By Jennifer S. Bard
What makes a bad public health decision?
What we’ve seen across both the Trump and Biden administrations is that relying on the CDC’s medical model of decision-making isn’t working. No matter how sound the underlying science or medicine, public health guidance cannot be effective if its target audiences don’t understand it and it’s impossible to deploy.
The recent U.S. Centers for Disease Control and Prevention (CDC) guidance suggesting that people who are vaccinated do not have to wear masks is an instructive example.
Reporters over the past few days have confirmed that this decision was made inside the CDC, by its director, without any notice to, let alone consultation of, the state and local health authorities, retailers, and schools that would have to implement it.
But the job of public health demands an approach that encompasses such groups. Unlike medical doctors (and practicing attorneys) who bear fiduciary duties to individual patients, public health professionals’ obligations are not to individuals, but to populations. And fulfilling these obligations is very hard. It’s one thing to tailor an intervention or craft an explanation for the person in front of you, and quite another to do the same for a community.
The obvious first question in response to the guidance was: “How can anyone in charge of maintaining a safe indoor environment know who has been vaccinated, let alone fully vaccinated, or not?” Yet the CDC has again and again ducked this question, first by stating that each individual was in charge of their own health, then by saying that anyone who doesn’t want to wear a mask should get vaccinated, and, most recently, reversing course entirely and denying that the policy was intended as an incentive to get vaccinated.
The reaction to the guidance has been the entirely predictable and very unfortunate mass cancellation of existing policies requiring masks in places where people are most likely to transmit and contract COVID-19. This leaves millions of Americans (including essentially all children and teenagers) vulnerable to not just the original virus, but a host of variants which appear to be even more contagious.
As I wrote on Thursday after this policy first came out, and as so many giants in public health have written since, the guidance is antithetical to public health principles. We don’t have a special “no serving utensils required” line at the salad bar for people who say they have tested negative for hepatitis A. Similarly, leaving it up to individuals capable of infecting others with an extremely serious and highly contagious virus to make their own decisions about whether or not to take the measures necessary to protect others flies in the face of the principles and practice of public health.
It’s not too late to clean up the mess this decision has created — but it’s more than time to revisit how public policy decisions are being made and should be made in the future.
How can we make good public health decisions?
Bad public health decisions are made in siloes. Good public health decisions require the pooled expertise of a multi-disciplinary, non-hierarchical team. A team in which doctors are participants, but not leaders. This is more than interprofessionalism — a bringing together of different disciplines to train together in solving patient problems — it’s a reconceptualization of public health decision-making that doesn’t automatically prioritize medical doctors or scientists. It’s a rethinking of the hierarchy so embedded in health care.
The scope of who hasn’t been part of pandemic decision-making is so large that it transcends a blog post — it was horrifying, but not surprising, that the original presidential COVID advisory group didn’t include a single nurse. There are no obvious representatives of the racial, ethnic, or religious communities who are being so disproportionately affected. The LGBTQ community does not seem to be at the table. But in terms of who has the expertise on how people behave, here’s a start at identifying some experts who should be more involved in future guidance:
- Sociologists and anthropologists, who know a lot about how people live and work. For example, guidelines that affect people who attend a house of worship need to reflect a reality that these are not just buildings, they are a sustaining force in many people’s lives. As are barbershops and hair salons.
In addition, we should be bringing in a whole world of people who are trained to do something we need a lot of: communicate and assist sick and frightened people. Many of these professions are hospital based, but, at a time when illness has spilled outside of hospitals, their expertise about how people learn, communicate, and behave could be just what’s needed to turn science and medicine into policies people can live with — here are some suggestions:
- Child life professionals.
- Special educators.
- Occupational therapists.
- Audiologists and speech pathologists (both to make sure of good communication, and to address the needs of those cut off from these services).
- Social workers (who know the barriers people face in keeping themselves & their families healthy).
- Human factors psychologists (who specialize in an under-the-radar field that focuses on how people actually use products or process instructions).
- Public administrators (the ones who actually have to turn these guidelines into policies).
- Public health workers (who may not have advanced degrees, but know how to educate and persuade the people we need to reach).
- Hospital chaplains.
It is not fair to ask the brilliant physician-scientists of the underfunded CDC to take on the task of making policy so far outside the scope of their expertise. But it is fair to ask the government to make public health policy with a focus on the public who has to follow it. And the way to do that is to develop a non-hierarchical decision-making process that integrates the expertise and experience needed to effectively translate science into policy.
Meanwhile, it’s still not too late for CDC to draw on interdisciplinary expertise in human behavior to not just clarify, but also to reissue their masking guidance in much more forceful terms — to share with the nation its best understanding of the vaccination levels needed to provide protection against the as-yet-unvaccinated without universal masking.
