Where is the “Public” in American Public Health? Moving from individual responsibility to collective action

American individualism continues to prove incommensurate to the public health challenge of COVID-19. Where the previous US Administration silenced public health science, neglected rising inequalities, and undermined global solidarity in the early pandemic response, the Biden Administration has sought to take action to respond to the ongoing pandemic. However, the Administration's overwhelming focus on individual responsibility over population-level policy stands in sharp contrast to fundamental tenets of public health that emphasize “what we, as a society, do collectively to assure the conditions for people to be healthy”.¹ When this misalignment of individual responsibility and public health initially became clear with the removal of mask guidance for vaccinated individuals in May 2021, we decried the CDC Director's public admonition: “Your health is in your hands.”² We argued that such statements – coupled with the label of “the pandemic of the unvaccinated” – represent a moral failing of US policy because they “undermine the fundamental notion that all people are equal in dignity and rights²” and implicitly shift blame to individuals for systemic failures.

This turn towards an individualised approach by US leaders has continued amid a series of new variants and a vaccination-focused response. With the Biden Administration claiming that variants were unpredictable,³ and that people are responsible for their own protection by getting vaccinated,⁴ this neglect amid the Delta and Omicron waves led to an additional 318,000 deaths in seven months, accounting for over a third of all US COVID deaths to date.⁵ By increasingly framing the escalating transmission and continued deaths as a “pandemic of the unvaccinated,” the Administration has overlooked systemic inequities in vaccination (resulting from housing or immigration status, income and insurance, unequal access to information and systemic racism) while ignoring the plight of those ineligible for vaccination (children younger than 5 years) and those who remain at risk even after vaccination (e.g., people who are elderly, disabled or immunocompromised). The Administration promised “no disruptions” for the vaccinated while the unvaccinated were left susceptible to a “winter of severe illness and death”⁴ — further deepening divisions and neglecting fundamental human rights. Where vaccine mandates were a central pillar of the pandemic response, the Supreme Court's rejection of vaccine mandates for employers outside health-care settings has undermined even this pillar, leaving an even more extreme, libertarian, and individualistic approach and ignoring the need for structural solutions.

Beyond vaccinations, few federal public health policies have been enacted to contain transmission of recent variants, letting the virus spread virtually unmitigated in a country where only 65% have received two doses of the vaccine⁵ (as of February 14, 2022) —among the lowest vaccination rates of any high-income country. Prompted by public pressure, the Biden Administration belatedly acknowledged the need to provide additional public health protections in January 2022 – setting up a website for ordering four free rapid tests per household and distributing free N95 masks – but these efforts have been slow and remain inadequate, with little attention to inequities in access.

Framing the Omicron variant as “mild” – shifting focus from spiking cases and “long COVID” to hospitalisations and deaths, both lagging indicators – has only compounded these failures. As hospitalisations reached and exceeded January 2021 levels,⁵ reports from overwhelmed hospital staff negotiating crisis standards began to reveal the consequences of this individualistic approach, leaving weak health systems and essential supply chains at the verge of collapse.

Despite the constant evolution of SARS-CoV-2 variants and the unprecedented health burden of the COVID-19 crisis, the solution to the pandemic response remains strikingly simple—a return to foundational principles of public health and human rights. Three principles must drive all US policy actions: population health as the primary focus for collective action, the prioritisation of those groups at greatest risk, and equitable access to COVID-19 prevention and treatment—both inside and outside of the United States.

The public health response to the pandemic must prioritise population health. Populations have a collective right to public health, meriting the restriction of individual liberties where necessary and proportionate to protecting public health.⁶ A multi-layered approach to COVID-19 prevention and response is foundational to a successful population health response.⁷ This response includes access to vaccination, high-quality masks, ventilation, physical distancing, testing, and treatments – coupled with supportive social policies and regulations.

In these equitable measures to promote the public's health, special consideration must be given to ensuring the rights of those who are at higher risk for SARS-CoV-2 infection and more severe health outcomes as a result of COVID-19. These groups include children, older people (especially those in nursing homes), people who are disabled or immunocompromised, pregnant and postpartum people, those in carceral and other institutionalised settings, insecurely housed people, and workers such as teachers, essential, and low-wage workers.^5,8 These groups’ risks are further compounded by a history of policies motivated by structural racism, with the effect of undermining the health of racial and ethnic minorities. Comprehensive action is necessary not only to prevent avoidable illness, hospitalisation, and death but also to prevent other chronic complications of COVID-19 such as diabetes,⁹ negative cardiovascular outcomes¹⁰ and “long COVID”, which are still poorly understood and are estimated to affect millions of Americans.

Finally, the United States should not only take positive steps toward remedying the policy response at the national level; it must do so on the global stage. The disproportionate focus on individualism in domestic policy has been mirrored by nationalism in foreign policy. In abandoning the global community, nationalism continues to undermine international cooperation in facing a common health threat. Without efforts to ensure increased equity to COVID-19 testing, vaccination, and therapeutics across nations, variants will continue to emerge, undermining individual country efforts. It is only through global solidarity that we can achieve the collective action across nations that is necessary to advance public health in the pandemic response.

Contributors

The authors conceived, drafted, and revised this commentary for publication jointly. All authors participated in each step of the process. The authors wish it to be known that, in their opinion all authors should be regarded as joint first authors.

Declaration of interests

The authors have no conflicts of interest to declare.