The Public Health System

Introduction

Former teacher Rachel Bardes protests in front of the Orange County Public Schools headquarters in Orlando, Fla., over Gov. Ron DeSantis' return-to-school order despite spiking coronavirus cases in the state. Public health experts have found their credibility questioned as the U.S. health care system struggled to address the crisis. (Getty Images/Tribune News Service/Orlando Sentinel/Joe Burbank)

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Overview

As the school year began in August, Florida was among the states hardest hit by the coronavirus, including a spike in cases among children.1 But Republican Gov. Ron DeSantis was convinced that closing schools was a mistake for both economic and educational reasons, so his education commissioner ordered schools throughout the state to reopen for in-person instruction.

“Now we're at the point where the people who advocate school closures are really the flat earthers of our day,” DeSantis said. “They're not doing it based on data. They're not doing it based on evidence. They're doing it based on either politics or emotion. And so, the harm of school closures, I think, is really considerable.”2

Teachers felt otherwise. Their main union, the Florida Education Association, sued to block the statewide reopening order. “Any sensible person would tell you that we've got to get the positivity [testing] rate down,” said Fedrick Ingram, then the union's president. “And we don't know what the fallout is going to be when you start to cram hundreds of thousands of children in our schools.”3

Lydia Newhall prepares COVID-19 tests at Whiston Hospital in the United Kingdom. While public health funding has increased during the pandemic, experts stress that sustained funding is necessary to address long-standing public health issues as well as to handle future challenges. (Getty Images/PA Images/Peter Byrne)

Around the country, the coronavirus pandemic has been marked by arguments like this over how to protect public health and whether politics is driving decision-making. Democrats were more likely to argue for strong measures, such as closing bars and restaurants and banning gatherings of more than 10 people. Republicans, from President Trump on down, called for more of a balance, warning that strict health measures were harming the economy for unclear health benefits. These divisions have continued, with some Democratic governors reimposing measures such as bar and restaurant closures as cases have climbed in recent weeks.

Ultimately, Democrats appear to have won the political argument. Polls point to Trump's handling of the coronavirus as a major reason he lost his re-election bid against Democrat Joe Biden. The pandemic was a top issue for most Biden supporters but only a fraction of Trump supporters, and Biden prevailed on the question of who could handle it more effectively.4 After being declared the winner, Biden asserted that battling the virus would be his top priority, and appointed a task force to address it.

Yet despite the election outcome, and Biden's promise to take a more aggressive stance to protect health, the debate over the efficacy of public health measures has not ended. After earlier spikes that were primarily regional in nature — the Northeast in the spring, the South and Southwest in the summer — caseloads are currently on the rise all over the country.

The coronavirus has unpredictable effects. Many people who become infected show no symptoms. Others die — almost 250,000 Americans as of mid-November, mostly, but not exclusively, those who are elderly.5

This irregularity, along with the fact that people who appear perfectly healthy can spread the virus, has made it difficult for many individuals to embrace the need for maintaining safe practices through the eight months of widespread U.S. infection thus far.

“People just think this is a nothingburger. So they think the risk is exaggerated,” said Andrew Noymer, an epidemiologist at the University of California, Irvine. “They're either just over it, or they've come to believe it's a phony pandemic because their own personal grandmother hasn't been affected yet.”6

Long Description

The pandemic is not the nation's only health problem, but it has trained a spotlight on the U.S. public health system. In fact, it is not a national system, but a conglomeration of agencies at the federal, state and local levels and private entities such as hospitals. These groups have not always pulled in the same direction this year, in part due to political disagreements. Health officials have long warned about the dangers of a potential pandemic. Now that the nation is experiencing the worst one in more than a century, it will confront continuing questions about what needs to change to address future emergencies.

Although the line between public health and health care is often blurry, there is a basic distinction. Health care is about treating individual patients, and public health concerns itself with protecting the well-being of the community.

“The health care sector is focused on the individual, a person sitting with a doctor or a nurse, what's happening with them,” says John Auerbach, president of the Trust for America's Health, a nonprofit in Washington that advocates for increased public health spending. “Public health is more interested in populations. It's thinking about what's happening in a family, in a community, in a city, in a state. What are the trends, and are there interventions that can help at a population level?”

There is a second major difference, he says. Health care is concerned largely with treatment, while public health is about prevention. Doctors may offer preventive care to individuals, but public health is focused on strategies and messages that help keep large groups of people from getting injured or sick.

Health care receives far more funding than public health. For example, spending on health care accounts for 18 percent of U.S. gross domestic product, but fewer than 3 cents out of every health dollar is devoted to public health.7 People in public health frequently complain that health departments — which are primarily found at the state and local levels but get financial assistance from Washington — are underfunded. They say politicians respond to particular crises but fail to offer adequate funding for the ongoing work of preventive measures.

“A key frustration that public health has had over the last decade is a lack of commitment from administrations and Congress … a lack of commitment to provide an adequate, sustained and rising funding for public health,” says Carolyn Mullen, chief of government affairs and public relations for the Association of State and Territorial Health Officials, which represents state health departments. “Reductions have happened over time with multiple Congresses controlled by both political parties.”

As a result, the United States has wide disparities when it comes to public health. Some states and localities fund health departments generously, while other departments receive little assistance beyond what comes from Washington. In Europe, public health tends to be centralized, but in the United States no single federal agency is in charge.

The fragmented nature of public health in this country was exacerbated by the politicized response to the coronavirus. In contrast to past crises, the U.S. Centers for Disease Control and Prevention (CDC) was largely sidelined, with the White House leading the federal response through its coronavirus task force. And when the CDC did try to offer guidance, it sometimes had to walk back its message — as when the agency said in September that small airborne particles could spread COVID-19, then abruptly removed the guideline from its website.8

“I surely don't recall once in my 45 years in public health where anything close to this has happened, where there's been this lack of federal coordination,” says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “We have counted on CDC in the past to be the key partner.”

President Donald Trump listens to coronavirus adviser Dr. Scott Atlas, a radiologist with no experience in infectious disease, during a September press conference at the White House. Atlas' appointment to the coronavirus task force led former Centers for Disease Control and Prevention (CDC) Director Dr. William Foege to urge Dr. Robert Redfield, the current CDC head, to resign. (AFP/Getty Images/Mandel Ngan)

This lack of clarity has led to charges of meddling by political appointees in the Trump administration. In September, Dr. William Foege, a renowned epidemiologist and former CDC director, wrote to Dr. Robert Redfield, the current CDC head, urging him to resign and publicly denounce the White House for political interference. Foege said his letter was triggered by the appointment of Dr. Scott Atlas, a doctor with no background in infectious disease who was skeptical about public health restrictions, to the White House task force.

“Despite the White House spin attempts, this will go down as a colossal failure of the public health system of this country,” Foege wrote. “The biggest challenge in a century and we let the country down. The public health texts of the future will use this as a lesson on how not to handle an infectious disease pandemic.”9

Trump and his top political advisers instead argued that stringent measures should be avoided to protect the economy, while emphasizing the prospects for improved treatment and a vaccine. Trump, who contracted the disease in October but quickly recovered, offered the success of his own treatment as evidence. The administration devoted billions to Operation Warp Speed, a vaccine development program (although Pfizer, which announced promising results from its vaccine on Nov. 9, had not taken federal funds for its research). In the days leading up to the Nov. 3 election, Trump repeatedly insisted the country was “rounding the turn” on the pandemic.

Still, with cases rising, Dr. Deborah Birx, a key figure on the White House coronavirus task force, circulated a memo the day before the election warning the administration's approach was failing. “We are entering the most concerning and most deadly phase of this pandemic,” Birx wrote, adding, “This is not about lockdowns — It hasn't been about lockdowns since March or April. It's about an aggressive balanced approach that is not being implemented.”10

The policy disconnects spread far beyond Washington. Republican governors were less likely than Democratic ones to impose restrictions on movements or mandate mask-wearing. While not dismissing the public health danger, they emphasized the need for personal responsibility over government orders.11 “I'm going to continue to ask South Dakotans to be extra diligent about their personal hygiene and to stay home if they are sick,” Gov. Kristi Noem wrote last month. “I'm going to continue to trust South Dakotans to make wise and well-informed decisions for themselves and their families.”12

Those governors who issued restrictions were sued by legislators, business groups and churches over limitations on gatherings. Particularly in the spring, state capitols became staging grounds for protests. In May, dozens of people, some heavily armed, entered the Michigan Capitol, venting their anger over Democratic Gov. Gretchen Whitmer's orders that people stay in their homes except for essential needs such as buying groceries.13 Two weeks earlier, Trump had implicitly criticized Whitmer's orders with a tweet that read “LIBERATE MICHIGAN!” (He sent the same message about Minnesota and Virginia, two other states with Democratic governors who imposed similar restrictions.)14

Whitmer has remained at the center of controversy. On Oct. 2, the Michigan Supreme Court ruled that the governor had overstepped her authority with her emergency orders.15 Six days later, state and federal law enforcement officials announced the arrests of 13 men on charges of plotting to kidnap Whitmer and hold a mock court to try her for “treason.” When Whitmer ordered new restrictions in November, White House adviser Atlas — who is not an epidemiologist — tweeted, “The only way this stops is if people rise up. You get what you accept.”16

The alleged plot against Whitmer was the most dramatic example of anger expressed against public officials during the pandemic, but not the only one. Some health officials have received death threats. Dozens of state and local health officials have quit or been forced out of their jobs. “We run the risk of losing some of our best, most well-qualified people right when we need them most,” says Dr. Georges Benjamin, executive director of the American Public Health Association, a Washington-based trade group representing people in the field. (See Short Feature.)

The public health system had its own failures, from the CDC's inability to roll out a coronavirus test quickly at the start of the pandemic to initial guidance from experts in the spring that most people should not wear masks. One of the biggest problems, however, is that the various messages coming from politicians undercut one of public health's most important tools — clear, consistent messaging.

Ultimately, the message from public health experts was fairly simple: Wash hands frequently, wear masks, maintain social distancing by staying at least 6 feet apart from other people and avoid large groups. Strategies based on hygiene and isolation of infected individuals have been standbys for centuries. “Public health works,” Benjamin says. “We know with focus, using good public health practice, we can actually eliminate diseases. There's a reason there's no smallpox in the world.”

The coronavirus pandemic may soon take new turns. Biden has made it his top priority and a vaccine or vaccines may be approved even before he takes office in January. Yet the death toll tells a story of failure: COVID-19 has been one of the largest mass casualty events in U.S. history, claiming more American lives than any outbreak except the 1918-19 influenza pandemic, or any military conflict other than the Civil War and World War II.17

As politicians and public health officials attempt to figure out what happened, here are some of the questions they are asking:

Will public health receive sustained funding?

There is a popular saying in public health circles: You wouldn't wait until there's a fire to build a fire station, yet that's what happens with public health.

Congress has responded with billions of dollars to combat public health emergencies during this century, from the terrorist attacks of 2001, which raised fears of biological warfare, through the Ebola and Zika virus outbreaks in 2014 and 2016. The same was true this year, with a series of relief bills passed this spring. But after emergencies subside, money for public health tends to dry up.

Long Description

Funding for the CDC has stayed flat over the past decade.18 Funding for the federal-state Public Health Emergency Preparedness program fell from nearly $1 billion in 2002 to $675 million last year.19 The federal Hospital Preparedness Program saw funding drop from $515 million in 2004 to $275.5 million this year.20

Per capita spending by state health departments has fallen 16 percent over the past decade, while spending at the local level has dropped 18 percent.21 According to the National Association of County and City Health Officials, 81 percent of local health departments cut their health preparedness and response funding last year.

“Earlier in the pandemic, we were hearing more and more elected officials saying we've got to stop this roller-coaster way of funding, we've got to make sure public health has sufficient resources,” says Auerbach of the Trust for America's Health. “Now, as state and local officials are tightening their belts, I think public health may be facing layoffs and cutbacks.”

Public health professionals do not have great hopes that this situation will change, despite the enormous costs imposed by the pandemic.

“It's very hard for me, having worked in public health for 15 years, to be optimistic that we are going to be adequately funded on the other side of this,” says Chrissie Juliano, executive director of the Big Cities Health Coalition, a forum for 30 of the largest municipal health departments. “We haven't sufficiently funded the public health system for years.”

State and local governments are facing enormous budget pressures due to this year's sharp recession. At the federal level, it has been hard to convince Congress that investing in public health is worthwhile. “We've had a challenge sustaining ongoing public support for public health, because when we do our job well, you see very few problems,” says Osterholm of Minnesota's Center for Infectious Disease Research and Policy. “Then people think you don't need it, because there are no problems.”

Just as funding spikes during an emergency, Congress and the states will sometimes increase funding in response to problems that gain political attention, such as opioid addiction or infant mortality rates. While such money is helpful, health departments generally cannot shift it to where it is most needed. They might not be able to use dollars approved to combat AIDS, for example, to address Ebola. And many one-time appropriations do not help health departments build up staff or capacity to handle new outbreaks. “If they can't get a grant, they can't hire on the government side, they contract it out,” the American Public Health Association's Benjamin says. “That doesn't build any capacity in the health department.”

Benjamin says he is skeptical that the usual boom-and-bust funding for public health is about to change, despite the historic challenges presented by the pandemic.

Others are more optimistic and intend to make the case to Congress for the necessity of sustained, predictable funding. Rep. Tom Cole, R-Okla., who serves on the House Appropriations health subcommittee, referred to the pandemic as a “biomedical Pearl Harbor” that demands the creation of more public health capacity.22

Sen. Patty Murray of Washington, a top Democrat on her chamber's Appropriations Committee, supports creating a fund to provide sustained public health support. Crystal Watson, a public health professor at Johns Hopkins University, says, “I think there are lawmakers who are really serious about considering this, how to support public health in the future so we're never in this position again.”

Last year, Auerbach was part of a task force that recommended Congress increase public health funding by $4.5 billion, or about a third, with most of that money going to states and localities. That may have seemed like a lot of money when the task force proposed it, he recalls, but it represents a bargain compared to the trillions the coronavirus has cost the country.

Still, he is not convinced that even the pandemic will be enough to change minds. “I'm certainly hopeful we've learned the lesson with this devastating pandemic,” Auerbach says, “but I'm fearful that the memory of policymakers might be short-lived, and we may find ourselves once again with an underfunded public health system.”

Has the CDC lost credibility?

In September, CDC Director Redfield told Congress that most Americans will not receive a coronavirus vaccine until the middle of 2021. President Trump said Redfield was wrong about that timetable and “confused.”23

It was not the first time they contradicted each other publicly. When Trump said in September that the virus affects “virtually nobody” who is young, Redfield pointed out young people account for a sizable and growing share of the infected population.24

The CDC and other parts of the Trump administration have not only sparred over characterizations of certain facts. The White House and the Department of Health and Human Services (HHS) have repeatedly made policy decisions that undermined the CDC's authority and threatened its credibility.

In recent months, the administration has pressured the public health agency to soften guidance related to mask wearing and the safety of reopening churches and schools; redirected the collection of hospitalization data away from the CDC; pressured the agency to change its guidance about testing asymptomatic individuals; and sought to alter and delay reporting information in its Morbidity and Mortality Weekly Report. 25 The administration also shifted $700 million away from the CDC budget to the Operation Warp Speed program to rapidly develop a coronavirus vaccine.26

“This is unprecedented, where a president is willing to exercise this level of political influence over a scientific institution,” says Brian Castrucci, president of the Bethesda, Md.-based de Beaumont Foundation, which supports health initiatives.

CDC Director Dr. Robert Redfield talks with Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Diseases, at a January press conference discussing the emerging pandemic. After Messonnier warned that there would be community spread of the coronavirus in February, President Trump sidelined her and other CDC experts. (Getty Images/Samuel Corum)

The CDC is the nation's leading public health agency — so well regarded that it is sometimes called the world's greatest health agency and a model for CDCs in other countries. Its mission is to protect public health from threats ranging from addiction to obesity. During past epidemics, including Ebola, Zika and the H1N1 flu, it has taken the lead in crafting the response of governments (including guiding state and local health departments) and informing the public with frequent briefings.

During the coronavirus pandemic, the CDC has found itself sidelined. The agency made some early errors on its own, notably the bungled rollout of its custom coronavirus test, which was practically unavailable as the virus began its domestic spread. That set back its credibility within the administration.

Trump was livid in February when Dr. Nancy Messonnier, director of CDC's National Center for Immunization and Respiratory Diseases, accurately stated that there would be community spread of the coronavirus in the United States, which caused a stock market sell-off.27 CDC officials rarely spoke publicly for weeks afterward. Redfield is a member of the White House coronavirus task force, but has seldom appeared at its news conferences. “Having the CDC not being the voice of the administration and having all of that coming out of the White House made the public feel that what was being pushed out wasn't science and data,” says Juliano, the Big Cities Health Coalition director.

In September, the CDC posted guidance about aerosol transmission of the coronavirus. Three days later, it removed the language, leading to widespread suspicion that it pulled the language at the White House's behest. CDC officials said there had not been political pressure in this case, just premature publication of draft guidance. Because there had been interference at other points, members of Congress, the media and the public were left wondering whether the CDC retained its independence and therefore its credibility.28

“It's been a terrible year for the CDC,” said Dr. Ross McKinney Jr., chief scientific officer at the Association of American Medical Colleges. “There's no question that their credibility and effectiveness have been damaged by a combination of external threats, leadership that has been perceived to be ineffective and mistakes they have made internally.”29

Juliano says local health officials continue to express nothing but praise for CDC line workers, the scientists and disease detectives who have fanned out around the country to share information and help local health departments respond to outbreaks.

“I don't think that public health professionals across the nation have lost faith in the CDC,” says Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials. “There's pretty much the same level of confidence in their ability and their professional expertise.”

Long Description

Entities from schools to movie theaters note they are following CDC guidelines when it comes to safety procedures, and that the agency's imprimatur is still seen as a gold standard. Most of the public continues to express trust in the CDC — although this trust is slipping. Sixty-seven percent of adults said they trusted the CDC in September, according to a Kaiser Family Foundation survey, a decline of 16 points since April — and 30 points among Republicans, to just 60 percent.30

Redfield announced ahead of the election that he would step down, regardless of the outcome. Some in the medical profession warn that it will take more than a change in leadership to restore the agency's reputation. A number of experts argue that the CDC needs more formal independence, and perhaps should be governed by a board whose members have terms that straddle presidential terms. Currently, the CDC director is appointed by the HHS secretary.31 “A reputation that takes 75 years to build can be destroyed in [a few] months,” said Dr. Mark Rosenberg, a former CDC official. “That's horrifying.”32

Are non-COVID conditions being neglected because of the pandemic?

It is not unusual to find recreational vehicles in Colorado. But six of them, driving along the state's backroads, are performing a surprising mission.

These RVs are operating as addiction treatment centers, bringing nurses, counselors and formerly addicted “peers” to less populous parts of the state, while providing video links for telehealth sessions with distant specialists in cities. Robert Werthwein, who directs the state Office of Behavioral Health, had heard about a similar program in New York and secured a $10 million grant to try the idea in Colorado.33

Kindergartner Jeremy Conner receives a vaccination in Santa Ana, Calif., as his father comforts him. Public health experts warn that as the coronavirus keeps kids out of in-person schools, childhood immunizations have been hampered. (Getty Images/David McNew)

It is an example of a health agency being creative about providing care where it is needed most. This year, that has become something of a rarity. Perhaps ironically, as health concerns have dominated the nation's attention, many forms of treatment and preventive care have been neglected, according to public health experts.

“No doubt health departments will struggle to be able to do everything right now, and for some time to come,” says Juliano of the Big Cities Health Coalition. “It's a real challenge to continue to respond to COVID-19 and do all the other things health departments do in normal times, particularly in substance abuse disorder work and HIV/AIDS.”

Many hospitals laid off staff during the early days of the pandemic, with elective procedures banned in some states. Such bans have mostly been lifted — although some hospitals have recently adopted such policies — but the closure of many school systems has hampered childhood immunization efforts. Many individuals are neglecting treatment, fearful of setting foot in hospitals or clinics due to the possibility of contracting the coronavirus.

By the end of June, 12 percent of American adults had avoided urgent or emergency medical care, while 32 percent had put off routine care, according to the CDC. The number of breast cancer diagnoses has dropped by half this year, with women putting off screenings due to fear of contracting the coronavirus.34 With states facing budget shortfalls and the pandemic claiming large amounts of health spending, states including Florida, New Jersey, Oregon, Utah — and Colorado — have each cut millions of dollars from their substance abuse and behavioral health budgets.35

While childhood vaccination rates are starting to climb back up, adult vaccinations for herpes and meningitis have dropped precipitously, says L.J. Tan, chief strategy officer for the Immunization Action Coalition, a nonprofit in St. Paul, Minn., that works with the CDC to provide immunization information to health care professionals. “Adults who missed required vaccines during the months we were sheltering in place, they didn't come back for their catch-up vaccines,” Tan says.

The problems that public health agencies were concerned about last year, including opioid addiction, suicide and teen vaping, have not gone away. But health department directors, who have been working 12- to 18-hour days all year, do not have much bandwidth left to deal with them. Everyone recognizes that the pandemic is the more urgent problem, and it is hard to argue that it should not take precedence, says Plescia, the Association of State and Territorial Health Officials' chief medical officer.

“We've had some conversations about trying to gear back up on some of these other efforts,” he says. “The [health department] leaders couldn't agree more, but they leave the discussion and get pulled into some other COVID thing. You can't say the pandemic is not as important as other things.”

Some department directors have appointed deputies to oversee non-COVID issues. But health officials were complaining that they lacked sufficient resources to address community health needs long before the pandemic. Now, the coronavirus is directly taking resources away, and not just in terms of dollars: With the huge demand for COVID testing, departments are running out of the reagents needed for tests for tuberculosis and sexually transmitted diseases.

“We really had to focus on treating people who needed to be tested” for COVID, says Jill Franken, public health director for the city of Sioux Falls, S.D. “We were only seeing real and true emergencies and didn't do any preventive care or other type of scheduled work.”

Public health experts worry that the lack of preventive care, and even diagnostic work, will continue to present problems even after the coronavirus emergency passes.

“People aren't being diagnosed with hypertension or diabetes, and the mental health crisis that's coming is not getting enough attention,” Castucci says. “We're going to see the repercussions of the pandemic for years, if not decades, to come.”

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Background

Lack of Central Authority

Themes that have dominated political discourse during the coronavirus pandemic — individual liberties versus the common good, balancing health against commerce — have recurred throughout American history.

The new nation faced a partisan divide over the right response to a yellow fever epidemic in Philadelphia in 1793, with Federalists pushing the idea of quarantines and the Republicans (who eventually became the current Democratic Party) supporting sanitary measures.36 In the end, politicians and the wealthy fled, and the city was left without support from higher levels of government, whether state or federal.37

Local officials were typically left to combat epidemics on their own during the nation's early decades, generally with limited resources. States did not build up much of a health infrastructure until well into the 19th century. The federal government — which was small prior to the 1930s — took even longer, with today's CDC not established until after World War II.

In 1840, Hungarian physician Ignaz Semmelweis showed that having doctors wash their hands before examining patients decreased infections and deaths — but it took another half century for American physicians to adopt the practice. (Getty Images/De Agostini Picture Library/Contributor)

When outbreaks occurred, local governments either had no funds to pay for sanitary measures, or boosted health funding only to let it erode quickly. For instance, Pittsburgh spent $10,000 to address a cholera outbreak in 1832, but cut its health budget to $864 by 1835.38

By the time of the 1832 outbreak, few cities other than New York had established local boards of health. But by 1850, Washington, Boston, Chicago, New Orleans and dozens of others had followed suit.39 “Not only was there no genuine federal leadership in public health in 19th century America, few states had laws or policies that extended to all of their counties and cities,” wrote science journalist Laurie Garrett.40

In 1850, Providence, R.I., became perhaps the first U.S. city to require children to receive smallpox immunizations before attending school, but legal and political challenges kept the idea from spreading for years.41 Due to infant mortality and childhood diseases, babies born in 1850 had only a 50 percent chance of reaching their fifth birthday.42

The toll from disease during the Civil War drew federal attention, leading to the creation of the U.S. Sanitary Commission. (More than 100,000 soldiers on the Union side alone died from infectious diseases, including dysentery, typhoid, malaria and pneumonia).43 A cholera outbreak in 1866 led New York City to create a Metropolitan Board of Health, bypassing the previous board, which had been corrupted by the Tammany Hall political machine.44 The new board's success in keeping death rates well below a previous outbreak of the disease in 1849 helped to demonstrate the value of a competent public health administration even in crowded, filthy conditions. “This was a major triumph and marks a turning point in the history of public health not only in New York City, but in the United States as a whole,” wrote historian George Rosen.45

In 1869, Massachusetts created the first state-level board of health, followed over the next few years by several other states, including California, Minnesota and Maryland.46 At its first meeting in 1872, the American Public Health Association called for a national board of health.47

One was created in 1879, but its funding was cut off by Congress after just four years. Due to a long-standing emphasis on quarantining ships at ports to prevent outbreaks, the military played the largest federal role in public health in the 19th century, and Surgeon General John Hamilton led opposition to the civilian national board.48 Unlike nations in Europe, the United States resisted taking a centralized approach to public health.

In the 19th century, American doctors often distrusted foreign medicine. The Semmelweis technique — having doctors wash their hands thoroughly before touching patients — was developed in Vienna in 1840, but not commonly practiced in the United States until the 1890s.49 American doctors also ignored the 1854 finding by British Dr. John Snow that cholera was caused by drinking contaminated water, not by “miasma,” or breathing bad vapors.50

In time, however, germ theory — the idea that microorganisms can cause disease — gained a scientific foothold. This gave the field of public health an empirical basis for addressing sanitation, by draining swamps and improving sewage and water systems in cramped, often dirty cities. “In the 19th century, epidemics were still regarded like earthquakes — as acts of God,” writes science journalist Laura Spinney. “Germ theory forced people to consider the possibility that they could control them.”51

Combating Infectious Diseases

When the 20th century began, infectious diseases caused half of all deaths worldwide.52 In the United States, the leading causes of death were infectious diseases such as pneumonia, influenza, tuberculosis, gastrointestinal infections and diphtheria. In 1900, children under the age of 5 accounted for 30 percent of all U.S. deaths.53 Life expectancy was 47.3 years, as opposed to more than 78 today.54

The field of public health concentrated on infection and isolation. By 1902, scientists had proven that asymptomatic people could spread disease, such as the bacteria that causes typhoid fever. New York City health authorities traced a cluster of typhoid illnesses to a cook named Mary Mallon, who refused to quit her trade despite being a laboratory-confirmed carrier. She eventually was incarcerated on an island and is remembered in folklore as Typhoid Mary.55

In 1905, the U.S. Supreme Court ruled, in a vaccination case known as Jacobson v. Massachusetts, that individuals could not refuse medical treatment when the broader public health was at stake.56 In 1908, Jersey City, N.J., became the first U.S. city to routinely disinfect drinking water, a practice quickly adopted by thousands of other municipalities, leading to dramatic drops in water-borne diseases such as cholera and typhoid.57

Beginning in 1918, a global pandemic known as the Spanish flu infected a third of the world's population, or 500 million people, leading to more than 50 million deaths, including an estimated 675,000 in the United States.58 (The influenza was so named because it was widely covered in the Spanish press, while many other European nations suppressed news of the outbreak; Spain was not a combatant in World War I and its newspapers were not censored.) Among those infected were President Woodrow Wilson and future President Franklin D. Roosevelt, although Wilson never publicly mentioned the pandemic — a clear demonstration of the limited role the federal government took at that time.59

U.S. health officials were divided over the use of masks and disinfectants; one non-mask-wearing person was shot by police in San Francisco.60 Chicago banned funerals with more than 10 attending, and city Health Commissioner John Dill Robertson ordered police to arrest people who sneezed in public.61

“Persons at large sneezing and coughing should be treated as a dangerous menace to the community, properly fined, imprisoned and compelled to wear masks until they are educated out of the ‘gesundheit!’ and ‘God Bless You’ rot,” declared Noble P. Barnes of the American Therapeutic Society.62

A boy grimaces while being injected with polio vaccine in the 1950s. The development of an effective polio vaccine was one of the public health field's triumphs. (Getty Images/Corbis/ University of Southern California Libraries/Contributor)

When the flu initially spread during the spring of 1918, it was relatively mild, but a second wave starting in August proved especially deadly. In September, Philadelphia decided to go ahead with a war bond parade that drew 200,000 spectators. Within two weeks, 2,600 people were dead, and by the third week of October, 4,500 people had died.63

Having learned from that experience, St. Louis Health Commissioner Max Starkloff closed schools, movie theaters, saloons and sporting events; he also quarantined soldiers. Despite pushback from business owners and residents, Starkloff imposed still stricter measures in November. The result was that the city's death toll from the flu ended up the lowest among the nation's 10 largest cities.64

To address high rates of infant mortality, Congress passed the Sheppard-Towner Act of 1921, which provided federal funds to states to educate people about prenatal health and infant welfare.65 The law set an enduring template, with the federal government sending health dollars to states and localities to address its own priorities.

Federal public health programs were scattered across 40 agencies.66 Health funding at the state and local levels was uneven, leading to local outbreaks of tuberculosis and diphtheria. Those diseases, along with whooping cough, typhoid, puerperal fever and maternal and infant mortality, all rose during the Great Depression, which began in 1929.67 Life expectancy dropped by more than five years just between 1933 and 1936.68

Beginning in 1932, the U.S. Public Health Service, along with the Tuskegee Institute, ran an experiment on 600 Black males without their informed consent, failing to treat them properly for syphilis. The so-called Tuskegee experiment endures as the most notorious example of African Americans receiving subpar or even harmful treatment, which has fueled historic and lingering distrust.69 “In the United States, from slavery well into the 20th century, doctors used African-Americans as a supply chain for experimentation, as subjects deprived of either consent or anesthesia,” wrote historian Isabel Wilkerson. “Scientists injected plutonium into them, purposely let diseases like syphilis go untreated to observe the effects, perfected the typhoid vaccine on their bodies, and subjected them to whatever agonizing experiments came to the doctors' minds.”70

Increasing Complacency

State and local health departments that had grown reliant on federal dollars saw them diverted to military funding during World War II. Efforts to combat disease during the war eventually led to the creation of the CDC, which addressed malaria in the South as its original mission, the reason that the agency is headquartered in Atlanta.

After the war, the field of public health enjoyed some triumphs, including the eradication of smallpox and the virtual eradication of polio. In 1947, after a tourist brought smallpox to New York City — its first such outbreak since 1902 — the city responded aggressively, with nearly every public building and union hall turned into a vaccination center. More than 6 million people were vaccinated, and the city was left with just 11 cases and two deaths.71

But the public health field was losing prestige, as well as potential recruits who went into medicine. The success in combating infectious and childhood diseases made public health measures seem less pressing, and spending shifted to individual care. Doctors were able to treat infected patients with antibiotics, and the major risks of deaths were increasingly noncommunicable diseases such as cancer and heart disease.

During significant outbreaks such as the Asian flu of 1957 and the Hong Kong flu of 1968, public health systems were caught flat-footed. Despite such scares, the public and health professionals alike grew complacent, based on the belief that pandemics were a problem of the past. Dr. Frank Macfarlane Burnet, a Nobel laureate in medicine, wrote in a 1972 medical textbook that “the most likely forecast about the future of infectious diseases is that it will be very dull.”72

When there were multiple cases of pneumonia among people who had attended an American Legion convention in Philadelphia in 1976, it inspired fearmongering and paranoia, with accusations of chemical warfare and terrorism. The local chapter of the Veterans of Foreign Wars called it “a sneak attack against the finest kind of Americans.”73 After a period of months, the CDC identified the atypical form of pneumonia, which became known as Legionnaires' disease, caused by bacteria found in heating and air conditioning systems. Cases have been on the rise, with about 10,000 reported in 2018.74

Also in 1976, President Gerald Ford sought an appropriation of $135 million to vaccinate all Americans against swine flu. Congress approved the request and indemnified manufacturers of the vaccine.75 The public had grown more skeptical about the need for a universal vaccine, with memories dimming of life before vaccines for scourges such as polio and measles. The feared pandemic failed to appear and 257 people who had received the vaccine came down with a condition known as Guillain-Barré syndrome.76 The swine flu campaign was considered a fiasco and undermined public health credibility, leading to the firing of longtime CDC Director David Sencer.77

Funding for the Department of Health and Human Services was slashed by 25 percent from 1981 to 1983, the opening years of Republican Ronald Reagan's presidency, with some public health programs eliminated entirely as part of his program of domestic spending cuts.78 By that time, state health departments depended on federal support for more than a third of their budgets and localities were even more heavily dependent on support from higher levels of government.79

AIDS activist Larry Kramer wears a shirt encouraging action to address the crisis in New York City in 1993. Gay rights organizations galvanized public awareness and support to demand increased funding for AIDS and HIV research. (Getty Images/Catherine McGann/Contributor)

“The first question of most local governments is how much of the federal cuts will be offset by state funding increases. The answer given by most states — none — is not the answer that local governments want to hear,” a 1982 analysis by the University of North Carolina dryly noted.80

In 1982, the CDC gave a name to AIDS, or acquired immune deficiency syndrome, which was caused by the human immunodeficiency virus, or HIV. Up to that time in the United States, AIDS primarily affected gay men living in a handful of cities, along with hemophiliacs and intravenous drug users, through blood and other bodily fluids, but not before a period of panic in which it was assumed it could be airborne.

AIDS patients often suffered forms of pneumonia and cancer. An AIDS diagnosis was initially considered a death sentence. Gay rights organizations lobbied heavily for increased funding for research, setting a template for activism around other underfunded diseases. When AIDS activist Larry Kramer died in May 2020, Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, recalled their initially combative relationship: “How did I meet Larry? He called me a murderer and an incompetent idiot on the front page of the San Francisco Examiner magazine.”81

Fauci proved to be an effective advocate, requesting and receiving $300 million in 1985, more than double his institute's previous budget.82 He created a national system to coordinate, fund and evaluate research on promising AIDS treatments. In time, therapeutic drugs were developed to increase the life expectancy of HIV-positive patients. Still, more than 30 million people have died from AIDS worldwide, including nearly 700,000 in the U.S.83

“If Legionnaires' disease had been a warning to an overly complacent public health profession, then AIDS was the epidemic that drove home the lesson: despite vaccines, antibiotics and other medical technologies, infectious disease had not been banished but posed a continuing and present threat to technologically advanced societies,” wrote medical historian Mark Honigsbaum.84

New Century, New Threats

The nation's public health system was further integrated and funding was increased after the terrorist attacks of 2001. Congress gave funding for the CDC to award money to states to improve their preparedness. The Strategic National Stockpile increased its supplies of vaccines to protect against smallpox, anthrax, plague and other diseases.85 More money was devoted to disease surveillance, public health laboratories, communications and planning.86

“When I started in public health 30 years ago, we didn't do emergency preparedness,” says Auerbach of the Trust for America's Health. “When 9/11 happened, policymakers and the public wanted public health to get involved in emergency preparedness. Billions of dollars were provided for public health to be on the front lines, because such a significant new risk was identified and they wanted to mobilize the most likely professionals to play an active role in response.”

It was part of a pattern that has held true in recent years. Public health is expected to address problems that gain salience and command public and political attention, from obesity and opioids to vaping. “Public health all happens at the local level, but public health is also heavily affected by what is determined at the federal level to be priorities,” says Osterholm, of the University of Minnesota Center for Infectious Disease Research and Policy.

However, overall public health funding has been declining since the post-2001 spike. In 2003, President George W. Bush created PEPFAR, or the President's Emergency Plan for AIDS Relief. Some $90 billion has been devoted to the global program, which provides antiretroviral support for millions of people, along with HIV testing and counseling.87

“The largest global health program devoted to a single disease is credited with saving millions of lives and helping to change the trajectory of the global HIV epidemic,” the Kaiser Family Foundation wrote of PEPFAR.88 But funding has been flat for years and remains below its peak.

After reading a history of the Spanish flu, Bush became convinced the nation needed to be better prepared for a pandemic. In 2005, he called for a $7.1 billion program to prepare for a flu pandemic that included increased disease monitoring and surveillance, the capacity to respond globally and accelerated vaccine development.

“A pandemic is unlike other natural disasters,” Bush said. “Outbreaks can happen simultaneously in hundreds, or even thousands, of locations at the same time. And unlike storms or floods, which strike in an instant and then recede, a pandemic can continue spreading destruction in repeated waves that can last for a year or more.”89 Congress approved a little more than half of Bush's request.90

The 2010 Affordable Care Act, often labeled Obamacare, expanded health insurance coverage, but the law also contained a number of public health elements, including funding for community health centers and requirements for free coverage of contraceptives, certain vaccines and wellness checkups. The law authorized $5 billion over five years, and $2 billion annually after that, for a Prevention and Public Health Fund.91 The fund now provides about half the authorized amount annually in grants for preventive programs to states, local governments, nonprofits and tribal organizations.92

During the 2009-17 Obama administration, the world faced a number of major disease outbreaks, including H1N1 flu, severe acute respiratory syndrome or SARS, Middle East respiratory syndrome or MERS, Ebola and Zika. The administration worked with other countries and international partners to combat those diseases near their sources. The effort was largely successful, with only the 2009 H1N1 flu killing a substantial number of Americans — 12,469.93

Insularity from these outbreaks not only caused complacency in the United States but led to a sense that public health officials were like the proverbial boy who cried wolf, warning about potential harms that never seemed to arrive. While the Ebola outbreak in 2014-15 killed more than 11,000 people in Africa, it killed only two Americans. Microsoft co-founder Bill Gates, who has helped shape global health policy through his charitable foundation, gave a speech in 2015 warning that the United States had gotten lucky. “The world is simply not prepared to deal with a disease — an especially virulent flu, for example — that infects large numbers of people very quickly,” he said. “Of all the things that could kill 10 million people or more, by far the most likely is an epidemic.”94

The Obama administration left behind a pandemic “playbook” and response structure that the Trump administration ignored.95 In 2018, Trump's national security adviser, John Bolton, disbanded the National Security Council's Global Health Security and Biodefense unit, which had been established under Obama.96 In the face of retrospective criticism this year, administration officials said the unit's functions had been redistributed to other parts of the government.

Despite all the challenges and complaints about underfunding, a recent Harvard and University of Michigan study found that public health programs were responsible for nearly half of the gain of 3.3 years in life expectancy between 1990 and 2015.97

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Current Situation

Transition Time

The Nov. 9 announcement by Pfizer that the coronavirus vaccine it developed with German drug manufacturer BioNTech showed better than a 90 percent effectiveness rate in clinical trials was cause for celebration among both political and public health figures. “This is really a spectacular number,” said Akiko Iwasaki, an immunologist at Yale University. “I wasn't expecting it to be this high. I was preparing myself for something like 55 percent.”98

Pfizer said it would seek approval from the Food and Drug Administration (FDA) later in November to distribute the vaccine, with the intention of rolling out 100 million doses by March. Independent scientists cautioned that the company's data were preliminary and announced via press release, not a peer-reviewed study.

Still, it was the biggest scientific breakthrough announced yet in the effort to control the coronavirus. Trump was quick to hail the news, although Pfizer was equally quick to note that it had funded its development independently, not relying on federal funds through the Operation Warp Speed program. If Pfizer's vaccine or any other is approved, the federal government will spend billions to pay for doses, which Americans would receive for free.

On the same day Pfizer made its announcement, President-elect Biden announced the 13 members of his Transition COVID-19 Advisory Board, which is led by former FDA Commissioner Dr. David Kessler, former Surgeon General Dr. Vivek Murthy and Yale medical professor Dr. Marcella Nunez-Smith. Murthy said that the new administration will aim to come up with a “national plan” to replace the patchwork response seen in 2020, with states and localities pursuing separate strategies.99

Biden, who repeatedly said he would be guided by doctors and scientists in his approach to COVID-19, released a seven-point plan during the campaign to address the pandemic. He said he would direct the CDC to offer tailored guidance about closures to businesses and schools based on community spread in their areas. His plan calls for invoking the Defense Production Act, which allows the federal government to dictate certain manufacturing priorities, to increase production of ventilators, masks and personal protective equipment. He promised to spend $25 billion on vaccine development and distribution.100

Biden intends to encourage universal mask-wearing when individuals interact with people outside their households, calling on governors to issue mask mandates. He wants to enlist 100,000 Americans to perform contact tracing and other services, both to address the pandemic and increase employment, while also calling for increases in health insurance coverage and the number of trained doctors and nurses.

Physicians and scientists largely applauded Biden's plan — and before the election, Biden had received the first political endorsements ever issued by Scientific American and The New England Journal of Medicine. 101 “I don't know any scientists or clinicians who aren't thrilled about Biden's victory,” tweeted Dr. Bob Wachter, chair of the department of medicine at the University of California, San Francisco. “The only way to defeat COVID is by being frank about the challenges while following the science & evidence. Biden will do all of that.”102

Public health professionals have been critical of the Trump administration's approach, which left decision-making largely up to states. The White House itself failed to be vigilant about safety protocols, leading to outbreaks affecting the president and numerous top aides and officials. A Columbia University study released in October estimated that at least 130,000 Americans had suffered avoidable deaths from COVID-19 due to the administration's handling of the pandemic.103 In the runup to the election, Trump threatened to fire Fauci.

People in Lansing, Mich., demonstrate for and against Gov. Gretchen Whitmer's emergency stay-at-home order in May. Similar protests erupted across the country against orders requiring masks and closing businesses and schools. (AFP/Getty Images/Jeff Kowalsky)

During the campaign Trump accused doctors of inflating coronavirus counts, because they were paid more for treating such patients (who often were more expensive to treat, in part due to safety requirements). Numerous other Republicans accused health providers of politicizing the issue. Hundreds of health experts signed a letter in support of racial justice protests this summer, calling white supremacy a “lethal public health issue.”104 The support for large protests drew charges of hypocrisy from critics who said experts were calling for bans on mass gatherings such as protests against COVID restrictions — unless the cause was one they supported.

Some saw a difference. “The anti-lockdown demonstrations were explicitly at odds with public health, and experts had a duty to oppose them,” epidemiologists Julia Marcus and Gregg Gonsalves wrote in June. “The current protests, in contrast, are a grassroots uprising against systemic racism, a pervasive and long-standing public health crisis that leads to more than 80,000 excess deaths among Black Americans every year.”105

Black, Indigenous, and Hispanic Americans are more likely to contract COVID-19 and are more than three times more likely to die from it than non-Hispanic whites.106 Even during the pandemic, mortality rates and life expectancy remained better for whites than they were for Black people during normal times, according to a study published in August by University of Minnesota sociologist Elizabeth Wrigley-Field.107

Dangerous Winter

Much of the country has grown weary of restrictions that have impeded social lives and the economy for months. Protests against government mandates continue to occur not only in the United States but Europe. Universal mask-wearing could save 130,000 lives by March, according to the National Institutes of Health, but masks have become a charged political symbol.108

During earlier pandemics, scientists did not have to contend with misinformation spreading rapidly through social media. “Go on social, you'll find people who'll tell you that this is a hoax,” says Castrucci, of the de Beaumont Foundation. “This is really the first time that, much more universally, you are confronting science with the thing that the guy who barely graduated high school said on Facebook.” (A Cornell University study found that Trump was likely the biggest driver of misinformation about the coronavirus in English-language media.109)

Most governors have issued statewide mask mandates, but a few have held out. Tennessee Gov. Bill Lee, a Republican, allows counties to set their own requirements. “At the end of the day, personal responsibility is the only way. People will either choose or not choose to socially distance,” Lee told reporters in October. “Or choose to wear a mask or not. They will choose to make that personal decision. What we can do is to remind them … that personal responsibility can protect them.”110

Getting the balance right between protecting communities and respecting individual rights and decision-making remains a challenge. After Republican Gov. Charlie Baker of Massachusetts required residents to wears masks anytime they leave the house, regardless of their distance from other people, Harvard epidemiologist Julia Marcus warned that Baker's order could erode public trust, since most transmission occurs indoors. “I think a mandate like this — that people know is arbitrary — is going to do more to reduce trust than it will to reduce infections,” she said.111

Hundreds of beachgoers enjoy the sun at the M Street Beach in Boston in July. While public health officials stressed the need to wear masks, practice social distancing and avoid large groups, their message was undermined by political bickering. (Getty Images/The Boston Globe/Matthew J. Lee)

With coronavirus cases reaching record levels — topping 100,000 day for the first time on Nov. 4 — and spreading all over the country, many political leaders are looking for ways to slow the spread.112 It seems unlikely that most states will return to the restrictions of the spring, when residents were ordered to stay home except for essential purposes such as grocery shopping. Various governors have recently tightened restrictions on capacity at indoor venues or closed bars and restaurants altogether.

The disease's most rapid prior spread took place at the end of spring. All year, health officials have warned about the coronavirus turning even deadlier during the winter. (During the Spanish flu pandemic, a so-called second wave in the fall was much deadlier than the initial spring outbreaks.) “We've got to get [the case count] down or otherwise, we're going to have a very tough winter in the next few months,” Fauci said in October.113

Doctors are pleading with Americans to get flu shots to avoid overlapping cases that would further strain the health system. Countries in the Southern Hemisphere largely avoided bad flu seasons, thanks to masks and distancing that kept flu viruses from spreading.114

In the United States, there are doubts about whether most people will remain vigilant, keeping themselves, their loved ones and their communities safe in anticipation of a possible vaccine in the spring, or whether pent-up demand for travel and family visits during the holiday season will worsen the spread.

“For many people, ‘home for the holidays’ doesn't have quite the same ring when we've been stuck at home with one another for nine months and our worlds have gotten much smaller,” wrote psychologist Maggie Mulqueen. “Ironically, ‘any place but home’ is the Christmas wish for some.”115

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Outlook

The Future of Public Health

Biden said he will urge governors, mayors and county executives to require masks within their jurisdictions.116 Like Trump, however, Biden may find that governors from the other party are not anxious to take his lead on restrictions.

“We live in a very politicized environment where people's perspectives on everything are influenced by their political affiliation,” says Auerbach, of the Trust for America's Health. “I think there will be some challenges, regardless of who's president, in reassuring the general public.”

Despite short-term fears about the holidays and winter months, most public health officials are confident the country will return to a more normal footing, with a vaccine or multiple vaccines likely to be widely available in 2021.

Every pandemic ends. The question is what this one has done to the field of public health. Even before COVID-19 struck, surveys indicated that roughly half of public health workers planned to leave their jobs within the next five years.117 The pandemic has been stressful for the field, with officials facing new levels of personal attacks and threats.

Plescia, of the Association of State and Territorial Health Officials, says the coronavirus pandemic has demonstrated the importance of public health and could help draw young people with a “social conscience” into the field. Applications for master's degree programs in public health have surged this year by 20 percent or more, according to the Association of Schools and Programs of Public Health.118 “If you're a progressive person who wants to change things for society and particular groups who aren't treated fairly or equally, it can be a very rewarding place to work,” Plescia says.

Attracting more people will require new incentives, as well as improvements in management and technology, says Watson, the Johns Hopkins public health professor. “As public health experts, we have to use this moment,” she says. “If we are too exhausted at the end and don't reimagine how to make public health function for emergencies and ongoing challenges, the moment could pass us by.”

Plescia predicts that the next Congress will want to do something big about public health, not just responding to immediate needs but rethinking the system.

Public health advocates argue that the traditional boom-and-bust cycle of funding their field in response to crises has to end.

“We have a lot of ideas about what works and need to put money behind it to have a sustainable system,” says Benjamin of the American Public Health Association. “If we rebuild it, it will be cheaper in the long run, and we can have a very robust system. We'll all be much healthier and all be much safer.”

Like other health veterans, Benjamin is nervous that politicians will decide instead to “muddle along,” spending money only when the next infectious disease outbreak occurs, or after deaths increase from some novel problem along the lines of opioid addiction. “We'll have a lot of people who die or get sick,” he says.

People in public health have seen this play out before, but they are still surprised that a pandemic that has killed a quarter of a million Americans and counting has not led to widespread, if not universal, calls to fund public health in the same consistent way national defense is funded, even during peacetime.

If the coronavirus pandemic does not convince policymakers of the need to take these issues seriously, Castrucci says, there may be an even heavier price to pay in the future.

“The only thing that helped us in the COVID pandemic was that the mortality rate was low,” he says. “Next time, we may not get so lucky. Play out a disease with a 25 percent mortality rate and then come tell me if we need to fund public health.”

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Pro/Con

Should a coronavirus vaccine be mandatory?

Pro Lauren S. Grossman, M.D. Faculty, University of Colorado School of Medicine, Department of Emergency Medicine. Written for CQ Researcher, November 2020 Our immune system is our best natural defense against the coronavirus, but it needs practice before it can best protect people. That preparation is a vaccination, which primes your immune system in a predictable way. Yet surveys show that more than a third of Americans would refuse to be vaccinated against COVID-19. That is no surprise. In three decades as an emergency room doctor, I've heard all manner of explanations for avoiding vaccinations. Some are afraid, a few paranoid; some are philosophically opposed, others lazy. A small number cannot take some vaccinations because of medical conditions. That is why a national policy requiring a COVID vaccination is our best chance to return to a robust lifestyle. At least 60 to 70 percent of Americans must be vaccinated to get even close to the herd immunity that quells virus spread. Waiting for herd immunity through natural exposure would take years, if ever. To date, fewer than 10 percent have developed antibodies to COVID. An effective vaccination given to most of the population, inducing an immune response in 50 to 70 percent of recipients, protects us from being infected and stops us from spreading the virus. Despite many Americans' fears, vaccinations are typically quite safe. One in thousands to one in a million have a serious adverse reaction. In contrast, vaccinations prevent 2 million to 3 million deaths worldwide while 1.5 million people die from vaccine-preventable diseases. And even if a treatment for COVID becomes available, it does not always mean a cure. In fact, there appear to be several serious complications of COVID even for those who had a mild case initially. And while more are wearing a mask, it is difficult to do consistently along with social distancing and regular hand-washing. Are Americans willing and able to commit to these practices for years to come? Without a national policy, we will remain isolated, as individuals and as a country, and stifle our American way of life. Mandates are not new. Schoolchildren, health care workers and the military must be vaccinated. The Supreme Court has upheld vaccination requirements. Would requiring a coronavirus vaccination be so different from a mandatory evacuation from wildfire? In any mandate, individuals can opt out, but articulating the expectation that all will participate is different from making it voluntary. A Revolutionary War patriot once exclaimed: “Live free or die.” In the case of COVID, it's “Live free and die.” We need a national mandate.

Con Barbara Loe Fisher Co-founder and President, National Vaccine Information Center. Written for CQ Researcher, November 2020 Measures taken by public health officials to slow the spread of COVID-19 have been extraordinary and unprecedented. In light of widespread unemployment, loss of small businesses, personal bankruptcies and impacts on mental health, the question about whether all the measures were necessary will be debated for years to come. That debate is now being eclipsed by another: Should new COVID-19 vaccines be mandated for everyone? To answer that question, we have to consider the 0.6 percent infection mortality rate of COVID-19, which is near the bottom of the infectious disease mortality scale. It is not like Ebola, which has a 50 percent mortality rate, or smallpox at 30 percent, or tuberculosis, which has mortality rates of 20 to 70 percent in some countries even today. Individuals at the highest risk for complications of COVID-19 are those who are over age 65 or suffering with one or more chronic health conditions, while the virus is far less likely to harm children or healthy adults. Scientists are still arguing about the origin of the mutated coronavirus; whether the lab tests for infection or immunity are accurate; whether the presence of T-cells or antibodies in the blood are markers of immunity and how long immunity lasts; and what exactly being asymptomatic means. Yet, in the absence of certain knowledge, COVID-19 vaccines are being rushed to market by pharmaceutical companies, which have been granted a total liability shield from lawsuits if the vaccines cause injury or death. According to surveys, up to two-thirds of Americans plan to decline or are worried about getting injected with a vaccine containing lab-altered parts of a new virus that scientists admit they still do not know that much about — vaccines that preliminary clinical trials have revealed may well cause more than just a few minor reactions. Doctors will not be able to reliably predict who is genetically or otherwise biologically at risk for harm. There is no civil liberty more fundamentally a natural, inalienable right than the freedom to decide for what reason we are willing to risk our life or our child's life. That is why voluntary, informed consent to medical risk-taking has been defined as a human right governing the ethical practice of modern medicine. Use of coercion and societal sanctions to force people to use vaccines destroy public trust in the integrity of medical practice and public health laws. COVID-19 vaccines should not be mandated.

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Short Features

Public Health Officials Face Growing Abuse

In June, Dr. Amy Acton stepped down as director of the Ohio Department of Health. Although praised in some quarters for her handling of the coronavirus pandemic, Acton was also subjected to harsh criticism, receiving death threats and experiencing armed protesters appearing outside her home.1 All that, coupled with the endless hours on the job, simply proved to be too much for her.

In September, Ohio Republican Gov. Mike DeWine announced that Dr. Joan Duwve, a top public health official in South Carolina, would replace Acton. Within hours, though, Duwve backed away, citing the treatment Acton had experienced. “In conversations preparing for the transition to the Ohio Department of Health, I was informed that the former director's family had faced harassment from the public,” Duwve said. “My family is off limits.”2 Finally, in November, DeWine appointed Stephanie McCloud, an attorney who had been running Ohio's workers' compensation program, to replace Acton.3

Ohio Department of Health Director Dr. Amy Acton was the target of a protest in Columbus, Ohio, in April. Acton stepped down two months later after receiving death threats and having armed protestors come to her home. (AFP/Getty Images/Megan Jelinger)

The situation in Ohio is not unique. At a time when there are yard signs all over the country thanking health care workers for their efforts during the pandemic, people working on public health policy — from Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, on down — have received death threats.4 The threats “started last month, during a COVID-19 Facebook Live public briefing when someone very casually suggested that I should be shot,” Barbara Ferrer, director of the Los Angeles County Department of Public Health, said in June.5

They have been subjected to anti-Semitic or transphobic slurs. “While these individuals may think they are only expressing their displeasure with me, they are in fact hurting the thousands of LGBTQ Pennsylvanians who suffer directly from these current demonstrations of harassment,” said Dr. Rachel Levine, the commonwealth's health secretary, in July.6

In September, California Democratic Gov. Gavin Newsom signed an executive order allowing health officials to keep their home addresses confidential, a protection previously afforded to victims of domestic abuse and stalking.7 The combination of harassment, threats, burnout from long hours and the lack, in some cases, of support from elected officials has led more than 70 state and local health officials to resign, retire or be forced out since April, according to Kaiser Health News. 8

Public health officials say they do not claim perfection, acknowledge they are learning about the coronavirus along the way, and understand that policymakers must balance health concerns with other priorities such as economic fallout and budgets. But people in the field say they have never encountered a level of vituperation to match the current situation.

“Whether it's nationally or locally, many people view the pandemic we're experiencing as a political issue, rather than a public health issue,” says Dr. Mysheika Roberts, health commissioner for the city of Columbus, Ohio. “We were put in the spotlight, and we are the bad guys.”

Having top health officials quit in the middle of a pandemic is an obvious and serious problem. Roberts notes that people who combine health expertise with administrative skill are not readily replaced. She says that three years after she ascended to her current position after serving as Columbus' chief medical officer, her old job still has not been filled.

“I've heard from a few who departed that they're concerned there isn't the ability to bring in people behind them who have the skill sets,” says Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials. “These jobs can't look that attractive right now. If you're a state health official, you're going nonstop every day, your staff is exhausted, there are nasty people sending threats.”

People working in public health have been subject to heated complaints in the past, from AIDS activists protesting at their offices to getting blowback from individuals angry about fluoridated water or smoking bans. Still, there is a widely shared feeling in the field that things have gotten out of hand this year. For a few individuals angry about the pandemic and the restrictions it has placed on their normal activities, “shoot the messenger” has become dangerously close to a literal idea.

“It's a really bleak time right now for people who are working so hard in public health,” says Crystal Watson, a senior scholar at Johns Hopkins University's Center for Health Security. “Not only are they not getting credit, they're being actively punished for the work that they're doing.”

For all the sense of unease in the field, state and local health officials are grateful to have received support from most residents in their areas, says John Auerbach, president of the Trust for America's Health, a Washington nonprofit that advocates for public health funding. “Polling shows this,” he says. Residents are “grateful that people are helping to keep their grandparents alive and keep their children safe.”

Still, Auerbach and others are troubled that at a moment when the value of public health should be highlighted, it has run into such loud and sometimes angry opposition. He worries that the experience of the pandemic, rather than inspiring people to enter the field, might scare them off. “We don't want to get to a point where people are fearful of going into the profession because, at the point where they're carrying out their duties, they won't be supported,” he says.

— Alan Greenblatt

[1] Jackie Borchardt and Jessie Balmert, “First came the pandemic, then came the politics: Why Amy Acton quit,” Cincinnati Enquirer, June 12, 2020, https://tinyurl.com/yxmuc4em.

[2] “‘My family is off limits.’ Dr. Joan Duwve backs out as ODH director, citing harassment directed at Acton,” WHIO, Sept. 10, 2020, https://tinyurl.com/yxpcnhcf.

[3] Hope Sloop, “Governor Mike DeWine names Stephanie McCloud to fill position of Ohio Department of Health Director,” WKYC, Nov. 5, 2020, https://tinyurl.com/y24g8npa.

[4] Michelle M. Mello, Jeremy A. Greene and Joshua M. Sharfstein, “Attacks on Public Health Officials During COVID-19,” Journal of the American Medical Association, Aug. 5, 2020, https://tinyurl.com/y5yrqe69.

[5] Julie Bosman, “Health Officials Had to Face a Pandemic. Then Came the Death Threats,” The New York Times, June 22, 2020, https://tinyurl.com/ybjbcd8m.

[6] Tim Fitzsimons, “Pa. health secretary on transphobic attacks: ‘Our children are watching,’” NBC News, July 29, 2020, https://tinyurl.com/y5z4lwbl.

[7] Anna Maria Barry-Jester, “California Expands Privacy Protection to Public Health Workers Amid Threats,” Kaiser Health News, Sept. 24, 2020, https://tinyurl.com/y2m6uyzp.

[8] Lauren Weber, Twitter post, Nov. 5, 2020, https://tinyurl.com/y2gakt56.

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Skepticism May Undermine COVID-19 Vaccine's Effectiveness

With roughly 180 different coronavirus vaccines in development around the world, some in the late stages of testing, one or more might be widely available in a matter of months, easily breaking records for vaccine development. That does not mean all Americans will line up to take it.

A survey released in September by the Pew Research Center found that barely half of Americans (51 percent) would definitely or probably take a COVID-19 vaccine.9 That share was down from 72 percent in a Pew survey in May.

Such polls reflect a distrust in government and the politicization of science, says Brian Castucci, president of the Bethesda, Md.-based de Beaumont Foundation, which supports programs that promote healthy communities. “You've seen a shift from those who were vaccine-compliant,” he says. “The danger is those who didn't hold anti-vax perspectives prior to this now are saying they wouldn't take the COVID vaccine.”

As the pandemic has worn on, views about a coronavirus vaccine increasingly have broken along partisan lines. The debate became part of the presidential campaign, with President Trump repeatedly insisting a vaccine would be available quickly. “We remain on track to deliver a vaccine before the end of the year and maybe even before November 1st,” he said on Sept. 4. A Kaiser Family Foundation Health Tracking Poll conducted the following week found that 62 percent of Americans worried Trump would pressure the Food and Drug Administration to release a vaccine prematurely.10

The Democratic nominees for president and vice president, Joe Biden and Kamala Harris, echoed that concern, although ultimately no vaccine was approved ahead of the election. “Let me be clear: I trust vaccines,” Biden said in September. “I trust scientists. But I don't trust Donald Trump, and at this moment, the American people can't either.”11

As it happened, Pfizer announced it would seek federal approval for a promising vaccine just after the election, on Nov. 9. The drugmaker, which did not take federal funding from Trump's vaccine development program known as Operation Warp Speed, said it hopes to put its vaccine into mass production by March. A second drugmaker that did accept significant federal funding, Moderna, announced promising early results from trials of its vaccine on Nov. 16.12

Two women hold anti-vaccination signs at the Washington state Capitol in Olympia in May. A survey by the Pew Research Center in September found that only 51 percent of adults would probably or definitely take a COVID-19 vaccine. (AFP/Getty Images/Jason Redmond)

As Castucci notes, many people distrusted vaccines well before the pandemic began. Some parents worry that children are being forced to take too many vaccines too fast. There is opposition from both the right and left, with different factions worried about personal liberties or the purity of the drugs involved. Vaccine skeptics have staged demonstrations this year in California, Colorado, Connecticut, Massachusetts, New Jersey and other states.

Protests against vaccines are as old as vaccines themselves, says Dr. Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia. “The first vaccine was in the late 1800s and that was the beginning of the first anti-vaccine movement,” he says. “People didn't like being required to get a smallpox vaccine.”

Over time, vaccines helped eradicate smallpox and greatly reduce other scourges such as polio and diphtheria. When measles outbreaks occurred during the 1970s, Offit says, states began to require that schoolchildren receive vaccines to prevent that disease and other illnesses, but nearly every state allowed exemptions for religious or philosophical reasons. “There were enough people who were choosing to exempt themselves from vaccines that diseases came back,” he says.

If a large enough share of a population is vaccinated, it can help create what is called herd immunity, offering protection even to those not vaccinated because it is more difficult for the disease to spread. The percentage that must be vaccinated to achieve herd immunity varies depending on the disease and the effectiveness of a particular vaccine.13

Due to recent outbreaks of measles and other diseases, a growing number of states have ended most exemptions. But they have encountered heated opposition. Health experts such as Offit have received death threats, while some state lawmakers have been harassed or even physically accosted.

“They are generally the most aggressive, hostile, rudest and threatening group of people I have ever experienced as a legislator,” said Bob Duff, Democratic leader of the Connecticut Senate, after needing a security escort to leave a February forum on the issue.14

Parents with children on the autism spectrum have expressed concern about links to vaccines that had thimerosal, a preservative that contained mercury, as well as about the measles-mumps-rubella, or MMR, vaccine. But studies have shown thimerosal, which is no longer used in childhood vaccines, was safe and not linked to autism. Similarly, a widely noted MMR study that purported to show such a link has been withdrawn and debunked.15

Out of 3.7 billion vaccine doses administered between 2006 and 2018, the U.S. Department of Health and Human Services has determined that there might have been an injury in fewer than 800 cases.16 “The choice not to get a vaccine is not a no-risk choice,” Offit says. “It creates different and more serious risks.”

But concerns about vaccines have, if anything, intensified during the pandemic. Anti-vaccine activists have helped organize statehouse protests against business shutdowns and other public health measures.17

“I'm not anti-vaccine,” Joshua Dunsky said during an August protest against a student flu vaccine mandate in Massachusetts. “I'm anti the government telling me what I can or what my child can do with our bodies.”18

While it was Democrats who worried that the Trump administration was rushing development for political reasons, it remains to be seen whether Republicans will be more trusting during a Biden administration.

“We know the flu vaccine is safe and healthy and effective, and yet people don't get it,” says Dr. Mandy Cohen, secretary of the North Carolina Department of Health and Human Services. “Transparency and building trust are going to be so important.”

— Alan Greenblatt

[9] Alec Tyson, Courtney Johnson and Cary Funk, “U.S. Public Now Divided Over Whether To Get COVID-19 Vaccine,” Pew Research Center, Sept. 17, 2020, https://tinyurl.com/yye63dkf.

[10] Tara Law, “More Than Half of Americans Worry That White House Pressure Will Lead to a Rushed Coronavirus Vaccine,” Time, Sept. 11, 2020, https://tinyurl.com/yxqdpklf

[11] Sydney Ember, “Biden, Seizing on Worries of a Rushed Vaccine, Warns Trump Can't Be Trusted,” The New York Times, Sept. 16, 2020, https://tinyurl.com/y6py4r8y.

[12] Katie Thomas, David Gelles and Carl Zimmer, “Pfizer's Early Data Shows Vaccine Is More Than 90% Effective,” The New York Times, Nov. 9, 2020, https://tinyurl.com/y3pa2hxv; Denise Grady, “Early Data Show Moderna's Coronavirus Vaccine is 94.5% Effective,” The New York Times, Nov. 16, 2020, https://tinyurl.com/yxlxpbp6.

[13] “Herd immunity and COVID-19 (coronavirus): What you need to know,” Mayo Clinic, June 6, 2020, https://tinyurl.com/yca5fyun.

[14] Ken Dixon, “Taking shots at anti-vax crowd in CT,” New Haven Register Citizen, March 1, 2020, https://tinyurl.com/y5vnsds8.

[15] Anjali Jain et al., “Autism Occurrence by MMR Vaccine Status Among US Children With Older Siblings With and Without Autism,” Journal of the American Medical Association, April 21, 2015, https://tinyurl.com/y3xn78eh.

[16] “Data & Statistics,” Health Resources Services Administration, November 2020, https://tinyurl.com/y9jeunej.

[17] Nicholas Bogel-Burroughs, “Antivaccination Activists Are Growing Force at Virus Protests,” The New York Times, May 2, 2020, https://tinyurl.com/y7rvkb6q.

[18] Erin Tiernan, “Hundreds protest new student flu vaccine mandate at State House,” The Boston Herald, Aug. 30, 2020, https://tinyurl.com/y4gvqapo.

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Bibliography

Books

Honigsbaum, Mark , The Pandemic Century: One Hundred Years of Panic, Hysteria and Hubris , Norton, 2019. A medical historian at City University of London tells the story of multiple epidemics in the United States from the Spanish flu to Zika, including a forgotten 1924 plague outbreak in Los Angeles and the “great parrot fever pandemic” of 1929-30.

MacKenzie, Debora , COVID-19: The Pandemic That Never Should Have Happened and How to Stop the Next One , Hachette Books, 2020. The danger of viral outbreaks has been clear for years, yet governments failed to prepare properly and ignored guidance from the World Health Organization as the coronavirus spread, according to a science journalist.

McCoy, Charles Allan , Diseased States: Epidemic Control in Britain and the United States , University of Massachusetts Press, 2020. The United States was slow to create a comprehensive health system and generally favored quarantine and other control measures to combat infectious disease, as opposed to the British method of addressing sanitation and overall living conditions, a sociologist at SUNY-Plattsburgh finds.

Spinney, Laura , Pale Rider: The Spanish Flu of 1918 and How It Changed the World , PublicAffairs, 2017. A science journalist compiles a narrative history of the disease that infected one-third of the world's population and killed an estimated 50 million.

Articles

Baumann, Jeannie , “Decades of Yo-Yo Funding Hampering Covid-19 Response,” Bloomberg Law, June 9, 2020, https://tinyurl.com/yybe6pm9. Public health advocates complain that decades of underfunding have left health departments without the personnel or tools they needed to respond to the coronavirus pandemic.

Bogel-Burroughs, Nicholas , “Antivaccination Activists Are Growing Force at Virus Protests,” The New York Times, May 2, 2020, https://tinyurl.com/y7rvkb6q. Vaccine skeptics have helped organize protests against shutdown measures in response to COVID-19, prompting concerns among public health officials who view them as promoting individual liberty at the expense of the greater good.

Mooney, Chris, Sarah Kaplan and Juliet Eilperin , “In the U.S., states — not science — decide what counts as a coronavirus outbreak,” The Washington Post, Oct. 7, 2020, https://tinyurl.com/y4f883nb. The nation has had a patchwork response to the pandemic, with states differing in approach and even definitions of medical concepts.

Smith, Michelle R., and Lauren Weber , “Public Health Officials Are Quitting or Getting Fired in Throes of Pandemic,” Kaiser Health News, Aug. 11, 2020, https://tinyurl.com/y3knnj3d. Public health officials have been second-guessed by politicians and confronted by members of the public, leading dozens of them to quit their jobs.

Sun, Lena H., and Joel Achenbach , “CDC's credibility is eroded by internal blunders and external attacks as coronavirus vaccine campaigns loom,” The Washington Post, Sept. 28, 2020, https://tinyurl.com/y32sjjlc. Internal blunders and political interference have marred the response of the U.S. Centers for Disease Control and Prevention (CDC) to the pandemic.

Thompson, Derek , “The COVID-19 Fall Surge Is Here. We Can Stop It,” The Atlantic, Oct. 12, 2020, https://tinyurl.com/y26mg6z2. Lessons from Asian countries that emphasized universal mask-wearing, aggressive testing and tracing and science-based communication can help the United States avoid a deadly winter, health experts say.

Yong, Ed , “America Is Trapped in a Pandemic Spiral,” The Atlantic, Sept. 9, 2020, https://tinyurl.com/yxrpoulh. The country keeps repeating the same mistakes: Partisans embrace different approaches while the nation seems unable to come up with a long-term strategy to minimize the coronavirus risk.

Reports and Studies

Buxbaum, Jason D. , et al., “Contributions Of Public Health, Pharmaceuticals, And Other Medical Care To US Life Expectancy Changes, 1990-2015,” Health Affairs, September 2020, https://tinyurl.com/y69oqxg7. Life expectancy in the United States increased 3.3 years between 1990 and 2015. Nearly half that increase was due to advances in public health, with pharmaceuticals also playing a big role, according to researchers at Harvard University and the University of Michigan.

Gadarian, Shana Kushner, Sara Wallace Goodman and Thomas B. Pepinsky , “Partisanship, Health Behavior, and Policy Attitudes in the Early Stages of the COVID-19 Pandemic,” Social Sciences Research Network, March 30, 2020, https://tinyurl.com/y3nncgay. A March survey of 3,000 American citizens found that political differences are the most consistent factor influencing their health behaviors and policy preferences.

Farberman, Rhea K. , et al., “The Impact of Chronic Underfunding on America's Public Health System: Trends, Risks, and Recommendations, 2020,” Trust for America's Health, April 2020, https://tinyurl.com/y3gwu82t. Public health funding levels heading into the pandemic were mixed at the state and federal levels. A long-term commitment is needed to recover from decades of underfunding, an advocacy group concludes.

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The Next Step

Funding

Lavita, Angelica, and John Tozzi , “Amid Hope for Pfizer Vaccine, States Grapple With Distribution,” Bloomberg, Nov. 10, 2020, https://tinyurl.com/y4f8b6vd. States are asking the federal government to provide more funding for facilitating the distribution of a potential COVID-19 vaccine.

Morse, Susan , “Facing COVID-19 surges, hospitals want additional money for the provider relief fund,” Healthcare Finance, Nov. 12, 2020, https://tinyurl.com/yx8ofnnr. The American Hospital Association is calling for additional money for COVID-19 relief, as well as support for health care workers and coverage for the uninsured.

Werner, Erica , “Democrats' ambitious agenda for 2021 runs into unexpected obstacle — McConnell's resilience,” The Washington Post, Nov. 5, 2020, https://tinyurl.com/yxeupgdm. Democrats are concerned that a Republican majority in the Senate could thwart future COVID-19 relief and plans to expand the Affordable Care Act.

Non-COVID-19 Conditions

Flanagan, Cristin, and Michelle Fay Cortez , “Less Effective Flu Shot Poses New Risk for Hospital Operators,” Bloomberg, Nov. 12, 2020, https://tinyurl.com/y4czvadw. Some evidence suggests this year's flu vaccine will be less effective than usual, but demand is very high for the injection.

Mascarenhas, Lauren , “Drop in non-coronavirus hospitalizations suggests people are skipping key medical care,” CNN, Oct. 26, 2020, https://tinyurl.com/yypvzk45. A new study found that far fewer patients were hospitalized for heart attacks and appendicitis during the height of the pandemic in New York City this spring, suggesting that people were forgoing necessary medical care.

Rosenbaum, Eric , “A Covid-19 surge of depression and anxiety is being treated by robots,” CNBC, Nov. 11, 2020, https://tinyurl.com/yy5o8fq9. Demand for mental health services during the pandemic is outstripping the availability of mental health professionals, and new artificial intelligence technology is being designed to help close the gap.

Politics and Public Health

Alexander, Harriet , “‘Really kind of unusual’: Fauci responds to Bannon calling for his beheading,” The Independent, Nov. 12, 2020, https://tinyurl.com/y6bxz27c. Former Trump White House official Steve Bannon called for Dr. Anthony Fauci to be beheaded on a podcast, which the infectious disease expert called “unusual.”

Allassan, Fadel , “Cuomo on Biden win: ‘The political pressure of denying COVID is gone,’” Axios, Nov. 8, 2020, https://tinyurl.com/y363rezh. New York Gov. Andrew Cuomo, a Democrat, predicted politicians would use a “different tone” when discussing the coronavirus once President Trump had left office, suggesting there would be less political pressure to deny the severity of the virus.

Feuer, Will , “Biden Covid advisor says U.S. lockdown of 4 to 6 weeks could control pandemic and revive economy,” CNBC, Nov. 11, 2020, https://tinyurl.com/y4jsfwpt. A coronavirus adviser to President-elect Joe Biden, Dr. Michael Osterholm, said a temporary nationwide shutdown, coupled with legislation to cover lost income for individuals, states and businesses, could bring the virus under control. He later explained that he had not recommended that Biden's virus task force call for a lockdown and that the group has not discussed it.

Vaccines

Domm, Patti , “Vaccine news unleashes new momentum in stock market as hunkered-down investors flee cash,” CNBC, Nov. 9, 2020, https://tinyurl.com/yxuva9sc. Pfizer's announcement that its COVID-19 vaccine showed great promise triggered a broad stock market rally — although share prices for companies such as Netflix and Zoom that have experienced greater usage during the pandemic fell.

Robbins, Rebecca, and David Gelles , “How Pfizer Plans to Distribute Its Vaccine (It's Complicated),” The New York Times, Nov. 12, 2020, https://tinyurl.com/y6b5tvmg. If approved by the Food and Drug Administration, Pfizer's vaccine will be distributed nationwide via networks of companies, federal and state agencies and health workers.

Szabo, Liz, and JoNel Aleccia , “Covid-19 vaccine may have unpleasant side effects. That will mean it's working,” NBC News, Nov. 12, 2020, https://tinyurl.com/yyy6f44p. Pfizer warned that its vaccine may have unpleasant side effects, including sore arms, muscle aches and fever, that could last for days.

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Contacts

American Public Health Association
800 I St., N.W., Washington, DC 20001
202-777-2742
apha.org
An association that represents public health professionals and publishes periodicals, hosts meetings and conducts public awareness campaigns.

Association of State and Territorial Health Officials
2231 Crystal Drive, Suite 450, Arlington, VA 22202
202-371-9090
astho.org
A group that represents public health agencies in the United States and its territories.

Bloomberg School of Public Health
Johns Hopkins University, 615 N. Wolfe St., Baltimore, MD 21205
410-955-3543
jhsph.edu
One of the nation's leading public health training and research centers.

Center for Infectious Disease Research and Policy
University of Minnesota, 420 Delaware St., S.E., Minneapolis, MN 55455
612-626-6770
cidrap.umn.edu
An academic center that is devoted to addressing public health preparedness and emerging infectious disease response.

Centers for Disease Control and Prevention
1600 Clifton Road, Atlanta, GA 30329
800-232-4636
cdc.gov
The federal agency that tracks mortality and morbidity and works to protect Americans from health, safety and security threats.

de Beamont Foundation
7501 Wisconsin Ave., Suite 1310E, Bethesda, MD 20814
301-961-5800
debeaumont.org
An organization that provides financial support for programs and policies aimed at improving community health.

Robert Wood Johnson Foundation
50 College Road East, Princeton, NJ 08540
877-843-7953
rwjf.org
A foundation that is devoted solely to health, supporting programs and policies in areas such as insurance coverage, equity, communities, leadership and public health.

Trust for America's Health
1730 M St., N.W., Suite 900, Washington, DC 20036
202-223-9870
tfah.org
A nonprofit that conducts research and advocates for policies that support public health.

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Footnotes

[1] Corky Siemaszko, “Florida students head back to class amid reports of more kids catching COVID-19,” NBC News, Aug. 31, 2020, https://tinyurl.com/y3fddpxb.

[2] “In Interview, DeSantis Says Closing Florida Schools In Spring Was A Huge Mistake,” Health News Florida, Oct. 3, 2020, https://tinyurl.com/y4qr9qp3.

[3] Rachel DeSantis, “Fla. Teachers Union Sues Governor: ‘We Don't Want to Be the Petri Dish’ for Reopening Schools,” People, July 21, 2020, https://tinyurl.com/y2qjormx.

[4] Jennifer de Pinto and Fred Backus, “How Biden won the 2020 election: Exit poll analysis,” CBS News, Nov. 7, 2020, https://tinyurl.com/yxfu6tv9.

[5] “COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU),” Johns Hopkins University, accessed Nov. 18, 2020, https://tinyurl.com/rnjqnnh.

[6] Lenny Bernstein, Rachel Weiner and Joel Achenbach, “Coronavirus recommendations ignored as case numbers rise,” The Washington Post, June 15, 2020, https://tinyurl.com/ycnm2hvl.

[7] David U. Himmelstein and Steffie Woolhandler, “Public Health's Falling Share of US Health Spending,” American Journal of Public Health, January 2016, https://tinyurl.com/y3t5ctu4.

[8] Richard Read, “CDC acknowledges risk of coronavirus aerosols in new guidelines, then reverses course,” Los Angeles Times, Sept. 21, 2020, https://tinyurl.com/yyxn8pmp.

[9] Brett Murphy and Letitia Stein, “‘It is a slaughter’: Public health champion asks CDC director to expose White House, orchestrate his own firing,” USA Today, Oct. 6, 2020, https://tinyurl.com/y55ptsa2.

[10] Sheryl Gay Stolberg and Maggie Haberman, “‘We are entering the most concerning and most deadly phase of this pandemic,’ Birx wrote in a White House memo,” The New York Times, Nov. 2, 2020, https://tinyurl.com/y6g2ynow.

[11] Mike Baker, “As the Virus Rages, Some Are Convinced It's Too Late to Stop It,” The New York Times, Nov. 2, 2020, https://tinyurl.com/y2tzfxss.

[12] Kristi Noem, “GOV. NOEM: Update on South Dakota's COVID-19 response,” Rapid City Journal, Oct. 21, 2020, https://tinyurl.com/yyoar4qc.

[13] Jason Slotkin, “Protesters Swarm Michigan Capitol Amid Showdown Over Governor's Emergency Powers,” NPR, May 1, 2020, https://tinyurl.com/ybnr6rcm.

[14] Craig Mauger and Beth LeBlanc, “Trump tweets ‘liberate’ Michigan, two other states with Dem governors,” The Detroit News, April 17, 2020, https://tinyurl.com/y95tyzcm.

[15] Dave Boucher and Todd Spangler, “Michigan Supreme Court rules against Whitmer on emergency powers but effect unclear,” Detroit Free Press, Oct. 2, 2020, https://tinyurl.com/y4vhlymo.

[16] Nicholas Bogel-Burroughs, Shaila Dewan and Kathleen Gray, “F.B.I. Says Michigan Anti-Government Group Plotted to Kidnap Gov. Gretchen Whitmer,” The New York Times, Oct. 8, 2020, https://tinyurl.com/y5wtghzj; Katie Shepherd, “Trump coronavirus adviser tells Michigan to ‘rise up’ against new shutdown orders,” The Washington Post, Nov. 16, 2020, https://tinyurl.com/yxcklgns.

[17] Mark Z. Barabak, “More U.S. deaths than World War I and Vietnam: How COVID-19 compares with other deadly events,” Los Angeles Times, May 1, 2020, https://tinyurl.com/y5rjp2es.

[18] Jeannie Baumann, “Decades of Yo-Yo Funding Hampering Covid-19 Response,” Bloomberg Law, June 9, 2020, https://tinyurl.com/yybe6pm9.

[19] Debora MacKenzie, COVID-19: The Pandemic that Never Should Have Happened and How to Stop the Next One (2020), p. 41.

[20] Rhea K. Farberman et al., “The Impact of Chronic Underfunding on America's Public Health System: Trends, Risks, and Recommendations, 2020,” Trust for America's Health, April 2020, https://tinyurl.com/y3gwu82t.

[21] Lauren Weber, Laura Ungar and Michelle R. Smith, “Hollowed-Out Public Health System Faces More Cuts Amid Virus,” Kaiser Health News, July 1, 2020, https://tinyurl.com/yb3ltwwx.

[22] Baumann, op. cit.

[23] Michael Collins and David Jackson, “Trump says CDC Director Robert Redfield ‘confused’ about coronavirus vaccine, mask efficacy. Redfield responded,” USA Today, Sept. 16, 2020, https://tinyurl.com/y6f2nemm.

[24] Monica Alba, “Redfield voices alarm over influence of Trump's new coronavirus task force adviser,” NBC News, Sept. 28, 2020, https://tinyurl.com/yyj88ccc.

[25] Lena H. Sun and Joel Achenbach, “CDC's credibility is eroded by internal blunders and external attacks as coronavirus vaccine campaigns loom,” The Washington Post, Sept. 28, 2020, https://tinyurl.com/y32sjjlc.

[26] John Tozzi, “HHS Steered $700 Million From CDC to Fund Warp Speed Program,” Bloomberg, Sept. 16, 2020, https://tinyurl.com/yxuufav4.

[27] Rebecca Ballhaus and Stephanie Armour, “Health Chief's Early Missteps Set Back Coronavirus Response,” The Wall Street Journal, April 22, 2020, https://tinyurl.com/ydxw9p3b.

[28] Tim Elfrink, Ben Guarino and Chris Mooney, “CDC reverses itself and says guidelines it posted on coronavirus airborne transmission were wrong,” The Washington Post, Sept. 21, 2020, https://tinyurl.com/y5kmqtx2.

[29] Sun and Achenbach, op. cit.

[30] Liz Hamel et al., “KFF Health Tracking Poll — September 2020: Top Issues in 2020 Election, The Role of Misinformation, and Views on A Potential Coronavirus Vaccine,” Kaiser Family Foundation, Sept. 10, 2020, https://tinyurl.com/y67yk33g.

[31] Dorit Rubinstein Reiss, “Institutionalizing the Centers for Disease Control and Prevention's Independence,” ConLawNow, Aug. 27, 2020, https://tinyurl.com/y5wcuazd.

[32] Helen Branswell, “As controversies swirl, CDC director is seen as allowing agency to buckle to political influence,” STAT, Sept. 16, 2020, https://tinyurl.com/y2tfrcc7.

[33] Markian Hawryluk, “Health on Wheels: Tricked-Out RVs Deliver Addiction Treatment to Rural Communities,” Kaiser Health News, Sept. 28, 2020, https://tinyurl.com/y5ubnpn3.

[34] Mark É. Czeisler et al., “Delay or Avoidance of Medical Care Because of COVID-19 — Related Concerns — United States, June 2020,” Morbidity and Mortality Weekly Report, Sept. 11, 2020, https://tinyurl.com/yx9zaocf; Noah Taborda, “Women are skipping breast exams, fighting cancer complicated by COVID-19,” Kansas Reflector, Nov. 16, 2020, https://tinyurl.com/y5g3zsqo.

[35] Amy Sokolow, “Opioid overdoses have skyrocketed amid the coronavirus, but states are nevertheless slashing addiction treatment program budgets,” STAT, July 16, 2020, https://tinyurl.com/y9ulzxgz.

[36] Charles Allan McCoy, Diseased States: Epidemic Control in Britain and the United States (2020), p. 53.

[37] Ibid., p. 55.

[38] Ibid., p. 57.

[39] Laurie Garrett, Betrayal of Trust: The Collapse of Global Public Health (2000), p. 283.

[40] Ibid.

[41] Ibid., p. 288.

[42] Ibid., p. 283.

[43] McCoy, op. cit., p. 88.

[44] Garrett, op. cit., p. 290.

[45] George Rosen, A History of Public Health (1958), p. 247.

[46] McCoy, op. cit., p. 95.

[47] Ibid., p. 98.

[48] Ibid., p. 104.

[49] Garrett, op. cit., p. 286.

[50] Laura Spinney, Pale Rider: The Spanish Flu of 1918 and How It Changed the World (2017), p. 27.

[51] Ibid., p. 28.

[52] MacKenzie, op. cit., p. 42.

[53] “Achievements in Public Health, 1900-1999: Control of Infectious Diseases,” Morbidity and Mortality Weekly Report, July 30, 1999, https://tinyurl.com/hjlmcza.

[54] “Life expectancy at birth, at 65 years of age, and at 75 years of age, by race and sex: United States, selected years 1900-2007,” CDC, 2010, https://tinyurl.com/y55ha3kd.

[55] Garrett, op. cit., p. 300.

[56] Lawrence O. Gostin, “Jacobson v Massachusetts at 100 Years: Police Power and Civil Liberties in Tension,” American Journal of Public Health, April 2005, https://tinyurl.com/yxqngzs9.

[57] “A Century of U.S. Water Chlorination and Treatment: One of the Ten Greatest Public Health Achievements of the 20th Century,” CDC, Nov. 26, 2012, https://tinyurl.com/y8v545k6.

[58] Spinney, op. cit., p. 4.

[59] Melissa August, “The 1918 Flu Pandemic Killed Hundreds of Thousands of Americans. The White House Never Said a Word About It,” Time, Aug. 11, 2020, https://tinyurl.com/yxsnttap.

[60] Catharine Arnold, Pandemic 1918: Eyewitness Accounts from the Greatest Medical Holocaust in Modern History (2018), p. 168.

[61] Ibid., p. 135.

[62] Ibid., p. 145.

[63] Mark Honigsbaum, The Pandemic Century: One Hundred Years of Panic, Hysteria and Hubris (2019), p. 50.

[64] Blythe Bernhard, “St. Louis saw the deadly 1918 Spanish flu epidemic coming. Shutting down the city saved countless lives,” St. Louis Post-Dispatch, March 28, 2020, https://tinyurl.com/y4xw66pf.

[65] Garrett, op. cit., p. 312.

[66] Ibid., p. 308.

[67] Ibid., p. 310.

[68] Ibid., p. 308.

[69] “The Tuskegee Timeline,” CDC, March 2, 2020, https://tinyurl.com/j7cuvwk.

[70] Isabel Wilkerson, Caste: The Origins of Our Discontents (2020), p. 147.

[71] Garrett, op. cit., p. 328.

[72] Honigsbaum, op. cit., p. 39.

[73] Ibid., p. 170.

[74] “Legionella: History, Burden, and Trends,” CDC, April 30, 2018, https://tinyurl.com/m36a98l.

[75] Honigsbaum, op. cit., p. 176.

[76] Ibid., p. 177.

[77] Matt Schudel, “David J. Sencer, CDC chief who resigned over swine-flu vaccine, dies at 86,” The Washington Post, May 4, 2011, https://tinyurl.com/yxruo5t5.

[78] Garrett, p. 381.

[79] Ibid., p. 383.

[80] Alan Greenblatt, “Why America's Public Health Has Always Been Fragmented,” Governing, May 13, 2020, https://tinyurl.com/y4ptugb5.

[81] Donald G. McNeil Jr., “‘We Loved Each Other’: Fauci Recalls Larry Kramer, Friend and Nemesis,” The New York Times, May 27, 2020, https://tinyurl.com/y8efnmdy.

[82] David France, How to Survive a Plague: The Inside Story of How Citizens and Science Tamed AIDS (2016), p. 193.

[83] Honigsbaum, op. cit., p. 199.

[84] Ibid., p. 198.

[85] Ali S. Khan, “Public health preparedness and response in the USA since 9/11: a national health security imperative,” The Lancet, September 2011, https://tinyurl.com/yxnrzzld.

[86] Jeanne S. Ringel and Jeffrey Wasserman, “The Public Health System a Decade After 9/11,” RAND, 2011, https://tinyurl.com/y3zxp88q.

[87] “The U.S. President's Emergency Plan for AIDS Relief (PEPFAR),” Kaiser Family Foundation, May 27, 2020, https://tinyurl.com/yyx7xuzx.

[88] Ibid.

[89] Paul Biasco, “All the things George W. Bush said we should do to prepare for a pandemic that Donald Trump ignored,” Business Insider, May 31, 2020, https://tinyurl.com/y47sxbcz.

[90] “House approves pandemic funding far below Bush request,” Center for Infectious Disease Research and Policy, Dec. 19, 2005, https://tinyurl.com/y5v7dumc.

[91] Randall R. Bovbjerg, Barbara A. Ormond and Timothy A. Waidmann, “What Directions for Public Health under the Affordable Care Act?,” Urban Institute, November 2011, https://tinyurl.com/y5fclbyn.

[92] Farberman et al., op. cit.

[93] “2009 H1N1 Pandemic (H1N1pdm09 virus),” CDC, June 11, 2019, https://tinyurl.com/t5f9ubr.

[94] Bill Gates, “We're not ready for the next epidemic,” Gates Notes, March 18, 2015, https://tinyurl.com/y39fg3uc.

[95] Jason Karlawish, “A pandemic plan was in place. Trump abandoned it — and science — in the face of Covid-19,” STAT, May 17, 2020, https://tinyurl.com/y9alvcwd.

[96] Camille Caldera, “Fact check: White House didn't fire pandemic response unit when it was disbanded in 2018,” USA Today, Sept. 10, 2020, https://tinyurl.com/y3en5x6l.

[97] Jason D. Buxbaum et al., “Contributions Of Public Health, Pharmaceuticals, And Other Medical Care To US Life Expectancy Changes, 1990-2015,” Health Affairs, Sept. 2020, https://tinyurl.com/y69oqxg7.

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About the Author

Alan Greenblatt is a staff writer at Governing magazine. Previously he covered politics and government for NPR and CQ Weekly, where he won the National Press Club's Sandy Hume Award for political journalism. He graduated from San Francisco State University in 1986 and received a master's degree in English literature from the University of Virginia in 1988. His CQ Researcher reports include “Trends in Philanthropy” and “Reparations for Slavery.”

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