Opinion
What should we do when public health principles conflict?
For the last four years, I have served as the public health officer for the Tule River Indian Reservation in central California. In this role, I have sought advice from several public health maxims: center equity so my work never loses sight of the most marginalized; listen to the community so my decisions reflect the public’s preferences; and follow the science so my efforts are effective, trustworthy, and dependable.
Though laudable, in my experience these maxims have rarely aligned. In fact, they often conflict: Either the community doesn’t want to follow the science, or the science didn’t center equity, or centering equity wasn’t the community’s priority. As public health problems become more complex and fractious, public health professionals like me need more insightful advice, and we need targeted research and training to get there.
Sign up for Harvard Public Health
Delivered to your inbox weekly.
Consider two personal examples from the COVID-19 pandemic.
In 2021, the Centers for Disease Control and Prevention (CDC) shortened the recommended time for isolation after a COVID-19 diagnosis from 10 days to five. I presented this change to the tribe’s health board so we could update our orders on the reservation. However, the board—composed of elected community members—voted to maintain the 10-day isolation period for several weeks, believing it was the safest course for their reservation. Thus, at that time, our COVID-19 isolation guidance responded to community wishes—but did not follow the science. (They later revised their the isolation period downward, following CDC recommendations.)
The second example occurred during our rollout of the COVID-19 vaccine. I recommended organizing a mass vaccination event and offering the shots at the tribal health center, which was the consensus “best practice” at the time. The goal was to get doses into as many arms as possible. But I knew this approach would not reach all members of the community. Some tribal members did not have an internet connection to see our messages about the event, and others did not feel comfortable visiting the health center; some didn’t even have a way to get there. Our vaccine rollout did not center equity, even if it did follow the science.
In both situations, I chose to break a maxim given the context. For the changes to isolation, I believed the science did not apply perfectly to the reservation’s risk level because compliance with the existing isolation order was uneven, despite high rates both of COVID-19 and pre-existing chronic disease. Being extra cautious seemed prudent, so I listened to the community, as represented by its elected health board, and did not follow the science.
For the vaccine rollout, the community was at high risk around this time. I felt that getting the vaccine out as quickly as possible was the most important issue. Centering equity to reach all community members would have meant downsizing the mass vaccination plan and keeping more people at high risk. I chose to follow the science and not center equity in order to decrease the general risk of catching COVID-19 (or worse, suffering or even dying from it) in the community.
My decisions were imperfect—as most decisions are in crisis response, especially in resource-constrained environments. But the dilemmas I faced are not going away. With the rising rates of syphilis in Indian Country, we are discussing how to apply national best practices, like universal testing, at our health center. A key question is: Does the community want these practices?
Moreover, long-standing challenges in neglected communities like Native American tribes raise questions about whether our public health tools are also equity tools. For example, we know that tribal public health officials lack access to the data they need to improve health outcomes in tribal communities, which face severe inequities. That makes it challenging to do what the maxim asks and center equity. But data collection itself is notoriously blind to inequities. Even if I had that data, would it help? But does that data itself account for equity? Resolving the problem—in this case, data access—does not necessarily lead us to the solution—in this case, equity.
Meanwhile, the U.S. could very well elect a president who has spoken brazenly against science and equity; there is ongoing backlash to DEI initiatives; and there is outright refusal to expand Medicaid resources we know people need—to say nothing of the many examples of outright racism, sexism, or xenophobia we can find across the country. In this environment, it’s no surprise elected officials are choosing public health professionals who refuse to follow the science, such as with measles prevention in Florida.
Public health professionals need more perceptive advice than maxims to navigate these complex situations.
Developing this guidance must start at the top: Senior state and federal public health officials must be exemplars by being more candid about their decision-making, sharing how they resolve competing priorities, and avoiding oversimplified wisdom to justify their actions.
Researchers also have a role to play. Health journals should publish qualitative research that lays out the thought process of leaders as they make major decisions. Those of us on the front lines of public health need more qualitative research that explicates individual decisions, rather than quantitative research that looks for commonalities across situations. P-values aren’t very helpful here.
Furthermore, public health practitioners need case studies, a method used to great effect in fields such as business and law. While many experts have called for such teaching methods, schools of public health are not required to use case studies in order to be accredited by the Council on Public Health Education. I was fortunate nevertheless to be exposed to case studies as part of the leadership training that prepared me, during my doctor of public health program, for addressing complex problems and making decisions facing competing priorities.
This kind of training, in turn, should be a job requirement. I have yet to see a public health job description that demands leadership training. Instead, I see hiring managers for top public health positions focus on advanced degrees and the number of scholarly publications—impressive, perhaps, but an insufficient stand-in for leadership. Communities need leaders who have the skills to make imperfect decisions and justify them to the public, other professionals, and researchers.
Public health practitioners face situations daily in which we can’t simultaneously center health equity, listen to the community, and follow the science, even though these ideals are what we strive toward. To reach them, we’ll need to go beyond current maxims and develop better research, training, and changes to hiring practices. We can’t wait any longer for better decision-making to improve public health.
Image: Dmitry Kovalchuk / iStock
Republish this article
<p>Few decisions in the field are perfect. We must be prepared to make them anyway.</p>
<p>Written by Eric Coles</p>
<p>This <a rel="canonical" href="https://harvardpublichealth.org/policy-practice/a-public-health-officer-on-the-reality-of-principles-vs-practice/">article</a> originally appeared in<a href="https://harvardpublichealth.org/">Harvard Public Health magazine</a>. Subscribe to their <a href="https://harvardpublichealth.org/subscribe/">newsletter</a>.</p>
<p class="has-drop-cap">For the last four years, I have served as the public health officer for the Tule River Indian Reservation in central California. In this role, I have sought advice from several public health maxims: <em>center equity</em> so my work never loses sight of the most marginalized; <em>listen to the community</em> so my decisions reflect the public’s preferences; and <em>follow the science </em>so my efforts are effective, trustworthy, and dependable.</p>
<p>Though laudable, in my experience these maxims have rarely aligned. In fact, they often conflict: Either the community doesn't want to follow the science, or the science didn't center equity, or centering equity wasn't the community's priority. As public health problems become more complex and fractious, public health professionals like me need more insightful advice, and we need targeted research and training to get there.</p>
<p>Consider two personal examples from the COVID-19 pandemic.</p>
<p>In 2021, the Centers for Disease Control and Prevention (CDC) <a href="https://archive.cdc.gov/www_cdc_gov/media/releases/2021/s1227-isolation-quarantine-guidance.html" target="_blank" rel="noreferrer noopener">shortened the recommended time</a> for isolation after a COVID-19 diagnosis from 10 days to five. I presented this change to the tribe’s health board so we could update our orders on the reservation. However, the board—composed of elected community members—voted to maintain the 10-day isolation period for several weeks, believing it was the safest course for their reservation. Thus, at that time, our COVID-19 isolation guidance responded to community wishes—but did not follow the science. (They later revised their the isolation period downward, following CDC recommendations.)</p>
<p>The second example occurred during our rollout of the COVID-19 vaccine. I recommended organizing a mass vaccination event and offering the shots at the tribal health center, which was the consensus "best practice" at the time. The goal was to get doses into as many arms as possible. But I knew this approach would not reach all members of the community. Some tribal members did not have an internet connection to see our messages about the event, and others did not feel comfortable visiting the health center; some didn’t even have a way to get there. Our vaccine rollout did not center equity, even if it <em>did</em> follow the science.</p>
<p>In both situations, I chose to break a maxim given the context. For the changes to isolation, I believed the science did not apply perfectly to the reservation’s risk level because compliance with the existing isolation order was uneven, despite high rates both of COVID-19 and pre-existing chronic disease. Being extra cautious seemed prudent, so I listened to the community, as represented by its elected health board, and did not follow the science.</p>
<p>For the vaccine rollout, the community was at high risk around this time. I felt that getting the vaccine out as quickly as possible was the most important issue. Centering equity to reach all community members would have meant downsizing the mass vaccination plan and keeping more people at high risk. I chose to follow the science and not center equity in order to decrease the general risk of catching COVID-19 (or worse, suffering or even dying from it) in the community.</p>
<p>My decisions were imperfect—as most decisions are in crisis response, especially in resource-constrained environments. But the dilemmas I faced are not going away. With the rising rates of <a href="https://www.npr.org/sections/health-shots/2024/03/21/1239772654/native-americans-are-hardest-hit-by-syphilis-surge" target="_blank" rel="noreferrer noopener">syphilis</a> in Indian Country, we are discussing how to apply national best practices, like universal testing, at our health center. A key question is: Does the community want these practices? </p>
<p>Moreover, long-standing challenges in neglected communities like Native American tribes raise questions about whether our public health tools are also equity tools. For example, we know that tribal public health officials lack access to the data they need to improve health outcomes in tribal communities, which face severe inequities. That makes it challenging to do what the maxim asks and <em>center equity</em>. But data collection itself is notoriously blind to inequities. Even if I had that data, would it help? But does that data itself account for equity? Resolving the problem—in this case, data access—does not necessarily lead us to the solution—in this case, equity.</p>
<p>Meanwhile, the U.S. could very well elect a president who has spoken brazenly against <a href="https://www.theatlantic.com/magazine/archive/2024/01/trump-reelection-covid-pandemic-science/676127/" target="_blank" rel="noreferrer noopener">science</a> and <a href="https://www.usatoday.com/story/money/2024/05/01/donald-trump-anti-white-racism-dei/73528246007/" target="_blank" rel="noreferrer noopener">equity</a>; there is ongoing <a href="https://www.cnn.com/2024/01/07/us/dei-attacks-experts-warn-of-consequences-reaj/index.html" target="_blank" rel="noreferrer noopener">backlash to DEI initiatives</a>; and there is outright <a href="https://www.kff.org/affordable-care-act/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/" target="_blank" rel="noreferrer noopener">refusal to expand Medicaid</a> resources we know people need—to say nothing of the many examples of outright <a href="https://www.aljazeera.com/opinions/2024/8/9/americas-promises-of-racial-justice-remain-unfulfilled-and-untrustworthy" target="_blank" rel="noreferrer noopener">racism</a>, <a href="https://abcnews.go.com/538/sexism-impact-harriss-presidential-campaign/story?id=112444102" target="_blank" rel="noreferrer noopener">sexism</a>, or <a href="https://www.msnbc.com/opinion/msnbc-opinion/trump-attack-kamala-harris-nabj-racist-xenophobia-rcna164871" target="_blank" rel="noreferrer noopener">xenophobia</a> we can find across the country. In this environment, it’s no surprise elected officials are choosing public health professionals who refuse to follow the science, such as with <a href="https://www.npr.org/sections/health-shots/2024/02/28/1234483734/floridas-response-to-measles-outbreak-troubles-public-health-experts" target="_blank" rel="noreferrer noopener">measles prevention in Florida</a>.</p>
<p>Public health professionals need more perceptive advice than maxims to navigate these complex situations.</p>
<p>Developing this guidance must start at the top: Senior state and federal public health officials must be exemplars by being more candid about their decision-making, sharing how they resolve competing priorities, and avoiding oversimplified wisdom to justify their actions.</p>
<p>Researchers also have a role to play. Health journals should publish qualitative research that lays out the thought process of leaders as they make major decisions. Those of us on the front lines of public health need more qualitative research that explicates individual decisions, rather than quantitative research that looks for commonalities across situations. P-values aren’t very helpful here.</p>
<p>Furthermore, public health practitioners need case studies, a method used to great effect in fields such as business and law. While many experts have called for <a href="https://journals.sagepub.com/doi/10.1177/00333549221121669?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed" target="_blank" rel="noreferrer noopener">such teaching methods</a>, schools of public health are not required to use case studies in order to be <a href="https://media.ceph.org/documents/2021.Criteria.pdf" target="_blank" rel="noreferrer noopener">accredited</a> by the Council on Public Health Education. I was fortunate nevertheless to be exposed to case studies as part of the leadership training that prepared me, during my doctor of public health program, for addressing complex problems and making decisions facing competing priorities.</p>
<p>This kind of training, in turn, should be a job requirement. I have yet to see a public health job description that demands leadership training. Instead, I see hiring managers for top public health positions focus on advanced degrees and the number of scholarly publications—impressive, perhaps, but an insufficient stand-in for leadership. Communities need leaders who have the skills to make imperfect decisions and justify them to the public, other professionals, and researchers.</p>
<p class=" t-has-endmark t-has-endmark">Public health practitioners face situations daily in which we can't simultaneously center health equity, listen to the community, and follow the science, even though these ideals are what we strive toward. To reach them, we'll need to go beyond current maxims and develop better research, training, and changes to hiring practices. We can’t wait any longer for better decision-making to improve public health.</p>
<script async src="https://www.googletagmanager.com/gtag/js?id=G-S1L5BS4DJN"></script>
<script>
window.dataLayer = window.dataLayer || [];
if (typeof gtag !== "function") {function gtag(){dataLayer.push(arguments);}}
gtag('js', new Date());
gtag('config', 'G-S1L5BS4DJN');
</script>
Republishing guidelines
We’re happy to know you’re interested in republishing one of our stories. Please follow the guidelines below, adapted from other sites, primarily ProPublica’s Steal Our Stories guidelines (we didn’t steal all of its republishing guidelines, but we stole a lot of them). We also borrowed from Undark and KFF Health News.
Timeframe: Most stories and opinion pieces on our site can be republished within 90 days of posting. An article is available for republishing if our “Republish” button appears next to the story. We follow the Creative Commons noncommercial no-derivatives license.
When republishing a Harvard Public Health story, please follow these rules and use the required acknowledgments:
- Do not edit our stories, except to reflect changes in time (for instance, “last week” may replace “yesterday”), make style updates (we use serial commas; you may choose not to), and location (we spell out state names; you may choose not to).
- Include the author’s byline.
- Include text at the top of the story that says, “This article was originally published by Harvard Public Health. You must link the words “Harvard Public Health” to the story’s original/canonical URL.
- You must preserve the links in our stories, including our newsletter sign-up language and link.
- You must use our analytics tag: a single pixel and a snippet of HTML code that allows us to monitor our story’s traffic on your site. If you utilize our “Republish” link, the code will be automatically appended at the end of the article. It occupies minimal space and will be enclosed within a standard <script> tag.
- You must set the canonical link to the original Harvard Public Health URL or otherwise ensure that canonical tags are properly implemented to indicate that HPH is the original source of the content. For more information about canonical metadata, click here.
Packaging: Feel free to use our headline and deck or to craft your own headlines, subheads, and other material.
Art: You may republish editorial cartoons and photographs on stories with the “Republish” button. For illustrations or articles without the “Republish” button, please reach out to republishing@hsph.harvard.edu.
Exceptions: Stories that do not include a Republish button are either exclusive to us or governed by another collaborative agreement. Please reach out directly to the author, photographer, illustrator, or other named contributor for permission to reprint work that does not include our Republish button. Please do the same for stories published more than 90 days previously. If you have any questions, contact us at republishing@hsph.harvard.edu.
Translations: If you would like to translate our story into another language, please contact us first at republishing@hsph.harvard.edu.
Ads: It’s okay to put our stories on pages with ads, but not ads specifically sold against our stories. You can’t state or imply that donations to your organization support Harvard Public Health.
Responsibilities and restrictions: You have no rights to sell, license, syndicate, or otherwise represent yourself as the authorized owner of our material to any third parties. This means that you cannot actively publish or submit our work for syndication to third-party platforms or apps like Apple News or Google News. Harvard Public Health recognizes that publishers cannot fully control when certain third parties aggregate or crawl content from publishers’ own sites.
You may not republish our material wholesale or automatically; you need to select stories to be republished individually.
You may not use our work to populate a website designed to improve rankings on search engines or solely to gain revenue from network-based advertisements.
Any website on which our stories appear must include a prominent and effective way to contact the editorial team at the publication.
Social media: If your publication shares republished stories on social media, we welcome a tag. We are @PublicHealthMag on X, Threads, and Instagram, and Harvard Public Health magazine on Facebook and LinkedIn.
Questions: If you have other questions, email us at republishing@hsph.harvard.edu.
More in Policy & Practice
Universal health care may drive the vote in Puerto Rico
Avoiding discussion of vaccine side effects isn’t pro-vaccine. It’s anti-science.
