of COVID-19.