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In a press briefing on September 6, 2022, the White House COVID-19 Response Coordinator Ashish Jha announced, “This is a moment when people can keep themselves healthy and safe as they think about the road ahead.” The same week the CDC, which dramatically undercounts cases, reported COVID transmission was at its highest level in 85% of all counties in the US; in other words, many, many people were sick. By “healthy,” then, Jha meant only not hospitalized immediately from COVID.
In our introduction to Keywords for Health Humanities, Priscilla Wald, Jonathan Metzl, and I described health, the noun, as a promiscuous term: “a broad description of proper functioning…an intimate term we use to understand our minds and bodies…a wide-ranging cultural imperative…a moral judgment…a word used to describe a set of professions, and…a central element of all life.” One reason health drew our attention for the volume is because of the broad global agreement achieved in the late 1940s that health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1946) and “a fundamental human right” (UN, 1948). The latter definitions were always aspirational, but prior to COVID-19, it seemed reasonable to expect at least “the absence of disease” in White House and CDC definitions of health. That no longer seems the case.
Not everyone can be “healthy” while sick with a pandemic virus, however. “If you don’t think you need [the vaccine] because you are healthy,” Jha implored later in the interview, “do it for your grandmother…for your vulnerable uncle, or for your friend.” Jha’s ableist and ageist framing of health echoes CDC Director Rochelle Walensky’s pronouncement in early 2022 that those dying while vaccinated during the omicron wave were “unwell to begin with,” adding that this fact was “really encouraging news” for a body politic now defined as healthy by virtue of its vaccination status, age, and ablebodiedness (“Fact Check”). The people who “can keep themselves healthy” are under fifty (per Walensky) and do not have pre-existing conditions, including not only heart disease, diabetes, and cancer, but also pregnancy, learning disabilities, mood disorders, physical inactivity, and symptoms associated with prior COVID infection. In truth, “healthy” Americans are a much smaller percentage of the population than most imagine—and, inconveniently, even “healthy” people can’t actually protect themselves from becoming “unwell” from infection.
Health is now, according to leading public health voices like Jha and Walensky, a narrow, individual quality. As early as May 2021 Walensky announced, “Your health is in your own hands,” a perspective that has been roundly criticized as against the public nature of public health. Activist public health experts like Ellie Murray continue to insist: “public health is a *public* responsibility & not an individual choice.” Bitter satire exposes the hypocrisy of an individually focused public health; highlighting the disastrous consequences contemporary positions would have had during the origin story of public health, tweeter “Neoliberal John Snow” declared in August 2022: “GREAT NEWS FOR OUR COMMUNITY. Unburdened by heavy handed, ‘health’ focused regulations, corporations…can continue to dump nourishing fecal contamination in our waterways. #FecalUrgencyofNormal #1854CholeraEpidemic.”
At best, the federal uses of health shift the burden from the government to individuals; at worst they are outright eugenicist. Disability activists point out that “@CDCgov has consistently refused to issue guidance protecting the health & wellbeing of chronically ill Americans – our deaths clearly don’t count.” In a sense, this is something we might have expected. As we observe in our original essay, “health is a site in which the social and global inequities of the world are writ large,” a sense of health that became more palpable and urgent during the pandemic.
The attenuation of the relationship between the adjective public and the noun health has a long history that by some accounts dates back to the late nineteenth century: germ theory and the rise of the medical profession and hospitals. Activists have repeatedly called for renewed connections between public and health under the banners of social epidemiology or “health from below”—often spurred by crisis like the Tuskeegee Syphilis Study and the AIDS pandemic—that would return to the field’s roots in activism and environmental mitigation to benefit all.
COVID briefly brought adjective and noun closer together again. The global move toward quarantine measures and “flattening the curve,” alongside the Black Lives Matter protests briefly solidified a “twin pandemics” understanding of COVID-19 and racism, returning an emphasis on the social and environmental dimensions of health for which activists had long clamored. Many institutions, like my own, founded new majors, departments, and schools of public health and enrollment numbers boomed.
Nevertheless, the unexpectedly quick development of vaccines in late 2020 provided a biomedical offramp for making health, even in public health conversations, an individual choice. With one-time activists and public health experts like Jha and Walensky promoting this individuated understanding of health, the connection between public and health seems more tenuous than ever, where no level of sickness, death, or disability from COVID will change our course.
This forceful suppression of the structural and public dimensions of health tracks closely with the rejection of frameworks that identify the public health crisis of structural racism surfaced by the "twin pandemics." Anti-vaccination and anti-CRT campaigns both emphasize the purported damage done to the health of individual (white) children over the health of the public; some deny altogether the efficacy of vaccines for the public or the accuracy of any structural analysis of race.
Defining health as an individual quality determined by personal choice is, of course, not new. Anti-vaxxers have long touted this understanding of health, but so have medicine and epidemiology by disproportionately emphasizing biomedical over social or environmental determinants of health. And people from historically marginalized populations are rightly wary of programs that subordinate individual choice for the public good. Furthermore, during the pandemic, abuses of population-level restrictions in the name of public health undermined health as a public rather than individual concern. In June 2022, the Chinese government used their COVID tracking app to quell dissent, flagging potential protesters as health risks in anticipation of planned demonstrations—a danger watchdogs had worried about since the launch of such technology. Likewise, in the largely Uighur city of Ghulja, residents were starved during a COVID lockdown in September 2022, a seeming extension of ongoing political persecution. Such examples serve as easy bogeymen of health regulations that tether the public too closely to health.
Surely many of us desire something in between. That is: something on the order of responsible governance for public health (better ventilation regulations, mask mandates where COVID transmission is high), not a definition of health that facilitates privacy infringement or sacrifices immediate somatic and psychological health. It seems, however, that the current framings of health have made this all but impossible. Health as a public good is too often maligned as political overreach in part because neoliberal logics of individualism and actual political overreach make commonsense positions seemingly unobtainable.
Writing for JAMA Health Forum in 2021, Mark Miller and Brian Castrucci opined that language was key to regaining control over the public health conversations about COVID. This line of thinking has been popular throughout the pandemic: if we could just get the words right, we could achieve better health outcomes. Such perspectives begin from the wrong premise: the language of health is not a stable well upon which we draw. Rather, tracking the changing definitions of health, the changing terrain of words associated with health, and the shifting concepts of the idea itself are crucial to achieving a better balance between health as an individual right and health as a collective ideal. That is if it is not, as I fear, already too late.