The New York Times recently called Dr. Anthony Fauci “America’s most loved and hated doctor,” and it’s difficult to argue with that assessment. Fauci was catapulted into the spotlight thanks to the COVID-19 pandemic, and his constant presence on the country’s television screens, combined with his public pushback against President Donald Trump, turned him into a hero in many Americans’ eyes—and a villain in many others.
But while Fauci has both his partisans and his critics, what both sides can agree on is that Fauci’s departure from federal service after decades as America’s leading face on public health leaves a large hole in the public health establishment. The controversy surrounding Fauci and his COVID pronouncements made it hard for him to continue in that role, but his departure raises the question of what to make of public health these days, in the aftermath of COVID, and what to make of the trustworthiness of our public health establishment.
Public Health Problems
Public health—the broad collection of federal, state and local health agencies and nonprofits—performs a vital function in this country. We need public health to help prevent the spread of disease and disseminate important messages in times of crisis. Unfortunately, the COVID crisis sowed more rather than less distrust in our public health establishment. Between March 2020 and May 2020, one Pew Research Center poll found, the percentage of Americans who said public officials were doing an “excellent” or “good” job in responding to COVID dropped from 79% to 52%. But while perceived politicization of the public health establishment during the pandemic certainly contributed to these numbers, that’s not the only explanation for waning trust in public health officials.
Part of the problem in recent decades has been the public health community’s obsession with behavioral health, which is an attempt to shape the collection of behaviors, good and bad, that can affect one’s health status, from eating to drug use to exercise. This focus has been particularly a problem with the U.S. Centers for Disease Control and Prevention (CDC), which bills itself as the nation’s pandemic preparedness agency, but actually spends more time and attention on behavioral health issues. Just to take one example, the CDC’s 2023 budget request asks for about $3.6 billion in spending on chronic disease prevention, environmental health, and occupational safety and injury prevention, which is larger than the agency’s approximate $3.5 billion domestic spending request for communicable diseases.
Behavioral health is of course important, but by focusing on the individual’s personal preferences, it also involves choices people make. As a result, judgments emanating from the public health community can alienate people struggling with their choices. Pandemic preparedness and response, however, is about dealing with diseases that can spread person-to-person and devastate entire societies: The effects of each choice reach far beyond the person making the choice. But if public health continues to stress behavioral health, it makes it harder to get the American people to go along with the necessary steps that have to be taken in terms of pandemic preparedness to keep people safe.
Another problem in recent years has been the apparent partisan alignment of public health with the Democratic Party instead of being nonpartisan. University of Chicago public health expert Harold Pollack, himself a liberal, has spoken out on the need for public health officials to be able to communicate with all Americans, regardless of their political ideology. Again, if the public health establishment can’t reach people in times of crisis, it will be unable to get people to do what they need to do to address or alleviate the crisis.
When Donna Shalala served as the U.S. secretary of health and human services, she would insist that public health officials who spoke out during health emergencies wear their white lab coats. According to Shalala, this would make them appear both nonpolitical and authoritative in their medical positions. It’s true: While we have often been lied to by politicians wearing suits, doctors in lab coats somehow seem more reassuring. But a lab coat is not everything.
What Shalala was really looking for was a metaphorical lab coat for public health officials, such as we saw with CDC official Richard Besser during the 2009 swine flu outbreak. He was such an effective and reassuring communicator during that crisis that he was hired as chief health and medical editor for ABC News. (He is currently president and CEO of the Robert Wood Johnson Foundation.) Such a metaphorical coat entails speaking truthfully, authoritatively and with humility on issues of national public health concern, and doing so without politics or condescension toward people who live in various parts of the country or who have different lifestyles.
Finding That New Face
Going forward, we need to come up with a pathway for how to proceed in the wake of hard times for public opinion on public health. First, it is important to have a national spokesperson for public health—and that person cannot, and should not, be a political figure. In these partisan times, Republicans will distrust a Democrat appointee, and Democrats will distrust a Republican appointee, and there’s not much to be done about that. Furthermore, the political appointees themselves serve limited terms at the pleasure of the president. As a result, political appointees have a hard time establishing themselves as trusted figures. Most Americans could not name a recent CDC director, and the most famous one of them all, C. Everett Koop, left his position decades ago, at the end of the Reagan years. In more recent times, Robert Redfield was head of the CDC during the early period of the COVID crisis, yet had very little public profile and never emerged as the face of the public health establishment in the way Fauci did.
For decades, though, Fauci was that face. He was a key figure in a search for an HIV/AIDS treatment, collaborated with presidents of both parties on pandemic preparedness, and worked closely with George W. Bush on the President’s Emergency Plan for AIDS Relief (PEPFAR), an important initiative that saved over 18 million lives. With Fauci’s departure, there is definitely a need for someone to replace him as the spokesperson for the public health establishment.
In searching for this new person, it is important that the public health community find someone who can approach these issues with a degree of humility and without engaging in overt paternalism. One of the challenges in recent years has been the feeling that public health officials as a whole talk down to the American people. An unfortunate example of this is the early guidance from public health officials that masks were not recommended during the COVID-19 outbreak because the officials wanted to preserve them for frontline health workers.
Furthermore, there is a very real sense that public health has a partisan alignment. Both condescension and partisanship are extremely problematic when trying to gain the trust of the vast majority of the American people. If the American people do not trust what they are hearing from public health officials, or think that they have a partisan bent, they will not go along with important public health recommendations when it comes to treatment, vaccines and prevention efforts.
Anthony Fauci’s period of service may be over, but America’s need for a trusted public health spokesperson continues. As the search for the new face of public health emerges, the U.S. government needs to take these factors into account. We need someone who can speak to the American people in a trustworthy, straightforward and non-ideological way about the many public health challenges that we might face in the future. Here’s hoping we find that person.