America’s Coming Public Health Crisis

In 1881, after studying nearly a century of weather patterns, an Army meteorologist named John Park Finley came up with a simple way to understand when tornadoes were likely to happen—observing a combination of low air pressure, high temperatures, and increasing wind velocity. This pattern could successfully predict 95 percent of all tornadoes with hours of time to get the word out. It was a game changer in preparing for tornadoes, which could wreak enormous havoc. Take the Tri-State Tornado, for instance. The deadliest tornado in history killed about 700 people and injured 2,000 others—and it happened more than 40 years after Finley discovered the key to tornado prediction. If officials and scientists knew for decades how to avoid such devastation, why didn’t they act?

This tragedy wasn’t about knowledge; it was about communication. When officials would observe the right conditions for a tornado to appear, they would issue warnings about severe storms or high winds—but they studiously avoided any mention of “tornado.” They worried that people would panic or lose trust in officials if they were wrong—and they deemed those consequences more devastating than the destruction wrought by a storm. “The stoppage of business and the unnecessary fright would in its summation during a year be worse than the storms itself,” Finley’s boss told a congressional committee in the 1880s. As a result, thousands of people died.

As Caitlin Rivers points out in her new book, Crisis Averted: The Hidden Science of Fighting Outbreaks, it’s an uncanny parallel to the lapses and missteps of, for instance, the early days of the Covid pandemic, when health officials, fearful of stoking panic, repeated that the risk to the public was low. Being forthright about the risks of a crisis is still too often seen as more damaging than the calamity itself. The price of eggs became a subject of intense scrutiny during last year’s presidential election, but neither candidate ever broached one of the main reasons for egg instability: Millions of hens have been killed because of the highly pathogenic H5N1 bird flu, which has infected new animals, and people, in the United States at shocking rates.

Scientific knowledge, particularly in rapidly evolving situations, can be nuanced and difficult to explain to the public, even when officials want to. And the accomplishments of public health in particular can be unusually tricky to demonstrate. When public health is effective, we rarely see it. It is concerned with the realm of the invisible—not just the microscopic but also the preventative. It is a hidden machinery toiling to keep our lives on track, a considerable and unrelenting effort to maintain normalcy. A net undergirding all of us that may only gain attention when its fibers fray. Often, we only see public health when it breaks down—a measles outbreak in an unvaccinated population, or the rapid spread of a new virus.

Public health isn’t a science with showy advances like smartphones and moon landings. Instead, its alchemy is turning something into nothing, Rivers writes: “If we do our jobs right, nothing happens.” The book is an attempt not just to highlight and celebrate hidden successes but also to prepare for the next outbreak, and the one after that. The stakes could not be more important, as emerging and recurring outbreaks of illnesses like bird flu, mpox, measles, and others continue raising alarms, at a time when leaders see addressing outbreaks as politically costly and a wave of incoming appointees opposes the basic public health wisdom that has staved off some of the worst diseases of the past century or more.

The greatest success of public health—indeed, one of the greatest accomplishments of humankind—is the eradication of smallpox. The virus felled kings and queens, maiming and murdering millions, and now it has vanished from the face of the earth, save for a few closely guarded vials. There was a business case for eradicating smallpox: With no more cases, countries wouldn’t need to maintain costly monitoring and outbreak response systems, and there would be less societal disruption.

The visionary campaign was carried out over several years through a regional patchwork of programs. Rivers recounts the story of Sudanese vaccinators who traveled through Ethiopia for two months, carrying everything they needed, through civil unrest and floods (and leeches and snakes), constructing bridges and clearing brush by hand, all to protect 20,000 difficult-to-reach people. But even in heroic narratives like these, the milestone of eradication was achieved through the careful and tedious work of reaching everyone at risk with vaccines, and then watching and working quickly to quash any other outbreaks.

A look back at some of the lauded achievements in the history of public health consistently shows how vital it is to respond to deadly outbreaks quickly, even in the most challenging conditions. In 1925, an outbreak of diphtheria among children in the Arctic led to the now-famous race across 674 miles of frozen Alaska wilderness to deliver antitoxin serum in a little over five days.

Measures to stop the spread of respiratory viruses—mask mandates, school closures, bans on public gatherings, even the six-foot social distancing suggestion—may seem recent, but they actually came about during the 1918 flu pandemic. It’s a reminder that crises can lead to innovation but that progress can soon be lost once the urgency fades, Rivers writes—something we are witnessing now with the rewriting of Covid history.

Infamous in the field of public health is the cycle of panic and neglect—the great rush to solve a deadly outbreak, sometimes with eye-popping budgets, and then a lapse in attention and resources. If you know what adenovirus is, did you know there was a vaccine for it? I didn’t! The U.S. military created a vaccine for the common virus, which causes respiratory and gastrointestinal infections and, after World War II, was landing half of Fort Dix recruits in the hospital. The adenovirus vaccine first deployed in 1971 was wildly successful at preventing illness and death among service members—but that success brought complacency, which in turn invited tragedy. The U.S. Defense Department allowed the vaccine program to lapse in 1996, and two young recruits soon died. The vaccine program was only brought back in 2011 at great financial and personal expense, costing 20 times more than if the original vaccine manufacturing process had been maintained in the first place.

Sometimes, the solutions to public health crises are simpler. Cholera can bring acute illness and death to some victims within hours. With extremely basic treatment—clean water and electrolytes, and a safe way to deliver them—more than 99 percent of very ill people will recover. But without them, as many as half will die.

And sometimes, the answers aren’t found in medicine but in painstaking procedure. After cases of melioidosis, an uncommon but deadly bacteria, appeared in four U.S. states in 2021, a “line list”—the exhaustive questionnaires epidemiologists use to determine the source of an outbreak—helped pinpoint the unlikely source: a contaminated aromatherapy spray. These are public health’s biggest unsung victories: the methodical, day-in-and-day-out grind of identification and action. But the field frequently only gains attention, and the funding it needs to continue this work, after disasters spiral out of control.

There are three main dicta in the handbook of the U.S. Centers for Disease Control and Prevention: “Be first, be right, be credible.” In fast-moving crises, officials must get it right, quickly, while maintaining trust—yet that is “the hardest attribute to secure and the easiest to lose,” Rivers writes.

It’s possible officials push “dubious” messages not because they wish to mislead people but because of the “misguided” belief that reassuring the public is more important than warning us, she writes; they shape their messages based on how they believe the public will react. At the start of the mpox outbreak in 2022, with echoes of the HIV/AIDS crisis in the 1980s, officials went to “comic lengths” to avoid mention of sexual contact, the primary mode of transmission, or men who have sex with men, the primary community affected, for fear of stigmatizing the people at risk. They focused less on controlling transmission of the disease than they did on controlling how the information made people feel.

There are other glaring weaknesses of a vibes-based public health strategy. Take the endless debate over medical masks. Many people still don’t understand when and why they should mask, but they did come away with the overwhelming message that public health officials aren’t telling the whole truth, a suspicion that further inflames tensions about Covid and other outbreaks. Ironically, by striving to keep trust by reassuring the public, officials lose it. That has enormous and often unpredictable ripple effects beyond a given crisis. The pandemic-era questioning of public health authority has supercharged vaccine skepticism and undermined long-established practices, with more parents forgoing vaccines for common yet alarming illnesses like measles and chickenpox—often because they falsely believe that the vaccines are worse than the illnesses or that the effects of vaccines aren’t well understood or discussed.

The Covid pandemic has been a humbling experience for Rivers, as it has been for many of us. She’d believed, without examining the belief too closely, that epidemiology had the power to address or even control a pandemic, a feeling that she soon recognized as hubris. Controlling outbreaks relies on more than the technical science of tracing contacts, understanding how the pathogen spreads, or developing and deploying vaccines. Instead, the most important tool is clear communication about the risks a community faces and what they might do to protect themselves, she writes—and that’s an ongoing challenge for the field. It’s a challenge that will likely only grow as the second Trump administration assumes office, with a proposed Cabinet of anti-science activists and, of course, an anti-science president. Existing challenges will be compounded by potential disruptions to our current vaccine program, even less funding for public health, and burnout and brain drain among researchers and health workers in an increasingly stressful and thankless job—all of which would create immense long-term setbacks for public health.

The book closes with a warning: not that another outbreak is imminent—you can’t have read this far without realizing there will always be another outbreak—but that the next crisis will require humility above all else. That’s not a quality many politicians embody, and the new slate of proposed health agency leaders has a long history of denying science and overlooking evidence of best public health practices. History shows again and again the importance of investing—money, time, talent—in public health. We have learned, and must continue learning, that giving out timely and accurate information is paramount for preparation, whether for a tornado or a pathogen.

It turns out that public health is not that different from democracy. Both become less visible in times of peace and calm, both suffer from their own success, both need constant tending. You may forget all of that, but not for very long.