When Public Health Forgot How to Fight
History shows that public health has never advanced by standing above politics—it’s advanced by wading into it.
We draw the line with a fat Sharpie: medicine treats individuals; public health protects populations. Medicine cures; public health prevents. It’s tidy, memorable—and mostly invented. The split was engineered a little over a century ago, and we’re still living with it. Seeing how public health lost its political edge while medicine perfected politics—often while pretending not to—helps explain why we keep fighting yesterday’s battles with tomorrow’s budgets. If there’s one lesson public health should take from medicine, it’s that power matters: to change policy, to fund prevention, to shape the future, public health must get more political, not less.
I teach this history every year as part of my class on The Historical Determinants of Public Health at Brown University School of Public Health. My students arrive fluent in the modern cliché—medicine equals the exam room; public health equals the community meeting—and leave with a more complicated story. In class, I show an image of two boxers squaring off in a cage: Medicine in a white coat, Public Health in blue trunks. It’s over the top, but it makes the point. The absurd part—the part my students always notice—is that Medicine’s punch lands squarely on its own face. Yet even when medicine hits itself, it somehow always wins the round.
That’s not just metaphor. During the early months of COVID, doctors were celebrated—pots and pans clanged from balconies, “healthcare heroes” signs sprouted on suburban lawns. Public health officials, by contrast, got pitchforks. They became the face of restrictions, the villain in a story medicine was still allowed to narrate as noble. The result is a familiar imbalance: medicine gets the spotlight, public health gets the blame.
You can see that disparity in the numbers. The United States spends more than $4 trillion a year on health care, but barely 4 percent of it goes to public health—one dollar in twenty-five. That ratio tells the whole story of who we reward for saving lives and who we forget once the crisis passes.
That was not inevitable. In the late 19th century, American medicine was the Wild West. Medical schools were abundant and wildly variable: some prized hands-on apprenticeship and laboratory rigor; others were diploma mills—tuition in, parchment out. Licensing was rare. Standards were porous. A profession with prestige and power? Absolutely not!
Public health, by contrast, was already political and proud of it. Its foundational texts didn’t whisper about risk factors; they shouted about drains, wages, and living conditions. Edwin Chadwick’s 1842 Report on the Sanitary Condition of the Laboring Population—a sort of birth certificate for the modern public health movement—proposed a radical program of pipes and policy. It centralized authority, legitimized state power in health, and laid the bureaucratic track for the 1848 Public Health Act. The argument was nakedly political and bracingly economic: sick laborers don’t work; sanitation makes industry run. Across the Atlantic, American reformers made similar cases. The water we drink, the air we breathe, the streets we cross—every meaningful intervention lived inside politics.
Rarely does history change so much in a single day. But on March 24, 1882, Robert Koch announced he had isolated the bacillus that causes tuberculosis. The discovery did not so much topple miasma theory as transfer moral meaning. Disease could be pinned to a bacterium—something you could stain, culture, and, someday, kill. When the enemy shrinks to a microbe, causality gets personal. TB shifts—from a signature ailment of the “refined” consumptive to an affliction of unsightly poverty and crowded tenements. Public health attention pivots toward the contagious body rather than the myriad injustices of the city. The result is not that the social disappears, but that the biological becomes newly seductive. It’s a lot easier to wrangle an individual than a community meeting.
At the same time, doctors—still struggling for legitimacy—made an audacious bid for authority. The 1910 Flexner Report, commissioned to clean up and standardize American medical education, did both good and harm. It established clinical and laboratory standards, elevated scientific rigor, and shuttered half of all medical schools in short order. It also decimated institutions training Black physicians, leaving only Meharry and Howard standing. Flexner’s legacy fused with licensing laws and an emboldened American Medical Association to professionalize medicine and consolidate its power. The public got better-trained physicians—and a guild that could flex.
Public health’s course diverged. The 1915 Welch–Rose Report, under the Rockefeller Foundation’s imprimatur, set up public health as a separate professional domain. That professionalization was necessary, but it also carried a price. The report called for public health schools that would sit near medical schools but stand apart. The new focus was on laboratory methods, epidemiology, hygiene, and statistics—skills you could measure, count, and certify. Over time, that technical rigor crowded out the field’s political fire. Public health became the supporting act to medicine’s main stage: still righteous in spirit, but increasingly bureaucratic in form. Advocacy moved from the podium to the footnotes.
The sociologist Paul Starr would later call this period the “social transformation of American medicine,” and his title is apt. Medicine rose not only on scientific merit but through political work: lobbying against public clinics that might offer free vaccination or primary care; opposing insurance schemes when they threatened physician income; securing licensing that protected their market and burnished their prestige. None of this was hidden. It was the point. Meanwhile, public health increasingly staffed the back office—collecting data, building surveillance, handing medicine better numbers with which to argue. The activist lineage lived on, but often outside the system: think of ACT UP forcing the FDA and NIH to move faster on AIDS. Inside the system, the mantra hardened: be objective, be technical, be invisible.
That invisibility shaped how Americans value health. When Robert F. Kennedy Jr. derides our system for lavishing money on high-cost interventions and neglecting prevention, he’s not wrong on the arithmetic. But the conclusion should be the opposite of his crusade to dismantle institutions: underinvesting in public health is the problem—so fund it.
And yet we pretend public health can do great things while staying out of politics. During the pandemic, “public health shouldn’t be political” became a scolding refrain. History suggests otherwise. Public health has always been political when it mattered most. It can’t regulate air quality, set building codes, or prevent gun deaths without stepping squarely into the political arena. The field shouldn’t be partisan, but it must be political.
Medicine, for its part, is political—but in a way that often pretends not to be. We talk about physicians as apolitical saviors—pots and pans clanging for clinicians in March 2020—but the profession’s political apparatus is muscular and omnipresent. The AMA and specialty societies have shaped policy for a century. Many professional organizations take substantial corporate funding. (Spend five minutes on the “corporate partners” pages of major societies and you’ll notice familiar logos.) The organizations will tell you donors don’t influence recommendations; the sponsorship tiers that buy privileged access tell a more complicated story. Meanwhile, direct-to-consumer pharmaceutical advertising—legal in only two countries—transforms clinical conversations into brand reinforcement. Ask who benefits from this arrangement, and the answer is rarely patients.
This helps explain an otherwise baffling split-screen: Americans struggle to see a primary care doctor, navigate Kafkaesque billing, and die younger than peers in rich countries—yet their trust in individual physicians remains sky-high. At the same time, trust in public health wobbles around a coin flip. We praise the doctor who meets us in the emergency room at the moment of crisis, but curse the public health official who tries to prevent the crisis in the first place. Prevention is the dog that didn’t bark, hard to hear even when it’s saving your life.
In class, a student asked me why people don’t recognize what public health has already done for them—pure water, safer food, clean air—and I thought about a lawn sign I saw in Massachusetts a few years ago: “Defund the CDC.” At the time, it felt fringe, almost performance art. Then the budget knives came out, and the sign looked prophetic. When your brand is the “Invisible Shield,” you can’t be surprised when the public doesn’t rush to defend what it can’t see.
Another student pushed on the conceptual sprawl of the field. If public health is everything—sidewalks and sewers, vaccines and violence prevention, climate and classrooms—does it risk becoming nothing? It’s a fair critique. But the answer isn’t to make public health small; it’s to make its politics precise. Name the levers. Build the coalitions. Show the receipts.
Meanwhile, medicine should resist the gravitational pull of self-dealing politics. We have built a payment system that overvalues procedures and undervalues prevention; that rewards specialization more than primary care; that lets dermatologists out-earn pediatricians many times over while wringing our hands about declining vaccination rates. None of this is destiny. It’s design. If we paid for what keeps people healthy, we’d have more pediatricians and fewer preventable hospitalizations. But that requires policy change, which requires political will—exactly the muscle public health chose to stop flexing a century ago.
So what would a healthier settlement look like?
First, reinvest real money in public health. Not a one-time surge after disaster, but a baseline. The four-percent figure is an indictment. If we want fewer ICU beds filled, invest more in real prevention: stable funding for local health departments, modern data systems, environmental health, overdose response, maternal health, injury prevention. Pick the levers; pull them consistently. The irony is that even as this administration voices support for many of these priorities, it is simultaneously cutting the very funding, staff, and infrastructure needed to achieve them. Public health can’t function on rhetoric alone.
Second, firewall medicine’s political economy. Professional societies should not be bankrolled by the companies whose products they recommend. Full stop. Ban direct-to-consumer pharmaceutical advertising. Tighten conflict-of-interest rules. If a $100,000 “platinum partnership” buys a private audience with leadership, it buys influence. Pretending otherwise corrodes trust.
Third, make public health visible between crises. A field that only surfaces to close things will be hated for closing things. Build a public that meets public health in parks, at schools, in the shade of new street trees and the quiet of less traffic noise. If public health is everywhere, let people see it everywhere.
Finally, sharpen the message. The move here isn’t to scold Americans into collectivism or to suggest that history absolves present failures. It’s to show, concretely, how politics keeps them from the outcomes they want: a pediatrician who calls back; air that doesn’t inflame their child’s asthma; an ER that isn’t boarding psychiatric patients for days; a community where guns are harder to reach in moments of despair. None of that is partisan; all of it is political.
I’m often asked whether I think of myself first as a doctor or a public-health person. The honest answer is both. I love a quiet, focused conversation with a patient in my ER (although, they are never all that quiet!). I also love watching a class light up as they discover how much of our modern “common sense” was hammered into shape by people with names like Chadwick and Flexner and Welch. The two roles sharpen each other. Seeing what doesn’t work in the emergency department makes me want to change the rules upstream. Knowing how hard it is to change those rules makes me a more empathetic clinician.
If medicine keeps punching itself in the mouth, it will keep winning rounds it doesn’t deserve, because we’ll cheer the spectacle we can see. If public health keeps insisting on invisibility, it will keep losing fights it should win, because we’ll forget to defend it until it’s too late.
We don’t need another tidy dichotomy; we need a realignment. Let public health be political. Let medicine stop mistaking prestige for progress. Then make both accountable to the outcomes we claim to value: longer, healthier lives—purchased not with pianos and waterfalls in new hospital towers, but with parks, prevention, and policies that keep people from needing those towers in the first place.
That, at least, is what the past keeps trying to tell us—if we’re willing to listen.
as a primary care physician, I truly appreciated your post and will have to audit your class some day
I agree with this and appreciate it so much! I can attest the story is much more complicated after taking your class.