Public Health's Under Fire but Saved Lives During the Pandemic

Any hopes people working in public health ever entertained that the pandemic would lead to sustained support for their efforts have long since been dashed. Although another pandemic is certain at some point, health budgets are being cut and public health powers have been limited, with the entire field’s techniques coming under political attack.

COVID-19 remains a top 10 cause of death in this country, but most Americans have stopped taking precautions and policymakers have clearly downgraded prevention as a priority.

The deficit reduction bill that averted the federal debt ceiling crisis included cuts to health programs of nearly $15 billion. Further cuts are likely to come during the fall appropriations season. A majority of states, meanwhile, have enacted new limits on the emergency health powers of governors or local officials.

There’s no question that health officials made mistakes during the pandemic, but they are now routinely subjected to complaints from politicians who say their approach was misguided, or even amounted to “COVID tyranny.” Florida Republican Gov. Ron DeSantis has produced a campaign ad, featuring doctored images generated by artificial intelligence, purporting to show former President Donald Trump hugging Anthony Fauci, who was until last year the top federal infectious disease expert.

Fauci, a hero to some, has been called a dictator and a fraud by commentators on the right. Nearly every day out on the presidential campaign trail, DeSantis makes some comment about ending “Faucian dystopia” or bragging that his state “chose freedom over Fauci-ism.”

Health officials and Democratic politicians have been slower to defend preventive measures. COVID-19 has claimed the lives of more than 1.1 million Americans. Everyone in public health believes that, absent interventions such as masking, social distancing and business closures, it would have been even worse. “To me, there’s not much question that the overall public health-oriented response over the first six months saved hundreds of thousands of lives,” says Robert Wachter, who chairs the department of medicine at the University of California, San Francisco.

Wachter notes that it’s hard to quantify just how many lives were saved. Most studies have tended to examine the effects of particular techniques, such as mask mandates or lockdowns, as opposed to finding out how many lives were saved compared to doing nothing at all. By contrast, the harmful effects associated with prevention efforts — such as learning loss in schools and the way working from home has turned many downtowns into ghost towns — are all too apparent.

Still, it’s certain that doing nothing would have led to even more illness and death. There were many missteps along the way, but the basic public health message — avoid crowded spaces and close encounters with most other individuals — remained essentially unchanged. “There’s no reasonable argument that we should have done nothing,” says Joshua Sharfstein, vice dean of the Bloomberg School of Public Health at Johns Hopkins University. “It would have been catastrophic to do all the things we can do today when there was a virus that had no treatment or vaccine.”

While it’s hard to calculate how many lives were saved by prevention efforts, it's easy to see how the death toll might have been worse, since outcomes varied in neighboring counties and different states that took different approaches (to say nothing of other countries). Wachter points out that San Francisco had some of the strictest health measures in the country, as well as plenty of what health officials call “social enforcement,” basically meaning community peer pressure. The result was a death rate roughly one-third as high as the national average.

San Francisco has become the poster child for empty downtowns and the city has a severe drug overdose problem. But its approach to COVID-19 saved many lives. “If the country mirrored San Francisco’s death rate, 600,000 or 700,000 people we lost would be alive today,” Wachter says.

Mistakes Were Made

Public health officials were guilty of a number of unforced errors that eroded their credibility with much of the public. Right off the bat, the federal Centers for Disease Control and Prevention (CDC) created its own flawed tests, rather than use those already developed abroad. That led to serious delays in getting testing underway.

Having all early test kits sent to the CDC for results meant that contact tracing, back in the early days when caseloads were still small, became essentially impossible to carry out. “I remember thinking that the centralized testing strategy was never going to be successful,” says Jessica Elise Justman, an infectious disease specialist at Columbia University’s Mailman School of Public Health. “This is a very big country.”

Back in the spring of 2020, health officials — including Anthony Fauci — told members of the public that they shouldn’t wear masks. Their goal was to prevent a run on masks, as had already happened with household items such as toilet paper, in order to ensure enough supply for health-care workers. As things turned out, however, this left many people dubious about the need to wear masks when the messaging changed later on.

The decision to keep schools closed to in-person learning for months, or more than a year in some jurisdictions, is now sometimes characterized as the biggest blunder of them all. Some teachers unions that advocated for schools to remain closed now claim they pushed to open them. Certainly, the consequences have been severe, with test scores for some ages and subjects dropping to 50-year lows.

There’s serious debate within the public health community about whether it was a mistake to keep schools closed as long as they were. They might have been safely reopened sooner, at least if masks were required. But Justman notes that children — while far less likely than adults to die from COVID-19 — were no less likely to get infected.

“Kids were getting COVID just as often as the adults were, but they weren’t getting as sick with it,” she says. “They have many, many more asymptomatic or mild infections, compared to adults. But if they were getting infected as often as adults were, they were helping to transmit it as much as the adults were.”

Counting the Costs

It may take years for kids to recover from missing school. And that’s just academically. School closures were also associated with increases in mental health disorders such as anxiety and depression, which have become rampant among teens. Meanwhile, downtowns have emptied out — notably in cities such as San Francisco where health measures were most strict. The murder rate increased dramatically around the country during the pandemic; its recent drop suggests pandemic-era changes were a major contributing factor.

In other words, evidence of ill effects is all around us. It’s harder to find evidence that public health measures did, in fact, save lives, even as more than a million Americans died. There are lots of contradictory claims out there — some of them intentional disinformation, some of them studies taken out of context.

One recent study that’s received a fair amount of media attention found that lockdowns early in the pandemic reduced the death rate in the U.S. and Europe by only 0.2 percent. But that study only compared mandatory lockdowns to calls from public officials to stay home. That is, the question wasn’t whether staying home saved lives, but how many more lives were saved by issuing stay-home orders instead of offering suggestions that individuals stay home.

Underlying this debate is the question of whether public health measures are responsible for bad social outcomes, or whether it was the disease itself. If there’d been no COVID-19, after all, there would have been no school closures or the vast switch to remote work. “What you don’t want to decide is that there’s going to be no response to something that could take away a lot of lives,” says Sharfstein, the vice dean at Johns Hopkins.

Lessons for the Future

No one is calling for a return to strict measures. Nearly all Americans have some degree of immunity to COVID-19 at this point, whether through vaccination, infection or both. What worries public health officials is that the takeaway from COVID-19 might be that it was all an overreaction from the very beginning.

The public doesn't seem to be there, or not completely. Parents have grown more skeptical about vaccine mandates, but they are no less confident about the safety of childhood vaccines. Legislation to end vaccine mandates more broadly have proliferated, but have mostly been unsuccessful. And, while many states have eroded health authority, not all bills have passed or ended up being as severe as when they were originally introduced, says Marcus Plescia, of the Association of State and Territorial Health Officials.

But the fallout is already clear. Aside from the ongoing political attacks against public health, increased skepticism is one reason why uptake has decreased with each iteration of COVID-19 vaccines, and tens of millions of Americans were never vaccinated to begin with. Once vaccines were widely available, the COVID-19 death rate stayed stubbornly higher in Republican-leaning areas. “If more people had gotten vaccinated, hundreds of thousands of people would be alive today,” Wachter says.

His concern is that the next pandemic could be worse — involving some infection that might be several times as lethal as the coronavirus. If the narrative out of the COVID-19 pandemic is that we overresponded, that will lead to much more death, Wachter warns.

“What worries the hell out of me is that this time we had several months’ reprieve before the libertarian parts of our politics pushed back against rules,” he says. “I think the next time, the pushback will begin on Day One. It will be very organized and probably relatively effective, and a lot of people will die.”