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August 5, 2020

Attacks on Public Health Officials During COVID-19

Author Affiliations
  • 1Stanford Law School and Stanford Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California
  • 2Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 3Department of the History of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
JAMA. 2020;324(8):741-742. doi:10.1001/jama.2020.14423

On June 24, 2020, California Governor Gavin Newsom remarked on a disturbing phenomenon: health officers are “getting attacked, getting death threats, they’re being demeaned and demoralized.”1 At least 27 health officers in 13 states (including Nichole Quick of Orange County in southern California, Ohio Health Director Amy Acton, and West Virginia Health Officer Cathy Slemp) have resigned or been fired since the start of the coronavirus disease 2019 (COVID-19) pandemic. Across the US, health officers have been subject to doxing (publishing private information to facilitate harassment), angry and armed protesters at their personal residences, vandalism, and harassing telephone calls and social media posts, some threatening bodily harm and necessitating private security details.1

The present harassment of health officials for proposing or taking steps to protect communities from COVID-19 is extraordinary in its scope and nature, use of social media, and danger to the ongoing pandemic response. It reflects misunderstanding of the pandemic, biases in human risk perception, and a general decline in public civility. Some of these causes resist easy fixes, but elected officials and health officials can take certain actions to help address the problem.

Today’s increasingly routine harassment and threats against health officials have much in common with growing resistance to childhood vaccination. Since the 2015 measles outbreak that focused attention on vaccine policy, individuals opposed to vaccination mandates have attacked health officials and legislators online or in person in Oregon, Washington, New York, New Jersey, and Colorado. For example, in 2019, protesters threw blood onto California legislators from the Senate gallery; State Senator Richard Pan received death threats and was physically assaulted. Some of the same groups, joined by other individuals frustrated with public health officials, are now actively resisting efforts to require masks, reinstitute business closures, and prepare for COVID-19 vaccination, jeopardizing the eventual acceptance of vaccines.2

What explains the unprecedented hostility to public health officials during COVID-19? Although acceptance of public health orders for COVID-19 is often framed as a “red vs blue” issue, even libertarians accept that liberty may be curtailed when its exercise harms others. However, people’s ability to perceive such harms can be undermined by decisional biases known to affect human thinking.3 Omission bias creates a preference for risks associated with doing nothing (ie, letting the virus spread) over those linked to affirmative acts, such as public health orders. Distance bias and optimism bias may be operating for those who believe COVID-19 will not seriously affect them or their loved ones. In an information space flooded with conflicting information, confirmation bias allows some people to dismiss evidence that does not comport with their preexisting beliefs.

These forces help explain resistance to COVID-19 orders, but the shape and ferocity the resistance has assumed can be traced to other factors. The general decline in civility in political discourse in the US has made ad hominem attacks commonplace and hollowed out traditional ways of grappling with value conflicts. Social media amplifies such attacks, with the #FireFauci campaign providing an early template. Joining these attacks may be an easy outlet for people under stress from economic disruption and social isolation. One Facebook network of 22 000 users organized protests on the front lawns of health officers.

The environment deteriorates further when elected leaders attack their own public health officials. Members of the current presidential administration, and various members of Congress, have displayed hostility toward experts inside and outside of government. In July, staff at the White House disseminated a misleading memo and op-ed about Dr Anthony Fauci, the leading infectious disease physician and pandemic expert at the National Institutes of Health. For his part, President Trump retweeted statements including, “Everyone is lying. The CDC, Media, Democrats, our Doctors, not all but most, that we are told to trust.”4

At the state and local levels, the attacks have been even more personal. In April, an Ohio representative referred to the state health officer, who is Jewish, as an “unelected Globalist Health Director,” using an anti-Semitic slur. Some elected judges have even contributed: in the Wisconsin Legislature v Palm decision striking the state health secretary’s stay-at-home orders, conservative Wisconsin Supreme Court judges censured the health secretary with unusual harshness, alleging “tyranny” by “an unelected official” exercising “controlling, subjective judgment.”5

These statements are not mere rhetorical flourishes; they become ballast for personal attacks in the midst of the pandemic. Administration officials, legislators, and judges should model the ability to civilly disagree, setting out their policy concerns and using the legal means at their disposal to effect change. Important debates are necessary, such as how to open schools safely and how to balance opening businesses with preserving health. Yet even those with policy disagreements should call for respect and appreciation for public health officials, who are acting in good faith. In some contexts, only health officers have authority to enter public health orders; their actions are not a subversion of democratic process, but its prescribed expression.

Instead of attacking their health officials, elected leaders should provide them with protection from illegal harassment, assault, and violence. States and the federal government should investigate all credible threats, provide security details as warranted, and prosecute those whose harassment crosses legal lines. Without protection and support, the already scarce supply of qualified individuals willing to serve in health officer roles will decline further.

In the face of harassment and personal attacks, health officials should seek effective and safe ways to engage the public on COVID-19 policy. In the initial stages of the epidemic, swift decision-making was necessary; now there is greater opportunity for communitywide reflection and input. Research shows that acceptance of public health laws is strongly influenced by people’s belief that officials understand the public’s values and that “people like me” can influence government priorities in public health.6 This is particularly important in the current discussion about opening schools in the fall; deliberations should involve parents, teachers, and others.7

Health officials today are neither isolated nor alone in their understanding of health threats and support for mitigating measures. It is possible, and advisable, for them to invite trusted community members to stand beside them in announcing measures likely to engender opposition. These could include nurses, physicians, paramedics and other first responders, city council members, local public health experts, and leaders of essential workers and racial and ethnic minority communities.

Public health leaders should transparently communicate not only the evidentiary basis for their decisions, but also their weighing of the burdens the decisions impose. The health officer for California’s San Mateo County, for instance, acknowledged there is “no playbook for the decisions we face or the balance we should attempt to maintain,” shared the reasoning behind “gut-wrenching decisions” in plain language, and appealed to community members to shape their own future through their decisions about social distancing.8 Such communications humanize health officers, telegraph that they are not acting alone, and involve citizens in the work of responding to the pandemic.

Health officers also can work to maintain public visibility outside of emergencies. Regularly reinforcing the important but invisible work they do cultivates familiarity and trust, which are much-needed reserves in times of crisis.

Amid a global pandemic that has already claimed more than 150 000 lives in the US, the nation needs strong public health leadership more than ever. Harassment of public health officials must stop; instead, all efforts and attacks should be directed against the virus. Success will require overcoming the inaction and division that have allowed it to spread.

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Article Information

Corresponding Author: Joshua M. Sharfstein, MD, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Room W1033F, Baltimore, MD 21205 (joshua.sharfstein@jhu.edu).

Published Online: August 5, 2020. doi:10.1001/jama.2020.14423

Conflict of Interest Disclosures: Dr Greene reported receiving grants from the National Library of Medicine, the Arnold Foundation, and Greenwall Foundation outside the submitted work. Dr Sharfstein reported being the former health commissioner of Baltimore, Maryland, and former health secretary of Maryland. No other disclosures were reported.

References
1.
Said  C. California health officers facing protests, even death threats, over coronavirus orders. San Francisco Chronicle. Published June 30, 2020. Accessed July 6, 2020. https://www.sfchronicle.com/bayarea/article/Area-health-officers-confront-harassment-15375304.php
2.
Poland  GA, Tilburt  JC, Marcuse  EK.  Preserving civility in vaccine policy discourse: a way forward.   JAMA. 2019;322(3):209-210. doi:10.1001/jama.2019.7445PubMedGoogle ScholarCrossref
3.
Halpern  SD, Truog  RD, Miller  FG.  Cognitive bias and public health policy during the COVID-19 pandemic.   JAMA. 2020;324(4):337-338. doi:10.1001/jama.2020.11623PubMedGoogle ScholarCrossref
4.
Forgey  Q. “Everyone is lying”: Trump undercuts public health officials in fresh attacks. Politico. Published July 13, 2020. Accessed July 13, 2020. https://www.politico.com/news/2020/07/13/trump-questions-public-health-experts-twitter-359388
5.
Wisconsin Legislature v Palm, 942 NW2d 900 (Wisconsin 2020).
6.
Morain  S, Mello  MM.  Survey finds public support for legal interventions directed at health behavior to fight noncommunicable disease.   Health Aff (Millwood). 2013;32(3):486-496. doi:10.1377/hlthaff.2012.0609PubMedGoogle ScholarCrossref
7.
Sharfstein  JM, Morphew  CC.  The urgency and challenge of opening K-12 schools in the fall of 2020.   JAMA. 2020;324(2):133-134. doi:10.1001/jama.2020.10175PubMedGoogle ScholarCrossref
8.
San Mateo County Health. Health officer updates. Accessed July 29, 2020. https://www.smchealth.org/coronavirus-health-officer-updates
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    3 Comments for this article
    EXPAND ALL
    Our health officials have one objective - our well-being
    Terry Grimmond, FASM, BAgrSc, GrDpEd&Tr | Consultant Microbiologist, New Zealand
    I thank you for your well-thought, well-written, and much-needed words on this vital issue in the US, an issue that even here in NZ leaves us aghast. However the attack on health officials is not confined to US; it is just the most public internationally. And yes, in many countries there is a red vs blue factor (perhaps with different colours). And yes, health officials do need to hear our concerns so they can modify their strategies to gain maximum adherence by the public. But they should never hear wrath, doubt or criticisms.

    In New Zealand we took
    a different approach: the whole country listened to our health officials because they were upfront in telling us what they did and did not know and we trusted and obeyed. And we eliminated COVID19.

    Yes, our borders are still closed and our economy is hurting. Yes, we are a small 5M population island nation but in lockdown (true lockdown) the nation stopped at 1pm every day for 30 min to listen to our health officials update us with what we precisely had to do - and why - and what would be the potential outcome if we did not.

    Yes, we were sceptical at times with the projections of possible cases and deaths, even myself. But all proved correct - and the early projections for US by Dr Fauci and other US experts have proved remarkably, and disturbingly correct.

    In uncharted diseases, we absolutely need to listen and trust our health officials. They have only one objective in mind: our well-being and that of our nation.
    CONFLICT OF INTEREST: None Reported
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    Lack of understanding of the rule of law invested with health officers.
    Avram Kaplan, MPH | UCLA
    Health officers of counties, some cities, and the state have quarantine and other powers that can infringe on human rights as viewed by many.

    In particular, in this epidemic we have decisions being made that influence economic viability and educational needs. This is different from vaccinations, mandates for which involve no stay at home orders.

    The mind set of those opposing the quarantine and the anti-vaccination crowd are similar, often based on erroneous information and spurred on by social media and political affiliations of all sides. This activity drills down to local enforcement, thru school districts and health
    districts.

    We have done a poor job explaining the powers of health officers and few understand their role in the economic shutdown and school shutdowns. We see many pediatric associations and the CDC advocate for safe school openings, as their view is that lack of in-person education is worse than the disease. No wonder people are confused.

    Our focus in this country is on acute medical care and there has been a lack of focus on public health and prevention, in providing services, and on education about the role of health offices to the general public. There has also been arbitrary enforcement of business closures, definitely not uniformly applied across states and counties.

    We are a different country than many, and certainly larger than most, with diverse geography and demographics, as compared to more heterogeneous and smaller countries. We are quite independent in our mind set; yet, I believe with appropriate public health and political education we can do better.
    CONFLICT OF INTEREST: None Reported
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    Generic Disregard of Science and the Scientists in America
    Amarlal Dave, MD | Pediatrics center
    Americans - while driving SUVs, drinking bottled water, living in heated houses, and flying in airplanes - denigrate medical science when it comes to preventive practices like immunizations, hand washings, masking and social distancing. In other words they pick what suits them and not because of the science behind them.

    Americans gave up many of their liberties following 9/11 meekly and I have never seen anyone objecting at airport security because their freedom is at stake! There, they behave orderly and follow what is asked. I'd like to see some of today's "freedom fighters" misbehave or attack the
    security personnel as they are doing to unarmed health officials and Walmart employees upon being asked to put on mask.

    Americans think they are Americans and not humans, and being Americans makes them invincible and they behave like that including the people holding highest offices. American might and wealth can scare other nations and humans but the virus does not care and affects them the same as any other human being anywhere on the planet with total disregard for who you are.

    The only recourse for people who question gravity is to jump off the roof and find out if they fall or fly. This is what the Americans at all levels are doing today by defying science to contain Covid-19.
    CONFLICT OF INTEREST: None Reported
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