The Weird Disconnect in a Debate About Whether Public Health is “Becoming” Illiberal

“Is public health becoming illiberal?,” asked Katelyn Jetelina last week. I assumed it would be a classic case of Betteridge’s Law – “Any headline that ends in a question mark can be answered by the word no.” It was the “becoming” part that, to me, made the answer obviously no. Illberalism can’t be a new development in public health because it’s been ingrained in it for a very long time.

It came as a jolt when I realized that wasn’t where Jetelina’s post was going. Her post grappled with a debate about mistakes in this pandemic, and “how to return to public health’s liberal roots.”

Liberal roots?

The roots of public health predate European “liberalism,” of course – including in Europe. But even leaving that aside, it’s an odd framing of complex history and inherent ethical challenges.

Jetelina’s post is a book review of Sandro Galea’s new book, Within Reason. It’s only just out in hardcover, and I haven’t read it. But the debate Galea wants to have is already set out in the public domain, as the book is essentially a collection of his blog/newsletter posts. He has posted excerpts and summaries as well. And as with so many contributions to the what-we-should-learn-from-this-pandemic genre, the book is sure to be interesting.

However, it’s the framing of the before-times that interests me in what Jetelina and Galea have put up for general debate. If these two prominent people promote this thumbnail view of their profession, then I suppose this perception must be very widespread. No wonder so many think pieces about what we need to learn from this pandemic are depressingly similar to those from decades ago on lessons from the HIV/AIDS one!

One sure way to fail to learn from history is to cultivate a romantic view of the good old days. The opposite mistake wouldn’t be good either, so their words were a through-the-looking-glass moment for me, sending me down a fact-checking rabbit hole.

Galea describes public health as a product of scientific traditions of the European Enlightenment. But in this pandemic, he writes, “We forgot where we came from. Namely, we forgot the liberal values that used to be the basis of all that we did.” He writes:

Small ‘l’ liberalism emerged from an intellectual culture that prized reason above all else. During The Enlightenment, thinkers tried to pursue lines of inquiry based on empiricism rather than on the passions of the moment. Illiberalism, in a sense, reflects the opposite of this, often emerging from climates of collective stress or fear. Such feelings can persuade us to put aside reason, and embrace some illberalism to make us feel safe in a dangerous world.

Sandro Galea (Chapter on Liberty and Health in Within Reason, 2023)

That quote doesn’t do justice to the full range of values Galea discusses. But as you would expect, the values people call liberal or progressive have changed dramatically since the 17th century, and even since the advent of university schools of public health a hundred or so years ago.

Galea’s version of liberal values also encompasses anti-racist and social justice ideals – and those were clearly not the values of old school liberalism. And he takes care to assure people he hasn’t crossed to the neoliberal side of the ledger.

To be fair, too, Galea’s perspective is not as absolute as is implied by his use of phrases such as “the liberal values that used to be the basis of all we did.” In his book’s conclusion, Galea acknowledges that public health hasn’t always lived up to the values he sees as its traditions – and that perhaps he had underestimated how committed public health was to the “liberal framework.” He writes: “I’ve always believed that public health is a noble profession. But it has had its darker moments, when it has perpetrated abuses, often in the name of the greater good. We now see such moments as aberrations, times when we strayed from our core values.”

Do we, though? Massive abuses of people’s rights in the name of public health weren’t only momentary – they sometimes spanned generations. This included crimes against humanity in many countries. They didn’t all result from over-reactions to sudden heightened fears, like pandemics or wars. And they weren’t always unexpected deviations from a shared set of unchanging core values across time.

This doesn’t mean that there isn’t a colossal amount to be proud of in public health history, with truly inspirational achievements and individuals. But the blinkers needed to minimize problematic traditions and legacies risk serious blindspots in the present, too.

For example, draconian public health actions in relation to sexually transmitted diseases based on contagious disease acts went on for many decades. This entwined with racism in particularly appalling ways for indigenous people and people of color well into the 20th century in many parts of the world. The operationalization of eugenic goals via birth control and forced sterilization went on for a very long time, too, in large part because the values and reasoning of eugenics were often shared, or at least accepted, by public health leaders.

There’s a strong case that a lot of this, like much in public health generally, sprang from religious beliefs, and the desire to “strengthen the race,” not currently liberal values. At the beginning of the 20th century, even people considered progressives in the US had a set of moral values in common that “grew largely out of a rather severe, northern European, Protestant background and were clearly evident in the moral indignation that suffused such health promotion campaigns as the ‘social hygiene movement’ or the ‘purity crusade’ against prostitution and sexually transmitted diseases, as well as the prohibitionists’ battle against ‘demon rum’.” That’s a great reminder of how much community’s values and drivers of social change themselves change over time.

The values of the past influences the shape of many layers of the present. Sanitation in the 19th century in the wake of industrialization and the massive growth of cities is arguably the beginning of modern public health. Sanitation changed the way many societies saw health, and public responsibility for individuals’ health: “Illness came to be seen as an indicator of poor social and environmental conditions, as well as poor moral and spiritual conditions. Cleanliness was embraced as a path both to physical and moral health.” Think “cleanliness is next to godliness.”

Even if many aren’t aware of it, powerful classes imposing their morality and priorities remains part of the public health heartbeat. Many have put great thought and effort into articulating what this means for public health’s core missions.

I return to a challenging article in this genre when I’m thinking about issues like this. It’s by Olav Helge Førde, a Norwegian community medicine academic, and it’s called “Is imposing risk awareness cultural imperialism?” The cultural imperialism he refers to is public health’s “moral and coercive crusade for increased risk awareness and purity in lifestyle.” Pumping out a constant stream of often highly manipulative communication about risks has unintended effects, Førde argues, increasing societies’ “intolerance to risk and uncertainty.” That has an impact on culture, values, perceptions of health in our lives, and more consequences than we may realize.

Førde writes that healthism – health as the principal life value – can have similar intensity to religion, with the risk of brutal blaming and intolerance travelling along with that. When I read it today, the cruelty of rising fat shaming and weight discrimination sprang to mind, and the impact of a focus on “body surveillance and control” in health promotion to young people.

As with any health interventions, public health interventions can do harm. That puts me in very solid agreement with Galea on the need for reliable science, though I’m pretty sure I would give public health interventions a much lower score on getting things right across time than he might. On the other hand, I might be more positive about some aspects of public health in this pandemic. I think there’s a risk, at the moment, of people jumping to firmly fixed convictions about entire interventions based on examples of poor implementation, or patchy actions where underlying societal problems made them highly unlikely to benefit.

Galea argues that public health professionals didn’t weigh trade-offs well enough. I wouldn’t lump everyone into that boat either, but again, I just don’t think that was something new that arose with Covid. Another of Galea’s key examples of illiberalism creeping in was also a longstanding problem: Labelling people who wanted to have legitimate discussions about new vaccines as “anti-vaxxers.”

Earlier this year, a journalist from the UK asked me to comment on a recent revelation from a freedom of information request. It turns out I was one of the people treated as a source of Covid vaccine disinformation by the UK government’s Counter-Disinformation Unit and Rapid Response Unit. Apparently I was on their radar because of a fairly viral article I had written which discussed adverse events after a British vaccine. I had no outraged comment to offer the journalist, though. It simply wasn’t remarkable. Of course discussing vaccines as I would any other drugs would put me in the firing line.

Imposing top-down orthodoxy around vaccines isn’t pandemic-related. It’s business as usual, and we’ve known it’s a problem for a long time. For example, when I discussed this here in July 2020, I cited a review from 2012 that overstating vaccine safety is a problem. It has probably been around ever since there’s been an anti-vaccine movement – which is nearly as long as there have been vaccines.

I think this is a good debate to have. Making decisions on behalf of populations is necessary, and doing it well enough is extremely hard, especially in crises. I suppose every pandemic includes calls for a “new” or “re-imagined” public health: The contest between competing values and interests is a forever one. But what about the original question Jetelina posed, put in a way I don’t find weird? Is public health becoming more illiberal?

I think it’s too soon to know. Some of the best research that will help us answer what went well or badly and why is sure to still be underway. With so much emotion and backlash in play, and major parts of the world becoming more hostile to government protection of vulnerable people, it could go either way, couldn’t it?

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Disclosures: My epidemiological specialty is clinical evidence/meta-science. During this pandemic, I’ve been sticking almost exclusively to evidence about Covid vaccines. My interest in Covid-19 vaccines is as a person worried about the virus, as my son is immunocompromised: I have no financial or professional interest in the vaccines. I have worked for an institute of the NIH in the past, but not the one working on vaccines (NIAID). More about me.

The cartoon is my own (CC BY-NC-ND license). (More cartoons at Statistically Funny.)