Evidence-based practice in public health is defined as the development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems and appropriate use of behavioral science program planning models. An additional definition of evidence-based public health, provided by Brownson et al., states that evidence-based public health is the process of integrating science-based interventions with community preferences.
The issue at hand is not evidence-based public health. Rather, the issue (or issues, in this case) are circumstances surrounding the successful implementation of evidence-based public health, such as needing a universal standard of implementing public health interventions, where evidence-based practices are utilized, including updating types of interventions. In addition, the politicizing of evidence-based public health practices recommended by scientific experts and health care professionals makes for a lesser likelihood of the public utilizing any recommended interventions.
A Pandemic During an Election Year
A global pandemic can cause an indescribable amount of devastation, and Covid-19 is no exception. First and foremost, there is a high loss of human life and trauma that stems as a result of an altered way of life for the global population. During Covid-19, people have died, and many of those who have survived Covid-19 are likely to have negative health effects (particularly respiratory) for years to come. In addition, there are people who have lost their livelihood during Covid-19, especially their jobs and their businesses in such industries as food and retail. In addition, Covid-19 has revealed to some and reminded others of varying forms of oppression that can have a negative effect on the health outcomes of those who belong to marginalized groups and are also suffering from Covid-19, such as those who are not white, not male, and not cisgender.
This is the first pandemic to occur during an election year since the Spanish Flu of 1918. As the world is experiencing the physical/mental/fiscal effects of Covid-19, there is also an experience of the politicizing of evidence-based risk reduction interventions, such as wearing a mask and maintaining 6 feet of social distance. In addition to these negative outcomes stemming from Covid-19, this also happens to be an election year. Depending on what someone can stand to gain or lose from this election cycle, Covid-19 for a politician can be leveraged to win an election. If a politician is currently holding office and is running for re-election, their response to Covid-19, as well as the support they offer to their constituents, can make or break their chances of re-election. If the current politician is seen as not handling Covid-19 and all the effects well, this gives the opponent of an incumbent the opportunity to develop a solid plan as part of their campaigning platform. In addition, voting for a candidate can also be affected due to the guidelines in place by Covid-19, as demonstrated by the governor of Ohio’s decision to delay the state’s primary by declaring a public health emergency. It is worth noting that this decision was made with the guidance of Ohio’s top public health officials.
While President Trump has never called Covid-19 a hoax, he has consistently downplayed the effectiveness of wearing masks or a face covering to prevent transmission of Covid-19. He changed his public statements on wearing masks in the summer and has worn them more consistently since he contracted the virus, although he has removed them in public when surrounded by crowds. The wearing of masks has been asked of him consistently by health experts and members of the press as the person who holds the highest office in the land to set an example for the nation. He has also continued to hold rallies with his supporters, although it is recommended not to do so during a pandemic to slow the spread of Covid-19 transmission. Both the wearing of masks (or face coverings) and maintaining social distancing have been recommended by public health experts from the Centers for Disease Control and Prevention. But due to President Trump’s dismissal of these interventions, his supporters (including politicians who support him) are not taking the same Covid-19 precautions as others who are adhering to the guidelines. An example of this would be Herman Cain, the former U.S. presidential candidate who passed away due to complications of Covid-19. His last public appearance was at a Donald Trump rally as masks were not worn. His case is a clear indicator of the effects of following politics over public health, and politics over prevention.
Outside of any individual politician’s views about Covid-19, there needs to be a firm mandate on adhering to guidelines to ensure the successful reduction of Covid-19 incidence or incidence of any disease for that matter. However, the United States stands apart from other countries in terms of personal liberties and freedoms. Setting firm universal health mandates for the entire United States, such as wearing masks and maintaining 6 feet of social distance, would be difficult to implement because of issues such as state’s rights and wanting to exercise personal freedoms, such as choosing to gather in large crowds and not wear a mask.
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Public Health: A Broad Field, Occasionally Without Mandates
In the public health field, one of the field’s weaknesses is that certain practices and standards are not mandatory. As a result, there are no universal procedures in place for executing evidence-based practices in public health. Agencies that are involved in public health work (for example, a community center with a department that handles public health issues) are often not held to the same standard as a public health department, outside of HIPAA compliance, that is. Among a public health workforce, there can be varying levels of adoption of the same intervention. In addition, a lack of access to resources for an organization can also be detrimental to adopting new information/implementing new & effective interventions. Another issue that was brought to light by Covid-19 was the capacity for organizations to rapidly adapt to the changing needs of the community/communities the organization serves, including the need to communicate health information. The impact of not knowing utilizing updated interventions due to slow adaption to change or capacity is the continued incidence/prevalence of health issues within a particular community. Chapter 7 of Turnock’s ‘Public Health: What It Is and How It Works’ discusses in detail the varying types of resources that contribute to the infrastructure of a public health program (such as human, informational, financial, and organizational). Do they have the people, latest information, finances, and organizational structure to do the work?
An example of the slow adaptation of an evidence-based public health intervention is the recommendation/prescribing of pre-exposure prophylaxis for HIV prevention. Pre-exposure prophylaxis, or PrEP for short, is a once-a-day HIV prevention medication that can be taken for HIV prevention. If taken correctly, PrEP can reduce the likelihood of the PrEP use contracting HIV by over 95%. However, some of the pushback on recommending PrEP stems from fears about a reduced likelihood of condom use and the fear of a rise in STIs. The debate that stems from this particular issue is whether or not the prevention of HIV can cause another epidemic to arise (STIs and unintended pregnancy from lack of condom use). In addition, there are public health professionals, as well as prescribers, who believe that a medication such as PrEP can increase someone’s likelihood of having multiple sexual partners. That can be argued equally as a legitimate public health concern in addition to a judgment on the client’s sexual activities.
Options and/or Recommendations
The Department of Health and Human Services suggested identifying the evidence of effectiveness for different policies and programs, translating that evidence into recommendations, and increasing the extent to which that evidence is used in public health. This is about existing policies and programs that are currently considered trustworthy and in wide use across the public health field.
To address the politicization of evidence-based practice in public health, there needs to be a champion of health who is not seen as pushing an agenda on their political party’s behalf. While medical experts such as Dr. Anthony Fauci should be considered such an advocate, he lost legitimacy with some Republicans after being openly criticized by President Trump. During the AIDS Crisis, there existed such an advocate, the late Dr. C. Everett Koop, the former attorney general of the United States. Dr. Koop was personally a deeply religious man who opposed same-sex relationships, pre-marital sex, and abortion. However, he served as a great champion in the fight against AIDS, much to the surprise of the Democrats who opposed his appointment and the Republicans who championed his appointment to his position. He advocated for the de-stigmatization of people living with HIV, which was especially important not only for the self-esteem and mental health of those living with HIV but also makes the virus that much more real for those who believe that they are morally superior to those who have HIV and therefore can’t be infected. Dr. Koop also advocated for safer sex practices including condom use while also, including suggestions such as abstinence and monogamy. Because of his message of prevention over politics, his prevention methods were well received by those across the political spectrum, and he had a hand in helping to decrease the rates of new HIV infections, as well as the reduction of deaths due to complications from HIV and AIDS. Although Dr. Koop was an incredible steward of best public health practices, it is worth noting that all it would’ve taken is one politician to loudly/consistently question his credibility or ‘agenda’ and Dr. Koop could’ve found himself in a similar situation as Dr. Fauci in terms of some people questioning his credibility.
Similar to the populations served in the public health field, those who are employed as stewards of public health need access to materials and the latest information in order to properly serve their community and help improve their health outcomes. This can be accomplished through the hosting of webinars where there is computer access as well as phone access so that public health agencies without strong internet capabilities can still listen and obtain/utilize updated information. The webinars themselves can be accessible to those who cannot afford to send staff members to conferences where their staff can bring information back to the agency. Linkage agreements or a more informal agreement where agencies who may have access to certain resources and materials can share with another agency that may serve a similar population to ensure clients are receiving optimal services from both agencies. The risk of working with another agency is a potential theft of intellectual property and another agency having the opportunity to take credit for an idea/concept, as well as a duplication of services.
Communications/Implementation
During Covid-19, one fact that has become abundantly clear is that there is a multitude of ways to communicate about a public health intervention. There are radio ads, commercials, bus ads, tweets, billboards, and a host of other communication methods that are all sending messages about Covid-19and Covid-19-related interventions to the general population. During Dr. Koop’s time as surgeon general, he relied on PSAs about AIDS as well as a pamphlet that was sent to every American with fact-based information about the virus. A similar plan was made for Covid-19, with the Post Office revealing that they planned to send 5 masks to every American household as an effort to promote public health, which was said to be allegedly halted by the White House. While no official word was given as to why this plan was canceled, the Post Office, often viewed as a politically neutral entity would’ve been an excellent asset in the promotion of wearing masks, especially if they provided them without any official word from any political entity. The question of how the recommendations will be communicated can be answered by a follow-up question of who is trying to be reached. That is the communication plan of the American people. However, how can the public health workforce be reached with a universal message of prevention of Covid-19 or any disease? Mass communication methods such as e-blasts can inform public health professionals about the latest information to provide to clients/the public. The CDC’s Morbidity and Mortality Weekly Report is another method to provide information to people in the public health workforce. However, the issue with all of these communication methods is that they are often optional to read/implement. In that optional framework, there needs to be a strong voice of mandatory universal language when discussing federal public health guidelines with the public. Granted, this language does need to be adaptable by the audience (especially when considering age and education level). However, the core message does need to be maintained at all times. A provision about the adoption of new evidence-based public health practices can be added to federal grant contracts so that the information/implementation is a grant deliverable and thus mandatory to maintain grant compliance. The grant monitor can contact agencies directly with educational opportunities with newer, more effective interventions, and follow-up to ensure the intervention is being properly implemented can occur during an agency’s site visit. Depending on the agency and the grant, there is often a work plan or an implementation timeline associated with a new intervention, especially if there are considerations such as which resources are available, including human, fiscal, and information resources. Before any implementation can begin, there needs to be agency buy-in, which can stem from leadership, the board of directors, staff, or the community (depending on how much the community has a voice or involvement in an organization’s procedures). Finally, organizations that perform capacity-building functions are able to work with agencies to ensure that their human, informational, organizational, and fiscal resources are available to best support the needs of the staff and the community. The United Nations defines capacity building as the process of developing and strengthening the skills, instincts, abilities, processes, and resources that organizations and communities need to adapt and thrive in a fast-changing world.
Conclusion
In current times, we are bearing witness to the adaptability of the public health workforce. The bold statement can be made that this pandemic has changed the course of work for every public health professional in some capacity. The ability to adapt can be hindered by issues such as politicizing public health interventions, as well as lack of public health infrastructural resources such as human, financial, informational, and organizational. This time is an opportunity for public health as an industry to focus on providing a unified core message to the public, which can be tailored for specific populations such as seniors and those with pre-existing conditions. There needs to be an assessment by agencies of the resources at their disposal, while also addressing concerns of public health interventions infringing on personal liberties. This is also an opportunity for public health to focus on emerging public health interventions and their success in advancing the well-being of the community while honoring/improving upon the current interventions that have been proven effective over time.
References
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- Brewster, J. (2020, May 14). Fauci Loses Support from Republicans After Trump Criticism, Poll Shows. Forbes. https://www.forbes.com/sites/jackbrewster/2020/05/14/fauci-loses-support-from-republicans-after-trump-criticism-poll-shows/#1053b40629d8
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- PolitiFact - Ask PolitiFact: Are You Sure Donald Trump Didn’t Call the Coronavirus a Hoax? (2020, October 8). https://www.politifact.com/article/2020/oct/08/ask-politifact-are-you-sure-donald-trump-didnt-cal/
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- Siegel, B. (2020, September 18). Postal Service’s Plan to Send 650M Face Masks to Americans Allegedly Nixed by White House. ABC News. https://abcnews.go.com/Politics/postal-services-plan-send-650m-face-masks-americans/story?id=73081928
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