Thread by @DrJayVarma

1/ Always enjoy and learn from reading @edyong209 essays, but I disagree with the thesis that US public health agencies need to return to the early 20th century approach of social reform to be more effective. 🧵⬇️

https://twitter.com/edyong209/status/1452289262712500226

2/What is the “public health” referenced throughout the essay? I assume @edyong209 is primarily referring to government agencies in the US often called “Health Departments.” Or does it also refer to govt programs that regulate food, medications, water, sanitation…

3/…and air since these are often (though not always) in other agencies? I think making these agencies (even) more politically active would jeopardize their credibility & funding, as we have seen with the politics of the FDA and EPA, for example.

4/I also don’t think we should conflate schools of public health or the discipline of epidemiology with the practice of public health. Few faculty at schools of public health, particularly epidemiology, have ever held leadership positions in govt public health agencies.

5/US public health schools are dominated by researchers, not practitioners, trying to win NIH & foundation grants. It's quite different to publish papers or serve on advisory bodies than to be legally answerable to legislators & constituents w/ diverse views & priorities.

6/Assuming the essay is about health departments, one of the main theses is that they would be more effective if they focused more on the social & political determinants of health.

7/I have rarely found the argument “this is good for health” particularly effective at convincing a legislator or govt executive to fund any program. For health programs, I have found the winning combination is often, in rank order, protection, opportunity, then justice.

8/Protection: This program will protect constituents from things they cannot protect themselves from and, if unaddressed, could cause widespread suffering and (**most important**) threaten your re-election.

9/ Opportunity: This program will generate X revenue, save X dollars, create X jobs or efficiencies, and grow the economy.

10/Justice: This is simply the right thing to do, because it will reduce inequality or correct historical wrongs. I have found this to be powerful only when combined with a protection or opportunity argument.

11/The essay argues that health departments should build stronger social coalitions as they did in the past. I strongly agree with this, but I disagree with the way it is framed.

12/I think health departments have progressively lost their coalitions, b/c they became too focused on norms, standards, & quality assurance rather than service delivery. Most have shrunk or eliminated direct clinical or social services & become invisible to the people they serve

13/This also rendered them less effective during #COVID19, b/c they had staff skilled in collecting, analyzing, and interpreting data but unable to also collect specimens, give vaccines, & train others in PPE use.

14/A culture within health departments that prioritizes technical guidance over front-line delivery has done more to destroy the coalitions & constituency that these departments used to have, rather than a failure to be politically active social reformers.

15/I found the lines contrasting embrace of vaccines rather than non-pharmaceutical interventions odd. Many of us in government continue to push for both, but we prioritize vaccines based on evidence from the past 60 years.

16/Vaccines are more durable & effective than individual behavior changes, particularly when those changes require constant adherence. We eliminated a highly infectious & dangerous airborne virus such as measles (for which we never used NPIs) with a mandated vaccine.

17/If health depts are to gain their rightful place in the hierarchy of government, my experience is they need to make a similar case to police/fire agencies & become more visible to the public: we are central to safety & economic productivity, & we serve the public every day.