Can Public Health Be Democratic?

The COVID-19 pandemic has made vivid a problem that has always characterized the relationship between, on the one hand, epidemiological data and the public health decision-making that is based upon it, and on the other hand, democratic decision-making. The pandemic has revealed the importance of decisions to do with appropriate policy responses being grounded in science. However, there has been an exaggeration both among pundits and within the public about the degree to which the evidence generated by epidemiology can be univocal. First,critical epidemiology accepts that the evidence generated by public health sciences is probabilistic, and that science itself cannot determine how policy should integrate considerations of risk. Second, public health is never solely focussed on one objective -- the short-term objective of mitigating the effects of COVID-19 must coexist with the simultaneous or longer-term public health objectives of various kinds. As in the case of determining what level of risk is appropriate in a given society, the articulation of these different public health objectives is irreducibly value-laden, and thus cannot be considered a purely scientific exercise. These gaps between data and decision call for public deliberation and political decision-making in the light of the evidence, rather than for evidence-driven decision-making. It therefore tells against ways of immunizing public health decision-making from the political sphere in the way that is characteristic most notoriously of the Swedish model, However, political decision-making has its own pathologies with respect to public health. For example, the logic of the electoral cycle favours short-termism, and thus, a focus on short term public health objectives. Second, electoral considerations also tend to favour cure rather than prevention -- the goals of public health are sometimes best achieved when nothing happens, and thus democratic decision-making with respect to public health can come to be data-resistant. How can public health decision-making avoid the dual excesses and pathologies of, on the one hand, misplaced scientism, and on the other, evidence-resistant, excessively partisan public health decision-making? My suggestion is to examine consultative models that have been employed in other policy contexts, such as land use and environmental impact, to define the terms and composition of public bodies that can be at arm's length of the partisan interests of ruling parties, while being fully sensitive both to the evidence generated by epidemiology and other related sciences, and to the irreducible value choices involved in responses to public health crises such as the COVID-19 pandemic.