Aligning Two Paths to Health

Like many public health crises in history, the COVID-19 pandemic is sparking discussion of reform. Much attention has focused on modernizing preparedness, such as speeding development of testing, treatments, and vaccines, as well as deploying advanced data and modeling systems. 

Less attention is being paid to undoing the profound social and economic inequities associated with suffering and death from COVID-19. Studies have documented elevated risks and illness in low-income communities and communities of color as a result of living conditions, working conditions, and other social factors. 

The field of public health stands at the crossroads of these different types of pandemic responses—spanning the technical and the fundamental, the “low-hanging fruit” and the “upstream,” the short-term as well as the necessary. Reconciling these approaches is possible in a framework that integrates public health with social justice. 

Social justice is defined by fairness in the distribution of resources and opportunities in society. A social justice perspective on public health starts with recognizing, in the words attributed to the 19th-century pathologist Rudolf Virchow, that “all disease has two causes, one pathological and the other political.” 

The pandemic is Exhibit A. The novel coronavirus struck all parts of society, but far from equally. The reasons for disparate impact cannot be found in the pathology of the virus. They were political in the broad sense of the word, related to structural racism, economic inequality, and ideological polarization.

The WHO has concluded that “social injustice is killing people on a grand scale.”

What’s more, COVID-19 exposed the limits of technology to overcome these challenges. Access to protective equipment, testing, care, and vaccination was uneven and unfair in many places. Massive amounts of misinformation and disinformation spread on social media platforms, undermining health. Despite having the most expensive health care system and the greatest supply of highly effective vaccines in the world, as of this writing, the U.S. has seen nearly 1 million people die from COVID-19.

It is a familiar pattern. Infectious disease, injuries, environmental threats, and chronic illness affect all corners of society, but, again, far from equally. Specific responses, including highly effective medical treatments and programmatic interventions, can save many lives and yet still fail to solve critical problems. Meanwhile, inequities in access to healthy and nutritious food, safe housing and communities, and reproductive health care leave populations vulnerable to a variety of health threats. That is why the WHO has concluded that “social injustice is killing people on a grand scale.” 

Given this reality, some may wonder whether incremental improvements are worth pursuing. The value of such efforts lies not only in what they themselves accomplish, but also in how they can generate momentum for more fundamental progress.

Take preparedness, for example. New data systems can shed light on patterns of health status and opportunity. New investments in medications and vaccines can be structured to consider and address barriers to access. New workforce programs can hire local residents for community engagement and mobilization. At every opportunity, public health leaders can pair the issue of the moment with ideas for broader change. Such an agenda today might include workplace protections and sick leave, reform of the criminal justice system, and policies that promote affordable housing—all under active consideration at the federal and state levels.

Of course, policy advocacy can generate opposition and threaten even modest gains. That’s why some prefer to stick entirely to areas of consensus and steer away from controversy. Professor Emeritus Vicente Navarro—teacher, researcher, and advocate—has never subscribed to this view. He once told a graduating class in public health: “Ours is a task, then, that forces us to side with the powerless against the powerful, and a task in which the illusion of being neutral is an indication of being on the wrong side.” This message can be heard decades later in the perspective of ethicists Madison Powers and Ruth Faden, who wrote that “the foundational moral justification of public health” is social justice.

In the aftermath of crisis, some improvements come easier than others, with structural change the most difficult to accomplish. The challenge facing public health is not how to choose; it is how to align. With social justice as the cardinal direction for public health, responding to short-term opportunities and working for fundamental reform are two routes to the same destination.