Photography by Kevin A. Roberts
The cheapest health care is the kind that you don’t need in the first place. Yet the prevention of illness and the encouragement of healthy behaviors—the twin goals of public health—receive only a tiny fraction of research spending in the United States. That’s not news to Ross Brownson, a professor at Washington University who’s an expert in chronic-disease prevention and applied epidemiology. It has become a central issue, however, as the nation stumbles its way out of one pandemic and begins thinking about the next one.
Why is investment in public health so meager, relatively speaking? Public health is prevention, so when it’s going really well, it’s invisible. We’re not conditioned to really understand that. We’re a lot better conditioned to say, “I’ve got symptoms of pneumonia, and I go to a doctor, and the doctor gives me treatment, and it goes away.” But public health is working best when events are not happening.
Are there economic or political reasons as well? If I’m a pharmaceutical company, there’s a reason for me to get drugs on the market: to make a profit. Same with surgical or medical devices. In public health, though, there’s nothing like that; there’s no industry there that fuels innovation. Then, in terms of policy, a lot of public health requires long-term investment, but what do most policymakers think about? They usually think in a very short-term window, often just an election cycle, say two to six years. The problem is that in the areas I work in—tobacco use or physical activity or cancer screening or diabetes prevention—policies might take decades to show an impact.
Did the pandemic upend your thinking in any way? We researchers have always had this assumption that the public understands that scientific discoveries are incremental and that scientists for a while might see things in one direction, then see them in another. The metaphor I always use is we’re building the airplane while we’re flying it. In this case, we’d never been through a coronavirus pandemic, so all these questions—are masks effective; how much does it spread in school environments; how effective is physical distancing as a mitigation strategy—every one of these was being answered in real time, in a natural experiment, and that can be very hard to explain to the public. For the most part the public and policymakers want a binary answer: Should I do this, yes or no? But scientists talk with caveats all the time. And then parallel to all that is how much the information ecosystem itself has changed. That’s another piece of this that I didn’t fully appreciate.
How so? Especially through social media, things spread at lightning speed, and there’s a lot of research showing that false information spreads three to six times more quickly than accurate information.
What does the research in your field suggest about how best to communicate with folks who reject evidence-based health advice? We could learn a lot from how businesses market products. You try to flood the information environment with accurate information; if it’s social media, you tailor it to social media. People learn by stories, so you turn it into short, digestible chunks. And you want the messenger to resonate with the person receiving the message—in other words, it’s someone they would trust, maybe a family physician or a local leader or someone like them. This is what we didn’t do with the vaccine, by the way: We invested a lot in vaccine development but not as much in vaccine delivery, and the delivery part has to include a strategic communication campaign. There’s a persuadable part of the vaccine-hesitant population, and solid communications could move them.
Could the pandemic be a boon to public health? We have an increased attention on racial inequities so that definitely can have a positive impact on public health. And I’m pretty confident that in the next few years we’ll have more students applying to learn public health and epidemiology. Public health is perhaps the one good infectious disease. It’s good to spread it.
