Benefits of a Balanced Public Health Strategy

On March 11, 2020, the World Health Organization declared Covid-19 a pandemic, deeming the virus to be a critical issue in global health. As of December 31, 2021 nearly two years after the first cases were detected, there have been an estimated 290 million confirmed cases worldwide, with some 5.5 million deaths. 

The early responses from policymakers around the world recommended traditional hygienic interventions: social distancing, increased handwashing, and self-quarantine, all commonly suggested interventions in the face of infectious disease. The desire for a clear plan to defeat the pandemic, however, quickly became the mantra of virtually every elected official and policymaker. These plans featured universal mandates and increasingly strict responses driven by newly ascendent public health policymakers who dominated the planning process. Their suggestions and ultimately the plans adopted included large-scale lockdowns, stay-at-home orders, capacity restrictions, travel bans, and compulsory masking. Since pharmaceutical interventions have arrived, these plans have included mandatory vaccinations, vaccine passports, and the redefinition of full vaccination in accordance with recent booster evidence. 

What is most striking about these plans is both the stringency of the policy approaches, and the assertion that deviating from them, or even suggesting that other considerations might be necessary, are out of bounds. Policy responses across geographies, population densities, life patterns, and local circumstances are indistinguishable.

By April 2020, when roughly half of Earth’s population – 3.9 billion people, in no less than 90 countries or territories – were under some form of government order to stay at home illustrates this well. The demands for continuing those lockdowns have played out again and again through progressive waves of reinfection and new variants, and both the traditional and more authoritarian measures have been instituted, lifted, and reinstituted. 

Whether and to what extent the plans adopted and policies they required helped thwart or delay the spread and potential lethality of Covid-19, especially where the elderly and individuals with comorbidities are concerned, was initially uncertain. The evidence since those early days shows lockdowns and other approaches to “flatten the curve” have offered diminishing marginal benefits at best. The cost of these measures however, which include increases in poverty, depression, alcoholism, drug addiction, child and spousal abuse, suicide, undetected cancers, interrupted education, and other consequences of heavy-handed measures will outpace the benefits of the plans in years to come. 

The reality of negative outcomes like these is especially clear when comparing rural and urban health outcomes. Long-standing research identifies, for example, differences between fighting infectious disease outbreaks in urban versus rural environments. Population density, proximity to mass transportation, the prevalence of chronic health conditions and other factors make the epidemiological approach in cities considerably different than in open, more sparsely populated areas.

Less populated areas tend to be disproportionately impacted by significant economic downturns, and experience faster, more severe increases in poverty and longer recovery periods. These economic conditions started to emerge when the most stringent plans to combat Covid-19 were implemented. The 2007-2009 economic downturn provides strong evidence for the health impacts these downturns can have. In the years following the downturn, rural areas documented more problems with substance abuse, obesity, diabetes, and low birthweight than more urban communities. The rural health literature is replete with calls for tailored interventions that acknowledge the on the ground realities in dealing with health outcomes in rural communities. 

Internationally, health and welfare outcomes are well studied, and vary based on diet, climate, and social customs. National Geographic’s “Blue Zone” project, for example, identified a handful of places on Earth where individuals in improbably frequent numbers live to 100 years of age or older. Curiously, these places are diverse in many ways, and include Ikaria, an island off the coast of Greece, Okinawa, Japan, the highlands of Sardinia, the Nicoya Peninsula of Costa Rica, and perhaps most surprisingly of all, Loma Linda, California. 

Virtually all share dietary hallmarks: largely (but not exclusively) plant-based diets, healthy fats, and an avoidance of tobacco and most alcohol. But the Blue Zones also share intangibles which are impossible to plan. A component of the extraordinary health permeating those communities is found in strong, indeed lifelong associations common within their societies. Further in each, fitness tends not to be derived from programs designed to achieve these ends but from natural human behaviors: walking and gardening, mostly. 

Policymakers attempting to draw direct, clear, and transferable principles from the Blue Zone regions would be hard pressed to come up with anything beyond a handful of guidelines, let alone anything resembling a plan to achieve the same outcomes. And if the operation of local economies and local culture were to be taken into account, even less of what’s known would be functionally viable as guidelines. 

No one aware of the vast, varied diversity of climates, geographies, and cultures around the world can reasonably argue for one-size-fits-all policies. Among the most profound contributions of the 1974 Nobel Prize-winning economist Friedrich Hayek was his framing of the Knowledge Problem. Collectivist economies fail because of the inability, indeed the impossibility, of those in charge to gather and possess every piece of information about every part of their economy at any given moment in time. Even if central planners could get anywhere near this amount of information, they would see the circumstances they face, and even the relative importance of those circumstances change from one moment to the next. Thus, their attempts to plan are clumsy, and unsuccessful. 

For the same reason the economic planner fails, so does the public health planner in responding to a pandemic. Public health planners have information which is at best stale, inevitably partial, and as we have seen in this pandemic, the realities they face continually change. Resorting to universal policy approaches destroys the nuance that necessarily distinguishes the realities of human life. 

A better pandemic response must acknowledge two fundamental realities. Health policies must first be comprehensive in the sense that they take into account what makes up overall human health, and do not simply target the spread of a single disease. Second, policymakers must recognize and harness the reality of difference that defines human life. Disease mitigation policy that fails to incorporate diverse demographic, geographic, cultural, and even historical subtleties that characterize localities will see the same long tail of unintended consequences and policy failure.

Leave a Reply

Your email address will not be published. Required fields are marked *