Accountability, Resistance, and Dissent in Public Health
EDITORIAL, Vol 28/1, 2026, pp. 41-45 PDF
Joseph J. Amon and Carmel Williams
In his 1970 book Exit, Voice, and Loyalty, economist Albert Hirschman observed that “under any economic, social, or political system, individuals, business firms, and organizations in general are subject to lapses from efficient, rational, law-abiding, virtuous, or otherwise functional behavior.”[1] He argued that society must be able to “marshal from within itself forces which will make as many of the faltering actors as possible revert to the behavior required for its proper functioning.”[2]
Today, as public health institutions face unprecedented attacks and the very foundations of evidence-based medicine are undermined by political interference, Hirschman’s framework offers critical insights into how public health professionals must respond when their institutions are unable to fulfill their fundamental duty to protect population health.
The courage to expose injustice
The history of public health is marked by individuals who refused to remain silent in the face of institutional wrongdoing. John Snow’s removal of the Broad Street water pump handle in London in 1854 is taught to all public health students as an example of causal analysis and decisive action to end a cholera epidemic. Less often discussed is the fact that politicians ordered the pump handle’s return and that periodic epidemics continued—a perhaps even more important lesson for students, and one reason why schools of public health teach human rights, policy, and advocacy alongside epidemiology and biostatistics.[3]
Unfortunately, the challenges faced by Snow are common among public health whistleblowers, who often face severe and sustained attacks when challenging authorities, whether government or private companies. For example, Dr. Jeffrey Wigand revealed in 1996 that Brown & Williamson, a major tobacco company, had intentionally manipulated its tobacco blend with chemicals such as ammonia to increase the addictive effects of nicotine.[4] His disclosures were instrumental in the case brought by state attorneys general against tobacco manufacturers, leading to major regulatory changes and historic financial settlements. But the personal cost was devastating—Wigand faced intimidation, legal threats, and character assassination.
In December 2019, Dr. Li Wenliang, an ophthalmologist, warned colleagues about a new SARS-like virus circulating in Wuhan, China. Rather than receiving support to fully investigate his early warning, Dr. Li was detained and reprimanded by Chinese authorities and forced to sign a statement acknowledging that he had made false statements that disturbed the public order. Dr. Li later contracted COVID-19 while treating patients and died in February 2020. His death became a rallying point for demands for freedom of expression in China, but only after his silencing contributed to delays in the global response that cost countless lives.[5]
Attacks on health researchers who are at odds with powerful interests often follow a predictable pattern that can include allegations of scientific misconduct, media campaigns, and administrative and legal assaults. The consequences for whistleblowers can be severe. Research shows that 84% of whistleblowers experience severe depression or anxiety symptoms, 84% report feelings of isolation or powerlessness, 78% develop distrust of others, 69% experience declining physical health, 66% suffer severe financial decline, and 53% report problems with family relations.[6]
Retaliation tactics can be sophisticated and multifaceted, attacking the scientific integrity of whistleblowers and undermining their reputation and accomplishments. Government persecution of public health professionals—especially in the face of an epidemic outbreak—represents a particularly dangerous threat to the right to health because delay can increase disease spread. Covering up the failures of disease surveillance systems and gaps in protection for vulnerable populations can prevent the implementation of effective strategies. In Ecuador, researchers who raised concerns about the H5N1 influenza outbreak faced disciplinary action.[7] In Brazil, as well as many other countries, Ministry of Health and frontline health workers during the COVID-19 pandemic faced bullying, harassment, threats, and defamation from their own governments.[8]
In the United States, the scale of government attacks on public health since President Trump has returned to office has been alarming, including the dismantling of the United States Agency for International Development (USAID), the gutting of the National Institute for Occupational Safety and Health, the termination of federal grants, reductions in research funding, bans on gender-affirming care, and the removal of health information from government websites.[9] Trump’s appointed public health leaders have embraced conspiracy theories, undermined confidence in scientists and public health research, and criticized universities as elitist institutions, contributing to the fracturing of public trust in biomedical advances and public health accomplishments.[10]
This is a situation different from retaliation against a single whistleblower. It is a political and ideological war against science and against social welfare, and quite clearly an example of what Hirschman characterized as a “lapse” from “rational, law-abiding, virtuous, or otherwise functional behavior.”
So how can the public health and human rights community “marshal from within itself” the forces required to “make as many of the faltering actors as possible revert” to sound science and respect for human rights? How does Hirschman’s framework of “exit, voice, loyalty” inform the moment we are in, where loyalty does not mean allegiance to protect rights, where voice is stifled and free speech is threatened, and where exit—and abandoning a mission to advance health and rights—is a difficult, last resort?
The ethical imperative for dissent
In this moment, when claims are made that vaccines are dangerous, access to sexual and reproductive health is restricted, gender-affirming care is contested, budgets are slashed, environmental regulations are gutted, and trust in public health authorities is diminishing, what does resistance and dissent look like?
Examples of resistance—or exit—abound. In August 2025, Susan Monarez, director of the Centers for Disease Control and Prevention (CDC), was fired after refusing to follow what her lawyers characterized as unscientific directives from Health and Human Services Secretary Robert F. Kennedy Jr., triggering a wave of high-level resignations, including those of Chief Medical Officer Dr. Debra Houry, Dr. Daniel Jernigan (head of the National Center for Emerging and Zoonotic Infectious Diseases), and Dr. Demetre Daskalakis (head of the National Center for Immunization and Respiratory Diseases).[11] Resignations of top public health leaders represent more than individual career changes—they constitute a hemorrhaging of institutional expertise and leadership at precisely the moment when evidence-based public health guidance is most needed. Each departure, forced or voluntary, removes decades of experience and creates gaps in the systems designed to protect population health.
The impact was felt not only at the top. President Trump’s fiscal year 2026 budget proposed a 50% cut in the CDC’s funding, slashing nearly five billion dollars. Chronic disease prevention funding was cut, along with US$12 billion for public health programs to states. Funding for disease surveillance and vaccines for children and uninsured adults were similarly targeted. Resistance has also come from litigation, filed by organizations such as Public Citizen, the American Public Health Association, the AIDS Vaccine Advocacy Coalition, and the Global Health Council. Outcomes have been mixed. While in some cases the courts have acted as a safeguard for the rule of law, the process is slow and often met with government appeals.
Nearly all of USAID’s 16,000 employees were laid off. An estimated 280,000 contractors, partners, and local hires worldwide lost their jobs. The Environmental Protection Agency, whose mission is critical to the protection of public health, was also targeted by the Trump administration and forced to roll back climate change and clean air protections. Post-exit, using their voice, there are now over 750 former Environmental Protection Agency staff in the Environmental Protection Network, volunteering their time and expertise to develop science-based policies to protect the environment and to defend agency staff against harassment and intimidation.[12]
Using exit, voice, and loyalty to advance human rights
Jonathan Mann, a pioneering voice in public health and human rights, and the first editor of this journal, engaged in all three strategies of Exit, Voice, and Loyalty in his work responding to the HIV pandemic. As the director of the Global Program on AIDS at the World Health Organization (WHO), he spoke out in the 1990s about the mishandling of the HIV pandemic by many governments and the decline of public health, ascribing the field’s failures to an ongoing “reluctance and inability to work directly on the societal roots of health problems.”[13]
After clashing with the WHO Director-General Hiroshi Nakajima, Mann left WHO, and he again used voice to challenge those working within the field of public health, writing that “while expanding enormously its scientific capacity to measure, public health may have lost clarity about why it is measuring, and to what purpose?”[14] In essence, Mann was appealing to the loyalty of public health practitioners and to the power of their tools, but exhorting them to apply those tools to realize the right to health for all.
Time moves on; 30 years later, WHO is also expressing dissent from the current anti-science trend with its choice of this year’s theme: “Together for health. Stand with science.”[15] The fight now is not just to work on the roots of health problems but to maintain a workforce and resources that can undertake such scientific pursuits. WHO calls on its global voice to fight misinformation and to “rebuild trust in science and public health.”[16]
United Nations High Commissioner for Human Rights Volker Türk told the Human Rights Council in February that the response needed at this time requires “calling out violations of international law, regardless of the perpetrators.”[17] In stating that the rhetoric of some leaders reveals a belief that they are above the law, including the United Nations Charter, and in accusing them of spreading disinformation to distract, silence, and marginalize, he used “voice.”
Health and Human Rights continues Mann’s legacy, stands with science, and fights the silencing; it offers authors a publishing platform that recognizes the importance of diverse voices advocating for a public health approach that is grounded in human rights and dignity and that is not simply technocratic but transformative.
This issue, June 2026, comes at a time of global anxiety over ongoing conflict, attacks on health facilities, discrimination against minority groups, regression on sexual and reproductive health, infectious disease outbreaks (including a resurgence of measles in the United States and Ebola in Uganda and the Democratic Republic of the Congo), mental health crises, environmental catastrophes and disaster-related illness and injuries, and a widely acknowledged rollback of human rights and support for the institutions upon which accountability mechanisms depend.
The right to health cannot be realized without robust protections for those who expose threats to population health.[18] The papers in this issue highlight the importance of collective action and professional solidarity as the struggle for health rights continues around the globe.
As Hirschman understood, institutions fail. They deviate from their stated purposes, they become captured by interests antithetical to their missions, they sacrifice principle for political expediency. What determines whether these failures lead to institutional decay or renewal is whether there are individuals willing to speak out, to take personal risks to call institutions back to their core purposes, and to demand—whether through exit, voice, or loyalty—that the right to health be assured for all.
Joseph J. Amon, MSPH, PhD, is Desmond M. Tutu Professor in Public Health and Human Rights, director of the Center for Public Health and Human Rights, and a distinguished professor of the practice in the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States, and editor-in-chief of Health and Human Rights.
Carmel Williams, PhD, is the executive editor of Health and Human Rights.
Please address correspondence to Joseph J. Amon. Email: joe.amon@jhu.edu.
Competing interests: None declared.
Copyright © 2026 Amon and Williams. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/bync/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
References
[1] A. O. Hirschman, Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States (Harvard University Press, 1970).
[2] Ibid.
[3] G. Davey Smith, “Behind the Broad Street Pump: Aetiology, Epidemiology and Prevention of Cholera in Mid-19th Century Britain,” International Journal of Epidemiology 31/5 (2002).
[4] J. Wigand, “The Fight to Stub Out Tobacco,” Bulletin of the World Health Organization 90/9 (2012).
[5] E. Petersen, D. S. Hui, D. H. Hamer, et al., “Li Wenliang, A Face to the Frontline Healthcare Worker. The First Doctor to Notify the Emergence of the SARS-CoV-2, (COVID-19), Outbreak,” International Journal of Infectious Diseases 93 (2020).
[6] P. G. van der Velden, M. Pecoraro, M. S. Houwerzijl, et al., “Mental Health Problems Among Whistleblowers: A Comparative Study,” Psychological Reports 122/2 (2019).
[7] E. Ortiz-Prado, J. S. Izquierdo-Condoy, M. A. Vasconez-Gonzalez, et al., “Upholding Academic Freedom: A Call to Protect Freedom of Expression and Science in Ecuador and Beyond,” Frontiers in Public Health 11 (2023).
[8] J. Paulo Roberto da Silva, P. Porto, M. C. Rocha, and E. R. Tamaki, “Women and Working in Healthcare During the COVID-19 Pandemic in Brazil: Bullying of Colleagues,” Globalization and Health 19/1 (2023); M. Razafindrakoto, F. Roubaud, M. R. Castilho, et al., “Investigating the ‘Bolsonaro Effect’ on the Spread of the COVID-19 Pandemic: An Empirical Analysis of Observational Data in Brazil,” PLOS One 18/19 (2024).
[9] J. J. Amon, “Politicized Science and Attacks on Public Health,” Health and Human Rights 27/2 (2025); A. E. Yamin, E. J. Lengle, and G. Gonsalves, “Building a Resistance to US Assaults on Public Health,” Lancet 406/10499 (2025).
[10] Amon (see note 9).
[11] S. Soucheray, “CDC Director Fired After She ‘Refused to Rubber-Stamp’ Kennedy’s Vaccine Directives” Center for Infectious Disease Research & Policy Research and Innovation Office, University of Minnesota (August 29, 2025), https://www.cidrap.umn.edu/public-health/cdc-director-fired-after-she-refused-rubber-stamp-kennedys-vaccine-directives.
[12] Environmental Protection Network, “Our Work,” https://www.environmentalprotectionnetwork.org/our-work.
[13] J. M. Mann, “Society and Public Health: Crisis and Rebirth,” Western Journal of Medicine 169/2 (1998).
[14] J. Mann, “Human Rights and the New Public Health,” Health and Human Rights 1/3 (1995), p. 233.
[15] World Health Organization, “World Health Day 2026: Together for Health. Stand with Science” (April 7, 2026), https://www.who.int/news-room/events/detail/2026/04/07/default-calendar/world-health-day-2026-together-for-health-stand-with-science.
[16] Ibid.
[17] Office of the United Nations High Commissioner for Human Rights, “High Commissioner Türk Opens the Human Rights Council: People’s Pursuit of Dignity, Equality, and Justice Is Unshakeable” (February 23, 2026), https://www.ohchr.org/en/statements-and-speeches/2026/02/high-commissioner-turk-opens-human-rights-council-peoples-pursuit.
[18] Amon (see note 9).