Public Health and Authoritarianism. Dr. Alfredo Morabia
I'm pleased to bring you this interview with Dr. Alfredo Morabia, who is Professor of Epidemiology at the Barry Commoner Center for Health and the Environment at Queens College, City University of New York. He is also Editor in Chief of the American Journal of Public Health. He lectures and writes on the history of epidemiology, and is a Fellow of the Royal College of Physicians of Edinburgh. Our conversation took place on August 10, 2021, and has been edited for clarity and flow.
Ruth Ben-Ghiat (RBG): Public health is about policy, and clear communication of that policy is so important. I feel like we'll be reading studies for years about the destructive impact of disinformation during this pandemic.
Alfredo Morabia (AM): There is a very fundamental communication issue with public health, which is that many people don't know what public health is. Many believe that public health is the opposite of private health. They think public health is medical care for the poor, for those who don't have private insurance, or who go to Medicaid instead of having their own private doctor.
Public health is primarily a focus on the health of the population. It doesn't focus on the health of any specific individual. It has to include the whole population in order to succeed. And we see this with Covid-19: if we want the population to become protected against new waves of the pandemic, everybody, almost everybody, needs to be vaccinated. By collectively protecting everybody in the community, we are fighting the pandemic. So public health is the health of the population. Medicine is the health of the individual, and they are very different things.
RBG: The pandemic has shown us the importance of leadership and the intention of those leaders: good governance versus negligence, or worse, as in the desire to manipulate the circumstance to increase power or profits.
AM: Authoritarian governments and populist far-right movements are totally incompatible with public health, because those ideologies exclude some part of the population on the basis of their religion, political beliefs, and so on, and so they cannot reach any public health goal. If you're not all-inclusive, you are not doing public health.
They use medical metaphors, looking at the nation as a body, and those who they want to exclude are like cancers or tumors or diseases that they must eradicate. Think of the Nazis, they used those bodily metaphors. The Jews, homosexuals and all the minorities that they wanted to eliminate were perils for that body. Some had to be sterilized, and some were eliminated, like people who were disabled or allegedly disabled. And then there was a final solution in the concentration camp. Public health requires an all-inclusive approach, it requires that leaders believe that everyone matters. This is incompatible with authoritarian and populist ideologies.
RBG: And yet this pandemic has been a stress test for democracy, given the greater regulations and restrictions on liberties that governments have had to enforce. In such situations it seems like the issue of trust in government, and the way a population feels about government as it goes into this experience, is key.
AM: That's a very important point and I really think it can go both ways. With the 1918 influenza pandemic the lack of trust was a big problem, it was all new. With Covid-19 the situation has improved. First of all, we've been lucky. The success of the vaccine is really fantastic. So there is an opportunity to build confidence in public health and in government approaches that we can then expand to other domains, like chronic diseases and diabetes and cancer and cardiovascular diseases and mental health issues that also need trust from the population in order for the public health intervention to be successful. So we have a really unique opportunity to explain to the public at large what public health is and what it does.
RBG: In an article you published in the Swiss newspaper Le Temps, you write that the aim of public health is not just to improve collective health, but to create a more just society.
AM: It's not that public health wants to have a fairer society, but that by its nature, being all-inclusive, it goes in this direction. When we think of COVID-19, for example, we can't leave some sectors of the population aside and only focus on the wealthier part or the urban part or whatever. This was also true in the 19th century. When cholera hit a city, you had to take care of it all over the city. You couldn't say, we'll let the slums go under and the rest of the city will be fine. You had to address the pandemic and its source and control it for the whole population.
And when you do this, those who benefit the most are the neediest, the most disadvantaged. By intervening at the entire population level with public health goals, you actually will reduce the gap between those that are more well off and those more disadvantaged. And by reducing that gap, you create a fairer society. It's intrinsically a part of public health to contribute to the creation of a more just society. History shows that it goes in this direction.
RBG: How will this pandemic evolve? Will we be living with it for years?
AM: I am a historian, not a futurist. I don't work with those types of projections. But no pandemic lasts forever. In general, pandemics last a few months, maybe a couple of years, and they tend to progressively get less and less lethal. I think we're most likely going in this direction for COVID-19 specifically, because now we have vaccines and it's in the interest of the virus to become less lethal and to become established in our population, as the flu is, or the common cold. I'm pretty confident that in a few years (or even less, if more people get vaccinated) it will become a common type of infectious disease, probably associated with cold in the winter and for which we could all be vaccinated as we are for the flu.