A Ghanaian colleague reminded us recently of a Ghanaian proverb, “You cannot cry harder than the bereaved.” The proverb suggests that what any of us can do to help ease the suffering of others is limited, and a reminder that it behooves us to have the humility to recognize that. In this second Covid-19 year, we have found this proverb useful, as we attempted to navigate the complicated balance of individual autonomy—what we need to do for ourselves— and collective responsibility—what we can do for each other.
The tug of war around the use of face masks was the first and most visible example of this balance. Although the issue has been cynically exploited for political ends, at heart it is a classic push-pull between those who wish for maximum individual autonomy—I can choose to wear a mask or not depending on my risk tolerance—and those who advocate for collective responsibility—you wearing a mask decreases my risk of getting Covid-19. A classic public health approach in this case suggests that the latter readily outweighs the former. Mask wearing is an inconvenience, but a relatively minor one, and the case that wearing a mask protects others is strong. We have as a society long decided that we are willing to limit some individual autonomy for a readily apparent public good. For example, worries about the risk of second-hand smoke were critical in the adoption of indoor smoking bans, as we collectively accepted that it was worth limiting the freedom of some to smoke anywhere, to preserve the freedom of many from unwanted cancer risk. In keeping with this logic, the majority of US states put in place mask mandates or other forms of masking requirements during the pandemic.
But as the pandemic evolved, the balance of individual freedoms and collective responsibilities became more complicated, particularly around the issue of vaccination. Early in the vaccination effort it was clear that many did not have ready access to vaccines, and as such we had a collective responsibility to continue preserving limits on our individual freedoms—physical distancing, masking, restricted availability of entertainment venues—until everyone had the opportunity to be vaccinated, to ensure we could all be protected.
But what happens when vaccines are genuinely abundantly available and some refuse to be vaccinated? Of course, the reasons why some are not vaccinated are complicated, many resting on deeply entrenched, entirely legitimate, historical mistrusts. But at what point, assuming a fair and readily available vaccine for all, can we reasonably expect individuals to simply get vaccinated so that we can restore society to normal functioning? In other words, when do we say that our collective responsibility has been fulfilled, and now it is on individuals to protect themselves, or not? That our campaigns and efforts and resources spent on attempting to reverse vaccine-refusal can be set aside and we can move to other public health concerns?
These are uncomfortable questions for public health. Ultimately public health is what we do collectively to ensure that we can all be healthy, and our natural inclination is to continue to insist that the collective responsibility is greater than the individual freedom. But what do we do when the few hold back the many even when the many have made every honest effort to help the few? Are there limits to the classic public health argument? It seems that the Covid-19 moment may push us to have the humility to ask these questions, even if the answers may be disheartening and difficult.
Michael Stein & Sandro Galea
As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.
Photo via Getty Images