Good Public Health Is Invisible
It's only when things go wrong that you notice it. It looks like people will really notice public health in the United States quite soon.
One of the most well-known sayings in the world of epidemiology is “when public health works, it’s invisible.”. I’ve seen this or some version of it attributed to many people over the years, and it’s one of the most obvious facts about how public health works. When things go well, people live their lives oblivious to all of the activity that’s going on around them to keep them healthy.
Vaccines are the most obvious example of how this works. When you vaccinate children against diseases that they’d otherwise suffer from, you remove the main thing that people notice. Some people take a moment to think about all the infections that their parents used to get as children, but most of the time they barely notice the massive reductions in infectious disease that we’ve achieved over the last century or so.
You can see the issue. People in the 60s noticed that their children occasionally died of SSPE, a fatal issue that is sometimes caused by measles. My parent’s generation knew that measles was really bad, because sometimes kids got it and then never came back to school. But it’s much harder to notice the absence of a problem. No one stops their day to consider the brilliance of vaccines* when none of the children that they know have permanent disabilities caused by congenital rubella syndrome (a pregnant woman catching rubella), but they do when it’s their own baby or the baby of someone they know who is sick.
The same issue takes place for almost all public health interventions. The rate of dental decay has fallen drastically in the last 50 years, in large part due to putting tiny amounts of fluoride in drinking water, but it’s rare that people make noise about their teeth not falling out.
The list of effective work on population wellbeing is a collation of stuff that most people almost never think about. Asbestos. Basic nutrition. Getting enough iodine (but not too much). Safe drinking water. And on, and on, and on. It’s remarkably easy to forget the work of decades that has lead to our ability to live long and healthy lives without worrying about things like river blindness and smallpox when there’s no one around who suffers from those conditions.
The flip-side, of course, is that good public health is also relatively unobtrusive. The best interventions are things that work in the background, because people get irritated at having to pay attention to this sort of stuff every day. Airbags and crumple zones in cars are great examples - speed limits, on the other hand, are not. That’s not to say that speed limits are bad - they can be very effective - but it’s a more complex intervention that requires a lot more buy-in from the community than things that work in the background.
There’s a careful balance that we have to observe between improving individual health and impinging on individual liberty. Public health is no good if people cannot do anything they enjoy - the entire purpose of improving health is to make our lives better.
However, there’s really no debate about whether these things work or not. From a scientific perspective, vaccines, fluoridation, basic food controls, and similar are all very useful ways to stop people from dying. They work, mostly in the background, to better the lives of people across the world.
And the United States of America appears to have just voted to get rid of many of them. The incoming administration has indicated that they are keen to do away with pretty much all of these basic, effective tools that the US was foremost in developing over the decades.
The problem with good public health is that it’s basically invisible. No one notices kids not dying of measles. But, as in the 2019 Samoan measles outbreak caused by low vaccination rates which killed 83 people, mostly under 18, they will definitely notice when children die. Of course, one could argue that this is already too late.
*Note: except for Hank Green, who is a delight.
I was born in 1944. I lived through measles and mumps and was one of the lucky kids that had no long term effects from it. I would never go back to those days and am so grateful my sons were protected as babies.