Recently, more than a thousand public health professionals, infectious diseases professionals, and community stakeholders issued an open letter advocating “an anti-racist public health response to demonstrations against systemic injustice occurring during the COVID-19 pandemic.” In their letter, these public health advocates defend and encourage active participation in demonstrations, even while coronavirus-caused health risks persist in communities throughout the country. Their letter thus reflects a convergence of two significant issues at this moment in American history—the coronavirus pandemic and the cause of racial justice—and it brings to the surface concerns that require our careful reflection.
This letter is, however, mystifying to many Americans, and it engenders cynicism toward the public health efforts of our federal, state, and local governments and the science that supported the public response to the pandemic. For several months, Americans have heard sobering warnings and dire predictions from public health experts and government officials about the urgent health crisis. In a spirit of neighbor love, they dutifully complied with public health orders and government guidance by staying at home, closing their businesses, schools, and churches, and taking other steps to protect themselves and others within their communities. These governmental actions and the compliance of citizens were defensible on the grounds of love and justice, and governments have largely kept within the boundaries defined by federal and state constitutions and statutes. But compliance with governmental guidance and orders has caused severe consequences for millions of individuals, families, businesses, and other institutions throughout our country. This letter now compounds the questions that Americans are asking about the various warnings, predictions, orders, and guidance issued over the last several months.
In this essay, we will seek to understand the concerns this letter brings to the surface by noting key points in the letter and setting the letter in the context of two contrasting views of the public health mission. The essay concludes with a note about discernment in this crucial moment.
Christians must be wise and discerning regarding the advocates, the movements, and the agendas at work in our society
Key Points in the Public Health Advocate Letter
The letter argues that “[w]hite supremacy is a lethal public health issue that predates and contributes to COVID-19.” It explains that “Black people are twice as likely to be killed by police compared to white people” and that “Black people suffer from dramatic health disparities in life expectancy, maternal and infant mortality, chronic medical conditions, and outcomes from acute illnesses like myocardial infarction and sepsis.”
These disparities, it states, are not adequately explained by biological determinants of health. Instead, they result from social determinants of health, specifically: “long-standing systems of oppression and bias which have subjected people of color to discrimination in the healthcare setting, decreased access to medical care and healthy food, unsafe working conditions, mass incarceration, exposure to pollution and noise, and the toxic effects of stress.” It adds that “COVID-19 among Black patients is yet another lethal manifestation of white supremacy.”
On these grounds, the advocates urge that their “first statement” in “addressing demonstrations against white supremacy” “must be one of unwavering support for those who would dismantle, uproot, or reform racist institutions.” They also contend that “[p]rotests against systemic racism, which fosters the disproportionate burden of COVID-19 on Black communities and also perpetuates police violence, must be supported.” Accordingly, they “do not condemn [protest] gatherings as risky for COVID-19 transmission”; rather, they “support them as vital to the national public health and to the threatened health specifically of Black people in the United States.” They express resolve to “support demonstrators who are tackling the paramount public health problem of pervasive racism” and “express solidarity and gratitude toward demonstrators who have already taken on enormous personal risk to advocate for their own health, the health of their communities, and the public health of the United States.” The letter also offers guidance for demonstrators to minimize public health risks while participating in such gatherings.
Two Contrasting Views of Public Health
This letter should be understood in the context of a larger debate within the public health law and policy field regarding the legitimate scope of public health. Just over a decade ago, Professor Larry Gostin, a public health law specialist, wrote the following regarding the scope of public health:
[Public health] activities at the cutting edge of population health often spark deep social and political dissent. . . . The controversy may be informed, in large part, by ideas of individualism, freedom, self-discipline, and personal responsibility that have been foundational in our society. There is a disjunction between the kinds of problems and solutions that are needed on a population level and the way the layperson conceptualizes these problems and their solutions. The lay public conceptualizes health as largely an individual matter rather than a societal issue.[1]
Gostin then discussed two contrasting views of the legitimate scope of public health. Under the first view, public health has a narrow scope that involves governmental exercise of distinct powers associated with disease surveillance, control, and prevention (through screening, reporting, vaccination, and quarantine activities) and injury prevention (through regulation of consumer products). This first view expresses the traditional understanding of public health, and social and political conservatives who favor limited government authority have tended to embrace this view.
Under the second view, public health is a broad, “all-embracing enterprise united by the common value of societal well-being.”[2] This view focuses on social, economic, and ecological causes of injury and disease (social determinants of health)[3] and emphasizes equitable distribution of social and economic resources. Proponents of this view seek to expand public health activities beyond traditional constitutional, statutory, and common law boundaries, use executive power and the modern administrative apparatus to undertake large social projects, and subordinate the rights of individuals to such projects. This view, embraced by contemporary progressives, extends John Rawls’s theory of justice in the area of health, and it has been on the ascendency over the last two decades. It is reflected in the titles of leading books published in the field, such as Norman Daniels’s Just Health—Meeting Health Needs Fairly (2008), Madison Powers and Ruth Faden’s Social Justice—The Moral Foundations of Public Health and Health Policy (2006), and Jennifer Prah Ruger’s Health and Social Justice (2010).
This debate over the legitimate scope of public health and the battle over public policies implementing the two contrasting views are intensely political and implicate significant moral concerns. Such a battle was waged over the Obama Administration’s contraceptive coverage mandate, which required employers and health insurers to cover all United States government-approved contraceptive methods, sterilization procedures, and patient education and counseling.[4] Progressives defended the mandate based upon public health and gender equity grounds and their conception of justice, and conservatives opposed the mandate based upon religious freedom and their conception of justice. The mandate also brought into focus another concern expressed by Gostin in his discussion of the legitimate scope of public health: “By espousing controversial issues of economic redistribution and social restructuring, the [public health] field risks losing its legitimacy. Public health gains credibility from its adherence to science, and if it strays too far into political advocacy, it may lose the appearance of objectivity.”[5]
Be Discerning
The open letter reflects the second view of public health, and it makes clear that the public health advocate signers understand the coronavirus pandemic and systemic racism to be coincident but related public health issues. Additionally, considering the political and moral dimensions of the debate regarding the scope of public health, the letter also reveals something of the political agenda and the vision of justice they seek to advance.
Christians must be wise and discerning regarding the advocates, the movements, and the agendas at work in our society. In this fallen world, we must seek justice, and we must address injustices where we find them, when we find them, in whatever form we find them, whether they involve private individuals, public actors, or institutions. We also must be careful regarding the individuals, the organizations, and the movements with which we align because the visions of justice some pursue may be incompatible with the biblical vision of justice.
[1] Lawrence O. Gostin, Public Health Law: Power, Duty, Restraint, 2nd rev. ed. (Berkeley and Los Angeles: University of California Press, 2008), 39.
[2] Gostin, Public Health Law, 39.
[3] Social determinants of health are “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as place.” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Social Determinants of Health, https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health.
[4] Michael J. DeBoer, “Legislating Morality Progressively—The Contraceptive Coverage Mandate, Religious Freedom, and Public Health Policy and Ethics,” Journal of Law and Health 28, no. 1 (2015): 62, https://engagedscholarship.csuohio.edu/cgi/viewcontent.cgi?article=1449&context=jlh.
[5] Gostin, Public Health Law, 41.
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