Mass exodus of public health leaders creates challenge for the field and society

“Vilified, threatened with violence and in some cases suffering from burnout, dozens of state and local public health leaders around the U.S. have resigned or have been fired amid the coronavirus outbreak, a testament to how politically combustible masks, lockdowns, and infection data have become.”

• Michelle R. Smith and Lauren Weber, Associated Press and Kaiser Health News, 8/10/2020

By Robert M. Pestronk, MPH

The coronavirus pandemic has brought conditions and consequences which are the worst I have seen in 40 years of public health awareness. While deep division and dissension in the body politic are not unprecedented in American public life – we did experience a Civil War – they are something to dread, and they portend worse not better health unless changed. We have it in our power to make those changes. Hopefully, we summon the energy, persistence, and courage. All will be needed.

Against a backdrop of pandemic public health officials nationwide confront a set of unexpected challenges. More than ever these include firings, angry questioning of the science they rely on, conflict over their authority to act, the deliberate spread and viral amplification of misinformation, executive and legislative diminution of their authority, and legal and personal harassment including threats to their family members. An unusually large number is resigning.

The general context for this extremely worrisome situation is our nation’s extreme polarization of political, philosophical, and moral beliefs. Tailored, diverse, and widely available media reinforce opposing beliefs among each set of believers, believers who started with different epistemological systems and are open to having those beliefs reinforced, but not open to having them questioned. Misinformation is attractive, widespread, and widely available.

These circumstances constitute serious and continuing threats to the public’s health, not only within the affected officials’ specific jurisdictions but elsewhere as well. They are representative of, and the consequences of, a larger assault on the necessary conditions for democratic governance and even for the conditions needed for people to live in close proximity to other people.

Little has been done to reinforce or encourage the public’s trust in governmental officials; in fact, quite the opposite has occurred. Public health officials are deliberately castigated as their work becomes increasingly visible as the pandemic spreads and lasts. Even their well-grounded assertion of legal authority is questioned. They are easy targets for elected officials and pundits in the face of a novel, infectious, and lethal virus about which we learn more every day, in response to which we are personally asked to take inconvenient actions (including empathic concern for others), and against which we have no vaccine or magic bullet treatment.

Expert recommendations change rapidly with expedited research, highly permissive emergency use authorizations, and uncommonly rapid information-sharing among physicians and other health authorities. For a public marginally and not unexpectedly poorly informed about the methods of science and the uncertainties and technicalities of risk analysis, changing recommendations are interpreted as inconsistency and unreliability. That errors in fact and judgment were made early in the outbreak has not helped inspire confidence and gain public trust and compliance. Some media, then, simply reinforce these negative biases.  Because experts erred in one situation, they must know nothing. Frustrated and angry at public health and medical authorities who in some cases order continuing and costly social and economic constraints, many members of the public and elected officials seek someone to blame and to hold accountable. Most also have a poor understanding of the roles and responsibilities of their local, state, and federal governmental public health organizations, let alone the international public health organizations with which they interact, confusing one with another.

Governmental public health practice is hard enough in normal times.  To assess jurisdiction-wide health status, develop appropriate policies, and assure dozens of essential outcomes is a multi-dimensional balancing act.  Decision-making must be well-grounded in law and administrative rule. Supportive information and data may be factual yet inadequate, incomplete, or relevant to populations of people rather than specific individuals. Resources of dollars, people, and technology for public health practice are not prioritized and have steadily diminished in purchasing power over time in local, state, and federal budgets. Philanthropic support is transitory at best. Data systems in many places are outmoded; and where investments have been made, they most often meet the needs of clinical and administrative practices rather than those of governmental public and population-oriented health organizations and almost never result in essential linkages among these disparate areas of activity.

More personally and individually, some public health officials may not have recognized the importance of politics in their practice, having usually been schooled to focus on science alone. And even if politically shrewd enough to weather the normal push and pull of life in government, they may not have developed sufficiently strong systems of personal and community support needed to withstand the public psychological pounding that a pandemic can bring down upon them.

Under these tougher conditions the stress normally faced by competent public health officials, accustomed to working each day for improved health and health equity, is greatly compounded. Missteps by governing officials and intolerance and disrespect from the public become more likely. Fortunately, some states and localities are better protected with well-tended and respectful relationships within the government and between the public and government. We can also look to other nations to find better examples of how to keep illness and death at bay, during pandemic times and otherwise.

We must hope that despite the continuing loss in our always small pool of career public health professionals and heroes, others will step in and forward to pick up the gauntlet. We must hope that many members of the public communicate with their elected officials to encourage them to be and know better. When our local, state, and federal public health officials act judiciously, responsibly, and in the public’s interest and behalf, we should let them know that their work is understood and appreciated. We should follow their direction. Ours is an imperfect nation needing constant redesign and repair. It’s not easy work, so those who are willing to assume it needs and deserves encouragement.

Robert M. Pestronk, MPH, is a graduate of Princeton University and the University of Michigan School of Public Health.  He was the Director/Health Officer at the Genesee County Health Department in Flint, MI, for 22 years, and leaving in 2008 to become the Executive Director of the National Association of County and City Health Officials in Washington, D.C.  He has widely published and presented his work to a nationwide audience and been the recipient of multiple honors and awards. In retirement from his public health career, he is a Trustee of the Ruth Mott Foundation.