The United States Public Health Service

The United States Public Health Service dates nearly to the founding of the United States of America, and it has witnessed every health crisis from smallpox and yellow fever to the opioid epidemic and COVID-19. Founded in 1798 by the Adams administration to care for sick and disabled seamen,Footnote ² the USPHS grew exponentially after the bacteriological revolution of the late nineteenth century, which caused a shift in how disease was regarded, from a moral failing to a societal- and state-level concern.Footnote ³ More than two hundred years after its founding, the USPHS is ‘the largest public health program in the world’ and provides crucial services related to ‘healthcare delivery, research, regulation, and disaster relief’ for the American people at large.Footnote ⁴ In fulfilling these roles, the USPHS has historically employed a variety of educational strategies adapted to the current situation and needs of American citizens, but it also faces certain impediments which crises exacerbate, as the following analysis demonstrates.

As the chief educational agency for health issues in the United States, the USPHS has relied on the latest scientific evidence and sought to avoid political or religious influence. As the point where medicine meets government, it must tread carefully around the First Amendment of the United States Constitution, which serves to protect citizens’ rights from governmental infringement. The First Amendment right to religious freedom has two parts: the establishment clause forbids the creation of a national religion, and the free exercise clause allows people to practise religion according to their consciences. Yet perhaps the context of the Public Health Services’ development attests more to its avoidance of religion than to constitutional trepidation, as the body grew out of scientific knowledge about disease and public acceptance of prevention as a social responsibility.Footnote ⁵ The USPHS embrace of bacteriology reflected broader public understanding, in which ‘[s]cientific measures were seen as replacing earlier social, sanitary, moral, and religious reform measures to combat disease. Science was seen as a more effective means of achieving the same desirable social goals.’Footnote ⁶ In 1988, a Committee for the Study of the Future of Public Health, commissioned by the Division of Health Care Services in the Institute of Medicine, issued a 240-page report on the status of public health services in the United States. This document reflected on the history of these services, assessed their present disorder and inefficacies, and recommended future actions that would enable the public health system to better address immediate crises and enduring problems. Tellingly, the quotation above, about science replacing religion, is the only place in the report where religion is mentioned. This omission arguably made some Christians wary of the authority of public health, as will be seen below.

One of the most common accusations levelled against the USPHS is that it tends to be reactive, rather than proactive, and thus is unable to respond to crises as quickly or efficiently as the public expects. This issue, highlighted both by the 1988 report and by a 2002 Health Affairs article entitled ‘The Unfulfilled Promise of Public Health: Déjà vu all over again’, in part reflects governmental priorities, but it also reveals a disjunction between academic analysis and practical implementation. In the Health Affairs article, Elizabeth Fee, chief of the History of Medicine Division at the National Institutes of Health's Library of Medicine, and Theodore Brown, professor of community and preventive medicine at the University of Rochester's School of Medicine and Dentistry, trace how events in US history have corresponded with changes (or the lack thereof) in public health services.Footnote ⁷ Fee and Brown narrate the constant struggle between progressive reform and conservative reaction regarding the funding and expansion of the USPHS. The USPHS draws national attention and a funding boom during disease crises or times of renewed interest in social inequities, such as the 1930s ‘New Deal’ and the 1960s ‘War on Poverty’. However, during leaner economic times or a New Federalism mentalityFootnote ⁸ as seen during the Reagan administration, when attention shifts away from diseases or care for the poor, the government slashes public health funding and the system falls into disarray.Footnote ⁹

Fee and Brown argue that the United States government and its people should invest in public-health preparedness at all times, and other academics have joined them in advocating consistent investment in national health initiatives. They assert that the boom-and-bust cycle challenges the ability of the USPHS to protect national health from regular stressors such as drug addiction or heart health. The lack of sustained support also inhibits the response of the USPHS to the sudden appearance of new epidemic diseases. In times of relative calm, medical professionals, politicians, sociologists and historians alike call for better preventative health. However, without funding, and with the next crisis always seeming to come too soon, the USPHS has been unable to implement necessary systemic changes.

When COVID-19, the disease caused by the novel coronavirus known as SARS-CoV2, reached the USA late in February 2020, the nation's public health systems were experiencing one of the ebbs in funding that occur regularly under conservative leadership. In an opinion editorial article published in the Washington Post on 13 March 2020, Beth Cameron, formerly Senior Director for Global Health Security and Biodefense in the National Security Council in the Obama administration, wrote:

Representatives from the Trump administration explained this elimination as a streamlining of the National Security Council.Footnote ¹¹ However, by the end of Trump's term of office, this decrease in disease prevention preparedness, combined with the rise of Christian nationalism in the Trump era as discussed below, contributed to the loss of more than 700,000 American lives.Footnote ¹²

Christian Nationalism and Science as an Affront to Religious Moral Authority

Christian nationalists can best be defined as a group of people who believe that the United States is a Christian nation and should base its policies on conservative Christian values and the Bible, which they perceive to be the inerrant word of God. Although Christian nationalists have promoted such views since the foundation of the USA, they have become increasingly vocal with the rise of the Religious Right and the increasing political power of the Moral Majority since the 1970s.Footnote ¹³ Although there is significant overlap between Christian nationalists and evangelicals, Andrew Whitehead and Samuel Perry assert in their study of Christian nationalism, Taking America Back for God (2020), that the groups are not to be regarded as one and the same. Whitehead and Perry argue that Christian nationalism must be studied on its own terms, separately from ‘Christianity’, and that ‘understanding Christian nationalism, its content and its consequences, is essential for understanding much of the polarization in American popular discourse’.Footnote ¹⁴ In subsequent studies, they examine more specifically the contest for moral authority between science and Christian nationalism, a crucial factor for understanding the spread of the COVID-19 pandemic in the United States. By understanding the perspective of Christian nationalists and seeking partnerships with local leaders, public health advocates can create educational campaigns that may better appeal to an otherwise non-compliant population.

People who believe that the USA should be a Christian nation, a position which politicizes religion and theologizes politics, often regard science as a competing authority that cannot be accommodated within the Christian nationalist worldview. Examining why Christian nationalism often corresponds with a rejection of science, sociologists Joseph Baker, Stephen Perry and Andrew Whitehead find: ‘Because it provides an alternative source of moral authority beyond divine revelation and, consequently, different narratives regarding human origins, social organization, and humanity's relationship to nature, institutional science is perceived as a threat to the supremacy of Christianity as the moral authority in the public sphere.’Footnote ¹⁵ Christian nationalist concern with the source of moral authority is not common to all religious people. As Whitehead and Perry identify, liberal Protestants are much more likely to find ways to accommodate religious beliefs and scientific knowledge as dual sources for understanding the world. Many Christian nationalists, however, dispute scientific authority in ‘an effort to (re)assert the dominant moral and cultural authority of a white, native-born, straight, masculine, and Christian social order’.Footnote ¹⁶ Their political, social and religious positions combine to combat both science and scientists, whom they view as detracting from the proper ordering of the USA. It is this stance that has created a significant backlash against public health measures in the current crisis.

While the greatest amount of public opposition between science and Christian nationalism in the past century has concerned evolution and climate change, the disjunction between these two sources of information has also had major consequences for determining responses to the COVID-19 pandemic. Suspicion about science has manifested in non-compliance with public health mandates requiring masking and social distancing as protective measures against COVID-19.Footnote ¹⁷ Ohio state representative Nino Vitale exemplified this position in a May 2020 Facebook post responding to masking mandates: ‘This is the greatest nation on earth founded on Judeo-Christian Principles. One of those principles is that we are all created in the image and likeness of God. That image is seen the most by our face. I will not wear a mask.’Footnote ¹⁸ In an article which focused on the behaviours of Christian nationalists during the current pandemic, Whitehead and Perry partnered with psychologist Joshua B. Grubbs to understand such responses to public health measures. Specifically, they argue that polls revealing ‘religious’ Americans as those most opposed to orders such as masking and social distancing are misleading, and that ‘Christian nationalism’ is a better predictor of distrust in scientific expertise.Footnote ¹⁹ Their study evaluates Christian nationalism as a predictor of the likelihood of undertaking incautious behaviours (attending large gatherings, shopping for non-essentials, eating inside restaurants) and ignoring precautionary recommendations (hand washing, mask wearing, decreased face touching). Their findings indicate that:

These results define a distinction between Christian nationalists and people who can more broadly be categorized as religious. In a webinar on the same topic, Whitehead and Perry shared additional results of their study. They found that rejectors of Christian nationalism were most likely to trust medical experts, scientists and the Centers for Disease Control and Prevention as the most reliable sources of information about COVID-19, while strong Christian nationalists most trusted Donald Trump, religious organizations and the Republican Party.Footnote ²¹ These behaviours and trusted sources further indicate how Christian nationalists view science as a challenge to their moral authority and provide the context for their newsworthy actions during the pandemic.

Although they are a minority, Christian nationalists have garnered a disproportionate number of news articles focused on their lack of compliance with public health orders in 2020 and 2021. At an April 2020 protest against COVID-19 precautionary restrictions in Michigan, a young white male held a sign that read: ‘Even Pharaoh freed slaves during a plague.’Footnote ²² This sign combines a biblical narrative with then-president Donald Trump's calls for governors to rescind state restrictions on business operations. It is emblematic of Christian nationalists’ methods of depicting public health orders as restrictions of civil – and God-given – liberties. This ideology also appeared as churches across the country refused to comply with government shutdowns. Religious leaders whose churches remained open decried government-mandated cancellation of worship services as a violation of religious freedom,Footnote ²³ especially as shutdowns coincided with Holy Week and Easter Sunday, and because other organizations such as casinos were permitted to remain open.Footnote ²⁴ When Texas Governor Greg Abbott declared churches an essential service, and thus exempted from closures, Pastor Shetigho Nakpodia of Redeemer's Praise Church in San Antonio called him ‘the pastor of Texas’ and declared, ‘I believe he's a man of faith … Maybe that's what the Lord told him to do.’Footnote ²⁵ The assertion that government officials should prioritize religion epitomizes Christian nationalism, especially as many of the same voices condemned other officials who prioritized public health and science instead. In the Christian nationalist perspective, Governor Abbott, like the Pharaoh of the Hebrew Bible, set people free during a pandemic. With this action, he earned in their eyes a position somewhere below God and certainly above medical experts who would have everyone remain ‘enslaved’, as the protest sign asserted.

Refusal to cancel religious services and charitable operations was not confined to Christian nationalist circles, but also occurred among Catholics, for whom sacraments are crucial and cannot be performed remotely. Jewish and Muslim leaders similarly struggled with the decision, knowing that many community members rely on their synagogues and mosques for food or religious rituals.Footnote ²⁶ These concerns for the well-being of people who might go hungry without essential church services differ, however, from Christian nationalist challenges to the authority of public health authorities. Christian nationalist objections to shutdown orders seem to take two contrary paths: either Christians are God's chosen people and God will protect them from any harm, or the virus is not as bad as scientists claim and the government is just using it as an opportunity to suppress churches. Both beliefs lead to the defiance of public health orders and to the view that individual freedom of choice is more important than the societal protection of health.

This individualism may represent a shift with which public health authorities must reckon. While early knowledge of germ theory led to public health measures based on a widespread recognition that disease prevention could protect all citizens, some citizens have come to deny the authority of the underlying science and to prioritize individual liberties. Nicole Bryant, a member of Life Tabernacle Church, which remained open in defiance of Louisiana's closure orders, demonstrates this view:

In this mythologized version of United States history, Christian nationalists argue that religious freedom, interpreted as the right to unrestricted practice of religious beliefs, originally predominated, but that it has been eroded in recent years. The question is one of moral authority: who has the right to determine how people act in public settings? In this understanding, the medical community, urging groups to stay at home, is pitted against religious communities, who advocate God's protection and the value of gathering for worship. For Christian nationalists, if the choice is between faith in God and fear of death, they know where they stand.

In addition to the rhetoric of individual freedom, race has played an important role in the present pandemic. Throughout their research on Christian nationalists, Perry and Whitehead identify ‘Christian nationalists’ as white, native-born, culturally Christian people. However, people of colour have not only contracted COVID-19 in disproportionate numbers but have also died of it at higher rates.Footnote ²⁸ Individual choices have communal consequences, especially for people who are more likely to occupy service-sector and essential-worker roles due to centuries of systemic racial and economic inequalities. Much like Christian nationalists, many Black communities also distrust medical information.Footnote ²⁹ However, for Black communities, this distrust results not from a perception of contested moral authority, but from centuries of unethical experimentation on Black bodies, from the times of slaveryFootnote ³⁰ through the USPHS-run Tuskegee and Guatemala syphilis studies.Footnote ³¹ Although their distrust results from different experiences and ideologies, and recognizing that Christian nationalist communities have refused to comply with public health standards at greater rates than Black communities, both groups demonstrate the need for the USPHS to intervene and to work to build greater trust in order to serve the American population more fully. The next two sections will explore historical moments when bridges were built between these communities and public health, exemplifying opportunities for future partnerships.

Bridging the Gap between Religion and Medicine

Community partnerships and educational campaigns have historically instigated a conversion in lifestyle that makes for healthier populations. The bacteriological revolution, the advent of birth control and the explosion of the human immunodeficiency virus (HIV) mark the beginning, middle and end of arguably the most scientifically revolutionary century in human history. Each of these shifts also required a rapid public health response to educate the population as new information became available. Although often driven by private citizens, interventions at these three moments in medical history can serve as models for how the USPHS might respond to increasing distrust in science and medicine in the twenty-first century. These models demonstrate how to build relationships with hesitant communities and ensure greater compliance with future public health measures.

The bacteriological revolution at the turn of the twentieth century was marked by the discovery of several disease-causing vectors and the realization that disease does not discriminate on the basis of race, religion, social class or any of the other factors that people perceive as setting themselves apart from others. In The Gospel of Germs (1998), historian Nancy Tomes explores how the American response to the early-twentieth-century ‘germ panic’ resulted in an obsession with hygiene invading United States culture. While analysing the ‘educational crusades that brought women and men from all walks of life to believe in the existence of germs and to alter fundamental aspects of their daily lives to avoid them’, Tomes identifies that ‘reformers of many stripes promoted this code of behavior with religious fervor and made believing in germs part of the credo of modern living’.Footnote ³² The bacteriological revolution provides an example of how both individual beliefs and societal consensus on proper public health behaviours may change, offering a potential remedy for the challenges of disinformation and the assertion of moral authority that underlie public health non-compliance among Christian nationalists.

Once scientists had identified bacteria and viruses as disease-causing agents, this understanding had to reach the wider public before social behaviour could change substantially. Although originally based on the miasmic theory of disease, which posited that sickness could spread through tainted vapours in the air, many Americans believed that cleanliness was a mark of ‘gentility and politeness’ among the upper classes, which then trickled down to middle-class people living in urban hotspots of disease.Footnote ³³ Once diseases began to spread even in these socially powerful circles, however, upper-class Americans quickly grasped the burgeoning bacteriological theory as an explanation, accepting it even before many in the medical community. Part of the reason germ theory caught on so easily, Tomes argues, was that Americans, as a largely religious people, ‘had been conditioned to believe in an “invisible world” dominated by unseen forces that held the power of life and death’.Footnote ³⁴ Even once scientific researchers identified the invisible agents of disease, people still regarded them with the mix of wonder and fear often reserved for God. They approached information dissemination about germs and bacteria and associated behavioural reform as they had for centuries approached gospel missionizing and ritual activity.

Because effective treatments for diseases did not yet exist, prevention was the best method of ensuring health, and public health campaigns swept through cities. The expansion of public health from 1890 to 1930 occurred for two reasons: first, people came to believe that the government should be responsible for societal well-being through the management of sewage, water supply and food inspection; and second, people recognized that individuals and households were responsible for the policing of ‘seemingly innocuous behaviors’, like hand-washing and refraining from public expectoration.Footnote ³⁵ One way these beliefs spread was through advertising and entrepreneurship, as new products hit the markets promising to protect families from common household germs. A second way they circulated was through union members and African American leaders who took on crucial roles in the tuberculosis crusade, because these two communities were disproportionately affected by what was then known as ‘consumption’. A third way information spread was through the education of women in ‘domestic science’ classes and missionary nursing training. As the family members typically most involved in the private sphere, wives and mothers had long run the home and taken a leading role in the religious education of the children. With the advent of germ theory, women took on the extra burden of sanitizing the home against disease vectors, but they also found new careers outside the home as nurses, physicians and home economics teachers.Footnote ³⁶ By appealing to the American public at large through advertisements, but also to smaller subsets by addressing their specific concerns, public health crusaders in the early twentieth century enacted a sea change in American beliefs and habits.

As understanding of bacteriology grew widespread, it developed into what Tomes calls the ‘gospel of germs’, an almost religious ‘belief that microbes cause disease and can be avoided by certain protective behaviors’.Footnote ³⁷ These behaviours included installing easily sanitized porcelain toilets in the home, preparing food more cautiously, sneezing and coughing into a handkerchief or the elbow, and campaigning against public expectoration. Advertisements in magazines such as Good Housekeeping and Harper's Bazaar, radio spots, and government mandates about food preparation in restaurants and sanitation practices in hotels combined to make Americans more sanitary and aware of disease. Many of these habits that were new in the early twentieth century – such as washing hands after using the restroom or before eating, keeping raw meat separate from cooked, and using white sheets in hotels because they are more easily washed with bleach – are now standard and unquestioned parts of modern life. Normalizing sanitary practices has not only changed American lifestyles but has also decreased the spread of infectious diseases over time.

Tomes argues that there was a lull in germ consciousness after the incidence of chronic illnesses overtook that of infectious diseases in the 1950s, following the dissemination of antibiotics and the poliovirus vaccine. However, writing in 1998, she contends that ‘the gospel of germs has taken on new relevance since 1980’.Footnote ³⁸ When HIV-AIDS began killing otherwise healthy young men, initially to the bafflement of medical professionals, a new germ panic reached the public. Education campaigns were again used, but this time to assure the population that neither handshakes nor nearby sneezes could spread the debilitating new virus. As the fear of AIDS began to abate in the early twenty-first century, however, it seems that germ consciousness has reached a new low. With a widespread view that COVID-19 is not as bad as scientists and the government have made it seem, the United States needs to target its public health information campaign concerning social behaviours such as masking and physical distancing more effectively to hesitant populations. The ‘gospel of germs’ mindset that was new in 1920 and faded by 2000 has again become necessary in the 2020s, and the way bacteriology entered daily life a century ago provides a model for the present.

However, information campaigns alone no longer seem as effective as they were a century ago. Because most Americans have ready access to the internet, misinformation and disinformation spread more easily than information from legitimate sources such as scientific researchers and the Centers for Disease Control and Prevention (CDC), which are bound by caution and protocols that delay the finding and publicization of research results. After a 2012 outbreak of salmonella, the CDC recognized that this delay could foster disinformation and distrust.Footnote ³⁹ Despite this retrospective recognition of the drawbacks of working in accordance with the scientific timeline, the CDC proceeded cautiously in the first few months of 2020, and disinformation often dominated.Footnote ⁴⁰ Between the information delay and the perceived challenge to religion's moral authority described above, the COVID-19 pandemic appears to have come at a challenging time for moderating social behaviours. Historically, in cases when disinformation and distrust have prevailed, partnerships between public health activists and community leaders have proved effective in combating these trends, as can be shown by the case of Margaret Sanger's birth control clinic in Harlem.

When Margaret Sanger (1879–1966) secured funding to open a birth control clinic in Harlem in 1930, she ensured that the clinic would be run under an advisory board consisting of Black community leaders. Sanger realized that working closely with Black leaders, including ministers, could help instil trust in medical and public health measures. The board at the Harlem clinic included social worker James Hubert; May Chinn, the only Black female doctor in Harlem; Baptist pastor William Lloyd Imes; and representatives from the National Association of Colored Graduate Nurses, Harlem Hospital and the National Urban League.Footnote ⁴¹ W. E. B. Du Bois’ magazine The Crisis publicized the Harlem clinic, and the Revd Dr Martin Luther King Jr and Coretta Scott King later commended Sanger's work there as well.Footnote ⁴² Mutual relationships underpinned this initiative: while Sanger recognized Black community leaders as crucial for spreading public health initiatives among distrustful populations, Black community leaders recognized Sanger's desire to help people control their bodies and in turn their futures. Working closely with one another enabled shared goal-setting and ultimately led to a healthier population.

In recent years, Planned Parenthood has distanced itself from the legacy of its founder, largely due to Sanger's advocacy of eugenics at home and abroad.Footnote ⁴³ Historians, medical doctors and liberal and conservative activists have rightly raised concerns about her beliefs in selective breeding and white maternalism,Footnote ⁴⁴ and this article in no way wishes to defend or justify her beliefs or those policies. Rather, the lesson the USPHS may draw from Sanger's work focuses narrowly on her partnerships with community leaders as exemplified through the Harlem clinic's advisory board. Local leaders need to be involved in shaping institutions and determining policies that affect them. This is especially true in communities which preserve strict divisions between insiders and outsiders, whether due to historical wrongs or to a contest for moral authority. Public health partnerships which intentionally include leaders of religious and other organizations can help spread accurate information, instil trust and bridge divides, helping to accomplish mutual goals of health and wellness.

A third example of public health advocacy crossing the religious-scientific divide came through the response of the evangelical Surgeon General C. Everett Koop (1916–2013) to the AIDS crisis in the 1980s. Anthony Petro argues in After the Wrath of God: AIDS, Sexuality, and American Religion (2015) that AIDS was not just a social and political issue, but also a moral and religious challenge that required a novel approach to sexual morality. When the Reagan administration appointed Koop as Surgeon General in 1982, AIDS cases had only appeared in the United States within the past year, and it was still known as ‘gay-related immune deficiency’ (GRID). An evangelical Christian and a paediatric surgeon, Koop had previously published a book making a case against abortion and euthanasia, aimed specifically at Christian audiences, and contributed to a ‘Christian Manifesto, which called for greater evangelical participation in political matters like abortion’.Footnote ⁴⁵ Although the media decried his lack of public health experience, Koop became the nation's guide through one of the most devastating and controversial diseases in American history. While many religious people and even physicians in the last two decades of the twentieth century viewed AIDS as a divine punishment for immoral behaviour and homosexuality, the USPHS under the guidance of Surgeon General Koop responded with an aggressive education campaign designed to encourage the public to reserve judgement, keep them updated on new developments in understanding HIV and ultimately stop the spread of the virus.

As already discussed, under a conservative administration in the 1980s, the United States government had been scaling back health care and medical research funding, leaving the country ill prepared for as sudden and horrific a virus as HIV proved to be. Although prevented from speaking publicly about AIDS until Reagan's second term, Koop took charge of the Executive Task Force on AIDS in 1985 and made it one of the administration's top priorities.Footnote ⁴⁶ Recognizing that ‘I am the surgeon general of the heterosexuals and the homosexuals, of the young and the old, of the moral [and] the immoral’,Footnote ⁴⁷ Koop enacted a campaign for sexual education and condom use that ‘surprised his conservative friends and liberal opponents alike, turning many of the former against him while garnering praise from the latter’.Footnote ⁴⁸ Although the campaign attracted a degree of conservative backlash, Koop intended his AIDS reports and other educational publications to appeal broadly to morality.

Recognizing the need for mass public education, Koop parsed his official report on AIDS into a six-page brochure that was mailed to nearly every American household. The pamphlet both corrected misinformation that the virus could spread through casual contact and detailed safe sexual practices that would prevent the virus from spreading.Footnote ⁴⁹ Koop balanced moral appeals for abstinence and monogamy with an educational campaign that went beyond his own religious views, attempting to work with both religious and secular, conservative and liberal, straight and gay people to achieve a healthier and more informed population. He followed the pamphlet with what Petro describes as ‘a lecture circuit among religious groups … that increasingly blurred the lines between the gospel of condoms and the gospel of Jesus, as the surgeon general's sphere of influence came to encompass that of the itinerant public health preacher’.Footnote ⁵⁰ Throughout the AIDS crisis, Koop worked with the gay community and with religious conservatives nationwide. For each audience, he shifted his language slightly to appeal to its worldview, yet he consistently maintained the message that everyone was an important player in the common struggle against AIDS.

Like Sanger, Koop is not a perfect model for public health advocacy. Liberals have criticized the way that his Christian morality often crept into his public health rhetoric, making certain groups feel ostracized or judged. Others have argued that despite his religious perspective, Koop viewed himself as responsible for the health of the entire American population. As former Surgeon General David Satcher eulogized, ‘[Koop] did not abandon his Christian principles, but he put the principle of love of one's fellow man above his judgment of them’.Footnote ⁵¹ Koop knew how to speak to evangelicals on their own terms, and he also recognized how crucial education was to alleviate fear and prevent the spread of a deadly virus. These lessons speak to the present as Christian nationalists fear that science will overtake their moral authority and advocate for individualistic civil rights in the midst of a pandemic that has infected over forty-five million Americans. Language, morality and education matter as much in the 2020s as they did in the 1980s.

A Proposal for the Present

Historians often worry how involved they should be in the present. I am not a sociologist, a politician or a healthcare worker, but as an American historian who studies the intersection of religion and medicine and now finds herself in the middle of a pandemic, I feel a responsibility to note how the past can help shape our present. While policy implementation should be left to the experts, the final section of this article offers a historically informed model for how community partnerships and attention to language and education may enable the USPHS to ensure greater compliance with guidelines that can save lives now and as the COVID-19 vaccines are distributed.

The US Public Health Service is required to instruct the American public at large, offering guidance to a diverse population divided by region, race, education and religion. In the digital age, educational campaigns may seem moot, as nearly everyone has access to a wealth of information. However, because people tend to accept the information that supports their beliefs, rather than seeking scientific truth, there is still a need for public health advocates to increase the effectiveness of their interventions by engaging community leaders and tailoring educational campaign language to their audiences. Yet perhaps a greater issue, especially for populations where infection rates are high, such as among Christian nationalists and Black communities, is trust. Whether these populations view the scientific community as an affront to the moral authority of other sources such as the Bible, or as unreliable due to a historical record of violence and deception towards them, overcoming such breakdowns in trust requires significant work and creative engagement. Through fostering community partnerships and emphasizing shared goals and values, the USPHS could take a proactive, rather than reactive, stance on health issues. This could result in greater compliance with guidelines and vaccinations, and thus in healthier populations, as everyone plays a role in keeping their neighbours safe.

Academics regularly call for the USPHS to be more proactive in facilitating community partnerships in times of relative calm. In 2013, the biomedical scientist and religious studies scholar Jeff Levin published an article advocating for partnerships between public health agencies and religious communities. Levin argues that these partnerships could not only enable better resource sharing, but would also make sense because ‘(a) these sectors share mutual concerns, (b) the tenets of many religions favor healthy living, (c) congregations provide tangible and emotional resources for health, and (d) religious organizations are able to foster participation among people otherwise hard to reach’.Footnote ⁵² Recognizing that there may be limitations and barriers to this partnership, both from the public health and the religious perspectives, Levin maintains that public health and religious communities share values. A partnership that emphasizes these commonalities would enable preventative measures, social justice and healthier populations both locally and globally.

A group of evangelical doctors has taken this mission to heart during the COVID-19 pandemic. The Christian Medical & Dental Associations (CMDA), an organization whose mission ‘is to glorify God by caring for all people and advancing Biblical principles of healthcare within the Church and throughout the world’, has issued guidelines for churches to reopen safely, and a plea for Christians to love their neighbours by following public health guidelines.Footnote ⁵³ Anchoring its ‘Plea to our Churches’ in love rather than fear, the CMDA reflects the dichotomy Christian nationalists have constructed between the love of God and the fear of death. They also echo the language Surgeon General Koop used when appealing to a similar population. Citing Romans and 2 Corinthians, the CMDA asserts: ‘Restricting meeting for a season is not about fear of contracting the virus ourselves. Rather, it is about loving one another and minimizing risk to the vulnerable around us.’Footnote ⁵⁴ Less than two weeks after the article was published, the comment section had divided between those praising the CMDA and saying they would forward it to their church and those advocating conspiracy theories about masking and the government.Footnote ⁵⁵ Although this article and the positive responses to it demonstrate the benefits of a partnership between religious community leaders and public health advocates, the fact that it was not published until November 2020, combined with the spread of disinformation since March 2020, highlights the need to foster these partnerships before crises strike. Establishing effective partnerships before the pandemic, which requires regular funding outside of crises, might have permitted earlier dissemination of information, and thus prevention of disinformation. Nonetheless, it is better to form these relationships now than not at all.

In addition to partnerships with religious community leaders, public health language and communication are crucial to how the pandemic will continue to be regarded, and to how the USPHS can prepare for future moments of crisis and calm. Most importantly, educational campaigns should follow the model of the bacteriological revolution and Surgeon General Koop's response to AIDS. Quick and public response to misinformation and disinformation, along with repetition of scientifically based facts, should circulate to every household, and these days also across the internet. A study of the El Paso Morning Times during the 1918 influenza pandemic reveals that although most media downplayed the virus to prevent alarm, newspapers also highlighted the lives of the dead, circulated the USPHS's preventative guidelines and recognized mutual support and altruism among the population.Footnote ⁵⁶ Some media outlets have followed suit today, as exemplified by the New York Times making all articles on the pandemic open access, or by famous journalists such as Katie Couric featuring the ‘Faces of COVID-19’ and bringing life to the numbing number of dead each day.Footnote ⁵⁷ What is needed is a more aggressive educational campaign by the USPHS and the Surgeon General that draws on the themes of historical public health campaigns as well as current news media. Furthermore, the USPHS, which has commissioned an increasing variety of healthcare professionals and academic scientists in the past century,Footnote ⁵⁸ should consider enlisting both communications professionals and humanities academics. This expansion of the range of expertise would not only foster better informational campaigns, but also has the potential to resolve tensions and prevent further strife between the USPHS and racial and religious minorities.Footnote ⁵⁹

The successful implementation of a COVID-19 vaccine programme also requires each of the above strategies. Republicans and white evangelicals on the one hand and Black Americans on the other are the two groups most hesitant about receiving a vaccine.Footnote ⁶⁰ Yet they are also two of the groups most at risk of contracting the virus, the former due to engaging in risky behaviours and the latter due to an often precarious social position. Although vaccinating hesitant populations remains a challenge at the time of writing in October 2021, continued implementation is essential for stopping the spread of the virus and minimizing infection and death rates among vulnerable populations. As they have done historically, public health advocates must combine community partnerships, educational campaigns and tailored language to ensure compliance, trust and healthier populations going forward.

Over its history, the United States Public Health Service has witnessed and responded to every crisis from smallpox to coronavirus, and every endemic issue from venereal disease to heart disease. Regular challenges due to lack of funding or distrust among religious and racial minorities have hampered its efficacy. It is only recently that Christian nationalists have come to view science as an affront to the moral authority of the Bible, and they have subsequently disregarded and disobeyed public health orders designed to slow the spread of COVID-19. Historical examples of how public health advocates partnered with community leaders, implemented educational campaigns and tailored language to ensure better compliance offer important models for the USPHS to consider during the present pandemic and in those still to come. It should especially hone these skills in times of calm going forward, aiming to be more proactive rather than reactive, and thus be better prepared for the inevitable next crisis. For the current crisis, however, a change in mindset and behaviour will be crucial as the pandemic continues to show its tragic power. Rather than masks versus God and country, the USPHS should foster strategies that shift American culture to believing in masking – or being vaccinated – for neighbour, country and God.