Sketch of Swiss Cheese Model of infectious disease control. Shows how different public health measures overlap to block virus transmission.
The Swiss Cheese model, Illustration by Ian Ian M. MacKay (CC BY 4.0)

COVID-19 and a Century of Medicalizing Public Health

I miss the Swiss (cheese, that is). Remember the beginning of the COVID-19 pandemic when the Swiss Cheese Model was all the rage? As the theory goes, no single preventative measure (masks, vaccines, air filters, contact tracing, quarantine) will ever be 100% effective. Thus, it’s a core principle of public health that you have to layer multiple measures to safeguard the health of a population. Don’t take my word for it. Look instead to the words of Charles-Edward Amory Winslow, one of the foundational thinkers in American public health. He famously defined public health as,

The science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventative treatment of disease, and the development of social machinery which will ensure to every individual in the community as a standard of living adequate for the maintenance of public health.

Winslow’s “The Untilled Fields of Public Health” sketched out this definition in Science during a very similar time. In January 1920, a weary American public had essentially decided that the Spanish Flu pandemic was over despite clear evidence of an emerging fourth wave. That wave would go on to be the most deadly in some areas of the country. In this context, Winslow’s essay lamented limitations of clinical medicine’s narrow gaze and called a new approach to public health built from the coordinated expertise of physicians, epidemiologists, nurses, engineers, bacteriologists, statisticians, and social workers.

The Limits of Medicalization

In many ways, June 2022 feels a lot like January 1920. The American public is tired and eager to accept political assurances that the worst is behind us. Yet, Center for Infectious Disease Research and Policy epidemiologist Michael Osterholm tells us that “There’s probably more transmission of SARS-CoV-2 in the last 30 days than there had been in any 30-day period in the entire pandemic.” Despite these blaring warning signs, the Swiss Cheese Model has all but vanished from our collective memory and given way to a comparatively narrow focus on vaccination. Don’t get me wrong; I think vaccines are amazing. I’m happily triple vaxxed with two shots of Pfizer and a Moderna chaser. However, despite all the wonders of vaccination, it can’t be our only solution. Yet, sadly, our approach to public health is now such that prominent members of the medical community will publicly proclaim that “if we want to contain the spread of the virus, the only way to do that is through mucosal immunity.” I’m 100% on board with nasal spray vaccines and mucosal immunity, but “only” is a strong word that actively ignores the historic insights of public health and the very real fact that not everyone can be vaccinated.

Narrowing the full resources of a Swiss Cheese approach to a primary focus on vaccination is a primary example of the much decried medicalization and pharmaceuticalization of public health. Medicalization actively minimizes our available repertoire of preventative measures to the detriment of public health. Community mitigation measures like HAVC improvements are discarded in favor of individualized clinical interventions. Even ostensibly community measures like masking are rebranded and repackaged as individual choices based on personal risk factors. Relatedly, much (digital) ink has been spilled lamenting that when MDs are overwhelmingly in charge of our public health apparatuses (as they are in the US), medicalization seems to quickly become the coin of the realm. Certainly, the art and science of medicine are responsible for many innovations that have been used for the benefit of public health. But medicine, as an institution, is not equally open to all life-saving advances.

Medicalization in History

Sociologist Paul Starr wrote about this in some detail in his landmark Social Transformation of American Medicine. In Chapter 5, he described efforts to establish a robust public health infrastructure in America and how those efforts were largely thwarted by economic protectionism on behalf of physicians. As Starr noted, “Doctors fought against public treatment of the sick, requirements for reporting cases of tuberculosis and venereal disease, and attempts by public health authorities to establish health centers to coordinate preventative and curative medical services.” In the late nineteenth and early twentieth century, doctors and professional medical organizations were tremendously invested in blunting the scope of public health. As a result, all manner of infrastructural improvements from free public clinics to indoor air quality regulations died in various legislative committees. (To be fair, professional medical organizations had the general support of the business lobby in stopping those pesky air quality regulations.) In the end, as Starr recounted, doctors “favored public health activities that were complementary to private practice, they opposed those that were competitive.” Following intense lobbying efforts, fledgling public health initiatives were ultimately transformed into substantial investments in individualized educational and clinical initiatives. Despite Winslow and others’ calls for something more comprehensive and interdisciplinary, personal hygiene and insurance-backed annual physicals (a then-new source of guaranteed income) became the new cornerstones of public health.

Medicalization and Money

This history reminds me all too well of the shift from the Swiss Cheese Model to our new narrow approach focused on vaccination. While intellectual commitments are certainly important aspects of medicalization and pharmaceuticalization, money should not be left out of the discussion. Moderna and Pfizer expect a combined $51 billion in COVID-19 vaccine revenue in 2022 alone. Additionally, the pharmacies and healthcare facilities administering those doses enjoy substantial profits. Medicare currently reimburses $40 a dose for COVID-19 vaccinations which adds up considerably at 590 million doses and counting. Emerging research indicates that institution-level financial conflicts of interest represent a considerable threat to the integrity of biomedical research and the quality of clinical care. Considering how coordinated multidisciplinary approaches to public health have been and continue to be stymied, it seems likely that sector-level conflicts of interest may also be a real cause for concern. On the whole, the history of American public health and its relationship with medical protectionism certainly suggest that public health ethicist Daniel Goldberg is right when he argues that conflicts of interest are best understood as a “population health hazard.” Indeed, for more on this topic in the context of COVID-19, check out Jennifer Cohen’s insightful “COVID-19 Capitalism.”

Now, I’m not here to comment on the specific mix of preventive measures that should be in use at the current stage of the pandemic. Rather, I want to advocate for a change in how we discuss what public health measures are most appropriate. This is a conversation that needs to be led by a broader range of multidisciplinary experts in public health working in concert with community leaders. Shared leadership is critical to help assure that these discussions can be had in the best way possible. We cannot let the economic interests of a few continue to artificially narrow the scope of the discussion and prevent the adoption of a more comprehensive and coordinated public health response.

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Health, communication, and technology. Author of The Politics of Pain Medicine and The Doctor and the Algorithm.

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S. Scott Graham

S. Scott Graham

Health, communication, and technology. Author of The Politics of Pain Medicine and The Doctor and the Algorithm.

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