How Public Health Can Respond to Dysfunctional Politics

Lori Tremmel Freeman is the executive director of the National Association of City and County Health Officials (NAACHO), the professional association that represents local health departments. She wrote an excellent article in the American Journal of Public Health accurately describing the attacks on public health during the COVID pandemic and calling for legal protections for local public health workers. Director Freeman said…

“Many of these attacks on public health are surprisingly well organized. Groups such as Freedom Angels, Sovereign Nation, the Boogaloo Boys, and Colorado Counties for Freedom have coordinated strong pushback on public health measures in communities and have specifically targeted local health officials by generating messaging that includes personal attacks on integrity, conducting in-person demonstrations at the homes of public health officials, taking out radio advertisements against public health, and using other tactics to pressure public health officials regarding unpopular health orders and mitigation efforts.”

These attacks cost lives. Using my home state of Michigan as an example, I estimate that at least half—maybe as many as 20,000—of Michigan’s nearly 40,000 COVID deaths resulted from these attacks (I explain how I arrived at that figure at the end of this post).

In other articles on this blog, we explain why this happened. Early in the pandemic political leaders clustered around former President Trump realized that memes attacking public health were effective in mobilizing their extremist political base. Adopting positions to galvanize the base, regardless of the consequences, was part of the overall effort to subvert the 2020 election and many anti-public health activists were also involved in the assault on the capitol on January 6^th. Unfortunately, local political leaders seeking to advance their own careers eagerly supported this effort and were actually the ones who did the most to spread COVID by encouraging people to forgo masks, spreading anti-vaccination fever and overturning public health orders. (Many of these details are in the previous post.)

Ms. Freeman’s article, with its acknowledgement that she knows what we went through and its description of NACCHO’s concrete efforts to help, is welcome. Here, however, I want to push a little farther. Her article, I’m sure she would agree, calls on legal authorities to do their duty to support public health, but it does not propose long-term solutions to the problem of widespread anti-public health mobilization. But we cannot protect the health of our communities if half the public is up in arms against us, even if we have good police protection. As public health well understands, health flows from the sense of being part of a caring community and a desire to sacrifice for the welfare of that community, not from the threat of a visit from the cops. This is what we lose when elected leaders, who are in fact themselves responsible for protecting the health of the public, instead try to score points with the base by repeating popular lies about public health. Therefore, we must develop the capacity to grapple with and overcome this political dysfunction. The purpose of this post is to talk about what public health must do right now to address this political dysfunction.

I’ve been doing a lot of public speaking about this topic. I have noticed that when people in public health try to talk about how to rebuild their profession, they tend to get stuck in two places which have to do, first of all, with the problem of how we communicate, and secondly with the problem of our failing of our democracy.

The first place where public health gets stuck is the problem of communication. People keep trying to think of better and better ways to explain to others that COVID (or some other health threat like climate change) is real and that they need to take precautions against it. I think people get stuck here because they are, in fact, already really good at explaining this. There isn’t a better way. I do not mean that good public information practices such as those advocated by Peter Sandman are not important, they are, and we should always strive to fix mistakes and improve. What I do mean is that research on public health communication shows that the current structure of the internet blocks public health communication. There has been an explosion of such studies and they show that disinformation spreads faster and farther than accurate information on social media. This includes your favorites like Facebook, Twitter and TikTok. As Jones, Trice, Olaniran and Williams concluded in the Nature Public Health Emergency Collection (doi: 10.1007/978-3-030-36525-7_5) online communication has become “pathological” and “it is imperative to figure out a way to maintain sensible dialogues that promote democratic principles”. This means that even though public health is communicating like crazy, many people never hear us anyway, so our efforts don’t influence enough people to prevent a lot of deaths. (The bibliography found on this website lists some of this research.)

If I can get my audience to understand that fixing public health is not about them saying things in a better way, they get stuck again, because they can’t think of what else to do. This is the problem of our failing democracy. Today public servants in health, education and many other fields can’t ask elected leaders to do their jobs and can’t call on other agencies for support—the system is locked in partisan conflict, and nothing seems to be working the way it is supposed to.

Fortunately, my co-authors on our upcoming article in Health Promotion Practice have developed a really clear proposal for the public health community about exactly what our next steps should be. What they came up with is summarized in this draft, but here I’ll try to provide a brief synopsis: There have been a number of changes in how politics works in America that mean that people running for office are not rewarded for getting good public policy outcomes, but they are rewarded for stirring up an extremist base. Some of these changes include the rise of social media, which we already discussed. To this we need to add copious dark political money and also anti-democratic practices like gerrymandering and voter suppression. We can’t fix public health until we undo these changes first.

Let’s start by looking at how to make the Internet work better. Hundreds of millions of people use social media platforms without understanding basic facts about health or about their democracy even though they spend hours a day engaged with these topics. One thing that would not help would be censorship or policing the content of what people say online. What we ought to do is make Internet use improve people’s knowledge. To do this we could require social media platforms to be licensed, and as a requirement of licensure they would have to demonstrate that their users have a minimum level of media, health and civics literacy. This is the same way we regulate hospitals. We require health care providers to show that most of their patients get better; if they don’t get better, we can yank their license and give it to another provider whose patients do get better. If we treat social media the same way, it would go a long way toward blocking disinformation.

While we are dealing with disinformation, we also need to address anti-democratic practices including dark money, gerrymandering and voter suppression. The dominant model of public health, promoted by the Public Health Accreditation Board (PHAB) assumes that public health is part of a real democracy. It assumes elected leaders have appointed public health officials because they (the elected leaders) feel responsible for protecting the health of the public, and that elected leaders therefore are listening to the advice they are getting from their appointees even if they sometimes disagree. When this is true it represents a very healthy form of democracy. But it is not true. In many places in our country political jurisdictions are so captivated by disinformation, so awash in dark money, so gerrymandered and voter suppression is so effective that political races are not competitive, and politicians gain power by activating their extremist not by fixing real world problems. And they do this by making up scary stories about non-existent government plots.

One reason public health may have let extremist politics get the upper hand, is that public health workers sometimes say they cannot take a stand on political questions because of Hatch Act type state laws. What most of these laws mean is that government employees are not supposed to seek favors from elected officials to line their own pockets, which is a good thing, but the laws actually don’t block most kinds of political activity. In fact, public health can take a stance in favor of real democracy. Public health is already explicitly anti-racist and anti-sexist. We already advocate for social justice and health equity. All of these things depend on a healthy democracy.

Before we close, I want to talk about one other thing—holding leaders accountable. To fix communication and elections we somehow need to get new laws through legislatures whose members benefit from the status quo, so they are likely to resist us. It might be necessary to turn up the heat to get them moving. How do we do that? It might be necessary to apply some pressure in the form of holding them accountable. One way to do this is by using gross negligence laws or class action lawsuits. By any reasonable standards our leaders have been negligent and have harmed entire classes of people. Consider the following:

In 2017 after the Flint water crisis the former director of the state health department in Michigan, Nick Lyon was charged with manslaughter. Twelve people had died of legionella in one summer because the water was not properly treated. Director Lyon was not charged because he knew the water was dangerous but allowed the plan to go forward anyway. He thought it was safe. He was charged because he was insufficiently curious about why people kept protesting despite the reassurances he had received. Contrast that with the COVID pandemic. During the pandemic leaders were told over and over again by their own scientists not to do what they were doing. They were told many times that their actions were spreading the disease and raising the death toll. Yet they persisted. The result was that multiple dozens of people in Michigan died every day, and the dying went on in waves over two years.

I am not in favor of punishing anyone for what happened. I believe in truth and reconciliation. I want to fix what is wrong and move on.

But remember, Lyon was charged by the same conservative Republicans who later spread COVID to their constituents. If we have to turn up the heat to get action, we should do it. 

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Note on Methods: The four big Michigan counties with very strong COVID policies had total COVID mortality of 2,219 per million people. The 22 counties where essentially there was little effort to fight the pandemic had total mortality of 4,101 per million which is almost exactly twice as high. This disparity is the same pattern seen nationally. 

Public Health and January 6th

State Representative Steve Carra has submitted a bill in the Michigan legislature to make the anniversary of the insurrection in Washington, DC on January 6^th, 2021 into a “Day of Remembrance” for the “heinous and tyrannical actions levied on society by an unhinged and politically motivated ruling elite”, specifically the “manmade” Coronavirus pandemic. He was also one of the most ardent backers of the so-called Refuse to Obey tour, a series of demonstrations that were a direct offshoot of the earlier armed invasion of the Michigan Capitol on April 30^th, 2020. The Refuse to Obey Tour brought maskless anti-public health rallies to communities across Michigan, and Carra was one of the first Michigan elected officials to campaign against COVID vaccination. Because of Carra and others like him, opposition to COVID safety measures like masking, vaccination and closures left red and rural counties with much higher rates of COVID mortality than other areas, and Carra’s home county of St. Joseph has a COVID mortality rate well above the State average.

There are many similarities and connections between April 30^th in Michigan and January 6^th in Washington. April 30^th was ostensibly about overturning Michigan’s COVID public health orders and January 6^th was an attempt to overturn the 2020 presidential election results, but US Rep. Jamie Raskin who helped manage the first impeachment trial of then President Donald Trump, called April 30^th a “state level dress rehearsal” for January 6^th. And the people and organizations behind April 30 quickly pivoted to “stop the steal” within a few months. Similarities between the two events include extensive organizing on the extremist web, collaboration with public officials, boogaloo style paramilitaries entering the Capitol and in Michigan, the subsequent hunt for Governor Whitmer by the Wolverine Watchmen, like the hunt for Vice President Pence by the Proud Boys in Washington. Connecting the two events were prominent Michigan officials, like Matt and Meshawn Maddock, who helped fund and build anti-public health organizations like Stand Up and Unlock Michigan and later arranged for Michigan to be well represented among the rioters assaulting Congress on January 6^th.

Here I don’t want to talk about all the connections between April 30^th and January 6^th. I want to focus on one connection: the public health connection. Why was public health the dress rehearsal for an attempt to overturn an election?

First, I want to say that there is nothing about being rural or “red” that makes a person anti-public health. The people I know in central Michigan are smart, kind, hard working and courageous. More times than I can count, I saw folks make deep personal sacrifices for the welfare of their community. It would take some pretty weird politics to get such good people to spread disease to one another. But weird is what we got.

One reason attacks on public health were precursors to January 6^th is chance. Then President Trump was looking for ways to mobilize his base and COVID provided an opportunity. He had observed the beginning of opposition to COVID lock down policies being organized by some of the same people who were responsible for Charlottesville and his advisors Mark Meadows and Stephen Miller told him it would benefit him politically to take an anti-public health position.

It wasn’t obvious that COVID would get so out of control. At the beginning of the pandemic almost all governors followed tough lock-down policies as their pandemic preparedness plans said they should. They all thought about 9-11, Katrina and the Flint water crisis, and none of them wanted to fail their people. They talked regularly, shared information and copied each other’s successful practices. Even Ron DeSantis. Then, on April 17, 2020, President Trump infamously tweeted “Liberate Michigan”, “Liberate Minnesota”, and “Liberate Virginia”, targeting three democratic governors (Gretchen Whitmer, Tim Walz, and Ralph Northam, respectively). Republicans Mike DeWine of Ohio and Eric Holcomb of Indiana didn’t get tweets, even though their state’s policies were almost exactly like the others’. The national pandemic preparedness plan called upon Trump to lead the nation in sticking to safety protocols until the vaccine arrived, but seeing a chance to weaken Democrats he took it. Encouraged by Trump’s tweets Michigan was hit by an armed demonstration on April 30^th, and Minnesota and Virginia on May 1^st. Republican governors took note, and began to turn away from fighting COVID.

Meshawn Maddock leads a maskless rally.

This is when Steve Carra and others like him came into their own. Instead of doing the difficult but responsible thing and calling on their constituents to be brave, like they were during the Great Depression or World War II, local politicians leaped at the opportunity to agitate their political base. With coordination from the Maddocks and others like Garrett Soldano, who started out selling bogus COVID cures, PAC dollars began flowing from GOP campaign war chests into operations aimed at overturning public health orders and weakening public health leadership. An entire class of paid political operatives focused on undermining public health sprang up, including political fixer Ron Armstrong, to whom prominent GOP donors funneled cash, and lawyer David Kalman, who built a business breaking public health orders. By fall, public health was effectively paralyzed, unable to persuade sufficient numbers of people in the red parts of the state to mask or get vaccinated and unable to gain cooperation for contact tracing. We were on our way to 40,000 Michigan deaths. The blueprint for attacking public health became the blueprint for attacking our democracy.

But there is a deeper connection between public health and democracy. I’ve been groping for a word to describe that connection and I’ll try one out here: Courage. It takes courage to defend public health just like it takes courage to defend democracy. In both cases we are defending the institutions we have built together, based on the hard lessons of history, that exist to maintain the integrity and well-being of our people.

To defend public health you have to tell people things they don’t want to hear: you have been exposed to a disease; your community needs you to make a sacrifice for the health of others. You also have to tell elected officials things they don’t want to hear: more needs to be done to protect the public; you must defend the workers defending community health.

That’s the same kind of courage it takes to defend democracy. Today, to defend democracy, you have to tell people the election was fair; you have to tell elected leaders they must count all the votes; you must tell them they may not prevent people from voting. If you defend public health, just as if you defend democracy, you see yourself called a “nazi” on the media and your kids and coworkers wonder “Why”? You have to keep going while people threaten you, dox you, threaten your family.

Public health and democracy are fundamentally two different aspects of one thing: they are both built upon the promises we have made to one another, and committed to law, about how we will treat each other, how we will care for each other, even when it is unpopular. We understand as we rebuild the public health system that we are renewing true democracy—the ability of a free people to control their destiny. Let us have the courage to continue that work. 

NOTES: This article was extensively researched and sources and citations can be found in the "Bibliography and Citations" linked in the right-hand column of this website. Much of the material comes from Michigan regional media. Most relevant material is in the "Michigan Case Study" notes in the second half of that bibliography.

COVID Health Disparities Don't Mean What You Think

Epidemiology is the science that proves shit flows downhill. Stated a little less baldly, one of the most important insights from epidemiology is that disease and premature death are often concentrated in low income, minority and other vulnerable populations. This insight leads to the single most important strategy for improving population health, which is to focus on the health of those vulnerable populations. Applying this strategy to a pandemic we find that to save the most lives we must ensure that vulnerable people, most of all, understand the risks and have the tools to protect themselves. Sadly, because of structural inequities, public health isn’t as good at protecting the vulnerable as we need to be. We know this and are constantly trying to improve. This is reflected in how we communicate about our mission. For example, on top of health equity and social justice components baked into national accreditation, our leading local public health association (NACCHO) embraces and promotes five “Compass” principles for ensuring health equity during the pandemic.  

Another reflection of public health’s concern about inequality is how we tell the story of the pandemic. In particular, when public health talks about COVID mortality we emphasize higher rates of death among populations of color. During the first month of the pandemic, April 2020, COVID mortality in the African-American community was nearly three times higher than in the White community. Public health held itself accountable for this disparity. One public health official I spoke with said the disparity was because the public health response was “dripping with racism”. I think the word “dripping” is over the top, but that attitude illustrates how seriously many took those deaths.

As I think about this, though, I wonder if this telling of the story of COVID stops us from really understanding what happened—both the bad and the good. I think taking a longer look at COVID health disparities can help us see both why we were so ineffective, and also what the possibilities are for the future.  

From the earliest days of the pandemic, a growing number of researchers found that COVID was starting to gain traction and take off, not in the African-American community, but in mostly White, mostly rural and Republican areas. The Brookings institution began reporting on this in September 2020, and this finding was tested and retested by others like Pew Research. It was one of the most robust epidemiological findings of the pandemic.

COVID deaths started increasing in red areas for three interconnected reasons. The first was that then President Trump’s advisors encouraged his predilection to frame COVID safety measures as an attack on freedom. The second was local politicians in red areas saw an opportunity to align themselves with Trump’s base and took up the cause. The third reason was the rapid emergence of a political machine built to dismantle public health protections. In Michigan, for example, political entrepreneurs like Matt and Meshawn Maddock, Ron Armstrong and David Kalman sought funding from GOP PACs to create Stand Up, Unlock Michigan and other anti-public health organizations. Because of their actions, these people literally spread COVID to others. Their propaganda meant most people living in red areas did not try to protect themselves from COVID by staying home or wearing masks, and only half of them got vaccinated. To this day rates of COVID mortality remain much higher in red areas than in blue.

This point has been made many times already. What I want to do here is contrast this fact with what happened in the African-American community. While rates of COVID mortality in red areas rose, mortality declined in the African-American community. By the end of 2020 when the second wave hit, COVID mortality in the African-American community was less than a third of what it was in the spring of that year. Meanwhile mortality in red communities had exploded to more than double the African-American rate. This fact dramatically demonstrates the importance of good public leadership in a crisis and the deadly consequences that arise when leadership fails.

The reason COVID declined in the African-American community was because of the actions of the community and its leadership. After the horrors of the first wave of COVID the African-American community understood it needed to organize itself to keep people safe. All kinds of people—community organizers, clergy, politicians—put themselves forward to fight COVID. In Detroit, organizations like the Community Health Corps focused on housing and clean water for people sheltering, the Detroit Association of Black Organizations launched the Choose Healthy Life COVID testing and education campaign, and churches like New Mount Moriah aggressively pushed vaccination. In Flint the Greater Flint Health Coalition leveraged neighborhood organizations to fight vaccine misinformation.

I was working in rural central Michigan. I don’t know the names of many of the people doing grass roots organizing in the African-American community. But I do know the names of some public health leaders who supported the community effort and I want to honor them here: Vernice Davis Anthony who came out of retirement, physician and scholar Dr. Abdul El-Sayed, Dr. Joneigh Khaldun who worked from her perch in state government, and Dr. Kanzoni Asabigi who fought for a better response from Detroit government.

It is true that in red and rural areas there were many who understood what was happening and community organizations did all they could to help, just like they did in blue areas. But local politicians who may have wanted to help often felt it was too risky and didn't speak up for them. As one elected leader said to me, “I really want to help you with this but I just don’t know what I can do. My party seems to have lost its mind.” To be clear I am not saying people lost their minds. I know from firsthand experience that everyone was doing what they believed to be right. What I mean is that the consensus that public health was trying “to take our freedom” was so forcefully policed that political leaders feared they would pay too high a price for telling the truth.

It is also true that vaccine hesitancy and misinformation remain a problem in the African-American community. But in contrast to red areas, local leadership was united in working to fight COVID. The result is that today attitudes toward COVID safety and vaccination rates in the African-American community as a whole are similar to White or general community attitudes as a whole. From a deep deficit the African-American community climbed to a better—if not perfect—place. 

In these times when so many things--gun violence, drug overdoses, child health, life expectancy--are moving in the wrong direction, let us lift up this powerful example of how people did the right thing and how they saved lives because of it. 

NOTES: Sources for this article are included in the "Bibliography and Citations" linked in the right-hand column of this website, particularly the data compiled by the WK Kellogg Foundation and Pew Research. African-American COVID mortality in Michigan comes from the tables in the Data and Modeling Updates found at michigan.gov/coronavirus/stats.