Liberty and health?

Simplistic arguments pitting health against civil liberties have harmed our response to Covid-19 and prevent us from moving towards a healthier world.

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I was in New York City on September 11, 2001. I remember the event and its aftermath. I recall that the fear in the city was palpable. In the days after the attacks, I started to see this fear reflected at the national, political level, among lawmakers, and eventually in the laws they passed. The Patriot Act, passed with near-unanimous support in the Senate, emerged from this climate of fear. 

There is much about the Patriot Act which has since been rethought. It has been seen as at best an overreach and at worst Constitutionally dubious, leading to no-fly lists and the discriminatory targeting of Muslims. Given how controversial it has become, it is important to remember how reasonable the Act seemed at the time it was passed, how, gripped as we were by fear, we were able to see its broad provisions for the pursuit of terrorists as a rational response to the threat we seemed to face. 

Nearly two decades after September 11, 2001, March 2020 put us in a similar state of fear, with the emergence of a novel pathogen that would eventually reach a point where it would kill each day roughly as many Americans as 9/11 did. As the new coronavirus swept the world, the fear of it was amplified across a range of media. Headlines from that time reflect how quickly we came to see the virus as a threat:

“Experts worry about pandemic as coronavirus numbers increase: report,” in Fox News on February 3, 2020. 

“Coronavirus Spreads Outside China as Officials’ Worries Mount,” in The Wall Street Journal on February 24, 2020.  

“C.D.C. Officials Warn of Coronavirus Outbreaks in the U.S.,” in The New York Times on February 25, 2020.

These concerns led us to take drastic action to protect ourselves, and to help flatten the epidemic curve so that the virus would not overwhelm the capacity of our health systems. We embraced a widespread lockdown, effectively closing large segments of society in response to what we had come to realize was a looming global pandemic. Like the passage of the Patriot Act, this dramatic action seemed like a reasonable response, given the threat we appeared to face and our information at the time. In hindsight, it remains a sensible choice, in the context of the moment in which we made it. 

But that context soon changed. As we entered the summer of 2020 with the lockdowns largely still in place, we began to have conversations weighing their public health utility against their economic consequences (consequences which were themselves deeply significant for health—see prior writing on this). These conversations also included the issue of keeping schools closed, with the threat of the virus on one hand, and the long-term health consequences of disrupting students’ education on the other.   

As with any honest conversation about health, these discussions involved difficult tradeoffs. They represented an effort to find the “least-worst” options in a time of unprecedented challenge. Such conversations would be hard enough in a context of civility and mutual respect, and this was not the context in which they unfolded during Covid-19. It did not take long for these discussions to become politicized, vehemently so, with favoring lockdowns and mask-wearing viewed as a liberal position, and opposing such measures becoming identified with conservatives. Informing—and, indeed, inflaming—all of this were the words and actions of former President Trump. The White House’s messaging on the virus changed constantly, sometimes even minute-by-minute, as the President leaned into his strategy of governing by Tweet. Trump’s tendency to weigh in on everything, undercut the advice of experts, and project a cavalier approach to Covid-19 even when he himself caught it, helped ensure that the conversation about the hard choices necessary to address the pandemic would remain dysfunctional.

It is important to note that, while this conversation may have seemed superficially to be about civil liberties—i.e., how much constraint we are willing to accept in the name of health—this was not really what was happening. The public conversation was soon hijacked by simplistic reductions (“Masks are good!” “No, masks are bad!”) that left no room for the important, nuanced conversations we should have been having. Because let us face it—masks are a minor imposition. Steps like closing schools or shutting down the economy, on the other hand, are not. As long as we confuse the superficial with the substantive, we will find it difficult, if not impossible, to have the honest, adult conversations that need to happen to move us forward in a crisis.

All this messiness, all this polarization, threatened to obscure the fundamental question we should have been having in the conversation about the Covid-19 response: how far are we willing to go for health? What are we willing to give up to support a healthy population? And how do we define health anyways? Is health simply not being sick? Or is it a means to an end—the end of living a rich, full life, characterized by education, time with friends, and all the other benefits we must leave our protected bubbles to access? If it is the latter, then our conversation about health cannot just include how best to avoid disease. It must also include the complete range of resources which support a rich, full life. This means when we talk about health, we must also talk about where we live, work, and play; about money and education; about love, family, and compassion, and about the political forces that shape our society. These may seem like odd areas of focus for a health conversation. Yet they are, I would argue, central to health, which is why I have spent much of my career discussing them, most directly in my book, Well: what we need to talk about when we talk about health. Their importance is also implicit in the Constitution of the World Health Organization, which defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Addressing health at this level means having a conversation which addresses the conditions that shape it. In practice, this means engaging with the socioeconomic forces that influence health, to channel these forces in a healthier direction. This means pursuing health through political policy, corporate practices, and creating a culture of health, among other measures. Embracing such a broad remit can lead to charges of paternalism—a classic objection to public health measures. (See, for example, Christopher Hitchens’ 2004 Vanity Fair piece inveighing against the public health measures promoted by then-New York Mayor Michael Bloomberg.) There is deep resentment, particularly in the US, against measures seeming to come from on high which tell people what to do, or constrain liberty in the name of anything, even health. During Covid-19, the actions of many Americans seemed to reflect the words attributed to Patrick Henry, “Give me liberty, or give me death!” In shunning masks and physical distancing, and arguing against lockdowns, some Americans were acting from the mistaken belief that the pandemic was a hoax, or, at least, overblown. But many did indeed seem well aware of the risks and nevertheless preferred to live in proximity to peril rather than accept anything which seemed to constrain liberty, even the not-very onerous step of simply wearing a mask.    

Given the strength of this sentiment, it is important to have a conversation which addresses the paternalism charge directly, if we are to engage with health at the structural level and truly make it better. It is true that shaping a healthier world can sometimes mean the tradeoff of accepting certain constraints. But the fact is, we accept these tradeoffs all the time. Imagine, for example, a group of people all meeting together for a rally against masks and lockdowns. After it is over, when they all return to their cars to drive home, the vast majority of them will accept the slight constraint on individual liberty that comes with wearing a seatbelt for the ride. Or consider the uproar that happened in New York City some years back, when Mayor Bloomberg tried to limit the size of sugary drinks sold in the city, an initiative which was ultimately defeated. Did this mean that companies began serving beverages in bathtub-sized containers, as so many asserted it was in theory their right to do? Of course not. While places like fast food chains kept serving beverages in containers that contributed to the obesity epidemic, companies nevertheless continued to self-regulate container size. The point is that high-level choices are made all the time which constrain the choices of individuals in this country. We are just selective about which we choose to get upset about—a choice deeply shaped by the prerogatives of those who most influence the political conversation, as we saw during Covid-19. Meanwhile, these constraints continue to emerge—there is no way to have a society without them. Even if we swept away all laws, all regulations, all institutions in the US, we would still have—necessarily have—a border placing physical limits on our country’s expanse. Liberty needs limits in order to exist—without them, we would dwell in a state of nature, where our lives would be sharply constrained by all the depredations our modern society keeps at bay. So, accepting that some limits will always be necessary, there is no reason not to shape these limits in ways that are conducive to health—and much reason to do so.   

Core to these reasons is another kind of freedom, one that is different from the freedom to do whatever we want at all costs, even when the costs are sickness or death. It is “freedom from”—from preventable hazard, from poverty, from undue economic hardship, from the political, institutional, and cultural failures that let a pandemic rage unchecked. In short, freedom from poor health. In a sense, any conversation about “freedom from” is inseparable from a conversation about human rights. The Universal Declaration of Human Rights, proclaimed by the United Nations General Assembly in 1948, lists an expansive range of resources and conditions to which all people should have access. These include rights before the law, a right to marriage and family, right to political participation, to employment, to rest and leisure, to an adequate standard of living, to education, and more. These rights reflect the conditions that support health—that support freedom from disease and preventable harm. As much as any right we have to embrace risk, they are examples of liberty worth our collective pursuit.      

So, what does all this mean? It means we should indeed be having a robust conversation about the intersection of liberty and health, but that this conversation should always be informed by core values, by a desire to shape a world where we are truly free because we are truly healthy, and by a nuanced understanding of the tradeoffs involved in shaping such a world. This means striking a balance between freedom to risk and freedom from risk. In the US, this balance has long been elusive, as our idea of freedom has been tilted toward freedom to do whatever we want as individuals, rather than freedom from the threats that stop us from doing what we want by making us collectively unhealthy. In attempting to correct this imbalance, we should be mindful that we are working against powerful historic and cultural forces. A useful analogy may be Mexico’s handling of Covid-19, where the country declined to use what could be seen as “coercive” measures to enforce pandemic restrictions, out of concern they would bring up memories of decades of heavy-handed authoritarian rule. Yet our history is not entirely one of an approach to freedom which can threaten health. The US also has a rich history to draw on of ambitious federal initiatives aimed at promoting freedom from disease and want. The legacy of the New Deal and the Great Society show that the US can balance freedom with the common good. 

Unfortunately, the conversation about our pandemic response has not much engaged with the deeper historical forces at play, instead reflecting a crude partisan binary. We are either pro-indefinite lockdowns or we are virus denialists. This distinction is false, counterproductive, and does not reflect the unfolding circumstances of the pandemic. It is disheartening to think that the virus, with its various mutations, has evolved more nimbly than our capacity to talk honestly about it, but this is the reality. Many simply staked out their positions early in the pandemic and have not changed, even as circumstances which supported mass lockdowns in the beginning developed into the basis for a more nuanced approach to shutdowns and reopening, and our understanding of how the virus spreads coalesced behind the utility of wearing masks. Then there is our understanding of the economic costs of indefinite lockdowns, and how these costs would undermine health in the long-term. There are those, of course, who suggest the government should simply pay everyone enough to ameliorate these costs for the duration of such a lockdown. It would be nice if we could do so, but a realistic appraisal of the situation reminds us that such spending would not be sustainable, even in a country as wealthy as the US, and could open the door to another economic downturn, with consequences for health.

What we are left with, then, are necessary tradeoffs and our aversion to making them. It is a valid consideration, always, to think about how much we are willing to do for health, how much economic pain we are willing to take for the feeling of short-term security. This entails difficult choices, a willingness to be honest with ourselves about the data, and a less zero-sum understanding of freedom. Patrick Henry was wrong: the choice is not between liberty and death. There is a middle ground, supporting both liberty and health, and it is there for us to claim if only we are wise enough to see it. We need a health conversation which supports our ability to do so.

Sandro Galea, MD, DrPH, is Professor and Dean at the Boston University School of Public Health. His upcoming book, The Contagion Next Time, will be published in fall 2021. Subscribe to his weekly newsletter, The Healthiest Goldfish, or follow him on Twitter: @sandrogalea