Ross Silverman, the College of Public Health’s new associate dean of faculty affairs, began exploring the complexities of vaccine compliance and mandates long before the COVID-19 pandemic. An attorney who earned a dual law degree and master of public health at Boston University, Silverman has spent his career examining public health law and policy with an eye toward making them work better. He arrives at Temple from Indiana University, where he earned his undergraduate degree in history and most recently served as professor of health policy and management in the Richard M. Fairbanks School of Public Health and professor of public health and law at Robert H. McKinney School of Law, both in Indianapolis, Indiana. He is associate editor for the journal Public Health Reports on legal epidemiology, which is the study of law as a social determinant of health. We spoke with Silverman about the current public health climate, the controversies over vaccine policies, and what he wants to bring to the College of Public Health. 

Are we in an especially fraught time for public health law and public health policy right now, or is it always this explosive?

Silverman: It's not always this explosive. One of the big differences now is that critical decision-making about the interpretation and implementation of public health law is happening everywhere at the same time. It used to be that if there was a measles outbreak in a school district, you faced a situation that was very time-limited and geographically limited. But this outbreak is happening across all 50 states, and across the globe, all at once. So it's a particularly challenging time for us, because the law, what it says on the books, is very different from actually implementing it. You need to have people who understand the law, people who are willing to interpret it appropriately, people who are willing to take the steps to actually make sure that those policies are being followed. And we've seen breakdowns in all of those areas. 

A lot of public health law is very local. It was built on a system just like medical licenses—every state has a slightly different system for how they regulate medical licenses. Our public health systems were all built that way, too. One state's approach may be very different from another state's approach in the best of times, and then in the middle of an emergency, all the nuances of local flavor really get magnified.

So one city may say you can’t come into any building without a mask, and enforcement may be vigorous, and the community buys into it. And every time somebody walks in without a mask and they say, “excuse me, can you put a mask on?” it doesn't turn into a fight that somebody posts on Tik Tok. Where I have been, in Indiana, by contrast, 51% of the local population is vaccinated against COVID-19, and many of the elected officials have not only stated preferences against mandates, but are supporting laws and lawsuits that challenge these and other public health interventions. People are just not supporting these population-based efforts the same way.

Another example from the recent news: In Tennessee, the medical board had posted a notice to doctors saying “we don't want you giving out false information about COVID,” and a state legislator there has made a demand that the medical board take that guidance down, or he’ll take steps to dissolve the medical board. You're seeing legislatures fight the science and fight the regulators with expertise in responding to infectious diseases from actually protecting public health.

It seems like there are so many jurisdictional conflicts and questions…

Silverman: Yes. Traditionally what vaccines are required at the local school for your child is based on your state and local policies. Same thing with vaccines for adults. Now, because this is a national pandemic, which doesn’t respect jurisdictional borders, we're really sort of at the limits of how our laws are structured, and we're playing right at those edges, because public health laws are primarily envisioned at the state and local level. So federal attempts to work in these areas are based on legal grounds that are less fleshed out. So every step that they're taking is being challenged.

You have looked at different approaches to vaccine policy, at mandates and vaccine passports. You have even studied shaming of anti-vax parents, pre-COVID. Are we figuring out what approach works?

Silverman: Well, if the goal is to maximize protection through vaccination—because you always have to weigh out what is the public policy goal here—if that's the goal, so you can slow down or stop a serious illness from circulating through our communities, mandates are the most effective. How you structure those mandates will have an effect on what share of the population is going to get on board.  

So if you have exemptions, there are different ways to structure that. You could say if somebody has a medical contraindication, they shouldn't get vaccinated. Okay. Everybody can agree you don't want to give somebody a shot if there is substantive medical evidence, like a severe allergy, that it could kill them. And there are very few people who would qualify for an exemption to a rule like that. But what if you allow a philosophical belief exemption? Can somebody who says “I hate needles,” or “I believe there's a conspiracy for how this is being created, and it's being used for mind control,” or “I don’t believe there’s a pandemic” get an exemption? Studies in childhood vaccination have found that places that allow exemptions based on philosophical grounds have much higher exemption rates from vaccine mandates.

In this pandemic, there's been some gaming of the system. People are realizing that, by law, if they say “I believe something, and it's a religious belief of mine,” it's very hard for the organization receiving the exemption request to try to prove something different. 

Businesses, schools, universities are going to have a hard time denying exemptions based on religious beliefs. A college of public health or a hospital could say, “We're dealing in our classes and our clinical settings with vulnerable populations, so you're not going to be allowed to participate unvaccinated.” And someone there might have to balance asserting their beliefs against their desire to get a degree. But in a lot of other places, what we're seeing with businesses, people are saying, “My body is a temple,” and backing that stated belief with a Bible quote, and businesses may have a hard time rejecting such a claim. And because our COVID testing and medical leave systems are not robust, we’re left with gaps in our protections.

Childhood immunizations like the MMR vaccine, and that's the area my work grew out of, tend to have really high uptake historically. But now we're even starting to see some backlash into childhood immunization rates, because of the doubt that's being sown with the COVID vaccine process.

So even as the law tries to catch up with the situation, does that even matter, if people aren’t buying in?

Silverman: It depends. Just to share an example, I wrote an article recently that was kind of a prediction. I described my worry about doctors writing fake or flimsy medical exemptions. Because we give so much deference to doctors, to the “doctor's note,” some doctors, for a fee, will take advantage of their professional status to create these loopholes that are not science based. I recommended that every medical board in every state come out with a statement that says, writing these medical exemptions is the practice of medicine, so physicians better be in line with the science and follow best practices while entertaining medical exemption requests. We've already seen, since we wrote that article, a few situations where physicians have basically set up exemption mills—the patient gives the doctor 250 bucks, the doctor will write that the patient has a medical problem and can't get vaccinated against COVID or wear a mask. Even if that patient has had every other recommended vaccine before.

How did you transition from law to public health and eventually land in Philadelphia?

Silverman: I'm originally from New Jersey, and I am a Hoosier by education and then by marriage. But my grandfather grew up in Strawberry Mansion, and my father grew up in South Philly. He went to what used to be the Philadelphia College of Pharmacy [now University of the Sciences]. He started as a pharmacist and became a family doc. So I grew up in a healthcare family. But I didn't really have an interest in going into medicine as a practice. When I was in law school in the early ‘90s, the Clinton healthcare reform debate was going on. I took a health law class and had a great professor, and it got me thinking about how interesting I found the systems of health, and the impact that law and policy would have in those areas. I also worked in politics, while I was in law school in the State House in Boston, and while in college for a few US senators. So this approach let me combine my interests by looking at issues and systems at the intersections of law, policy, politics and health. And that took me into exploring the underlying ethics questions in these areas as well.

What kinds of things are you hoping to bring to the College of Public Health?

Silverman: One of the key things I want to do is make sure that we have systems in place that help us to have as diverse a faculty as possible, demographically as well as in the kind of research that they do, that can have an impact on the public's health. My hope is also…I have taught courses on public health ethics, and I'd like to explore opportunities to integrate more of that teaching into different places within the college. I teach negotiation and dispute resolution, and think those skills could be valuable to people coming out of our programs, as well as to our faculty.

I've become a collaborator with the Temple University Center for Public Health Law Research. They’re doing great cross-disciplinary work on things like policy surveillance. I’m really interested in interdisciplinary studies, and that is one of the great appeals of coming to Temple for me, just how many different types of issues are being tackled here. All the problems out in the world today are at these intersections of different disciplines. I'm really interested in being a collaborator with colleagues across the college, and across the campus and the community, to try to address these really tough challenges that are keeping people from having the chance to flourish.