During my Honours degree in public health, I learned about the history of the public health movement, from its beginnings in the sewage disposal systems, aqueducts and public baths of the ancient Chinese, Egyptians, Greeks and Romans; to the formation of the World Health Organization in 1948; to the rise of the New Public Health movement in the late 1980s.
In Part 1, I’m going to lay out the backdrop to the global response to COVID-19, from the standpoint of public health.
What exactly is ‘public health’? Here’s the definition given by the US Centers for Disease Control (CDC), which describes itself as “the nation’s leading public health agency”:
“Public health is the science of protecting and improving the health of people and their communities. This work is achieved by promoting healthy lifestyles, researching disease and injury prevention, and detecting, preventing and responding to infectious diseases.
Overall, public health is concerned with protecting the health of entire populations. These populations can be as small as a local neighborhood, or as big as an entire country or region of the world.
Public health professionals try to prevent problems from happening or recurring through implementing educational programs, recommending policies, administering services and conducting research—in contrast to clinical professionals like doctors and nurses, who focus primarily on treating individuals after they become sick or injured. Public health also works to limit health disparities. A large part of public health is promoting healthcare equity, quality and accessibility.”
To be sure, I’m a self-confessed nerd, but this unit of study was the most fascinating in my entire degree, not least because the diverse set of practices grouped under the rubric of ‘public health’ has made a greater contribution to the well-being, quality of life, and life expectancy of humanity than any other innovation introduced since human civilisation began.
Indeed, the ancient Romans very intentionally employed public health measures to reduce the risk of rebellion by improving the quality of life of both their own citizens and the peoples they conquered, as the Monty Python team satirised so deliciously in The Life of Brian:
However, as I also learned in my university studies, the public health movement has come under increasing fire from neoliberalism and its offshoot, philanthrocapitalism: the application of business-like strategies to philanthropy, including harnessing the profit motive in order to achieve social good. The history of the World Health Organization since the 1980s pointedly illustrates this conflict between irreconcilable forces.
The heyday of the New Public Health movement was encapsulated in the World Health Organization’s Ottawa Charter for Health Promotion, emerging from the First International Health Promotion Conference, held in 1986 in Ottawa, Canada.
The Ottawa Charter emphasised developing health-promoting public policy (including legislation and taxation policies), creating environments that are supportive of health, empowering communities to improve health by taking “ownership and control of their own endeavours and destinies”, developing personal skills so as to “increase… the options available to people to exercise more control over their own health and over their environments, and to make choices conducive to health”, re-orienting health care services toward prevention of illness and promotion of health, and achieving health equity by addressing the social determinants of health, including access to education and gainful employment.
Two subsequent International Health Promotion Conferences in the late 1980s and early 1990s reaffirmed the centrality of healthy public policy, building supportive environments for health, and community empowerment. The 3rd conference explicitly linked human health promotion with environmental issues and sustainability.
However, the global ascendancy of neoliberalism – an ideology and policy model that emphasises the value of free market competition, and the transfer of control of economic factors from the public sector to the private sector – during the 1980s directly contradicted the new public health movement’s focus on healthy public policy, community empowerment and environmental sustainability.
Neoliberalism prioritises shareholder returns, but the new public health agenda has little to offer corporate shareholders. Addressing the social determinants of health or resolving health inequity does not produce corporate profits; in fact, those profits are directly threatened by healthy public policy initiatives such as sugar taxes, strict regulation of polluting industries, and legislation that protects workers’ rights to safe workplaces and a living wage.
Hence, the tide began to turn against the new public health movement during the 1990s. In 1997, the 4th International Health Promotion Conference, held in Jakarta, Indonesia, for the first time – and very controversially – involved representatives of large corporations including Coca-Cola, Guinness and SmithKline Beecham (now GSK), a major pharmaceutical company.
Unsurprisingly, the ensuing Jakarta Declaration on Health Promotion into the 21st Century affirmed the importance of public-private partnerships in achieving health promotion goals.
The 6th Global Conference, held in 2005, produced the Bangkok Charter for Health Promotion in a Globalised World, which was criticised for
“tak[ing] the corporate line that the interests of the powerful corporations are basically (or at least potentially) pro-people, and that their commitment to equity, public health, and sustainable environment should be voluntary rather than through strong regulation and democratic process.”
WHO’s subsequent attempts to put the new public health agenda back on the map, such as the Commission on Social Determinants of Health which issued its report in 2008, did not placate critics who pointed out that
“Health inequities between and within countries have been tending to increase rather than decrease.”
The People’s Health Movement was formed in 2000 in response to the perception that WHO had fallen out of touch with the health concerns of people at the grassroots, and subsequently published the People’s Charter for Health.
The People’s Health Movement fingers WHO’s funding as the primary reason for its failure to achieve the ambitious new public health agenda that it laid out in the 1986 Ottawa Charter.
WHO’s 2018-19 biennial budget (i.e. its budget for both 2018 and 2019) was US$4421.5 million. In contrast, the US CDC’s 2018 annual budget was US$7339.025 million. The multinational drug company Pfizer declared US$51 170 million in total revenue in 2019. US$29 900 million is spent annually by pharmaceutical companies on drug marketing in the US alone.
As the People’s Health Movement points out, WHO’s budget is self-evidently “simply not enough for WHO to properly fulfil its responsibilities in global health”.
But that’s not the worst of it. WHO’s funding is derived from two sources:
- Assessed contributions from member states, which are proportional to each country’s wealth and population. These are predictable and flexible – that is, WHO can use assessed contributions to accurately budget for its future activities, and can direct these contributions to its various programs, as it sees fit. These provide 20% of WHO’s funding.
- Voluntary contributions from member states and non-state actors, including charitable foundations. These contributions are far less predictable and flexible; donors can direct WHO to spend these contributions on specified health issue/s of their choosing. These provide 80% of WHO’s funding.
The devastating consequences of the inadequacy of WHO’s funding are clearly evident in budget projections for 2018-19, which show massive shortfalls in funding for all its program areas:
Now take a look at where WHO’s funding comes from:
After the US (which directs most of its funding to specified projects), the WHO’s next biggest funder is the Bill and Melinda Gates Foundation, with the Gates-controlled Global Alliance for Vaccines and Immunisation (GAVI) being the 5th-largest donor. Notably, over 70% of the US’s contributions, and 100% of the Gates Foundation and GAVI contributions, are specified voluntary contributions – that is, the donors have complete control over the ways in which WHO spends their donations.
These specified voluntary contributions are overwhelmingly directed toward a handful of donors’ ‘pet projects’, condemning the majority of the public health projects that WHO would like to undertake to wither on the vine:
“Ten programme areas receive 80% of all specified voluntary contributions. Fourteen programme areas receive less than 2% of the overall specified voluntary contributions; that means that they do not attract sustainable voluntary specified funding necessary to achieve the Programme budget results.”
Financing of the Programme budget 2018–2019: Report by the Director-General of the world health organization
Note the program areas that receive no funding whatsoever from specified voluntary contributions: equity, social determinants, gender equality and human rights; nutrition; food safety; violence and injuries; disability and rehabilitation; and ageing and health. Apparently WHO’s donors do not consider these issues sufficiently important to commit money to addressing them.
Notably, WHO’s programs for country health emergency preparedness, health systems, information and evidence, infectious hazard management, health emergency information and risk assessment, strategic planning, resource coordination and reporting, and antimicrobial resistance – all of which are directly relevant to the SARS-CoV-2 pandemic and the global response to it – were all significantly underfunded in WHO’s current budget.
In this light, President Trump’s decision to halt US funding of WHO rings particularly hollow. If WHO’s wealthy member states were less stingy with their funding in the first place, and if they and WHO’s non-state donors had not spent the last couple of decades derailing WHO’s public health agenda and coercing WHO to spend their funding on a narrow range of PR-friendly projects that have limited impact on global public health, WHO may have been better placed to detect the emergence of SARS-CoV-2 and coordinate the response to it in a more timely and effective manner.
In Part 2, I’m going to narrow in on the ways in which philanthrocapitalism has directed the global response to SARS-CoV-2, and differentiate this from a response guided by true public health principles.
Remember, taking good care of your health is even more important than usual due to the high levels of stress generated by the world’s response to COVID-19, and the fact that people with pre-existing chronic disease, as well as smokers and people with obesity, are at higher risk of serious complications of infection.
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