In a recent issue of JAMA, Daniel Morgan (U Maryland) and Deborah Korenstein (Icahn/Mt. Sinai) offered a viewpoint article that revisits the important evaluative conversation about the performance of our public health system during the COVID-19 pandemic and offers four useful principles for a “new approach to public health.” In this post, I will briefly summarize these principles and offer an important additional principle that I described in my comment published in JAMA this week.
Morgan and Korenstein noted that during COVID-19 there was an increase in distrust in public health institutions, with 65% of people having no trust or only partial trust in the CDC and 75% distrustful of their local public health departments. The authors admirably called for open discussion of “what went wrong” and “opportunities to build trust.” The authors implicitly kicked off that discussion by asserting that inconsistent, subjective and politically motivated guidance was among the causes of such distrust. They also implicated “unpopular aspects of public health” such as vaccine mandates, school and business closures and the “suppression of debate.” They proposed that trust-building opportunities should be based on four principles: (1) Do no harm, (2) Meet the public where they are, (3) Respect individual autonomy and a range of opinions, and (4) Be transparent and apolitical.
Before I propose a fifth principle, let me offer some commentary and quibbles about the authors’ first three.
During the final stretch in medical school, MD candidates in the U.S. reverently recite the Hippocratic Oath, which is commonly summarized as “first do no harm” (although the Latin phrase “primum non nocere” does not actually appear in the oath itself). Such a principle is of obvious importance in the context of ancient unethical healers who gained status and wealth offering theatrical treatments that were harmful but for which there was little or no scientific evidence of effectiveness — a problem that continues today with some “nutritional supplements” and, sadly, in parts of mainstream medical and surgical disciplines. But, in the context of the modern science-based practice of medicine, the “do no harm” principle is an unhelpful oversimplification. We obviously do not withhold chemotherapy from cancer patients just because it might have harmful side effects. And in the field of public health, we should not — as a matter of principle — forego quarantines and other mandatory policy options just because the expected outcomes include some harms to some individuals. The real principle should not be “do no harm.” It should be to balance benefits and harms. Or, even better, to carefully consider all relevant outcomes — including health benefits, health harms, economic benefits and economic harms.
In regard to the second principle, “meeting the public where they are,” I strongly agree with the authors’ admonition that public health officials should prioritize being physically present (rather than just remote) and that they should communicate through social media (rather than just TV). But the really important aspect of improved communication that the authors offer is in regard to the content of the communication. The authors correctly assert that public health officials must “present absolute risks and benefits” and “clarify the study type” to help the public understand the “level of trust to have in the data.” But, “risks” and “benefits” imply that only health outcomes are to be considered, while public health policies also influence economic outcomes. And, while communicating the study type is useful for experts, the public probably will not understand the implications of randomization, risk adjustment or other study methodology parameters. Therefore, what is needed to build trust and to support decisions by the public (and by policymakers authorized to represent the interests of the public) is information about the range of uncertainty around the outcome metrics presented. Therefore, I would prefer stating the principle as “explicitly estimate the magnitude and uncertainty of all relevant outcomes.”
Regarding the third principle, respecting “individual autonomy and range of opinions,” that seems like two separate things to me. The first is about dealing with the unavoidable reality that some of the outcomes from public health interventions accrue to individuals while other outcomes accrue to populations — the “public” in public health. For example, herd immunity is a herd-level outcome. Shutting down schools and businesses might affect the gross national product and unemployment rates as well as the crime rates and suicide rates that are causally downstream from economic desperation. Just as we should not say “do no harm” when we really mean “consider all outcomes,” we should not say “respect autonomy” when we really mean “consider both individual and population outcomes.”
Which brings me to my proposed fifth principle: science should stay in its lane.
Those who follow this blog might complain of repetition, since I’ve harped on this point frequently, such as in November, 2024 and November, 2021.
David Eddy, MD, PhD
In a famous series of articles in the early 1990s in JAMA, David Eddy described the “explicit method” for developing policies for clinical practices and public health. I summarize Eddy’s method as follows: All decisions inherently involve the selection among available alternatives. The process of supporting decision-making regarding public health policies and clinical practice guidelines rationally involves four steps: (1) identifying the alternatives, (2) identifying all the outcomes that are thought to be materially different across those alternatives, (3) estimating the magnitude and uncertainty of those outcomes for each alternative, and then (4) considering those estimates and applying values to determine which alternative offers the best set of outcomes.
Eddy’s explicit method called for doing those four steps explicitly — written down, providing transparency and accountability. When public health and medical scientists try to do all four steps implicitly inside our heads, using what Eddy disparaged as “global subjective judgment,” we step out of our science lane, applying our own values. We naturally want to make sure the epidemic does not get out of control and overwhelm the capacity of our health care facilities. We naturally prioritize deaths and other health outcomes directly connected to the outbreak, assigning lower value to health and economic outcomes indirectly associated with the disease or the public health policy responses. Morgan and Korenstein acknowledged this issue, noting:
“During the pandemic, initial guidance against community masking was intended in part to prevent mask shortages in health care, but the public was not informed of this rationale. A rapid switch to recommending masks eroded trust, as the public felt manipulated.”
This substitution of expert priorities for public priorities may be noticed by the public, contributing to a decline in trust in public health institutions, professionals and officials. This kernel of distrust can then be magnified by political actors that benefit from such distrust, leading to firings, budget cuts and derogatory messaging and the downward spiral of public health capability we observe today (as I described in my September 2025 post).
But there is an important difference between the way the authors frame this problem and the way I think it should be framed. The authors think the problem is just about the sharing of information by scientists when the scientists make public health decisions. Therefore, they propose that the solution is more “transparency” and “full honesty” and a commitment for the scientist decision-makers to be “apolitical.” But for more than thirty years, I’ve seen the problem and the solution through the lens of Eddy’s explicit method.
The first three of the steps in my summarized version of Eddy’s explicit method require scientific expertise in the fields of public health, medicine and perhaps health economics, since some of the relevant outcomes are economic outcomes. At the end of those three steps, there should be written-down documentation, including what Eddy calls a “balance sheet” with columns corresponding to the decision alternatives selected in step 1, rows corresponding to the outcomes considered in step 2, and the cells filled in with quantitative estimates of the magnitude and uncertainty of each outcome for each alternative, based on modeling done for step 3. I prefer to call that artifact a “decision outcomes table.” [Eddy’s PhD was in mathematics and not accounting, so he probably did not realize that “pro-forma income statement” is the more appropriate accounting artifact for summarizing relevant outcomes across decision alternatives.]
The forth step can then be described as the process of looking at the decision outcomes table that was produced in the first three steps and applying values and deciding which of the decision alternatives offers the best collection of outcomes. The key point is that the process of applying values and making a decision is more appropriately handled by people that are capable and authorized to represent the values of the public. In the case of consequential public health policies regarding such things as social isolation, vaccine mandates, and the closure of schools and businesses, it is local and state-level units of government and the associated elected officials that are the ultimate policymakers. So, when Morgan and Korenstein call for public health to be “apolitical,” I understand that to really mean that they want to avoid the entanglement of public health policymaking with partisan chaos. But consequential public health policies are unavoidably and appropriately political. When the authors assert that “public health officials must trust the public,” I would prefer to add “and the public officials they elect to represent them and make consequential decisions in their interest.” If those elected public officials cannot be trusted with those decisions, then perhaps we need to elect different public officials.
We will need to rebuild our public health system. When we do so, we can learn from the current evaluative conversation to try to build structures and processes that follow Eddy’s explicit method, where science builds up respect by staying in its lane.
