Public health and the temptations of power

(Re)considering the influence of public health

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My kids and I have loved the musical Hamilton since its music was first released a few songs at a time. At one point, it seemed that my daughter had the entire music book memorized. One of the most memorable parts of the musical is the song “One Last Time.” In the song, President George Washington announces his decision not to run for a third term, over the objections of Alexander Hamilton, his Treasury Secretary. The song’s catchiness is a musical echo of just how notable it was when the real Washington made the decision to leave office. By that point in his career, he was seen by almost everyone in the young United States as by far the preeminent figure of the age, and could have kept serving, could even have made himself king. The fact that he did not, that he willingly relinquished power after two terms in office, was a decision both striking and celebrated. He has been compared to Cincinnatus, the Roman statesman who, after assuming the role of dictator to manage a military crisis, gave up power and returned to his farm once victory had been won. 

Washington’s choice to give up power ranks high among his achievements not just because of what it said about his character, but because of the legitimacy it conferred on American institutions. Had he stayed, the system would have become all about him, and while he may have continued to do good in office, it would have come at the expense of the very institutions he spent his life helping to build. By leaving, and assuring a peaceful transition of power, he helped assure these institutions would remain strong and enjoy the collective buy-in of the people; a necessary condition for the functioning of a healthy republic.

Public health now finds itself at a similar crossroads with respect to power. We have amassed substantial power through our efforts to address the COVID crisis. This has been something of a change for us. In the past, it was not uncommon to hear complaints that public health is sometimes neglected, that its recommendations to policymakers and the public can fall on deaf ears. The pandemic reversed this. Notwithstanding the polarization that has kept a vocal faction of the population at odds with the recommendations of health authorities, we are in a moment when public health is more influential than it has ever been. And with the arrival of vaccines and signs that the pandemic has started to wane, this moment may well be ending. COVID itself is likely to remain with us in some form, as an endemic threat. But the emergency of COVID, the crisis of the pandemic year—its days are numbered. 

With the end of the emergency comes the question of what public health will do with its newfound power. It is a sensitive question. We do not like to think of ourselves as wielders of power. In some ways, perhaps, public health is more comfortable seeing itself as the underdog; it is easier to imagine our influence lies entirely in the data-informed efficacy of our solutions. But the fact is, public health has historically wielded power in key areas, and this power has only grown during COVID. We are now in a position of deciding whether we should maintain this power at its current level once the crisis has passed, or whether, in doing so, we place at risk the legitimacy of the broader institutional framework which supports health, and the integrity of public health’s efforts. 

Before attempting to resolve this issue, it is worth asking: how does power shape health? My thinking on this has long been influenced—as has that of many—by the work of the social theorist Steven Lukes, who articulated “three dimensions of power”—overt power, covert power, and power to shape desires and beliefs. I think this has many extensions/applications for public health. A few years ago, for example, Joana Lima and I adapted this framework to think about corporate activity’s influence on health. 

These categories can help illustrate how public health has used power during the pandemic. Overt power is the most visible of the three; it is when choices are made by public-facing figures, such as policy decisions made by elected officials, and often involves one course of action winning out over another (as in the debate over lockdowns being resolved in various ways by different state governments). Examples of public health wielding such power during COVID include the CDC, backed by federal authority and the Constitution’s Commerce Clause, detaining travelers for examination or ordering them to quarantine. 

This is distinct from covert power, which is when power is used to shape procedures and set the terms of debate behind closed doors, helping determine which issues are given a hearing and which are dismissed by key decisionmakers. This power has been reflected by public health’s increased sway with policymakers, as we have helped raise issues and shape the conversation at the highest level about what must be done to address the crisis. We have also helped set the terms of the conversation in the media, as public health’s voice has had special status in the public debate throughout the COVID crisis. 

Finally, there is power to shape desires and beliefs; this is the power to shape the public consciousness, influencing how people think and what they value. During the pandemic, public health did much to shape attitudes towards masking, distancing, school closing and reopening, and more. These were all examples of this power, as was the elevated profile of public health figures, whose newfound celebrity allowed them to shape opinion as household names. This status was especially influential on Twitter, where epidemiologists suddenly found themselves gaining thousands of followers, their words resonating with a public anxious for guidance at a disorienting time. 

This is not to say public health did not exercise power in these ways before the pandemic. We have long engaged with power in the interest of supporting health. Public health’s successful push to change attitudes about smoking, for example, reflects the effective use of the power to shape desires and beliefs. Yet the pandemic has clearly expanded the role of public health, deepened its influence on policymakers, and amplified public health voices. By accepting this power, public health was able to do much good. But this power also comes with challenges, risk, and new responsibilities. 

It seems appropriate then to ask: what risks have accrued to public health due to this new power? And how should we think of this power going forward, to the end of minimizing harms we do and maximizing our capacity to fulfill our mission?

To answer, let us examine the practical effects of how public health has used power during COVID. In terms of overt power, public health has worked with lawmakers to put in place protocols for navigating the pandemic. While these rules have helped mitigate the spread of the virus, they have also sparked backlash, as a sense of arbitrariness in their application has led to challenges to the paternalism inherent in these efforts. It is also true that we have asked much of the population. While many have diligently followed public health’s advice this past year, continuing to ask them to do so when we know it is no longer necessary risks shaping a public less willing to listen to us in the future. 

In the area of covert power, public health has held tremendous sway with policymakers. Yet, as I wrote last week, our recommendations can at times exist in tension with practical realities and the tradeoffs inherent in making political choices about difficult issues like lifting lockdowns and reopening schools. For our influence in this area to remain constructive, it must acknowledge changing circumstances on the ground, and support an easing of public health interventions, when these interventions become less acutely needed.    

Finally, public health has effectively used the power to shape desires and beliefs to influence norms around behavior during COVID. In doing so, however, it has occasionally veered into the territory of moralism, which can also inform backlash, causing populations to rebel and flout precautions. 

In each of these areas, we can see how public health, while doing good, also risks overreach, a risk which only grows as the gap widens between what is necessary for supporting health and what we ask of people. Then there are the deeper risks posed whenever administrative overreach is paired with political power. We saw during the War on Terror, for example, how the imperative of safety can lead to abuses, such as mass surveillance. An entrenched administrative apparatus tasked with preventing disease through restriction, surveillance, and the shuttering of economic sectors could run a similar risk. The creation of such an apparatus was a subject of much interest for Michel Foucault, who wrote about how the state’s response to plague could serve as the basis for new forms of administrative control. Meanwhile, a more recent take on this comes from the Italian philosopher Giorgio Agamben, who has expressed deep concerns about the expansion of state power which can come with crisis; in particular, the use of such crisis by elites to push through measures they have long wanted. That these concerns are to some extent justified is self-evident. We in public health, who could well be characterized as “elites,” have long worked towards the structural changes that shape a healthier world. As COVID has exposed many of the conditions which make us sick, we have tried to use the lessons of this moment as the basis for reforms we have indeed long agitated for. Put bluntly: we are acting opportunistically in the name of a good cause, the cause of health. I do not think there is anything wrong with this; in fact, we would be neglecting our responsibility if we did otherwise. However, we should be under no illusions about what we are doing, and how easily projects of fundamental reform, backed by state power and carried out with the best of intentions, can create the conditions for abuse.

We might well protest we would never support abuses of power, that the suggestion that we could is so much conspiracy thinking. Yet history is full of examples of how the first steps towards committing abuses is the unwillingness to suspect one’s own motivations, as we assume other groups are susceptible to the temptations of power but not our own. The truth is that we are all vulnerable, and when we are occasionally accused of bureaucratic overreach and the desire to control others, the accusation springs not just from paranoia, but from a basic understanding of our common nature.  

Finally, if we do not gracefully relinquish some measure of influence and control, we run the classic risk of power: corruption. Not corruption in the dramatic sense of, say, the scandals that topple politicians. I mean the kind that finds us, in small ways and then, one day, maybe in big ones, compromising on doing what must be done for health because it looks like what must be done might diminish our influence. Consider: last month, Zeynep Tufekci wrote in The Atlantic on the difference between the jubilation that greeted the development of the polio vaccine and the COVID vaccine’s more muted reception. It strikes me that part of the reason for this gap is because public health has not done enough to convey the remarkable effectiveness of these new vaccines, how the data paint an ever-clearer picture of their potential to take society off high alert. This is partly because of our understandable inclination to be cautious. But there may also be a deeper, less seemly motivation: the vaccines will mean an end to the crisis, which will mean an end to much of the power we have enjoyed. This seems perhaps shameful to even suggest, but it really is not. It is human nature to become attached to power, even when it emerges from a crisis we all wish had not happened. And we must guard against this. As public health professionals, our motive must always be to support health. When we use power, it should always be in service of this goal, never as an end in itself.   

I am stating this plainly because it is only by confronting the possibility that we may have become a bit too used to power that we can be fully effective in ending this pandemic and laying the groundwork for a healthier world. For a year, the focus has been on us, on public health. This focus has been necessary; navigating the pandemic meant looking to public health as never before. The measures we recommended were emergency steps we needed to take to meet the demands of the moment. But underlying the pandemic, always, were the structural drivers of poor health; the racism, injustice, inequality, and political neglect which create the conditions for poor health and which helped the virus take hold. Lockdowns, distancing, mask-wearing, so central to public health messaging and power during the pandemic, can do nothing to fix these challenges—and can even worsen them, by deepening inequality through economic disruption. 

Shoring up the foundations of public health demands relinquishing bureaucratic power in favor of sustained collective engagement with the foundational issues that shape health. This work does not require a concentration of power in the hands of a single sector; it is diffuse, democratic. By placing the focus on health—not just on pandemic mitigation, but on creating a world that is truly healthy—we can leverage our power towards the greatest possible good, by sharing it with everyone else who wishes to see a healthier post-pandemic future, and by working together to make it a reality. 

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