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Zika and the trouble with public health directives

The disease points out the tension between the government’s macro view of health and our micro one.


More than 1 million people in Brazil have been stricken with the mosquito-borne Zika virus, suspected of having caused brain damage in thousands of newborns. With Zika sweeping northward into Central America and the Caribbean, many governments are working as quickly as possible to thwart the further spread of illness and reduce the risk of birth defects. The US Centers for Disease Control has advised pregnant women to consider postponing travel to areas where Zika virus transmission is ongoing. Most dramatically, health officials in El Salvador are urging women not to get pregnant until 2018; women’s rights campaigners have decried such public health directives in a country where limited access to contraceptives and a high rate of sexual violence often lead to unplanned pregnancies and all abortions remain federally banned.

The controversy over the Salvadoran government’s advice is certainly genuine. At the same time, the case exemplifies the fear and confusion that result whenever there is a tug of war between overarching health directives and the people whose bodies they affect. The conflict generally boils down to this: Public health organizations are tasked with caring for the health of a large group of people, whereas we, as individuals, tend to think about health only on a personal level.


The repercussions of this gap are visible each year around this time in Massachusetts, as cases of influenza start peaking. Despite an arctic winter in 2014-2015 that led to more than 30,000 cases of lab-reported flu, only 49 percent of our state’s residents have gotten the flu shot so far this season, despite knowing the vaccination also protects those we might otherwise inadvertently expose.

Daniel Wikler, a professor of ethics and population health at the Harvard T.H. Chan School of Public Health, isn’t surprised that people don’t always think of the larger community. “It’s understandable that the health of populations is abstract to us, even though it’s just another way of talking about health problems of a great many individuals, each of whom we’d probably sympathize with if we knew them,” he explains. “We don’t respond to abstractions with the same urgency that we feel in the case of individual distress.”


Because individualistic thinking often drives our behavior, large-scale public health interventions sometimes are perceived as being blind or even contrary to the plight of the individual. In her 2014 book On Immunity, Eula Biss writes that the deep American suspicion of vaccination springs partly from fear of the individual being controlled by the state. This is exemplified by vocal anti-vaccination movements across the country. A study published last month revealed that the rate of vaccine refusal for personal belief doubled from 2007 to 2013 in California, with exemption rates in some suburban areas approaching 50 percent.

Or consider this: In 2012, the New York City Board of Health passed a regulation prohibiting the sale of sugary beverages in containers larger than 16 ounces in restaurants. Such drinks have been repeatedly implicated in our obesity epidemic, which kills 100,000 people a year in this country. When researchers investigated testimonials submitted to the city’s Department of Mental Health and Hygiene, they found that many individuals felt the policy represented government encroachment on personal freedom — even though New York never restricted the number of sugary drinks a person could buy.

“We’ve failed,” says Dr. K. Viswanath, a professor of health communication at the Harvard public health school, when I asked him about the big-drink ban. “That was a real opportunity for [public health entities] to connect with people on moderate soda intake, but we weren’t strategic enough in getting the message across.” He pointed out that public health groups are often ridiculed as being “scolds” (as they were in a popular Daily Show clip mocking the attempted ban), rather than working on the behalf of citizens. But obesity is a consequence of the environment we build together, and to make public health policies more effective, Viswanath says, we have to figure out how to better communicate the goals of these directives to the public.


Fighting disease, whether obesity or a virus, at the community level means considering more carefully how our individual roles relate to the larger group. Each person is a part of creating public health — whether rich or poor, young or old, white or black — and the cost or benefit of an individual decision is borne by society. In her book, Biss describes new metaphors that might help us better understand the value of population-level thinking: “The cooperative work of bees,” she writes, “is an example of the kind of collective problem solving our own society depends upon.” Through advocacy, community literacy, and by taking open responsibility for one another, we change the way we behave. We might vaccinate more as well as alter what we eat and how we respond to health recommendations, not because we’re thinking only about ourselves but because we’re all inextricably connected.


Eventually, we may not have a choice. As the US Ebola cases in 2014 and a multi-state measles outbreak last year showed us, the constant threat of new diseases will continue to make us recognize how tightly we are all interlinked. Although Zika, a mosquito-borne illness, doesn’t appear to be primarily transmitted primarily between people, the consequences of its spread are bound to require broad public health measures that affect both global and local communities: formerly restricted to South and Central America, cases picked up from travel abroad have already been reported in Massachusetts.

More coverage:

Photos: Zika virus spreading in Latin America

Zika virus ‘spreading explosively,’ WHO official says

Bostonian who traveled abroad is first Mass. Zika case

Virginia college student contracts Zika virus

US reports first case of Zika transmitted through sex

Pregnant travelers urged to stay away from countries with Zika

Dr. Sushrut Jangi is an internist and instructor in medicine at Beth Israel Deaconess Medical Center. Send comments to