Many in public health, which is increasingly tangling with politics, have a red line that when crossed leads them to walk away from their jobs when frustrated in not being able to accomplish their goals or are asked to do things they cannot stomach.
Walking away from public positions has risks, as one can unwittingly find oneself in the uncomfortable public spotlight and incur political invective.
Recently in Florida, we saw the red line principle play out.
An explicit directive from the governor’s office to use the Florida Department of Health to support Gov. Ron DeSantis (R) in opposing the abortion rights amendment on the ballot this November led to the resignation of Chief General Counsel John Wilson.
Wilson’s letter of resignation stated, “A man is nothing without his conscience. It has become clear in recent days that I cannot join you on the road that lies before the agency.”
Public health, at its core, is unconditional and selfless. It typically happens behind the scenes, quietly, anonymously, every day across this vast country, keeping us safe and prosperous.
Public health involves scientists, health care providers, outreach workers and experts in policy and law, expertly trained in their craft. It involves thousands of individuals across the U.S. who often work in positions paying far less than in the private sector now faced with challenging external political pressures and outright threats.
In medicine, upon graduation, new graduates recite the Hippocratic Oath on the day they are awarded their diplomas that set forth principles of excellence and equitable, and ethical patient care.
In public health, there is no such spoken oath. Rather, the activities of the daily job of serving the public — be it in infection control, community health promotion or maternal and child programs — binds public health workers in an ethical obligation to do their jobs the best way possible, even in the face of challenging political circumstances.
During the great pandemic of 2020, we saw an intrusion of politics and political theater into public health unprecedented in modern history, with political ideology impacting policy. At the state and federal levels, we saw scientists and public health experts that this country raised and respected stepped on and threatened while they were acting to keep us safe when we were still learning about a deadly new virus.
In medicine, decisions are made based on the patient in front of us. In public health, decisions are made differently based on large numbers of individuals, young and old, across varied geographical distances and settings, making public health especially challenging and politically vulnerable, as we saw.
During the pandemic, more than half of public health employees left their positions. Building on pre-pandemic trends, an even greater proportion of state health officers either walked away or were terminated from their positions, leading to troublesome leadership voids for complex and intricate agencies. It is estimated that more than half of state health officers were not in their positions during the pandemic, resulting in a loss of important institutional memory for their departments.
Over the course of the pandemic, we saw major shifts in the response to COVID-19 from when the different states in the U.S. followed that same initial anti-COVID-19 game plan to a year later when there were major differences in responses among Republican and Democratic-led states.
In Florida too, there was a major shift by DeSantis from strong COVID-19 vaccine promotion policies to opposition. In the absence of vaccine promotion by the governor for several months, although the Florida Department of Health continued vaccination efforts, there was a devastating impact from the COVID-19 Delta variant, where two-thirds as many Floridians died over four months as over the preceding 16 months.
Around this time, there was also a shift from allowing local communities and school boards to develop their own COVID-19 control policies to state-directed policies to limit face mask use. This change in direction resulted in broad disagreements and acrimony within communities.
I too was vilified during this time for not publicly opposing the governor, although the Florida Department of Health’s rule for school return encouraged mitigation measures and put in an opt-out policy related to mask-wearing.
Seeing an escalation concerning policies and being moved away from the podium, my red line coincided with the end of the statutorily defined end of my appointment. I was replaced by an out-of-state physician, Dr. Joseph Ladapo, whose political and non-traditional public health views were embraced by DeSantis.
Since then, we have observed COVID-19 vaccination promotion programs rolled back and a measles outbreak response that did not follow standard response measures. We also saw a parade of false claims about COVID-19 vaccines and no mention of legitimate COVID-19 protection measures for the unvaccinated, even for those who are medically vulnerable.
We saw a rollback in school health programs and an easing of vaccine exemption for parents in Florida. We also saw the surgeon general make campaign appearances with the governor for his presidential bid.
Florida Department of Health practices are increasingly directed by ideological philosophies, rather than standard public health practices. Putting the department in a position to actively block opposition to an abortion rights ballot amendment by having it issue cease and desist letters to media outlets running pro-choice advertisements subjugates, undermines and shows a lack of respect for public health and the people they protect in the state.
It’s a big red line. A federal judge, in fact, issued a temporary restraining order against the Florida Department of Health’s actions, stating: “It’s the First Amendment, stupid”.
Among the dedicated and heroic Florida Department of Health workers — who persevered through a pandemic and saw their core mission and principles increasingly challenged by political ideology — we can be thankful for a courageous voice taking a stand on behalf of an agency of the state, for the people of the state.
Scott A. Rivkees, M.D. is a professor of practice at the Brown University School of Public Health. He is the former state surgeon general and secretary of health of Florida.