by Dr David Bell
Public health concerns the public, and the improvement of their health. Yet over the past two years this area of specialisation has been widely attacked for promoting job losses, economic collapse, increased mortality, and the loss of freedoms. Many have blamed ‘public health’ for rising malaria mortality among African children, millions of girls being forced into child marriage and nightly rape, and a quarter of a million South Asian children killed by lockdowns.
But blaming public health for these disasters is like blaming an aerosolised respiratory virus for the same outcomes. It completely misses the mark. Blaming greed, cowardice, callousness or indifference may be closer. This damage was done when certain people decided to impose harm on the lives of others, sometimes through stupidity but frequently for personal benefit. Atrocities are perpetrated by individuals and crowds, not by an art or science.
Humans have caused mass harm to others throughout human history. We do this because we are driven by a desire to benefit ourselves and our group (which in turn benefits ourselves). Satisfying this desire frequently requires restricting, enslaving or eliminating others. We have a history of demonising ethnic or religious groups to take their money and jobs, and of stealing whole swathes of territory and subduing the inhabitants to extract wealth or take their land. We push commodities – talismans, medicines, unhealthy foods – onto others for our own gain, knowing they would be better off investing their resources elsewhere. We mistake money or power for personal benefit, rather than valuing the relationships and aesthetic experiences that give life meaning. We easily fall into a very narrow, blinkered view of human existence.
Public health is intended to achieve the opposite. It is there to support human relationships and improve the aesthetic appeal of life. The World Health Organization (WHO), for all its failings, was founded on this idea, declaring:
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
The WHO definition of health implies that human existence is far deeper than being simply a lump of organic material self-assembled according to the coding of DNA. It is responding to the horrors of corporate authoritarianism, division and oppression promoted by fascist and colonialist regimes of the years preceding its writing. It is also built on thousands of years of human understanding that life has intrinsic worth that extends beyond the physical, and basic principles arising from this span time and culture. The wording implies that human health is defined as a state in which humans can enjoy life, freely congregate with and belong to a wider humanity. It supports autonomy and self-determination, as determinants of physical, mental, and social health, but is not compatible with restrictions or injuries that reduce ‘wellness’ in any of these areas. It therefore fits poorly with fear, force or exclusion – these denote unhealth.
For principles to be translated into actions, we require people, institutions and rules. Some of these people are involved because it pays well, some seek power, and some genuinely strive to benefit others (which in turn may benefit their mental and social health). Implementation of these principles can therefore be pure or corrupt. The principles themselves remain absolute.
The distinction between principles and their implementation is often confused. A religious belief based on fundamentals of love and free choice can be claimed as justification for military crusades, inquisitions, or public beheadings. This does not mean truths upon which the religion is based support these acts, but rather that humans are using its name for personal gain at the expense of others. The same applies when, in the name of a political doctrine that espouses equality and dissemination of power, its name is employed to concentrate personal wealth and centralise authority. In both cases the principles underpinning these movements are corrupted, not implemented.
Implementation of public health can therefore attract criticism on two fronts. Firstly, it can restrict some from gaining by harming others, whether through intent or neglect (and in this regard ‘public health’ is doing its job). Alternatively, it can be co-opted by self-interested people to inflict harm on others (in which case it is being corrupted). The true intent can be determined by weighing actions made in its name against the principles that underpin it. These are well established and should not evoke controversy. What matters is the honesty with which they are implemented, as it is always humans through which these principles must be filtered.
The list below reflects orthodox public health concepts developed since of post-World War Two, and WHO’s definition of health. It was articulated by public health professionals and published recently by the Academy for Science and Freedom.
Ethical Principles of Public Health
- All public health advice should consider the impact on overall health, rather than solely be concerned with a single disease. It should always consider both benefits and harms from public health measures and weigh short-term gains against long-term harms.
- Public health is about everyone. Any public health policy must first and foremost protect society’s most vulnerable, including children, low-income families, persons with disabilities and the elderly. It should never shift the burden of disease from the affluent to the less affluent.
- Public health advice should be adapted to the needs of each population, within cultural, religious, geographic, and other contexts.
- Public health is about comparative risk evaluations, risk reduction, and reducing uncertainties using the best available evidence, since risk usually cannot be entirely eliminated.
- Public health requires public trust. Public health recommendations should present facts as the basis for guidance, and never employ fear or shame to sway or manipulate the public.
- Medical interventions should not be forced or coerced upon a population, but rather should be voluntary and based on informed consent. Public health officials are advisors, not rule setters, and provide information and resources for individuals to make informed decisions.
- Public health authorities must be honest and transparent, both with what is known and what is not known. Advice should be evidence-based and explained by data, and authorities must acknowledge errors or changes in evidence as soon as they are made aware of them.
- Public health scientists and practitioners should avoid conflicts-of-interest, and any unavoidable conflicts-of-interest must be clearly stated.
- In public health, open civilised debate is profoundly important. It is unacceptable for public health professionals to censor, silence or intimidate members of the public or other public health scientists or practitioners.
- It is critical for public health scientists and practitioners always to listen to the public, who are living the public health consequences of public health decisions, and to adapt appropriately.
Implications of applying ethical principles
If someone advocated that people be prevented from working, socialising or meeting as a family to prevent the spread of a virus, they would be advocating to impair, at a minimum, the mental and social health of these people in order to protect one aspect of their physical health. The clause “not merely the absence of disease” in the WHO definition requires public health to support people and society in achieving human potential, not just in preventing a specific harm. A vaccination programme would have to show that the money spent could not achieve greater gains elsewhere. It would also have to prove that vaccination was what the recipients wanted. In all cases the public would have to drive the agenda, and not be driven primarily by public health officials. The decision would be theirs, rather than being made by those who stood to gain money or power from implementing such a programme.
These ten principles demonstrate that public health is a difficult discipline. It requires those working within the field to put aside their egos, desire for self-promotion, and their preferences regarding how others should act. They have to respect the public. Achieving health according to the broad WHO definition is incompatible with people being scolded, coerced, or herded. This is difficult, as public health professionals have generally spent an above-average period of time in formal education and earn higher than average salaries. Being flawed humans, this makes them prone to considering themselves more knowledgeable, important and ‘right’ than the public. People may point to recent examples among leaders and sponsors of the Covid-19 response, but it is an inherent risk at all levels.
Something to hope for
There is a way out of this. It does not require articulation of a new approach, formation of new institutions, or new declarations and treaties. It simply requires those working in the field, and the institutions they represent, to apply the basic principles that they previously claimed to adhere to.
Insisting on ethical public health may result in the abandonment of certain programmes, redirection of certain policies and corresponding changes in leadership. Those financially profiting would have to be side-lined as conflict of interest impedes focus on public good. Programmes would have to reflect community and population priorities, not those of central bodies. This is not radical, it is what virtually all public health professionals have been taught. When ‘solutions’ are forced, coerced irrespective of local priorities, or when fear and psychological manipulation are used, these should be defined accurately for what they are: commercial, political, or even colonialist enterprises. Those implementing such programmes are political operatives, salespeople, or lackeys, but not health workers.
Much of society’s future will be determined by the motivations and integrity of public health institutions and their workforce. A lot of humility will be required, but this has always been the case. The world will have to watch and see whether those in the public health field have the courage to do their jobs with integrity.