Finding a Way Forward for Public Health

The thinking was that infectious diseases were behind us, a problem of the past and of impoverished places that were stuck in the past. Antibiotics, better sanitation, improved nutrition, a higher standard of living — they combined to push infectious diseases to the margins of health concerns. Twentieth century public health experts called it the epidemiologic transition, from a healthcare past dominated by diseases, such as tuberculosis, diphtheria and typhoid fever, to a healthcare present and future concerned with heart disease, cancer and diabetes.

“The most remarkable change in patterns of health during the (past) century has been the largely successful conquest of infectious diseases,” wrote Allan Brandt, Harvard medical historian, in “No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880,” his highly regarded history of venereal disease that was first published in 1985.

When Ezekiel Emanuel, M.D., Ph.D., an oncologist and prominent health policy expert at the University of Pennsylvania in Philadelphia, was in medical school and residency in the 1980s, he was captivated by oncology because of the power of the science, the complicated ethical issues and the seriousness of the disease. Yes, the HIV/AIDS pandemic had started, but how about infectious disease? “It wasn’t the sexy area,” Emanuel says.

It has been said that time makes fools of us all. Certainly, the past two years have made that confidence about the decline and fall of infectious disease seem wildly wrongheaded. When government healthcare statisticians calculated the age-adjusted death rates for 2020, COVID-19 was the third leading cause in the U.S., trailing only heart disease and cancer. From 2019 to 2020, the age-adjusted death rate increased 16.8%, which is the largest single increase ever recorded. Life expectancy for the total population decreased by 1.8 years, which is the largest single year decrease in over 75 years.

Other mortality statistics are just as grim. Researchers at the Institute for Health Metrics and Evaluation at the University of Washington reported estimates of the excess mortality due to COVID-19 in March in the Lancet. Their figures show 824,000 reported COVID-19 deaths in the U.S. from Jan. 1, 2020, to Dec. 31, 2021. They also tabulated excess mortality. Worldwide, it was over three times greater than the number of reported COVID-19 deaths (18.2 million compared with 5.9 million). For the U.S., the researchers put the excess mortality at 1.13 million. Reasons for the difference between excess mortality and reported COVID-19 deaths include the possibility of undercounting COVID-19 deaths and knock-on effects of the pandemic, such as deaths from delays in healthcare or the widely documented worsening of mental health.

COVID-19 made it impossible to ignore the enormous disruptive power of an infectious disease. However, there were plenty of warnings before 2020. In 1992, the Institute of Medicine (now called the National Academy of Medicine) released “Emerging Infections: Microbial Threats to Health in the United States.” Two years later, journalist Laurie Garrett sounded the alarm with her book,…