Public Health Monitoring: An Active Phrase for Vigilance, Warning, Guidance, and Accountability

Kudos to AJPH for calling the long overdue question: Should the field of public health use “public health monitoring” instead of “public health surveillance” or even “public health data”?”^1(p662) Tellingly, “public health monitoring” leads the list, as it should—a term to be preferred, because it uniquely encompasses people, technology, and systems and actively connotes vigilance, warning, guidance, and accountability.

In 2023, Kassler and Bowman cogently argued in their essay “Overcoming Public Health ‘Surveillance’: When Words Matter” that the field of public health needs to drop the phrase “surveillance,” given its deep links to state and corporate efforts to collect data to control people as political subjects and as consumers.² Reminding readers of the etymology of “surveillance”—as “derived from the French roots sur (over) and veiller (to watch)”^2(p1102)—they called for a reframing of “public health surveillance” so that it prioritizes “protecting data privacy and restoring public trust as foremost objectives.”^2(p1104) They did not, however, offer alternative terminology to describe their alternative: “epidemiological regime.”^2(p1104)

“Public health monitoring” fits the bill. To support this claim, I offer three lines of argument: etymology, scope of work, and recognition that social justice has been the foundation of public health since the mid–19th-century emergence of public health agencies.³

“Monitoring” and the word “monitor”—which can be either a verb or a noun—are, according to the Oxford English Dictionary (OED), terms that are “a borrowing from Latin,” whereby “monit-” is the “past participial stem of monēre to advise, warn, or remind.”⁴ As the dictionary explains, “monitor” simultaneously can refer to instruments, systems, and people, with the OED definitions including both “something that advises or monitors” and “a person who advises or monitors.”⁴

Examples accompanying these definitions include, for instruments, “an instrument or device for continuously measuring some quantity or property” (e.g., radiation monitor, fetal heart monitor, apnea monitor), “a computer program which monitors and controls the running of other programs; an operating system,” and “a visual display unit connected to a computer to display text and images; a computer screen.”⁴ For people, examples of those who are monitors include “a person who oversees or observes; one who observes or comments on a process or activity, esp. in an official capacity to ensure that correct procedure is followed” (e.g., human rights monitor) and “a person who uses monitoring equipment to check levels, standards, etc.”⁴ All of these examples involve familiar public health roles and technology.

From the standpoint of both etymology and scope of work, “monitoring” is thus vastly preferable to both “surveillance” and “data.” To begin with, it is an active word and makes clear that someone or something is doing the monitoring—and this monitoring can be implemented by individuals and by communities for themselves to advance their health and thus is not reducible to surveillance conducted by government agencies or corporations to control populations and behaviors. It also avoids the problem of “data” being a passive word⁵—effectively meaning “that which is given,” since it is derived from the “neuter past participle of dare to give.”⁴ Stated bluntly, data are never simply a “given” but instead are a social product whose content and cost reflect societal priorities and intellectual frameworks—with the work and resources required to obtain the data necessarily involving human labor, technology, and concepts regarding the phenomena to be measured.^3,5

Additionally, “monitoring,” unlike “surveillance,” provides a sense of purpose that is in accord with a public health focus on prevention: monitors warn to guide action to prevent harm. It is also connotes “vigilance,” a term notably used in the name of the Brazilian public health agency Agência Nacional de Vigilância Sanitária (Brazilian Health Regulatory Agency)^6,7 that is becoming more common in the English-language public health literature.^8,9 Thus, as observed by Alvarez da Silva et al., “Brazil has its own specific expression for health surveillance—‘health vigilance’—but their actions are of a universal practice.”⁷ Similarly, Wier and Mykhalovskiy argued in their 2010 book Global Public Health Vigilance: Creating a World on Alert:

Vigilance directs analytic attention to apparatuses that continuously monitor phenomena that may give rise to catastrophic events. In the public health sense, vigilance refers to an attitude of being attentive, alert, and watchful; vigilance is an ethical standard to be used by public health officials in the course of their work.^8(p9)

No such ethical standard is implied by “public health surveillance” or “public health data.”

“Monitoring,” additionally, is compatible not only with public health activities to promote population health and health equity and individual and community efforts to monitor their own health but also with civil society engagement to monitor how actions by governments and corporations affect people’s health and planetary health.^3,5 Monitoring involves both accountability and agency^3,5: one monitors to give warning and to hold accountable those who cause harm. Such monitoring is central to advancing health justice and stands in opposition to older frameworks emphasizing surveillance, whose roots extend back to 18th- and 19th-century conceptions of “medical police.”^3,10

Changing long-used terms is not easy, but it is feasible. “Surveillance” has long been interwoven with public health discourse, practice, and systems.^2,10–12 It is central to the US Centers for Disease Control and Prevention’s Office of Public Health Data, Surveillance, and Technology, including its new “data modernization” initiative.¹³ Yet concepts and standards can and do change if people decide to and are able to implement these changes.

One instructive example is the name change, in the mid-1990s, of the venerable publication Control of Communicable Diseases in Man to Control of Communicable Diseases Manual.¹⁴ This change occurred because I initiated and circulated with colleagues a petition at the American Public Health Association’s annual meeting in 1992¹⁴ titled “APHA Publications Should Not Use ‘Man’ to Mean ‘Women and Men.’” The text stated:

We, the undersigned members of APHA, petition APHA to change the title of its publication Control of Communicable Diseases in Man. The use of the term “man” to refer to women and men is irritating and outdated. We suggest that APHA update the title so that it is inclusive of women; a more accurate title would be: Control of Communicable Diseases in Human Populations.^14(p20)

Agreeing with the need to shift to a “gender neutral”^14(p20) title, the APHA Executive Board devised a pithy solution, whereby it replaced “in man” with “manual.” This new title was conceptually valid and more accurate (describing the book as a “manual”), was typographically feasible (both “in man” and “manual” had the same character count of six characters), and allowed the book to retain its “well-known acronym, CCDM.”^14(p20)

Similarly, the 2024 decision of the journal Substance Abuse to take the major step of revising its name, after 15 years, to Substance Use exemplifies shifts in public health terminology paralleling shifts in understandings and values.¹⁵ In an editorial tellingly titled “What’s in a Name? Destigmatizing Language Regarding People Who Use Alcohol or Drugs in Publications and Journal Title[s],” the journal editors Stuart and Ramsey offered two reasons for the name change:

1. Scholars have compellingly argued that use of certain terminology, such as “substance abuse,” carries a variety of negative connotations. Renaming the journal is motivated largely by our desire to move away from stigmatizing language and the harms it causes… . Referring to people as substance abusers defines them by their problem and increases stigma, increases blame and culpability, and decreases help-seeking behavior.

2. [We] had another important reason to change the journal title. We are interested in research with a focus that is broader than problematic substance use. Specifically, we are interested in research on substance use, not solely disordered use.¹⁵

The name change thus simultaneously offered greater conceptual clarity, expanded the journal’s scope, removed stigmatizing language, and institutionalized the new language in a way that will affect what it publishes and the public health discourse going forward.

In closing, changes in terminology are evidence of people’s thoughtful engagement with changes in ideas, values, and knowledge.^3,10 It is time, past time, to replace “public health surveillance” with “public health monitoring.”