To make public health officials more accountable, they should be elected, not appointed

In the United States, the Covid-19 pandemic has resulted in the widespread firing and resignation of public health officers. According to one analysis, more than 300 state and local health officials were fired, resigned, or retired between April 1, 2020 and Sept. 12, 2021. One reason for this unprecedented exodus of health officers was the unresolved tension between them wanting to use their legal authority to “follow the science” by imposing restrictions on businesses versus their public legitimacy and the permission granted them by governors or other elected officials for them to actually use that authority. In September, Florida’s top health official resigned, and the governor immediately replaced him with a physician who, similar to the governor, dismisses the benefit of business restrictions, vaccines, masks, and testing to control Covid-19.

When questions for science (“how many lives can we save by doing X?”) clash with questions for democracy and governance (“how much value is a life worth?”), health officials necessarily defer to the governors, mayors, and others who appointed them and who were duly elected to manage the tradeoff between lives and livelihoods for the millions of people under their governance. But what if we elected our health officials, just as we do other public safety officials (e.g., judges, attorneys general, sheriffs) in many cities and states?

Although the job of a local health official varies across jurisdictions in the U.S., they are required, in most places, to have a medical degree or other advanced health credentials and are appointed by an elected executive or by a board of elected officials. Health officials are responsible for responding to acute threats to health from infectious or environmental agents, administering services to prevent diseases, and providing an accurate accounting of disease rates for their community.

CDC’s framework for essential public health services specifically notes the responsibility of health officials to “utilize legal and regulatory actions designed to improve and protect the public’s health.” And, both globally and domestically, there’s been a long-standing consensus that public health decisions should be made by public health officials free from political interference; this is further codified in the report from the first major panel that evaluated World Health Organization’s response to Covid-19 through May 2021.

However, the decisions public health officials make can never be purely about science. If public health officials were to have complete independence from political interference while also being appointed, rather than elected, this would give them regulatory power that contradicts many essential components of democracy: health experts would get to decide the tradeoff between lives saved versus livelihoods saved without being directly accountable to either the person that appointed them or the population that they serve.

Electing, rather than appointing, the executive of a government public health agency would ensure that health officials are both accountable to the population they serve and independent from interference by other elected officials. Based on my experience leading New York City’s Covid-19 response, it is likely that a commissioner of health who was elected and able to act completely independently would have enacted even stricter public health measures during the pandemic, such as delaying the reopening of indoor dining and fitness centers and enacting temporary “stay at home” orders during the winter 2020-2021 wave.

Elections also have the ancillary benefit of making health officials more free to communicate during their campaigns and while in office about the values and beliefs that inform their decisions, rather than having to act as if their decisions are exclusively informed by scientific data and knowledge — which, during the pandemic, has evolved, and consequently required adjustments and flexibility on the part of health officials.

Indeed, one of the most important challenges I faced leading in New York City was how to present myself during daily press conferences and public meetings as a steward of science while also transparently acknowledging the balance of factors — harms, benefits, feasibility, and acceptability across all sectors of society — that informed shifting city policies on schools, restaurants, gyms, public gatherings, and other issues. I and other government health officials have frequently been criticized by academics and activists for not rigidly “following the science” and imposing more strict restrictions throughout the pandemic, but we are often constrained in publicly acknowledging all the factors that must be weighed in decision-making. Ultimately, it has been the person duly elected — for instance, the mayor — who makes those tradeoffs for society, not us.

Electing health officials does have risks. In the mid-1800s, the United States became and remains the only country in the world in which citizens elect local prosecutors. While the impetus was to minimize the influence of partisan politics and to strengthen their accountability to the citizenry, some argue that the election of local prosecutors increased corruption and bias. Prosecutors may decide which cases to pursue not exclusively on the merits of those cases and the law, but on how special interests who can assist them in future campaigns view those cases, and the attention they may garner to enhance their political standing. Would an elected health official, for example, be less likely to restrict cigarette smoking or close a hazardous restaurant if those decisions could adversely impact influential people or organizations?

It is also possible that misinformation could become even more entrenched if there are candidates for health office who embrace extreme positions, given the tendency of people to assume that there are, in fact, two equal sides to a position, to remember false information once it’s publicly stated even after they are later told it is not true, and to align themselves with views that comport with their ideology, rather than established facts.

Another concern is that persons who are most qualified to run a public health agency may be the ones most reluctant to enter the political arena, where they have to spend time raising money, knocking on doors, and making deals with political parties rather than keeping up to date on the latest science. A counter-argument is that one of the failings of public health leadership during the pandemic has been a failure to communicate effectively to lay audiences and that the electoral process can help select for this critical skill.

The system in which public health agencies operate today is clearly broken. Leaders of those agencies need to be duly authorized and legally empowered to protect public safety, weighing and publicly explaining all the factors involved in these often difficult decisions. Public health officials who have been elected would have a mandate that they only rarely have today to regulate public health emergencies, as the health commissioner and Board of Health, for example, currently have in New York City. State legislatures would have to pass laws and/or amend their constitutions, ensuring that elected health officials have the authority they require. Many states may be reluctant to do this, given that 19 have already rolled back public health agencies’ authority during the pandemic. And mayors and governors would have to work with newly empowered health officials as collaborators and equals in making public-health-driven policy changes.

During the pandemic, the most important decisions, such as the timing and severity of public health restrictions, have been exposed to be as much about what the public broadly wants and tolerates as about what the science suggests is the best course of action. It’s time to elect public health officials, and give them the authority to deal directly with such tradeoffs, and explain them fully to the public.

Jay Varma, an infectious disease physician and epidemiologist, is a professor of population health sciences at Weill Cornell Medicine and directs its Center for Pandemic Prevention and Response. He was the senior advisor for public health to New York City Mayor Bill de Blasio from April 2020 to May 2021, advising on the city’s public health response to the pandemic and organizing its Covid-19 testing, tracing, and vaccination campaigns.