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A review of the pandemic suggests Americans have lost interest in public health


The pandemic exposed giant gaps in the American health system. That may be part of the reason the United States leads the world in COVID deaths. The analyst Ed Yong says the results have revealed a longer-term problem even larger than the pandemic, the generations-long decline of public health in the United States. Writing in The Atlantic, he says people in the U.S. once thought differently than they do now about the underlying causes of disease.

ED YONG: So in the late 19th century, public health was a much more dispersed field. It had scientists, sure, but also a lot of activists, civil servants, a lot of public figures. The way they thought about health problems were informed by the social model of medicine, in which the factors that led to the spread of epidemics included things like poverty, poor sanitation, hazardous working conditions, poor education, political inattention. And they were sort of possessed of this crusading spirit, this idea that these problems, though vast, required action and active efforts to address.

INSKEEP: As you're talking, I'm thinking of Jacob Riis, this journalist in the late 1800s, who wrote this book called "How The Other Half Lives." And he was arguing that crowded tenements and windowless bedrooms and dirty alleys and so forth made people less healthy, contributed to their poverty and their death.

YONG: Absolutely. And I think this was quite a common view at the time. But that view started to fall by the wayside at the turn of the century because of the rise of germ theory, the discovery that many long-standing illnesses that have plagued humanity were the work of microscopic organisms. That gave people an easy target, a villain to focus on. And it meant that those knotty social problems could be ignored even now. Like, if you think about COVID, so much of our attempts to control the virus, the SARS-CoV-2 virus, have focused on medical countermeasures like drugs and vaccines. And there's been much less emphasis on things like paid sick leave, universal healthcare. That would address the sort of foundational social problems that were much more understood as drivers of poor health some time ago.

INSKEEP: Are you saying that this is a conflict between collective action and individual solutions?

YONG: Yes, partly. The idea is that you can collapse all the complexities about disease and the causes of poor health down to this battle between a host and a pathogen. And so you can treat it entirely as a problem of individuals. Now this is, I think, the wrong way of looking at it. Social issues like poverty and so on affect the kinds of choices people can make to protect their own health. And if you don't think about that, then the biomedical solutions, like the vaccines and drugs, don't have the effectiveness that they seem to have on paper.

INSKEEP: Is there a fundamental ideological problem the United States has here? We know about conservative resistance to collective action. But honestly, as the pandemic has gone on, the tolerance for that sort of thing has eroded in more liberal cities, as well. It does seem to be a universal thing that Americans don't like to be told what to do.

YONG: I think that is true. I have argued for a while now that America's particular breed of toxic individualism is, you know, antithetical to an effective pandemic response. You cannot think about infectious diseases solely through the lens of individual risk. They are fundamentally a collective problem because they spread and because people's circumstances constrain their choices. So their health is profoundly influenced by the choices of everyone else around them. If you think about this in terms - entirely in terms of what individual people can do, you're going to fail at this specific kind of problem.

INSKEEP: So help me define the problem now. When it comes to public health, what is it that we're failing to do?

YONG: There are several problems. The field is struggling with long term disinvestment. There's simply not enough money going into public health. And there hasn't been for almost a century now.

INSKEEP: Money to do what things, exactly?

YONG: Money to do the basics of the work, which are to prevent diseases in communities. So when COVID happened, the lack of testing, the inability to do contact tracing, the inability to really do community-based prevention work that some other countries did much better than we did, a lot of it comes down to lack of resources. Many people have rightly argued that public health needs to be more expansive. It really needs to start tackling these social problems, these social inequalities that are the bedrock of so many health problems, not just COVID.

INSKEEP: When we heard during the worst of the pandemic that poor communities were more affected by COVID, which in America tended to mean people who were more diverse, more people of color, was that a public health failure?

YONG: Yes, it is. And I think it's sort of a failure for all of us, this idea that the social conditions that underpin poor health persist over time, even though the threat of the day changes and even though medical progress is ostensibly made. And that's fundamentally because epidemics and medical interventions flow in opposite directions. Epidemics flow downwards into society's cracks, taking out the most marginalized people first. Medical interventions like drugs and vaccines rise up into society's penthouses. They go first to people with connections, power, privilege and money. And those people then move on from the problem before addressing the societal rot that actually made it worse. If you only look to drugs and vaccines as the solution to these problems without addressing the underlying inequalities, all you do is plaster over the problem for now and leave the same gaping wounds to get infected and fester the next time around.

INSKEEP: Are you suggesting that despite whatever we've learned in this pandemic, if there was another pandemic five years from now, it might go just as badly?

YONG: Yes. That is exactly what I'm suggesting.

INSKEEP: Ed Yong is a staff writer for The Atlantic. Thanks so much.

YONG: Thanks for having me.