5: In this Together? Pandemics, Politics, and the Public Interest

Introduction

If you visit Disneyland during the winter holidays, you are in for a long, loud, crowded day of standing in line with thousands of others: lines for food, lines for rides, lines to watch the Christmas Fantasy Parade. The self-proclaimed Happiest Place on Earth is packed with people during the holidays, and viruses love people, especially unvaccinated people. In December 2014 at least one person infected with the measles virus visited Disneyland, setting off an outbreak that spread to nearly 300 people across seven states in the U.S, and into Mexico and Canada (CDC 2015; Doll & Correira 2021). Among U.S. patients, more than 75 percent were unvaccinated and 20 percent had symptoms severe enough to require hospitalization. In light of the U.S. experience with Covid-19, the story of Disneyland’s measles outbreak is fascinating: Recognizing the public health threat posed by the unvaccinated, public support for vaccinations increased. This led to legislation that strengthened California’s childhood vaccination requirements to be among the strictest in the nation.

Managing outbreaks of contagious disease such as measles is the original purpose of public health measures, and remains among the most basic functions of local, state, and federal health agencies. Public health, defined as “organized efforts to improve the health of communities” (Novick & Morrow 2008, p. 1), emphasizes the collective and collaborative nature of protecting and improving health as a means of broadly serving the public interest. This case study uses the Covid-19 pandemic as the backdrop to consider the many difficulties of providing public health services in the U.S.

Among those difficulties are the inequalities in health care and health outcomes, which were highlighted during the pandemic. Second, is declining public trust in government, professional expertise, and science. This problem was especially pronounced during the pandemic as vaccine hesitancy and distrust of public health experts grew dramatically, often as a result of misinformation on social media (Albrecht 2022; Larson, Gakidou, & Murray 2022; Motta, Stecula, & Farhart 2020). Finally, is the political reality for those implementing public health programs, as distrust of government has led to vitriol against public employees that sometimes leads to personal threats and violence, and that is frequently misogynistic (see At Public Meetings video, below). As you read this case study, consider what it means for public health agencies and their employees to serve the public interest during the outbreak of a new contagious illness like Covid-19. What role should political parties and elected officials play in protecting the public health? During health emergencies, where should the line be drawn between individual freedoms and responsibility to the greater society?

What is “Public Health”?

While it is common for those in public service to discuss the concept of serving the “public interest,” given the diverse U.S. population and its disparate variety of concerns, scholars of political science and public administration have long debated how best to define this concept. Many have noted that democratic values are key to defining the public interest in the U.S. (Douglass 1980; King, Chilton, & Roberts 2010; Lewis 2006; Sorauf 1957). Other values include the constitutional rules and processes of our system (King et al., 2010; Sorauf 1957), issues of broad representation and community dialogue (Douglass 1980; Lewis 2006), ethical decision-making (King et al., 2010; Lewis 2006), and concern for future generations (Lewis 2006). Many scholars agree that the best definition of public interest came from Walter Lippman in 1956, who wrote, “The public interest may be presumed to be what [people] would choose if they saw clearly, thought rationally, acted disinterestedly and benevolently” (p. 40). With the public health system’s emphasis on collaborative efforts to secure and improve health at the community level, it is among the best examples of government’s role in serving the public interest.

The practice of public health is in contrast to clinical health care, which involves medical professionals addressing individual health concerns. Consider the example of cigarettes, which were identified as causing lung cancer among smokers in the 1950s, and given warning labels about possible health hazards including many types of cancer, emphysema, and heart disease beginning in 1965 (Derthick 2011). While doctors and even the government encouraged individual smokers to drop the habit in the 50s and 60s, by 1972 the U.S. Surgeon General reported similar health risks from secondhand smoke for nonsmokers. These health risks were particularly acute among young children, pregnant people, and those wishing to become pregnant (Jacobs, Alonso, Sherin…Lowe 2014). Based on this research, indoor smoke-free policies were created over the next few decades, first for airplanes and buses, later for restaurants and other public facilities to protect nonsmokers from the harmful effects of secondhand smoke. Governments at all levels played a key role in creating these policies, just as they establish other health measures and mandates, like vaccine requirements, to protect the public health.

When contagious illnesses like measles or Covid-19 spread, people often gain immunity through natural exposure or through vaccination; while there are risks from both, most diseases have far greater health risks than their vaccines.[1] In these cases, public health professionals seek to vaccinate a large enough percent of the population that the spread of illness can be stopped, thereby protecting overall community health (Morens, Folkers, & Fauci 2022). This is often called attaining “herd immunity,” a concept from veterinary medicine wherein doctors seek minimal vaccination thresholds at which the herd will be protected from widespread illness. For the public health system, the herd is society, and the public interest is served by vaccinating enough people that contagious illnesses do not cause high rates of disease or put extreme pressures on the health care system such as crowded emergency rooms, shortages of medicine and health care workers, or unavailability of hospital beds.

The Public Health System in the U.S.

The federal government’s U.S. Department of Health & Human Services is the nation’s leading public health agency. In addition, all 50 states have public health departments. The California Department of Public Health (CDPH) describes its role as protecting “the health of families and communities by promoting healthy lifestyles, preventing disease, and removing environmental dangers” (2023). State health departments work with nearly 3,000 local agencies, typically at the county level, to manage public health and its risks. For example, the Los Angeles County Public Health Department’s webpage highlights issues of current concern for community health; in mid-2023, these include information about fentanyl in the community, CPR training opportunities, how families can reduce the threat of lead poisoning in the home, how to access Covid-19 vaccine boosters, and frequent updates on water quality at county beaches.

Given the diverse problems addressed by the public health system and the scientific nature of much of its work, it is not surprising that these public servants represent a wide variety of careers including epidemiologists, registered nurses, behavioral health specialists, social workers, home-health aides, environmental health workers, health teachers, and data analysts (Franzel 2020). The nature of its work means that this workforce is better educated than the broader public sector workforce, with 65% of state and local public health workers holding at least a bachelor’s degree. It is also more diverse. While approximately 67% of the general state and local workforce is White, a 2021 survey found that only 54% of public health employees are White, with 18% Latino/a/x/e, 15% Black, 7.5% Asian American/Pacific Islander, 1% Native American/Alaskan, and 4% two or more races (de Beaumont Foundation 2022a). Further, nearly 80% of this workforce are women.

Importantly, public health professionals have been under a great deal of stress as a result of the workload and political conflict precipitated by the Covid-19 pandemic. In a 2021 survey of almost 45,000 public health workers, nearly one-third were considering leaving their organizations in the next year, with 40% of those saying that the pandemic affected their decision (de Beaumont Foundation 2022a), and if trends continue, it is estimated that up to half will have left the field by 2025 (Smith 2023). More than half of public health workers reported experiencing at least one symptom of post-traumatic stress disorder (PTSD) as a result of their work during the Covid-19 outbreak (de Beaumont Foundation 2022a). Due to the anger of individuals and groups opposed to public health mandates and recommendations such as social distancing, masking, and vaccinations, 41% of those in executive management positions said they felt “bullied, threatened, or harassed by individuals outside of the health department,” and 59% agreed that their public health expertise had been undermined by external forces during the pandemic (de Beaumont Foundation 2022b).

Pandemics, Society, & Politics

Pandemics, and their effects on people, communities, and the very fabric of society, have long captured the creative imagination. This interest has led to well-known works of literature including Albert Camus’ The Plague, Gabriel García Márquez’s Love in the Time of Cholera, and Blindness by José Saramago. All three novels reflect truisms of society during widespread outbreak of disease, from the inequities highlighted as the wealthy continue to live comfortable lives even while the pandemic rages, to dissatisfaction with government’s response and efforts to escape quarantine, to social breakdown when government is unable to manage the crisis. Similar issues are portrayed in movies like Contagion, and even the video game-turned-TV-series, The Last of Us. In the case of the Covid-19 pandemic, each of these issues arose: The pandemic took a greater toll on the economic and physical health of those at lower ends of the economic ladder. While early efforts to quarantine people were largely followed, it was not long before angry mobs took to the streets and state capitols to protest Covid-19 lockdowns. Eventually, the lives of public officials, especially those in the field of public health, were threatened (see podcast, Hazardous, below).

All of this is perhaps best exemplified by the situation in Michigan in early May, 2020, just six weeks after Governor Gretchen Whitmer ordered the state shut-down due to the spreading coronavirus. Michigan was hit particularly hard at the start of the pandemic, especially Detroit, its largest city, which is majority Black and has high levels of poverty. In the first 3 months, the state of Michigan had the fifth highest Covid-19 death rate in the country (Austin & Hershbein 2020; BBC 2020), and 15 months into the pandemic, Black Michiganders constituted 40% of the state’s Covid-19 deaths, but only 14% of its population (Bowman 2021). After Governor Whitmer extended the initial state lockdown to May 15, hundreds of protestors, some of them armed, descended on the state capitol and attempted to enter the legislative chambers, which were blocked by state police (BBC 2020). The protestors, led by Michigan United for Liberty, implored business owners to defy state orders and re-open immediately. Two weeks later protestors returned; this time one brought a child’s doll—nude, with long brown hair, and hanging from a noose—which he said was hung in effigy to Whitmer (Barrett 2020). This incident was far from the worst of it, as at least 13 men were eventually arrested as co-conspirators in a plan to kidnap the Governor, hold a mock trial, and potentially execute her for treason (Singh 2022). Several members of the group surveilled Whitmer’s vacation home, and practiced detonating explosives in preparation for the attack (del Valle 2022). In the end, charges were dropped against some of the defendants, and two were found not guilty. Seven others are serving prison terms: three were given 7-12 years in state prison, two pled guilty and were sentenced to 2.5 years in federal prison, one was sentenced to 16 years, and the leader of the plot was given a sentence of nearly 20 years in federal prison.

While psychologists and philosophers may be better able to answer questions about what causes people opposed to public health measures to turn violent, political scientists and scholars of public health know that this type of anger, harassment, and violence against public officials is increasing in the U.S. (Bridging Divides Initiative 2022; Leider, Castrucci, Robins, Bork, Fraser, Savoia, … & Koh 2023; Topazian, McGinty, Han, … & Barry 2022). For example, a national study found the percent of Americans who believed it was justified to harass public health officials over pandemic business closures had increased from 20% in November 2020 to 25% in August 2021 (Topazian, et el. 2022). These threats can be particularly violent when directed at women in public service, especially high profile women, and women of color (Bridging Divides Initiative 2022; Krook & Sanín 2020; Leider, et al. 2019; Thomas, Herrick, Franklin, Godwin, Gnabasik, & Schroedel 2019). In a 2019 study of mayors, women were more likely to experience “threats of death, rape, beating, or abduction,” and more than eight times more likely than men to experience sexualized violence or harassment (Thomas, et al., p. 63).

For public health professionals—more likely to be women and/or Black, Indigenous, and other people of color (BIPOC)—this environment has made it harder to stay in the profession. By the end of 2021, over 500 public health leaders—often state and county public health directors—resigned or were fired as a result of opposition to their exercise of professional duties to protect the public’s health (Baker & Ivory 2021; Barry-Jester, Recht, & Smith, The Associated Press, & Weber 2020; Shihipar 2021; see Backlash video below). At the same time, at least 32 states and dozens of local governments passed legislation to weaken the authority of public health agencies and give more power over public health decisions to elected officials (Baker & Ivory 2021). As one public health expert noted, “’It’s a depressing moment,’… ‘What makes a society if you can’t even get together around keeping your people healthy?’” (Baker & Ivory 2021, n.p.).

Pushback against Covid-19 public health measures were not completely surprising. Even during the Pandemic of 1918, some balked at mask wearing as an affront to personal freedom (Hauser 2020). But the partisan political nature of the public response to Covid-19 was likely as much about its moment in U.S. history as anything else. On January 31 2020, the Department of Health & Human Services declared the novel coronavirus a public health emergency as the highly contagious illness spread rapidly, killing thousands, and overloading healthcare systems across the globe. This announcement came at the start of a presidential election year, and by March 13, President Trump had to declare a national state of emergency due to the spreading pandemic. A declaration of this magnitude, and its business shut-downs and stay-at-home orders would have dire economic effects that no incumbent president would want to face. Perhaps for that reason, members of the Republican Party and conservative media downplayed the severity of the pandemic from the beginning. One result is that those who got their news from conservative media sources were far less likely to consider Covid-19 a serious issue; by election day in November, 74% of Democrats were very or extremely concerned about Covid-19, but only 26% of Republicans were similarly concerned (Hegland, Zhang, Zichettella, & Pasek 2022). Those consuming conservative media were also found to be more likely to endorse misinformation and conspiracy theories about the virus, its origins, and the public health measures designed to curb its effects (Motta et al., 2020). Similarly, those who took their cues from conservative political elites were less likely to trust public health professionals, wear face masks, or intend to be vaccinated than others (Hegland et. al, 2022). These factors led to regrettable health outcomes for many, as we will see below.

Covid-19: A Tale of Two Pandemics

As noted in the introduction, Disneyland was the epicenter of a measles outbreak in 2014, however it never closed its doors during that time. In fact, in over 65 years of operation, Disneyland has only closed on rare occasions: in 1963 after the assassination of President John F. Kennedy, in 1994 after the magnitude 6.7 Northridge, CA earthquake, and on September 11, 2001 (Martín & Martens 2021). None of these closures lasted more than a day so the park’s March 14, 2020 coronavirus pandemic closure, which lasted 412 days, was absolutely unprecedented. Even after reopening, public health measures limited park capacity to 25%, and required masking and social distancing of guests and workers. A closure of that magnitude took an economic toll, not just on Disney, which is among the wealthiest companies in the world, but on the entire Southern California economy, estimated to have lost up to $10 billion due to the 13-month closure (MacDonald 2021).

The travel and tourism industry was hit particularly hard in the first year of the pandemic due to public health shut downs and social distancing requirements, but also public fears of contracting the virus during travel. When Disneyland closed in March it was unclear when the park would reopen, and employees were furloughed with health benefits, but without pay (Watson 2020). By September 2020, Disney theme parks in Orlando, Japan, France, and China, had at least partially re-opened, but California’s strict public health mandates meant that no re-opening was in sight. At that point, the company announced layoffs of nearly 12,000 Disneyland employees, most of whom worked part-time.

Disney argued that California public health measures were too strict, publicly urging the state to lift restrictions. Some workers, however, worried that their living situations would put vulnerable family members at risk of serious illness or even death (Sainato 2020). This sentiment highlights the many inequities evident during the pandemic. First, Covid-19 did not affect people equally. It was particularly dangerous for those over the age of 65, those with compromised immune systems, and those with pre-existing conditions such as obesity and diabetes. Especially before vaccines became available, these vulnerable populations had no protections other than social distancing and masking.

Second, one’s occupation created other inequities. Low-income, frontline workers who are in close contact with large numbers of people, including the retail and service jobs common in travel and tourism, were most at risk of contracting Covid-19, and therefore bringing the virus home to their families (Bateman & Ross 2021; Wolfe, Harknett, & Schneider 2021). These employees were often deemed “essential” at the start of the pandemic, but critics noted that a large number of these risky, low-paying jobs “are occupied by people at the most marginalized intersections: racial/ethnic minorities, women, and undocumented workers” (Bowleg 2020 p. 917). They are also the workers least likely to have health insurance, paid sick days, or the financial means to seek new employment if their work environment created a threat to their health (Wolfe et al., 2021). White collar workers, on the other hand, were far more likely to be able to work-from-home and avoid exposure to Covid-19; they were also likely to be older, better educated, and more affluent. The Disneyland experience tracks well these employment inequities. While 12,000 Disneyland employees were laid off, Disney executives, who avoided furloughs by taking salary cuts of 20-30%, had full pay reestablished in August, a month before the park announced layoffs (Andreeva & Patten 2020).

The Covid-19 pandemic highlighted other inequities as well. For example, as vaccines were rolled out in early 2021, Black Americans were far less likely to seek vaccinations (Ober 2022). Vaccine hesitancy has long been recognized in the Black community, often explained by historical medical injustices such as the Tuskegee Syphilis Study, in which Black men with syphilis were studied but never treated for the disease even when a cure became available. However, it is also rooted in current, personal experiences with the health care system, in which Blacks are less trusting and feel less cared for by their doctors than Whites, a feeling often shared in the Latino/a/x/e community (Balasuriya, Santilli, Morone, Ainooson, ... & Venkatesh, 2021; Ober 2022).

Other issues of equity involved access to Covid-19 vaccines. A 2021 study sponsored by the Rockefeller Foundation (n.d.) found that while more than 70% of Black and Latino/a/x/e adults intended to be vaccinated, more than 60% either did not know how to make vaccination appointments, or did not have access to a vaccination site. In another study of these communities, participants echoed these concerns, and complained about difficulties with the automated systems for making vaccine appointments (Balasuriya, et al. 2021). Similarly, older adults—those most at risk of severe illness and death from Covid-19—were often frustrated when seeking vaccinations because they lacked the technology to make appointments, including internet access, computers, and medical apps (Browning 2021). This problem was particularly acute among elderly immigrants for whom English is not their primary language (Fuchs, Fuchs, Tietz, & Lum 2021).

Other inequities are apparent in terms of health outcomes for those contracting the coronavirus. The U.S. Centers for Disease Control (CDC) reported that by 2023 the largest number of Covid-19 cases were in those of typical college-age, 18-29, but hospitalization and death rates were far greater in older groups (2023a). Those aged 50-64 were 3x more likely to be hospitalized and 25x more likely to die of the virus, while those aged 75-84 were 9x more likely to be hospitalized and 140x more likely to die.

The CDC also tracked coronavirus cases and health outcomes by race and ethnicity. Although the majority of Americans infected with Covid-19 were White, Native Americans and Alaska Natives had the worst health outcomes of any racial/ethnic group. They were 2.5x more likely to be hospitalized and 2x more likely to die than Whites. Table-1 indicates the health outcomes for all racial/ethnic groups. Black and Latino/a/x/e populations were both more likely, and Asian/Pacific Islander populations were slightly less likely to be hospitalized and to die of Covid-19 than Whites (Centers for Disease Control 2023b). While the public health perspective engages collaboration to attain good health outcomes for the wider community, it has been noted that the idea that we were “all in this together” during the pandemic rings hollow given the reality of pandemic inequities based on age, occupation, race, and economic status (Austin 2020; Bowleg 2020). Many people accepted the public health advice of distancing and masking to help protect those most vulnerable to the virus, but many did not; as detailed below, this opposition was often rooted in partisan politics.

Table 1: Covid-19 Health Outcomes by Race/Ethnicity

Compared to Whites	Native American/ Alaska Native	Black	Latino/a/x/e	Asian American/ Pacific Islander
Hospitalizations	2.5	2.1	1.8	.7
Deaths	2	1.6	1.7	.7

Covid-19: A Tale of Two Political Parties

Politics played an unfortunate role during the pandemic leading to differing rates of Covid-19 infection, vaccinations, and deaths between conservative and liberal constituencies. The reader should note that political party identification is so strongly related to geography that rural residents are typically Republican voters, while urbanites are typically Democratic voters—even when factors such as age, education, and sex are taken into account (Gimpel, Lovin, Moy, & Reeves, 2020). Note also that both party affiliation and geography were important determinants of personal behavior during the pandemic.

Some of the differences in political and public response, particularly based on geography, were likely rooted in the early trajectory of this new, highly contagious coronavirus. The federal government declared a public health emergency on January 31, 2020, and within six weeks, most states had followed suit. Urban areas, with their greater density, use of public transportation, and likelihood of hosting travelers, were initially hit hardest as the virus quickly spread. For example, within two months of New York City’s first Covid-19 cases, refrigerated trucks were parked outside of hospitals to store the dead as city morgues and funeral homes became overwhelmed with bodies (Ochs 2020). At that point, swift public health measures in urban areas made sense, but in rural communities they seemed excessive. By the second half of 2020, however, infection rates and deaths per capita had increased rapidly in rural communities, but politics, rather than public health guidance, often impacted how these populations reacted to their growing risks (Albrecht 2022; Sehgal, Yue, Pope, & Wang 2022).

From the start of the pandemic, Democrats, who have greater trust in science and therefore in medicine and public health experts, were more likely to be concerned about the health risks of the coronavirus (Albrecht 2022; Camobreco & He 2021; Hegland et al., 2022). Republicans, on the other hand, were more likely to worry about the economic impacts of public health measures such as business closures and stay-at-home orders. Republican officials acted more slowly in imposing lock-downs, were less likely to enact health mandates, and reopened sooner than did Democrats, regardless of Covid-19 infection rates in their states and counties (Albrecht 2022; Camobreco & He 2021; Shvetsova, Zhirnov, Giannelli, Catalano, & Catalao 2022). Further, residents in Republican-led states were less likely to abide by public health measures including masking and stay-at-home orders, regardless of studies indicating that mask wearing was effective at reducing the spread of the coronavirus (Cowger, Murray, Clarke, ... & Hall, 2022; Gettings, Czarnik, Morris, et al. 2020; Oliver, Ungrin, & Vipod 2023). As Albrecht explained, “Wearing a mask became a political statement with many Republicans arguing that mask mandates violated their individual freedoms” (Albrecht 2022 p. 97). From the public health perspective, however, arguments about personal freedom are far less important than protecting the most vulnerable and securing community health through measures that stem the spread of contagious disease.

As discussed above, vaccine hesitancy has always existed for some populations, but during the Covid-19 pandemic mistrust of the vaccine was highest among Republicans and rural residents (Khubchandani, Sharma, Price, Wiblishauser, Sharma, & Webb 2021; Kricorian, Civen, & Equils 2022; Motta 2021). The fact that vaccines were created during the Trump administration, and that the president and his family were vaccinated makes this mistrust somewhat perplexing. In addition, the science eventually made it quite clear that while coronavirus vaccines did not create long-term immunity, they were very effective at preventing serious illness and death (Krieger, Testa, Chen, Hanage & McGregor 2022; McLaughlin, Khan, Pugh, Swerdlow & Jodar 2022; Morens et al., 2022; Sehgal, et al., 2022; Wallace, Goldsmith-Pinkham & Schwartz 2022). Studies found that counties with the highest levels of fully vaccinated individuals had the lowest levels of Covid-19 cases, and lowest levels of death (McLaughlin, et al., 2022), and that once the vaccine had been widely distributed, 99% of Covid-19 deaths were among the unvaccinated (Balasuriya, et al. 2021).

Several studies confirm that political party was an important factor in coronavirus health outcomes. For example, Intensive Care Units (ICUs) in Republican congressional districts were more likely to have filled with Covid-19 patients than ICUs in Democratic districts (Krieger, et al., 2022). In all, by mid-2023 an estimated 1.1 million Americans had died of the virus and on this measure, Republicans also fared worse, experiencing higher death rates than Democrats (Krieger, et al., 2022; Sehgal, et al., 2022; Wallace, Goldsmith-Pinkham & Schwartz 2022). The examples of Florida and California are illustrative. By the end of 2022, Florida, which famously spurned public health measures, had 381 Covid-19 deaths per 100,000 residents, while California, which followed strict public health guidelines had 244 (Greenblatt 2022). A 2022 study of all U.S. deaths from Covid-19 found that in solidly Republican counties, 73 more people (per 100,000) were likely to have died than in solidly Democratic counties (Sehgal et al., 2022). Further, the study found a direct relationship between counties with the highest levels of Trump support in the 2020 election and counties with the highest levels of Covid-19 death.

While refusing to abide public health mandates and vaccinations may be a personal choice, public health professionals are less concerned about the individual and more concerned with the broader public interest. Their goals during the pandemic were to keep the most vulnerable safe, maintain ICU and hospital capacity, and retain a sufficient workforce of medical professionals to attend to everyone’s health needs. From that perspective the Covid-19 experience resulted in both wins and losses for the field of public health. In the win column are recent studies indicating that states with strong public health measures were successful in lowering risks which led to lower levels of disease and death (Diab & Kumar 2023; Greenblatt 2022). However, there were also missteps by public health officials, for example, initially telling the public not to mask led to confusion and questions once mask mandates were instituted (Greenblatt 2023). At least two additional aspects of the Covid-19 experience can be considered public health failures. First, are the disparate levels of illness and death based on factors such as poverty and race; the field is looking at how to better protect these communities including improved communication, better health access, and stronger sick and family leave policies. Second is the opposition to public health measures that were rooted in politics and misinformation and that led to disparate health outcomes based on distrust of the system. Unfortunately, this may be the harder problem to fix.

Conclusion

The goal of ensuring healthy communities is obviously in the public interest, but the strategies engaged to do so are not welcome by all. During both the Pandemic of 1918 and the Covid-19 pandemic, facemask opponents argued that wearing a mask should be a choice and not a requirement. Others argue that protecting the health of the most vulnerable requires cooperation of everyone, even those at little risk. Further, while public and political response to the pandemic spotlighted the difficulties of the public health system, support for and understanding of the system has been eroding for years. Growing vaccine hesitancy and refusal, for example, worry public health professionals because both have led to increased incidence of serious illnesses once thought eradicated, including polio, which was reintroduced in the U.S. in 2022 (Greenblatt 2022).

Having entered the post-pandemic era, the public health system finds itself at a crossroads (Greenblatt 2023; Smith 2023). It is distrusted by a vocal, sometimes violent minority, faces worker shortages, has had its authority and expertise undermined by elected officials, and knows that many of its efforts to protect the public and fight Covid-19 failed. How it can address health inequities, regain the trust of the public and politicians, fight the misinformation spread via social media, and use the lessons learned during Covid-19 to meet the challenge of the next pandemic is on the minds of public health leaders across the country.

Podcasts/Videos

Hazardous to your Health Official. Anna Maria Berry-Jester. This American Life. (20 minute podcast) April 23, 2021

Backlash Accelerates Public Health Leaders’ Exodus Kaiser Health News. (3 minute video)

At Public Meetings: Local officials making health decisions have endured threats and hostility over pandemic restrictions. (2 minute video) New York Times. October 20, 2021

Questions for Consideration

The public health system is described as being “among the best examples of government’s role in serving the public interest.” However, scholars have debated the definition of “public interest” for decades. In your own words, how would you define this concept? How do we know if government actions have served the public interest?

In this case study you learned that the field of public health is quite diverse, dominated by women, and over-represented by Black, Indigenous, and other people of color (BIPOC). At the same time, the scholarly literature tells us that women and BIPOC are more likely to experience harassment and threats from the public. As a future public sector leader, what suggestions do you have to address this problem for the public health workforce?

The introduction to this case asks you to think about where the line should be drawn between individual freedoms and responsibility to the greater society. When facing a contagious disease, where should the line be drawn on requirements for social distancing, facemasks, and vaccines? Consider whether or not your answer would differ if you were a different age? Different race? Different socio-economic status? Different health status?

The conclusion to this case sets out a variety of challenges facing the public health system and its leaders moving forward, including health inequities, public distrust, political interference, social media misinformation, and worker burnout and shortages. How would you advise public health leaders to take on each of these challenges?

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NOTES

[1] Common reactions to any vaccination include redness, swelling, and/or soreness at the injection site (Kimmel & Wolf 2005). More severe reactions, such as high fevers or seizures can occur, but are less common. Allergic reactions to vaccines are very rare, and often the result of stabilizers used in the production of the vaccine. It is important to note that in addition to clinical trials and Food & Drug Administration (FDA) approvals, medical providers in the U.S. are required to record the date, manufacturer, lot number, and patient name along with their own contact information every time they administer a vaccination. Further, the Department of Health and Human Services collects information about adverse reactions to vaccines through the Vaccine Adverse Event Reporting System. This system, in use since 1990, was designed as an early-warning system to alert the FDA and Centers for Disease Control (CDC) of any potential problems with vaccines as they are distributed throughout the population. For more information about this system, see https://vaers.hhs.gov/about.html