Public Health and Active Agency

"If I'm right and we can stop this thing, then, Lenny, you will have saved the lives of millions of registered voters."
--Dr Peter Venkman (Ghostbusters)

Public health problems are breeding grounds of active agency. Public health officials, and the politicians who they work with, are the agents. They are employed by citizen principals. The principals would like their public health agents to keep them safe from illness and disease while not overreacting and cause needless upset to everyday life.

Public health agents, however, have personal goals that may not align with those of their principals. For instance, public health agents generally prefer to remain employed, advance their careers, and garner recognition and prestige. Because the principals are unable to accurately monitor their agents' behavior all of the time, an 'agency problem' arises where public health officials might act in manners that are not in the best interests of the citizenry.

Now, suppose a potential threat to public health arises, like a novel new virus. Little is known about the virus early on. Infection rates, mortality rates. effects on particular demographic groups are uncertain. There is also a significant time lag between cause and effect, i.e., it takes time for the virus to spread and the consequences to become empirically understood.

Given the uncertainty of the situation, what are public health agents to do? How should they act today to best address a potential public health crisis in the future?

Imagine a 2x2 matrix. On the horizontal axis are two general responses for public health agents today: don't act (declare that there is no threat and do nothing), or act (declare that a public health threat exists and enact countermeasures).

On the vertical axis are two possible general futures: no significant public health threat occurs, or a significant public health threat occurs. Keep in mind that these are future outcomes. In the present, prospective outcomes are uncertain. Public health officials must act today on limited information.

Now, put on your public health official hat and consider your options. If you do nothing and no significant health threat occurs, then you will be perceived as sagely doing your job. You weighed the information available and prudently decided that declaring a public emergency and enacting countermeasures would have squandered economic resources responding to a false alarm. However, if you do nothing and a significant public health crisis does occur, then you will be chastised as incompetent and not doing your job--and perhaps blamed for many deaths. To most public health officials, this is a worst case scenario. Many people die plus you get fired (a.k.a. career risk).

On the other hand, if you act and no significant health threat occurs, you might be able to get away with it if you can convince your principals that the countermeasures that you enacted actually led to no significant outbreak of illness of disease. "No public health crisis occurred because we acted." Of course, there may be no way to prove that--but naysayers may not be able to disprove it either. If you act and a significant health crisis does occur, then you can take credit for reducing the severity of the effects. "It could have been a lot worse had we not acted." Even if many people die, you may be able to take credit for saving some lives.

It should be readily apparent that acting, i.e., declaring a public health crisis and implementing countermeasures, is favorable for public health agents regardless of subsequent outcome. Unlike not acting, which offers the unpleasant scenario of getting blamed/fired in the event that a crisis arises, acting presents public health agents with opportunity to advance their self interests regardless of outcome.

Acting, therefore, is the preferred choice, what game theorists refer to as a 'dominant strategy,' of public health officials.

It should also be clear that, in order to avoid being found out, public health agents will be prone to muddy the information waters--to make it difficult for principals to monitor the situation to accurately assess the public health risks on their own. For example, agents are likely to drag their feet on expediting vital biomedical studies of infection rates and other important factors, because data from such studies might reveal that officials had grossly overreacted to the situation.

Further, it is probably that public health agents will seek to perpetuate some measure of fear among their principals because the agents understand that a fearful state of mind impedes capacity for rational thought.

Uncertainty is the friend of public health agents. Maintaining conditions of uncertainty for as long as possible benefits them, and fosters conditions of active agency where officials pursue their own interests--perhaps to the detriment of their citizen principals.