Public Service in the Pandemic Era: A COVID Commentary.

This viewpoint reflects on basic aspects of American public health and politics that are making the COVID crisis response less effective than it might be. The performance of public service during a crisis depends as much on self-reflectiveness and hope as on the achievement of measurable results. Anthony Fauci is offered as an exemplar of authentic public service, understood as "living within the truth."

Evidence for Practice

In American public health, a long‐standing decentralized institutional structure and individualistic political traditions are barriers to significant reforms.

Good “performance” in public service consists not only of achieving measurable results but also of self‐awareness about one's role as a public servant and a commitment to “living within the truth” according to one's conscience.

Anthony Fauci demonstrates to the rest of us by his performance how scientific truth can be meshed with truth to one's own conscience in service to the public.

I give the appearance of being optimistic. But, deep down, I just do everything I possibly can, assuming that the worst will happen, and I've got to stop the worst from happening. Anthony Fauci (Specter

Public space is alive with discussion of the COVID‐19 pandemic. A noteworthy aspect is the unusual attention the American public health system is receiving. Public health ordinarily receives little public scrutiny and is routinely taken for granted by Americans if they notice it at all. As a result, it is typically starved for resources and has had little active political support among citizens (Fairchild et al. 2010; Jennings 2003; Morrow 2005; Turner 2008). This essay deals with the ways in which American political attitudes and practices have kept in place a politically weak public health system and suggests implications for practice and scholarship going forward.

It seems important that public servants and public administration scholars not pass up the opportunity to learn from what the COVID crisis reveals about American governance. Given the uphill battle any U.S. policy faces when it targets community needs rather than individual beneficiaries, there seems little chance that the current pandemic will work a sea change in our public health system. I will suggest that the political dilemma of public health—its lack of advocates among the general public—is not fixable simply by replacing one chief executive or one party with another. Yet a fresh look at the nature of public service itself may suggest a worthwhile response short of regime change. Using the exemplary role played by public health expert Anthony Fauci on the public stage, I explore the possibility that Fauci's performance offers a model for the practice of American public health, in its current crisis and beyond, as well as public service more broadly. The discussion first documents basic aspects of public health's continuing disarray, followed by a brief argument that individualism, the language of American political common sense, helps to account for public health's perennial weakness. It then offers Anthony Fauci's role in the crisis as a concrete example, not of heroism but of a career official whose performance spotlights an authentic stance public health and other public servants can take.

The three‐level public health system in the United States focuses largely on community‐wide disease prevention and control rather than the treatment of individuals. Many of the nation's greatest advances in lowering death and disease rates resulted more than a century ago from immunization, sanitation, and other community efforts to slow or stop the spread of infections (e.g., yellow fever, tuberculosis, sexually transmitted disease). The very effectiveness of community‐wide campaigns made it possible for individuals to forget how deadly these diseases are and for the policy emphasis to shift: “As the memory of epidemics faded, individual rights became much more important than collective responsibility” (Interlandi 2020). This “great forgetting” has skewed the way public funding for health is allocated. In 2017, community‐wide health made up just 2.5 percent of all U.S. health spending despite the fact that the median return on public health investment in high‐income countries is 14 to 1 (Trust for America's Health 2020, 2019). “Nobody wakes up in the morning and says, ‘Thank God I don't have smallpox’. Or, ‘Thank God my water is potable’,” comments Alfred Sommer, former dean of the school of public health at Johns Hopkins University (Sellers 2020).

Public health's classic activities include sanitation, communicable disease prevention and control, health education, and support of efforts necessary to maintain a community standard of living consistent with good health. Yet in the United States, public health governance has long been fragmented in structure and politically feeble, in part because of our decentralized system (Kettl 2020) and in part because of individualist ideologies and interest group politics.

The Institute of Medicine (IOM; now the National Academies of Medicine) has conducted two national studies of American state and local public health agencies and activities (Institute of Medicine 1988, 2002). Both found serious evidence of what the 1988 report called “disarray.” That report identified huge variance among the states, which traditionally play a leading role in public health efforts with federal backup. Some state health departments are enclosed in social service superdepartments, some are free‐standing. Some handle environmental health or Medicaid, others do not. Nearly all collect vital statistics; perform epidemiological and laboratory studies; and conduct maternal and child health activities, immunization, and health facility licensing, but few generalizations can be made about how well or at what magnitude.

Even more diversity exists at the local level. In some states, local agencies are branches of the state health department; in others, they report to local elected officials. Some are larger than the typical state‐level department, others are bare‐bones operations with few staff. In some rural states, large areas have no local agency. The 1988 study found, based on more than 350 interviews, that neither local and state officials nor the general public can be counted on to know what is available in any given locale or who is in charge.

To add to the disarray, members of the public tend toward vagueness on what public health is. When asked to describe it, interviewees said things like “public health does things that benefit everybody,” or “what the private sector won't do,” but when pressed for details, they remarked: “They take care of poor people…You can go there to get a shot…Don't they inspect restaurants?” (Stivers 1991, 360). This is evidence of the “great forgetting” mentioned above.

A subsequent study (Institute of Medicine 2002) found that basic infrastructure was continuing to erode. The fragmentation between and within governmental levels remained. In addition, over the last decade, local health department budgets shrank by 24 percent even as health care spending overall grew by 52 percent (Trust for America 2019). Inattention to the need to prepare for and, if possible, prevent the spread of communicable disease means that we ignore public health until there is an outbreak, and “then we throw a pile of money at the problem. Then we rescind that money as soon as the crisis abates,” according to the head of the Association of Public Health Laboratories. “The nation's default public health strategy [is] neglect, panic, repeat” (Interlandi 2020).

The fragmentation and weakness of U.S. public health are longstanding and persistent. This suggests that band‐aid fixes and crash interventions will fail to address deep‐seated problems in the public health system because they stem from fundamental American political dynamics and values.

At the time of the 1988 IOM study (of which the current author was a staff member), dozens of interviews showed that public health officials believed that science gives you the facts, and the facts tell you what to do. One state health director commented, “The professionals should make the decisions and then take the heat.” Many were well aware that their views are often discounted when policy decisions are made: “Statistics don't make people act…the public and the legislature don't listen…What's the use? Nobody really cares about public health” (Stivers 1991, 360).

They were not mistaken. Recommendations by public health professionals were often met with skepticism, if not sidelined entirely. Interviewers heard that “public health practitioners are consummate bureaucrats, saving their own jobs.” According to one respondent, “The health department has never done anything…I never saw [them] develop a strategy.” Perhaps most damning were comments to the effect that elected officials do not turn to the health department for advice (Stivers 1991, 360).

The 1988 study and others point to a major factor in public health's dilemma: the strong streak of individualism in American culture that puts community‐wide need at a political disadvantage. Public health has no constituency of individuals or citizen interest groups that see themselves as directly benefitting (Institute of Medicine 1988, 42–43, 96–97). Despite the report's recommendations, which stressed measures to rationalize public health's institutional structures, the interview evidence suggested that scientific fact, at face value, will never determine public decision‐making. Even if research results did not need to be adjusted in applied settings, the nature of American political ideology resists putting scientific expertise in the driver's seat. “Do what I say because I'm the expert” sits uneasily within a system that claims to operate democratically, especially one in which individualism predominates. The current resistance to mask wearing is one illustration of how claims to scientific truth can be taken as a threat to individual liberty.

Since Alexis de Tocqueville visited America in the early nineteenth century, many have noted as he did that, in our nation, individual rights and needs take precedence over the collective (Turner 2008). They shape the American dream, as well as the American knee‐jerk reaction to the very word “socialism.” Tocqueville himself thought that governance practices, particularly at the local level, could temper individualism, but his hopeful forecast has not panned out. This does not bode well for efforts to develop and strengthen the nation's capacity to fight the next pandemic, which by definition will require not only scientific expertise but also cooperation and collaboration among individuals for the common good (Jennings 2011).

If the above can be entertained for argument's sake, what next practical step can be envisioned? Given the urgent need to cope with COVID and other pandemics yet to come, public health expertise is a resource the nation cannot afford to neglect. Yet there will be no quick fix despite the 2020 election results. As skeptical as one might be of granting public health experts the power to act on the facts and then take the heat, their role in the present crisis still seems both fundamental and potentially exemplary. In a similar way, “key [managerial] competencies” (Van der Wal 2020) and “agile adaptivity” (Moon 2020), important as they are, seem not to reach the depth of the public service dilemma in this pandemic era. Beyond management skills looms the threat of a loss of meaning in public service. That prompts the question of what role personal authentic action by public service professionals might play in improving our current situation rather than (metaphorically) just “waiting for the barbarians” (Coetzee 1982).

Take the case of Anthony Fauci, an exemplar of how to survive as a senior career official in the Trump era, even while occupying the hot seat. According to a recent profile (Specter 2020), Fauci is that rare individual trained as a scientist (a physician) who utterly accepts science as factual truth but, faced with the urgent need to be heard by decision makers and the public, has taken an unusual path.

When the AIDS crisis hit in the 1980s, Fauci held the job he still occupies, heading the National Institute of Allergy and Infectious Diseases. One of the first to sense the threat posed by the new disease, he started laboratory research on potential treatments. Experimental drugs were required to go through a lengthy process to prove them both safe and effective. As it became clear that AIDS killed everyone who got it, activists demanded that persons with AIDS be given the drugs while tests continued. Because of his research, Fauci had become the face of the federal government on the issue. Instead of dismissing the protests and hiding in his office, Fauci listened to what protesters were saying:Fauci did something rare: He changed his mind—not about scientific truth but about how to make it effective in public space. Not only did he listen to activists and, in essence, become one of them, but within the bureaucracy, he argued strategically for changing the policy on AIDS, from the traditional slow, cautious process to making the drugs available once they were proven safe, even as clinical trials continued.

Let me put aside [their] goth dress—the earrings and the Mohawk haircuts and black jackets—and just listen to what they have to say. And what they were saying made perfect sense…And I said, What would I do if I were in their shoes? And it was very clear: I would have done exactly the same thing. (Specter 2020, 41).

This story reveals something of why, today, Fauci has played the unusual role of a government scientist whose public remarks Donald Trump tolerated and who manages to say helpful things to the public in a calm and persuasive way. Fauci's expertise lies in his mastery not only of scientific truth and managerial competence but of the art of performative truth‐telling. In my mind, he embodies the stance in public life articulated several decades ago by Vaclav Havel, a public official who took up a similarly risky position and then wrote about it.

As is widely known, Havel was a Czech playwright who became an activist after Soviet tanks invaded his country in 1968. He argued that the very idea of “reforming” communism warped reality and weakened truth. After the Velvet Revolution that toppled communism there in 1989, Havel served as president of Czechoslovakia and (after the split between Czechs and Slovaks) as president of the Czech Republic (see Havel 1991).

Havel saw public service as a performance. He characterized it as “living in truth.” In the current era, with the blizzard of lies, deception, and fakery issuing from social media, Trump TV, and from Donald Trump himself, living in truth has a rather quaint air about it. Nevertheless, it is a stance that anyone, especially public servants, can take up amid the storm. Living in truth describes Fauci's public actions in the current crisis, which differ from the traditional stance—that public health experts should make decisions even without public input and then take the resulting heat.

As an example, Havel offers a greengrocer, inside of whom one day “something snaps.” He stops following the rules of totalitarian politics. He ceases putting up official slogans in his store; he refuses to vote in fake elections (i.e., all of them); he begins to say what he thinks at phony public meetings. In these ways, he attempts to live within the truth as he sees it. For these actions, he will pay a price: reduced pay, transfer to a menial job, perhaps his children's loss of access to higher education, and so on (Havel himself was imprisoned several times for speaking his mind). The system must punish the greengrocer because he has stopped following its rules. He “has exposed it as a mere game. He has shattered the world of appearances…He has upset the power structure by tearing apart what holds it together…. And…by his action, the greengrocer has…enabled everyone to peer behind the curtain. He has shown everyone that it is possible to live within the truth” (Havel 1991, 146–147).

Havel's faith is that “individuals can be alienated from themselves only because there is something in them to alienate” (1991, 148). It is that “something” which the greengrocer's actions reveal. As Daniel Brennan points out, Havel lived and wrote to convey that he was an ordinary and flawed man rather than a hero (e.g., he deliberately mentioned his bleeding hemorrhoids in writings he intended to be published). Havel saw public action as situational and mundane: not grand gestures but humble yet visible steps. As Brennan observes:As Havel put it:This matches Fauci's way of playing the role into which he was thrust by the COVID pandemic and the Trump administration's reaction to it. And, Fauci all but says so, as quoted at this head of this commentary. He plays the role of optimist but “deep down,” he just does “whatever I possibly can” in order to “stop the worst from happening.” In this way, Fauci does his best to live not only within the scientific truth to which he has dedicated his life but also the self‐reflective truth‐to‐self that is the potential of every human being. As Stephen K. Bailey (1964) once observed, optimism in public service mobilizes creative responses: not with a guarantee of success but with possibilities for good out of uncertainty. Thus, we gain the courage to persist.

Havel's understanding of living in truth is better understood as a constant vigilance over one's own behavior…not a call to arms,…rather to reflect on which of [our] own behaviours helps keep the current situation in power (Brennan 2019, 59).

[Who] among us has never, from time to time, been forced into playing some role? The important thing is to be conscious of that role and to be able to reflect upon it and one's relationship to it. (Ibid.)

Fauci's power as he occupies the public spotlight is what DeLysa Burnier (2018) describes as “performative.” In contrast to the ubiquitous public management notion of performance as actions that get measurable results, Fauci's performance is what Burnier sees as a personal politics of resistance and possibility, one that questions the dynamics of the unfolding situation, especially as defined and “managed” by the Trump administration. This is Fauci's way of living within the truth, which Havel understood as speech that shows the rest of us another public stance to take than going along with the charade. It is a form of radical hope, “the certainty that something makes sense regardless of how it turns out” (Deneen 1999, 580)—or, as Bailey (1964) terms it, the courage to decide.

Living in truth sees the purpose of governance as more basic than how it functions. It is the voice of individual conscience, of vigilance over the “irrational momentum of anonymous, impersonal, and inhuman power.” Havel sees conscience as the “only genuine starting point of meaningful human community” and as an explicit alternative to relying exclusively on “science, rationality, and impersonal power to tell us what is real and meaningful” (1991, 264, 267). This is not to dismiss the usefulness of science but to caution that it cannot be the sole guidance in addressing public issues. In a similar argument, the philosopher Hannah Arendt (1954) says that the necessary check on science in public life is what she calls the “it appears to me,” that is, the considered viewpoint that each of us can express in public conversations based on personal experience and reflection. In using judgment rather than taking bureaucratic commands or scientific findings for granted simply because they come from above, public servants can live in truth.

It is worth noting that, in current public administration and public management scholarship, science and the scientific method have taken pride of place. In my view, interpretive and critical studies must be added to this work of the interpersonal dynamics of administrative practice and narrative documentation of the thought processes that practicing bureaucrats bring to bear as they cope with complex situations (Starke 2020). As Ralph P. Hummel (1991) once found, the war stories managers tell one another, from which they gain perspective on their own work, are as valuable to them and potentially to scholars as are the results of experiments. Such conversations exercise the judgment muscles and the ability to perceive what is really at stake. The same goes for detailed, well‐interpreted cases added to class syllabi and conference sessions for discussion. The more opportunities public administrators have to stand back from fighting the next fire, reflect, compare their situation with others, question conventional wisdom, and recall exemplars like Fauci, the better prepared they will be, as Arendt once put it, “in those rare moments when the chips are down” (Arendt 2003, 159).

The role Fauci plays, the stance he takes, invites public servants at every bureaucratic level to the project of building the public community that scientific truth all by itself cannot construct: the community that American individualistic political culture tells us is dangerous but on which the nation ultimately depends. Few if any bureaucrats, including those at the street level, have no leeway as to how they respond to orders, interact with members of the public, or apply research results. By speaking within the truth as it appears to them, public servants change little by little the fabric of the reality that, when lived by vast numbers of people, keeps a regime in place—or alters it. Fauci, like Havel's greengrocer, has shown us that there is something accessible to each of us if we are willing to consider how, by staying silent, we help to keep the curtain of lies in place and how, instead, we might be able to live within the truth. My hope and belief are that American public servants will let what Arendt called “the wind of thought” blow as they deliberate and decide, inspired by Fauci's example and others':Anthony Fauci's role in public service performance will one day end or may have already ended. Even so, he shows us possibilities that will persist. Efforts to live and speak within the truth, like public service at whatever level of government we find it, must be judged not simply by results but by whether they show others a stance worth taking.

“Perhaps by the end of the winter,” I think, “when hunger truly bites us, when we are cold and starving, or when the barbarian is truly at the gate, perhaps then I will abandon the locutions of a civil servant with literary ambitions and begin to tell the truth” (Coetzee 1982, 154).