Why public health must always be led by economists

Dr Anthony Fauci was obsessed with covid. On 13 May 2020, the Wall Street Journal reported that Fauci is “not … making the case that continuing to restrict activities will make Americans healthier overall, but only that it will, in his opinion, reduce Covid-19 deaths”. This blinkered focus, in which overall health does not matter, informed Fauci’s testimony to the US Senate. He displayed no interest in “the need to get the country back open again”, stating that “I don’t give advice about economic things”. 

This episode summarises everything that’s wrong with public health today. Excluding Sweden, most public health officials, globally, ignored society-wide health during covid, leading to hundreds of thousands of lives directly or indirectly lost from lockdowns, reduction in the life expectancy of hundreds of millions, and $15 trillion in wealth destroyed. All for a pandemic which is invisible in the aggregate mortality statistics of Sweden – the only country that didn’t lock down. 

But Fauci was not to blame. He was simply following public health textbooks. The problem is that public health textbooks are wrong about almost everything. For instance, textbooks cherry-pick a few instances when quarantine seemingly worked without assessing the harms caused, and never evaluate the enormous cumulative harms of the myriads of historical quarantine episodes. The absence of a whole-of-society methodology in public health underpins its support for totalitarian interventions. 

This was not always so. At the commencement of modern public health, it was standard practice to use cost-benefit analysis (CBA) to assess quarantine and sanitation. But the golden age of public health, when rational thought and empiricism prevailed, lasted only for a few decades before medical doctors took public health back to the Dark Ages. 

1.Economists started modern public health

After centuries of quarantine quackery (led by medical doctors) the economist Jeremy Bentham proposed a systematic approach to public health in his Constitutional Code (1822-32). His disciples, the lawyer Edwin Chadwick (who was also a competent economist), and Dr Southwood Smith, used the CBA method to show that quarantine causes great harm while sanitation creates vast societal benefits. This led to the Public Health Act of 1848.

2. Chadwick was clear:  medical doctors must not lead public health

In his 1842 report into the Sanitary Condition of the Labouring Population, Chadwick was happy to have doctors involved in the delivery of public health, recommending that the 2,300 doctors who provided Poor law medical relief should also undertake sanitary inspections when they visit someone’s house. But he ruled out medical doctors becoming leaders of public health: “the physician … has done his work when he has pointed out the disease that results from the neglect of proper administrative measures, and has alleviated the sufferings of the victims”. He advocated for “the science of the civil engineer” as public health leaders. In his 1885 book he explained that sanitary engineers can vastly reduce mortality rates. 

At all times, he wanted the preventive and curative functions to be separate. He explained in 1885: “[t]he curative service, acts by the diagnosis of the individual. The preventive service acts by diagnoses, as it were, of the condition of a town” (i.e. the whole of society).

3. But the medical fraternity hijacked public health

The medical community was enraged that an economist-lawyer was leading the General Board of Health. The medical journal, The Lancet, attacked him bitterly, claiming that Chadwick’s 1849 report against quarantine was “especially malignant” … “towards the medical profession”. His medical enemies managed to push him out and take charge of the role of chief medical officer. 

Very soon, all economic content and thinking was expunged from public health. In a 1913 article, Dr Charles Chapin claimed that “losses by disease and gain through sanitation produce little impression … [It is] dangerous to rely upon a balance sheet of life and death”. 

4. Core competencies for public health require economics, not medicine

Chadwick was right to firmly resist the encroachment of medical doctors into public health which needs minimal medical knowledge, no more than high school biology. Public health is also aware that medical doctors are not needed. In a 2003 book, “Public Health in Practice”, Andrew Watterson et al listed ten competencies for public health, none of which had any medical content. In a book chapter, Dr John Middleton wrote: “Does the Director of Public Health need to be a doctor? Not necessarily. All of the ten … competencies for public health practice can be encompassed in individuals who are not doctors”.

Instead, public health leaders need deep knowledge of society-wide health and well-being, which is the specialisation of economics. But not all economists! Many economists wrongly advocated lockdowns during covid based on “negative externalities” and “public goods”. Likewise, health economics textbooks wrongly promote vaccine mandates. As Harold Demsetz showed conclusively, these concepts have no empirical content and can’t guide public policy. We need empirically minded scientist-economists. 

Public health leaders should know about the drivers of life expectancy, about opportunity costs and human factors, about CBA including the measurement of mental health through WELLBYs, and be able to empirically unpack historical experience. They should understand panics and function rationally when the public goes into hysteria. Only a small group of economists who specialise in happiness and wellbeing, fit the bill, but they will need additional training.

Some doctors are finally realising the problem. In 2022, the Hillsdale College’s Academy for Science and Freedom wrote that “public health advice should consider the impact on overall health” (Chadwick had said that over 150 years ago!). But medical doctors know nothing about such analysis. Till today, no public health textbook incorporates a CBA of any form of quarantine, let alone of covid lockdowns. Instead, textbooks resort to subjective, speculative tools such as mathematical epidemiological models and ethics, which neither have anything to do with medicine, nor can they ever lead to robust policy. 

Can this competency gap be filled by training medical doctors in economics? No. To develop Treasury-style economists skilled in society-wide assessment takes at least a decade. It is far easier to identify good economists and teach them elementary biology. 

Conclusion

Exactly as Chadwick had anticipated, medical doctors have badly botched up public health. We need economists to lead public health, with inputs from appropriate medical doctors and engineers. In particular, I recommend that a post of Chief Public Health Officer – always to be held by an economist – be created in each jurisdiction. Academic schools of public health should be transferred to economics departments. Medical doctors worldwide should be limited to what they know best: the curative function (Chief Medical Officer).

Given the hegemony of medical doctors in public health, however, we will need a transitional strategy. First, let’s create a Centre for Scientific Public Health headed by an economist, tasked with publishing textbooks to educate the world on the right way of doing public health. Second, more economists should write in established public health journals, demonstrating the value they bring. Third, a new branch called “public health economics” should be created in economics to analyse the knowledge and incentive problems in public health, and irrationality during pandemic panics.