Improving health, preventing disease, and reducing threats to the wellbeing of a population are the principal goals of public health. These are accomplished through organized efforts within society. Achieving such objectives, however, requires policy enticements, effective messaging, legal mandates, robust enforcement and, most importantly, social engagement. Protecting the public’s health necessitates a fine balance between the rights of the individual and the good of the many. Strategies must be data-driven and reflect the lived reality of those it seeks to affect. Whether we are talking about guns or (vaccine) shots, the challenges, and the approaches for solving them, are the same.
Public health practitioners rely on the principle of utilitarianism—the greatest amount of good for the greatest number of people. Yet any approach that aims to reach the majority can often conflict with the principle of autonomy, namely the right of individuals to make their own decisions. Over many decades the public health system in the US has been chronically underfunded. More insidiously, it has been systematically undermined under the guise of individual rights and personal freedoms, which has compromised well established, highly effective public health strategies.
Pandemic control and gun control offer vivid examples and useful lessons.
During the pandemic, US government policies to control infections and mitigate the health disaster have focused on a few core objectives: (i) prevent the spread of SARS Co-V 2; (ii) protect those most at risk of severe disease; and (iii) avoid overwhelming hospitals and health systems. These eminently reasonable and appropriate goals resulted in vaccine and mask mandates, business and school closures, travel bans, and social distancing requirements. Such policies, however, conflicted with another core function of our government—to enable the pursuit of life, liberty, and happiness by protecting inherent individual rights.
In the US, we have reached the point of policy limits. Those willing to be vaccinated mostly are, while those resistant are unlikely to voluntarily accede. There are also those unwilling to engage in other infection reduction measures, such as mask wearing and social distancing. Resistance occurs irrespective of evidence and reflects an unwillingness to sacrifice personal comforts for the greater good. Legal mandates are being challenged, and indeed, mandatory closures of work, school, and places of worship may cause more problems than they solve. In short, the general public’s willingness to maintain restrictions on movement and social interaction is wearing thin.
Omicron has demonstrated that the natural mutations of a rapidly evolving and highly prevalent virus can evade our most sophisticated tactics of elimination. Even those who are twice or thrice vaccinated appear to be at risk for infection, albeit with less severity and with vastly lower risks of hospitalization and death. Even the best efforts of cautious, conscientious individuals have failed to prevent infections within families and amongst peer groups.
Take healthcare workers as an example. I am a surgeon, and most of my colleagues and fellow healthcare workers are fully vaccinated. We are accustomed to strict hand hygiene routines, the wearing of effective surgical or N95 masks, and social distancing practices. Yet our workforce has seen dramatic rates of infection during the Omicron wave.
Vaccinations, routine masking, social distancing, and improved hand hygiene are our most effective tools of Covid mitigation. But mandates risk alienating many and could prove counterproductive. This is where the utilitarian approach starts to break down, as infringements upon individual liberties begin to chafe. In addition, essential functions of society, such as educating children and ensuring businesses can operate, would be sacrificed to our detriment. Our social contract demands that we engage in important mitigation strategies, but eventually our tolerance is exhausted.
School closures are a perfect example. In-person schooling undoubtedly spreads the virus, and vulnerable teachers ought to be protected, yet the harm to students from not attending school is exceptionally profound. We will not fully understand the social, emotional, and financial impacts on the current generation of students for many years to come.
At the outset of the pandemic, authors of the Great Barrington Declaration made what was at the time a controversial plea to resume a more normal life, even before vaccines were available. They made this once it became clear that the virus, dangerous as it was, was nowhere near as lethal as originally described. They also recognized that the societal effects of lockdowns were of increasing concern, and that the widening gap between the haves and have nots would exact a heavy price on our society well into the future.
With the spread of the Omicron variant, COVID increasingly appears to be endemic, much like many other respiratory illnesses that we routinely live with. As such, we must adopt new policies that allow us to continue to function as a society. Living in a perpetual state of emergency is not only unhelpful, it is counterproductive, especially when we have other tools and approaches at our disposal that are effective, egalitarian, and balance the risk of infection against the risks of mental, educational, financial, and social harm.
The challenge is finding balance. It is like the challenges posed by gun ownership and regulation. Expanding civil liberties is something to be championed. But the arming of society and the pervasiveness of gun violence, where the benefits to the greater good have been inappropriately sacrificed to the rights of the individual, ought to elicit a pause. The year 2021 saw the highest firearm homicide rate in decades, and a 13% increase in mass shootings, yet policies can be implemented that meet the desires of both camps – those who cherish their right to bear arms and those who desire schools and workplaces and social gatherings free from terror and bloodshed. Waiting periods, background checks, ownership prohibitions against perpetrators of domestic violence and felons are policies supported by the vast majority of Americans and can be accomplished without undermining the rights of responsible firearm owners.
Yet a vocal minority demands instantaneous access to deadly weapons without oversight, accountability, or controls to ensure safety. A similar vocal minority refuses vaccinations proven to reduce transmission of infection and risk of severe disease. It rejects mask use proven to reduce spread. It denies even the fact of the virus itself. The parallels between guns and shots are clear.
Our challenge is to cut through the vitriol to enact reasonable policies that accommodate best knowledge and practice, adapt effectively to evolving knowledge and circumstances, and recognize complex social and community dynamics. As we seek to develop and deploy public health strategies to reduce harm to society from the pandemic and other challenges, we would do well to balance our utilitarian approach with concerns for autonomy. But most importantly, we must focus on ways to implement and rebuild the most fundamental strategy of all—common decency.