Although the pandemic now resides mostly in our memories, the discourse on public and personal health is forever changed by it. Who should get to make decisions about vaccine requirements, nutrition, reproductive rights, and more? Individuals, or the government? And if the government is to be involved, how much control should they have?
Dr. Barbara Spivak is a primary care physician practicing in Watertown, Massachusetts at Mount Auburn Medical Associates. She was the former President and Chairperson of the Board of the Mount Auburn Cambridge Independent Practice Association (MACIPA) and past President of the Massachusetts Medical Society. Spivak is also a panelist in the Community Conversation “Our bodies, whose rules? Government and individuals’ roles in personal and public health,” co-hosted by the Lexington Lyceum and The Lexington Observer at the Lexington Community Center on Oct. 21.
The following interview with Dr. Spivak touches on the topic of government mandates, declining trust in scientific institutions, and what role local communities can play in bridging the distance between government and regular people.
Note that these are Spivak’s personal opinions, and in no way reflects the views or opinions of the organizations that she is involved in. This interview has been edited for length and clarity
To begin, would you like to tell us about yourself and what you’ve worked on in the past?
I am primarily a primary care doctor in Watertown, where I’ve practiced for over 40 years, and affiliated with Mount Auburn hospital. I’m a past president of the Massachusetts Medical Society and I do a lot of advocacy work around two main areas. One is around quality measurement, because I believe that in healthcare, it’s really important to measure the quality of what we do so we know we’re doing right by our patients. I’ve also been an advocate for primary care, so I’m currently on a primary care task force that the state has set up to try to solve the primary care crisis in the state.
When you say the primary care crisis, could you expand on what that is?
We do not have enough clinicians in our country to provide the primary care that our communities need. In Massachusetts in particular, if you look at the number of physicians that we have in the state, we have a lot of physicians who are doing research, teaching, and doing innovative work, but if you look at the number of clinicians doing primary care, we don’t have enough for everybody in the state to have a primary care doctor.
If you call today to see a primary care doctor, you can wait months if you’re a new patient. The reality is that when you have less primary care, people don’t get acute care easily. Instead, they go to emergency rooms, which are much more expensive than going to a primary care doctor’s office. But not only do they not get acute care, their chronic care gets delayed and all of the screenings get delayed. So if you don’t screen for something and it gets diagnosed several years later at a more advanced stage, that’s not good care.
So we end up spending a lot of money in this country with much poorer results than some other economically well-developed European countries that spend less on health care and get much better results.
What do you think is the best way to strike a balance between the role of government and individual choice in public health?
That’s a difficult question because the reality is that every scenario is different. Imagine a child goes to the hospital with a curable illness, and the parents, for religious reasons, do not believe in medical treatment. What is the role of the government in taking care of that child versus the parents’ wish? Almost everyone would agree that that child, because they need protection, should get treated, and that the government has to take guardianship of that child and get the child well, because it’s a treatable, curable illness. Then, presumably, the family loves the child enough to take them back.
What is the role then, of the government in vaccinating children? If you’re sending your child to school, don’t you want all the other kids around you to be vaccinated? Now for the flu, most kids don’t die of the flu, but what about polio? If you’re not vaccinated against polio or measles, those are serious illnesses where kids not just may die, but have serious, lifelong consequences. If you are sending your child to school, you have a right to know that they’re safe.
As a public health person, I feel that all children need to be vaccinated no matter what, unless they have a medical reason not to be, because you’re putting other kids at risk. So do not allow religious exemptions, for example.
Many people seem to have lost trust in science and government institutions. Why do you think this trust has disintegrated over time?
I think part of what happened is that during the early COVID-19 years, the science was constantly changing. As a physician who was actively practicing during 2020-21, what we knew in week one was different from what we knew in week two. So people were being given different messages all the time — we were learning as we were doing.
Our goal was to produce a vaccine, test it, and then know that it’s safe. But during the COVID-19 era, we produced vaccines that were based in science, safe, but we really didn’t have time to do all the testing that [some people] thought was needed, and I think that created an environment of mistrust, especially among people who already distrusted the government. So we now have a group of people who are so mistrustful that they’re putting things out in the media where we have good science that just doesn’t support it.
I don’t think it personally matters whether you get your vaccines as a child at the same time or you wait a few months in between. I think that that is an irrelevant issue, as long as at some point you get the vaccine. But to not get vaccinated at all – look at what’s happened with measles. We have measles epidemics and children dying of it. We have children dying of it years later because they get the encephalitis that’s associated with it. So it’s not just the immediate death, it’s the long-term consequences.
How do you see the government’s role in public health changing in the future?
I think that the role of the government should always be to be a trusted source of the science so that people know what the science says and where opinions in the scientific community differ.
For example, you look at mammogram screening for breast cancer. There are many organizations that look at that, and they come up with slightly different recommendations because the science can be looked at in several ways. But everybody agrees that 50 and over, you should get mammograms. There are subtle differences between 40 and 50, and I think it’s the government’s role to make sure that people understand what the differences are, why there are slight differences, and ensure that screening is covered by health insurances. Without that kind of legislative push, it isn’t clear what insurance companies would do.
But I think the problem is so nuanced. What is the government’s role in a pandemic, in requiring that people be masked? And the reality is, do we have the right masks? Are the blue surgical screening masks enough? They might be enough in a situation where you’re walking past someone in the street, but are they enough if you’re sitting in a train for four hours next to someone? So I think the government’s role during a pandemic in protecting the individual versus the public is very nuanced, and each individual situation has to be looked at.
What role do you think local communities play in bridging this distance between the government and regular people?
That’s a really important question. And I think what’s really interesting and unfortunate is that one would think that each town or city usually has a Department of Public Health, but the resources that each town has in the state vary widely. So you look at a town like Cambridge, which has Cambridge Hospital in it; they have a very sophisticated and robust Department of Public Health. You look at other towns and they have a part-time person running the Department of Public Health, or one full-time person for the whole town.
What you can do with one person versus a robust department is entirely different. So one of the problems that we face is we don’t have a consistent resource at the local level for the state or federal government to say “we want local departments of Public Health to do A, B or C,” because the resources are not there.
One of the things we need to be thinking about is, how do we make those resources equal across the state? And then you can answer the question you asked, which is, what is the role of the Department of Public Health?
As a final takeaway, Spivak had this to say:
Every situation that pits the individual against the public must be looked at separately; always keeping in mind the science and understanding that every situation has many nuances that must be accounted for.