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\begin{document}

\title{The year public health lost its soul}



\author[1]{Damien Contandriopoulos}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\begin{abstract}
The COVID pandemic was an acute test of public health capacities
worldwide. Many will hail the successes obtained and stress the
importance of the discipline. On the contrary, this commentary defends
the idea that the COVID pandemic response forced public health to enter
in a Faustian bargain with governments and realpolitik that threaten the
very core of the discipline's principles.%
\end{abstract}%



\sloppy


\section*{Introduction}

{\label{162797}}

The COVID pandemic is, at many levels, an historical turning point and,
for some, the poster-child illustration of the usefulness and centrality
of public health. My own understanding is radically different, and I
contend that the pandemic pushed the field of public health in a
Faustian bargain where it reneged its core principles in a way that will
have long lasting implications.

\section*{\texorpdfstring{The ``Soul'' of Public
Health}{The Soul of Public Health}}

{\label{938807}}

Public health, as a~discipline, rests on three basic tenets. First, its
goal of fostering individual and collective health and well-being
implies benevolence. Second, interventions ought to rest on principles
tested through scientific approaches. Finally, as the discipline evolved
during the 20th century, equity became its third core pillar:
Interventions should aim at reducing health disparities between
individuals and between groups. Over time, the discipline also developed
a tendency to debate how many angels can dance on the head of a pin, so
any simple definition could certainly be discussed and debated.
Nevertheless, few would contest that being equity driven,
evidence-based, and benevolent are central to the very nature of
public~health.

However, public health isn't only a scientific discipline, it also is an
applied practice, mostly taking place through specialized state
bureaucracies. From national public health agencies to regional or local
public health units, public health is firmly embedded in the state
administrative~apparatus. This operationalization of public health as a
function of the state always had to contend with specific challenges
related to its relations with governments and politics. Especially
since, given the existing evidence on the social determinants of health,
taken seriously, few goals would be as politically disruptive and
subversive than trying to reduce health disparities. State-run public
health bureaucracies therefore always had to carefully thread the line
between their disciplinary ambitions and the political acceptability of
their interventions. The resulting modus vivendi varied between
jurisdictions but generally didn't involve renouncing to the core tenets
described above as much as being selective in their translation into
practices and recommendations. As a side note, it is plausible that
public health disciplinary fondness for intensely scholastic debates
around equity and evidence-based policy stems, in part, from
the~double-bind its applied arm must contend with

\section*{And then came COVID\ldots{}}

{\label{322344}}

Over the past decades, many events, from communicable diseases like HIV
and Ebola to noncommunicable epidemics such as~tobacco and
opioid-related deaths, challenged the connection between public health
disciplinary tenets and it's applied arm constraints. But none of these
challenges came close to the disconnects that COVID brought.~

Early 2020, public health state bureaucracies everywhere suddenly found
themselves working hand-in-hand with governments to draft unprecedented
emergency measures to control COVID transmission. Over the following
year, this emergency period slowly turned into odd symbiotic relations
between political powers and public health structures.

Most jurisdictions in Western countries adopted ``balanced-containment''
strategies regarding COVID. This approach is characterized by the
ambition to balance, on the one hand, the number of coronavirus
infections, hospitalizations and deaths and, on the other hand, the
economic and social disruptions caused by strict infection control
measures such as lockdowns~(Oliu-Barton et al., 2021). The
balanced-containment approach is different from the COVID-zero or
elimination approach adopted by Atlantic provinces, New Zealand, China,
and others. It is also different from the necrophiliac~laissez-faire
tried in Brazil and some US states.

Initial infection control measures implemented at the onset of the
pandemic were drafted in the absence of strong evidence on transmission
routes for the new coronavirus. For historical reasons~(Molteni,
2021)~the emphasis was on fomite and respiratory droplets. However, this
focus ended up being misguided. By the summer of 2020, it became clear
that the virus was likely airborne and by early 2021 the scientific
consensus was that most COVID cases were caused by aerosol
transmission~(Allen \& Ibrahim, 2021; Tang, Marr, Li, \& Dancer, 2021).
However, it also soon became clear that most Western state-run public
health bureaucracies -- as well as international public health bodies
such as the WHO -- actively defended erroneous initial theories on COVID
transmission long after it was rational to do so. Instead of working
toward the development and communication of evidence-based COVID
prevention strategies, public health institutions found themselves
stonewalling and actively contradicting scientific developments in the
field~(Greenhalgh, Ozbilgin, \& Contandriopoulos, 2021).~

Over the same period, the focus of containment strategies shifted.
Economic actors impacted by lockdowns and infection control measures
successfully convinced many governments to slowly push the balance of
the containment strategies toward looser infection control measures and
the acceptance of higher infection rates. The reference point of
balanced-containment strategies slowly shifted from minimizing cases to
optimizing intensive care bed occupancy rates near or above 100\%. The
combination of outdated and misguided infection prevention advice and
looser restrictions contributed to fuel higher and higher waves of
cases.

In the meantime -- and unsurprisingly -- the balanced-containment
strategies were also shown to be deeply inequitable. Both the incidence
and relative risk of death from COVID were highly correlated with
income, social status and racialized status~(Karmakar, Lantz, \&
Tipirneni, 2021). The likely reason being that people in high incidence
groups were also the ones whose work could not be done remotely, being
exposed to high-risk occupations~(Middleton, Reintjes, \& Lopes, 2020),
living in higher density tenements, and not having much of a choice in
those matters. The weaker infection control measures were, and the
further they were pushed toward the maximization of economic activity,
the worse the impact on equity.

By early summer 2021, some jurisdictions -- such as Western Canada, the
UK, many US states -- decreed that the pandemic was over and that
preventions measures weren't needed anymore. Those decisions, explicitly
endorsed and defended by public health officials, were announced while
international evidence on the transmissibility and immune evasion
capacity of the Delta variant showed that vaccination alone would not
prevent further waves of infection. Like clockwork, those ``reopening''
plans~(Bell, 2021; Lafontaine, 2021; Wyton, 2021)~paved the way to a
brutal 4\textsuperscript{th}~wave. A situation made worst by the fact
prevention advice remained anchored in debunked theories about droplets
and that few (if any) effective prevention measures -- such as improved
ventilation of indoor public spaces, advice on good masking techniques,
limits on large indoor gatherings, etc.-- were implemented.

\section*{The Faustian Bargain~{[}1{]}}

{\label{106995}}

In most Western countries, and in the majority of Canadian provinces,
the COVID response symbiotically produced by political actors and public
health institutions caused multiple disconnects: between the scientific
evidence on COVID transmission and the public health sanctioned advice;
between public health and governmental discourses prioritizing the
wellbeing of the population and containment strategies focused mostly on
economic indicators; and between inclusive discourses putting forward
collective sacrifices for a common good and deeply inequitable
interventions.~

At the time of writing this commentary, those disconnects have grown too
deep to be hidden. More efforts seem to go in controlling the political
spin and rationing the information made available than in trying to
correct documented deficiencies~(Daflos, 2021; Thomas \& Gervais, 2021).
This is not to say that there is no push back by some public health
officials and it could be that fierce debates are taking place behind
closed doors. But, in most jurisdictions there have been little to no
place for open dissension~(Deep Singh, 2021).

Somewhere in the last year public health lost its soul. The goal of
fostering individual and collective health and well-being became
secondary to disputable economic growth indicators and radical
utilitarianism regarding the value of human lives. The focus on equity
that was central in all public health discourses fell as one of the
first victims of the discipline turn toward political symbiosis and
realpolitik. The ambition to be a science-driven evidence-based practice
continues to be daily trampled in evidence-free statements~(Daflos,
2021; Goldman, 2020).

In the following months and years, we should expect the COVID pandemic
to be used to support calls for increased budgets by public health state
bureaucracies. And many valid arguments can be made in support of
stronger public health. However, it would be a huge mistake to ignore
what the discipline lost in the pandemic, and the causes explaining the
disconnects discussed here. The pandemic caused public health to turn
back to its medical roots instead of leveraging the interdisciplinarity
it long preached~(Greenhalgh et al., 2021). It pushed many public health
state bureaucracies to become tools for governments instead of being
carriers for evidence-based information. And more generally it caused
the discipline to renege most of its principles.

\section*{References:}

{\label{371166}}

Allen, J. G., \& Ibrahim, A. M. (2021). Indoor Air Changes and Potential
Implications for SARS-CoV-2 Transmission.~\emph{JAMA, 325}(20),
2112-2113. doi:10.1001/jama.2021.5053

Bell, R. (2021, Sept 14, 2021). Kenney's Best Summer Ever to Worst ICU
Numbers Ever.\emph{~Calgary Sun}. Retrieved
from~\url{https://calgarysun.com/opinion/columnists/bell-kenneys-best-summer-ever-to-worst-icu-numbers-ever}{}

Daflos, P. (2021). Reduced contact tracing, child vaccination debate
revealed to B.C. doctors as province pushes return to normal.~\emph{CTV
News Vancouver}. Retrieved
from~\url{https://bc.ctvnews.ca/reduced-contact-tracing-child-vaccination-debate-revealed-to-b-c-doctors-as-province-pushes-return-to-normal-1.5586795}{}

Deep Singh, K. (2021, Sept. 14, 2021). As India's Lethal Covid Wave
Neared, Politics Overrode Science.\emph{The New York Times}. Retrieved
from~\url{https://www.nytimes.com/2021/09/14/world/asia/india-modi-science-icmr.html?smtyp=cur\&smid=tw-nytimes}{}

Goldman, E. (2020). Exaggerated risk of transmission of COVID-19 by
fomites.~\emph{The Lancet Infectious Diseases, 20}(8), 892-893.
doi:10.1016/S1473-3099(20)30561-2

Greenhalgh, T., Ozbilgin, M., \& Contandriopoulos, D. (2021). Orthodoxy,
illusio, and playing the scientific game: a Bourdieusian analysis of
infection control science in the COVID-19 pandemic.~\emph{Wellcome Open
Research, 6}(126). doi:10.12688/wellcomeopenres.16855.1

Karmakar, M., Lantz, P. M., \& Tipirneni, R. (2021). Association of
Social and Demographic Factors With COVID-19 Incidence and Death Rates
in the US.~\emph{JAMA Network Open, 4}(1), e2036462-e2036462.
doi:10.1001/jamanetworkopen.2020.36462

Lafontaine, A. (2021, Sept. 17, 2021). mer of hubris has led Canada's
health systems to the verge of collapse.\emph{~The Globe and Mail}.
Retrieved
from~\url{https://www.theglobeandmail.com/opinion/article-a-summer-of-hubris-has-led-canadas-health-systems-to-the-verge-of/}?

Middleton, J., Reintjes, R., \& Lopes, H. (2020). Meat plants---a new
front line in the covid-19 pandemic.~\emph{BMJ, 370}, m2716.
doi:10.1136/bmj.m2716

Molteni, M. (2021). The 60-Year-Old Scientific Screwup That Helped Covid
Kill.~\emph{Wired, May 13, 2021}. Retrieved
from~\url{https://www.wired.com/story/the-teeny-tiny-scientific-screwup-that-helped-covid-kill/}{}

Oliu-Barton, M., Pradelski, B. S. R., Aghion, P., Artus, P., Kickbusch,
I., Lazarus, J. V., . . . Vanderslott, S. (2021). SARS-CoV-2
elimination, not mitigation, creates best outcomes for health, the
economy, and civil liberties.~\emph{The Lancet, Online first}.
doi:10.1016/S0140-6736(21)00978-8

Tang, J. W., Marr, L. C., Li, Y., \& Dancer, S. J. (2021). Covid-19 has
redefined airborne transmission.~\emph{BMJ, 373}.~

Thomas, B., \& Gervais, B. (2021, Sept 14th 2021). Hinshaw believes
`Open for Summer' plan led to current spike in COVID
cases.\emph{~Calgary Herald}. Retrieved
from~\url{https://calgaryherald.com/news/local-news/hinshaw-believes-open-for-summer-plan-led-to-current-spike-in-covid-cases}{}

Wyton, M. (2021, Aug. 5th 2021). BC to Stay the Course on Reopening Plan
Despite Rise in Cases.\emph{~The Tyee}. Retrieved
from~\url{https://thetyee.ca/News/2021/08/05/BC-Stay-Course-Reopening-Plan/}{}

~

{{[}1{]}}~The term ``Faustian bargain'' implies sacrificing one's values
for power or material gain. It comes from a middle age legend about
Johann Georg Faust, a German Alchemist who allegedly sold his soul to
the devil in exchange for infinite knowledge and pleasures.{}



\textbf{Declaration:}

-Conflict of Interest: The author declares to have no conflicts of
interest to report.

-Funding Statement: This work did not receive any funding

-Author's Contribution: I wrote the commentary as a sole author.
However, I want to thank Trish Greenhalgh and Mustafa Ozbilgin who
provided numerous insights during informal discussions

-Availability of data and material: All material used is in the public
domain

-Code availability: n/a

-Ethics approval: This commentary did not use data that require ethical
approval

-Consent to participate : n/a

-Consent for publication n/a

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