{"id":179795,"date":"2026-04-01T16:42:41","date_gmt":"2026-04-02T00:42:41","guid":{"rendered":"https:\/\/lukeford.net\/blog\/?p=179795"},"modified":"2026-04-03T09:45:11","modified_gmt":"2026-04-03T17:45:11","slug":"what-public-health-was-doing-before-covid-came","status":"publish","type":"post","link":"https:\/\/lukeford.net\/blog\/?p=179795","title":{"rendered":"What Public Health Was Doing Before COVID Came"},"content":{"rendered":"

Before COVID arrived, American public health elites had largely remade their field in their own image. The transformation was not secret or subtle. You could read it in journal priorities, accreditation standards, and the speeches of deans. The field had decided that its highest calling was not managing pathogens but reordering society.
\nThe organizing framework was Public Health 3.0<\/a> (on April 1, 2026, I scrolled through the top 50 Google results for “Public Health 3.0” and none were critical), a model the CDC promoted<\/a> and academic leaders embraced<\/a>. Under this logic<\/a>, the local health official was no longer primarily a disease fighter. He was a chief health strategist, coordinating housing agencies, transportation departments, and school districts. The pathogen receded. The social determinant advanced. By 2019, this thinking governed curricula. The Council on Education for Public Health had revised its accreditation criteria in 2016 to require every student to demonstrate competence in social justice and the social determinants of health. Schools built administrative layers around diversity, equity, and inclusion. Those roles grew faster than faculty lines in infectious disease or biosecurity.
\nFollow the individuals who set the agenda and the pattern sharpens. Sandro Galea<\/a>, dean at Boston University and a prolific public health intellectuals, published essays arguing that the central task of the field was transforming the conditions in which people live. Health was downstream of inequality, housing, and political systems. Epidemiology (study of disease) remained relevant, but it was no longer the organizing core. At Harvard, Howard Koh<\/a> translated this into institutional doctrine, promoting the idea that public health leaders should function as cross-sector coordinators of social services rather than as specialists in disease control. Victor Dzau<\/a>, president of the National Academy of Medicine, reinforced the message from the prestige apex. NAM reports leading into 2020 consistently elevated health equity as the central objective of the American health system.
\nThe professional associations followed. Georges Benjamin<\/a>, executive director of the American Public Health Association<\/a>, oversaw conferences and policy statements that framed structural racism, gun violence, and social inequality as the defining public health crises of the era. The APHA adopted a policy statement in late 2018 identifying law enforcement violence as a public health issue, treating the police as a source of health inequity for Black and Latino communities. The American Journal of Public Health filled with research on structural racism and gun policy. These topics offered moral clarity, political relevance, and a ready audience.
\nThe opioid epidemic consumed additional bandwidth. In 2018, nearly 47,000 Americans died from opioids. This was a genuine emergency, and the field responded accordingly. The National Academy of Medicine launched major collaboratives. Deans built research centers. Faculty careers formed around overdose modeling and treatment access. None of this was wrong. But it drew talent, grants, and institutional energy away from low-probability, high-impact threats. Vivek Murthy<\/a> spent the pre-COVID period finalizing a book arguing that loneliness was the primary threat to American health. Ashish Jha, then at the Harvard Global Health Institute, built his reputation on healthcare costs and insurance coverage. Tom Frieden<\/a>, former CDC director, focused on cardiovascular disease and tobacco control at his organization Resolve to Save Lives. Even the most experienced operators in the field were oriented elsewhere.
\nMeanwhile the physical infrastructure for crisis response deteriorated quietly. Between 2010 and 2018, public health spending dropped 10 percent in real terms. State and local health departments lost 56,000 staff members. Surveillance systems ran on outdated technology. Laboratory capacity at the local level shrank. These facts appeared in reports and footnotes. They did not command rhetorical urgency. They lacked the moral charge of equity work and the political salience of opioids and guns. Pandemic preparedness existed in a semi-detached niche. The Johns Hopkins Center for Health Security ran the Event 201 simulation in October 2019, correctly modeling supply chain failures and information disorder in a coronavirus outbreak. It was technically serious work. It sat at the margin of elite discourse.
\nThe incentive structure explains this more clearly than ideology does. A junior scholar in 2018 choosing a research agenda faced a clear gradient. Grants, publications, and tenure ran through disparities, equity, and high-salience domestic crises. Pandemic logistics, stockpile management, and surge capacity were harder to fund, less prestigious in journals, and less integrated into the field’s expanding moral mission. This is what made the pre-COVID priorities convenient. Not because they were false, but because they aligned almost perfectly with career incentives, institutional expansion, and the self-understanding of elite academia.
\nNiche construction, drawn from evolutionary biology, describes the process by which organisms modify their environment in ways that then feed back to shape the selection pressures acting on them. Beavers build dams. The dams change the local ecology. The changed ecology then favors beaver traits suited to that new environment. The organism and the environment co-evolve through the modifications the organism makes.
\nApplied to the public health elite before COVID, the concept adds something the standard incentive story does not quite capture. The standard story says: elites responded to incentives that already existed, chasing grants, prestige, and tenure through equity language. That is true but incomplete. What niche construction adds is that these elites were simultaneously building the environment that generated those incentives. They were not just adapting to a landscape. They were constructing it, and the constructed landscape then selected for more of them.
\nThe Council on Education for Public Health revised accreditation standards in 2016 to require competency in social justice and social determinants. That was not a response to pre-existing pressure. It was a modification of the environment. Once in place, it selected for students, faculty, and programs fluent in that language. Those graduates then populated journals, associations, and deans’ offices, where they made further modifications: new grant criteria, new hiring expectations, new journal priorities. Each modification fed back to reinforce the next generation of selection. The niche became self-sustaining.
\nThis is why the shift proved so durable and why pandemic preparedness stayed marginal even when individual voices warned otherwise. It was not that no one valued outbreak readiness. It was that the constructed niche did not reward it. The environment public health elites built over roughly a decade selected against the traits, careers, and institutional investments that a pandemic response requires. By 2019, the field was not simply ignoring infectious disease. It had built an ecology in which infectious disease specialists, stockpile managers, and surge capacity planners could not easily thrive.
\nNiche construction also explains the post-COVID reabsorption the essay describes. When COVID hit, the field pivoted under duress. But the constructed niche remained intact. Journals, accreditation bodies, grant criteria, and administrative roles had not changed. So within months the equity framework reasserted itself, now attached to the virus. The environment selected for what it had always selected for. The shock was real. The niche was more durable than the shock.
\nThe deeper point is that this was not drift. It was, in biological terms, extended phenotype work: the field externalizing its own values into institutions that then reproduced those values autonomously. By the time COVID arrived, the public health elite did not need to consciously defend their priorities. The niche defended them.
\nWith COVID, the field did not discover infectious disease for the first time. It rediscovered something it had deprioritized. The pivot was real and in some cases impressive. Fauci became a national figure. Epidemiological models drove policy. Supply chains, testing rates, and ICU capacity dominated daily conversation. But the underlying structure proved more durable than the emergency.
\nWithin months, the dominant equity framework reasserted itself, now attached to the virus. Disparities in infection and mortality rates became central research topics. Structural explanations layered onto virology. Funding calls translated the pandemic back into the existing paradigm. The scholars who had spent years studying racism as a fundamental cause of health outcomes found COVID fit their framework with minimal adjustment. The system bent under the shock and then snapped back into its preferred shape.
\nWhat this reveals is not hypocrisy but something more structural. The pre-COVID field was not populated by people who knew the right priorities and chose the wrong ones. It was populated by people operating rationally within an incentive system that rewarded certain problems, certain methods, and certain moral languages. Pandemic preparedness did not fit that system well. It was technical rather than systemic, operational rather than analytical, and its payoff was invisible until the moment it became catastrophic.
\nThe honest reckoning with COVID requires acknowledging that the people who set agendas, controlled prestige, and allocated attention in the years before 2020 were overwhelmingly oriented toward a different set of problems. The field got the test it was least prepared for, not because its leaders were foolish, but because the system they built rewarded something other than readiness.<\/p>\n

The heroic figures in the COVID response were largely not the ones who dominated elite public health discourse before 2020. They came from the margins of the prestige system.
\nTom Inglesby at the Johns Hopkins Center for Health Security is the clearest case. He spent years warning that the United States was underprepared for a respiratory pandemic. He co-led Event 201 in October 2019, the simulation that correctly modeled supply chain breakdown and information disorder in a coronavirus outbreak. He testified before Congress in 2018 for stronger preparedness legislation. When COVID arrived, his framework was vindicated almost immediately. He was not a figure celebrated by the equity-focused establishment before 2020. He was a niche expert in a semi-detached corner of the field.
\nMichael Osterholm at the Center for Infectious Disease Research and Policy at the University of Minnesota holds similar standing. He spent decades warning about pandemic risk and was consistently outside the dominant prestige circuits of schools like Harvard Chan and Hopkins Bloomberg. He wrote a book in 2017, Deadliest Enemy, arguing that a respiratory pandemic ranked as the gravest threat to human health. Few of the elite conference speakers and journal editors took that seriously as their organizing concern.
\nCaitlin Rivers, an epidemiologist also at the Johns Hopkins Center for Health Security, had built her career on outbreak science and early warning systems. On January 1, 2020, she was already raising alarms about the novel virus emerging from Wuhan. Her subsequent book, Crisis Averted, chronicles what functional outbreak response looks like. She represents the type of figure the incentive system consistently undervalued before COVID: technical, operational, focused on logistics rather than social theory.
\nRick Bright at the Biomedical Advanced Research and Development Authority deserves mention for a different reason. He raised early alarms about the inadequacy of the U.S. supply chain for protective equipment and diagnostics, and was pushed out of his position in 2020 in disputed circumstances. Whatever one thinks of the politics, his warnings about preparation gaps proved correct.
\nAnthony Fauci is the complicated case. Before COVID he focused heavily on HIV, which was legitimate and consequential. He was not a pandemic preparedness evangelist in the Public Health 3.0 mold, and his institutional position at NIAID kept him closer to actual pathogen science than most of the equity-focused deans. When COVID arrived he moved to the center credibly, at least in the early phase. His standing later became contested for reasons unrelated to his pre-COVID record.
\nWhat unites the clearest heroes is their distance from the dominant pre-COVID consensus. Inglesby, Osterholm, and Rivers were not the people filling AJPH pages with structural racism frameworks or building administrative equity offices. They were working in a less prestigious register, on problems the field had decided were too technical and too narrow to command serious attention. COVID promoted them retroactively. It did not change the incentive system that had kept them peripheral.<\/p>\n","protected":false},"excerpt":{"rendered":"

Before COVID arrived, American public health elites had largely remade their field in their own image. The transformation was not secret or subtle. You could read it in journal priorities, accreditation standards, and the speeches of deans. The field had … Continue reading →<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[21791,42861,220],"tags":[],"class_list":["post-179795","post","type-post","status-publish","format-standard","hentry","category-america","category-covid","category-health"],"aioseo_notices":[],"aioseo_head":"\n\t\t\n\t\n\t\n\t\n\t\n\t\n\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t