In my well-worn copy of Public Health Ethics, there is a 1985 essay by political scientist Dan Beauchamp about the concept of community in public health. I have returned to one excerpt from this essay a lot during COVID-19:
Public health… reminds us that we are not only individuals, we are also a community and a body politic, and that we have shared commitments to one another and promises to keep. As the Preamble to the Massachusetts Constitutions puts it:
The end of the institution, maintenance and administration of government is to secure the existence of the body politic; to protect, and to furnish the individuals who compose it, with the power of enjoying, in safety and tranquility, their natural rights, and the blessings of life… The body politic is a social compact, by which the whole people covenants with each citizen, and each citizen with the whole people, that all shall be governed by certain laws for the common good.
The danger is that we can come to discuss public health exclusively within the dominant discourse of political individualism, relying either on the harm principle or a narrow paternalism justified on grounds of self-protection alone. By ignoring the communitarian language of public health, we risk shrinking its claims…
Public health belongs to the realm of the political and the ethical. Public health belongs to the ethical because it is concerned not only with explaining the occurrence of illness and disease in society, but also with ameliorating them. Beyond instrumental goals, public health is concerned with integrative goals – expressing the commitment of the whole people to face the threat of death and disease in solidarity.
Dan E. Beauchamp, Community: The Neglected Tradition of Public Health
I return to this essay now, on a day where we watched in horror as white supremacy and fascism played out violently in our nation’s capital. Where we saw the power of community and political organizing, driven brilliantly by Black women, succeed in Georgia, in the face of suppression both blatant and insidious. Where we saw accountability for police violence again denied in Kenosha. Where our nation marked the deaths of 360,000 people due to COVID. This essay is one place I go to remind myself in this absurdity of how government and public health should function – in synergy. To remind myself that the responsibility and promise to community, to each other, remains true.
The discourse in Beauchamp’s essay is grounded in U.S. constitutional law, and there are considerations it does not address. Who is included and excluded from the so-called social compact? What are the implications of state regulatory power in the context of structural oppression? How is community conceptualized differently in other ethical traditions, and who decides what public health ethics ought to be? But it always strikes me that even in this relatively conservative discourse, it articulates that government must function for the common good in order for public health ethics — oriented around community wellbeing — to translate into practice at scale. This is so basic.
Public health is grounded in the idea that we share collective responsibility for all that it takes for people to thrive. I will never stop believing in this. Bearing witness to suffering would break me were it not for the people and communities that continue to speak to and demonstrate what equity and justice can be. It would break me were it not for the structural analysis: that the distribution of harm is shaped by the distribution of power and resources in society, which in turn is shaped by economic & political systems into which racism and other forms of oppression are built. It is not random. It can be changed.
COVID-19 has been a nightmare. Today has felt like chaos. These forces are interconnected and longstanding. So much harm could be prevented through compassionate, equity oriented, properly financed policy and leadership. The weight of poverty, hunger, violence, eviction, untreated illness, and stress does not need to be so heavy, and so disproportionately carried by people already made to carry too much. The failure to protect people is an atrocity. None of this is surprising. None of this is okay.
We are so capable of creating systems that are humane, that acknowledge our interconnectedness, that refuse to accept inequity as a foregone conclusion. It is no accident that we have not. It is still a choice.
Laura McNulty, MPH, MSW 