By Daniel Goldberg
The failure to control the COVID-19 pandemic in the United States rests, in part, on the individualist nature of our public health responses.
Public health simply does not work well when we base our interventions on the individual level. This is known as “methodological individualism,” and the evidence suggests it is both ineffective and can expand existing health inequalities. It is problematic in any public health context, but especially in pandemic response and control.
Take, for example, the ongoing debate over mask mandates. Multiple governors have refused to issue mask mandates, instead simply requesting that people don masks. The objection, interestingly, is not to the idea of masking as a public health intervention, but to the existence of a mandate itself.
Yet a model of public health which consists of nothing more than pleading with individuals to avoid behaving in ways injurious to public health would be an abject failure. Imagine if, instead of imposing minimum requirements for clean water, we simply asked regulated industries to avoid polluting watersheds. Or perhaps instead of passing laws discouraging or even criminalizing obviously harmful behavior, we simply asked people to avoid driving drunk.
It is important to note here that there is an ongoing, decades-old debate over the extent to which individual health behaviors explain health inequalities. But even if we assume that our own behaviors have a significant impact on health in general and during the COVID-19 pandemic in particular, we still need to think about the best level of intervention. We need to know what mix of policies and approaches are most likely to move people to behave in ways that improve both their own chances for good health and improve the chances for others.
One way to think about different levels of intervention is via macro-, meso-, and micro- level approaches. There are strengths and weaknesses to each level.
Macro-social changes tend to have the most dramatic effect on upstream determinants of health – they can be very powerful. But they can also have a lengthy time horizon; changing federal or even state statutes can take many years. That is a serious problem in a public health emergency like COVID-19.
Meso-level approaches seek to affect health and health behaviors via intermediate policies and processes, such as changing policies within a local health system, for example. These can have significant local and regional impact but can also take more time to implement than is ideal. They also lack the reach and scope of macro- level approaches.
Micro-level approaches can be implemented quickly and do not require structural change, but their evidence of efficacy is generally weak.
Despite the lack of efficacy for micro-level approaches, public health initiatives in the U.S. unfortunately tend to favor them, especially for health promotion. This is ethically problematic, since it funnels resources towards interventions likely to be of little effect.
Micro-level approaches also have the distinct tendency to expand health inequalities, because they often depend for their efficacy on the particular resources and privileges an individual can bring to bear. For example, possessing significant resources makes quitting smoking much easier; interventions designed to help individuals quit smoking will therefore tend to favor the most well-off, and this is tendency is exactly what we see when we look at the sharp inequalities in smoking-related disease (Figure 1).
Figure 1 (source: CDC, “Cigarette Smoking and Tobacco Use Among People of Low Socioeconomic Status”)
The bottom line is that if an intervention depends for its efficacy on thousands of individual, micro-level decisions, the intervention is extremely unlikely to be effective.
The stakes of emphasizing a micro-level, methodologically individualist approach rise significantly during a pandemic.
Consider, for example, the evidence suggesting that bars and indoor dining are high-risk contexts for COVID-19 superspreading events. What should the public health response be? One answer might be to simply ask people to avoid bars and indoor dining. Many jurisdictions have adopted this approach. The problem, of course, is that while many people likely will obey a request to avoid bars and indoor dining, if such establishments remain open for business, others will choose differently and will congregate in such settings. The latter group risks not only their own health, but the health of many others via a cluster or superspreading event.
An alternative public health response might thus be to simply close, by public health order, bars and indoor dining for a certain period of time. (These orders can be carefully crafted to pass statutory and constitutional muster – and indeed they probably ought to be so designed given the historical injustices that have occurred during public health responses to epidemic disease in the U.S.).
If a jurisdiction closes bars and indoor dining, then people will not congregate there. Of course, such closures are, of course, insufficient by themselves to arrest an out-of-control pandemic, and they can also contribute to new problems that require intervention (i.e., closing bars could, in theory, increase the likelihood of private gatherings, which are harder to control via public health law responses).
Yet, as Lindsay Wiley has pointed out, controlling one of the most significant drivers (bars and indoor dining) via law and policy can enable us to flatten the epidemic curve sufficiently even where other variables are less amenable to such response.
So the approach used in some cities in 1918, during polio outbreaks, & in the 1st 2 waves of 2020 was to break the transmission chain before it reaches so many households, by intervening upstream at workplaces & commercial & institutional indoor gathering places.
— Lindsay Wiley (@ProfLWiley) December 2, 2020
In other words, the very fact that some factors intensifying the pandemic are less ameliorable via public health law is an excellent reason for addressing the factors that are more ameliorable.
Micro-level approaches to public health are wasteful and ineffective. The evidence overwhelmingly shows that asking large numbers of individuals to behave in ways salubrious to public health is extremely unlikely to work. While in non-emergent circumstances, this is problematic enough from an ethical perspective; in the midst of an out-of-control pandemic, it is anathema. The wiser path is governance – the use of legal and policy mechanisms to lower risks for the population as a whole and especially for the most vulnerable and marginalized among us.
Public health governance is, of course, not an unqualified good. As noted above, the history of infectious and epidemic disease response in the U.S. is riddled with racist, sexist, ableist, and classist approaches that extended patterns of domination, oppression, and subordination. Public health officials have actively participated or been complicit in structural violence against People of Color, disabled people, the poor, women, and immigrants, among others. Yet the answer to these real problems cannot be to abandon any commitment to public health law itself, to reduce public health to nothing more than begging individuals to behave in health-producing ways. If unaccompanied by law and policy approaches at meso- and macro-levels, the latter course is simply a public health Potemkin Village.