Public health concerns the public, the general population, improving their health. Yet over the past two years this idea or movement has been widely attacked for promoting job loss, economic collapse, increased mortality, and loss of freedoms.
Humans have caused mass harm to others throughout human history. We do this because we are driven to benefit ourselves and our group (which in turn benefits ourselves), and we frequently find that satisfying this drive requires restricting, enslaving, or eliminating others.
We have a history of demonizing 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 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.
“Health is a state of complete physical, mental and social well-being, not nearly the absence of disease or infirmity.”
The wording implies that human health is defined as a state in which humans can enjoy life (mental well-being) and freely congregate with and belong to the wider population of humanity. It supports autonomy and self-determination, 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, some genuinely seek 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 unchanged.
The differences between principles and their implementation often get 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 on 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 in taking a political doctrine espousing equality and dissemination of power if its name is employed to concentrate wealth and centralize authority. In both cases the 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 (it is doing its job). Alternatively, it can be co-opted to inflict harm on others (it is being corrupted).
The truth 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.
Ethical Principles of Public Health
1. 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. 2. 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. 3. Public health advice should be adapted to the needs of each population, within cultural, religious, geographic, and other contexts. 4. Public health is about comparative risk evaluations, risk reduction, and reducing uncertainties using the best available evidence, since risk usually cannot be entirely eliminated. 5. 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. 6. 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. 7. 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. 8. Public health scientists and practitioners should avoid conflicts of interest, and any unavoidable conflicts of interest must be clearly stated. 9. In public health, open civilized 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. 10. It is critical for public health scientists and practitioners to always 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, socializing, or meeting as a family to prevent spread of a virus, they would be advocating to reduce aspects of the health of these people, at a minimum mental and social, in order to protect one aspect of physical health. “Not merely the absence of disease” in the WHO definition requires that public health support people and society in achieving human potential, not just in preventing a specific harm.A vaccination program would have to show that the money spent could not achieve greater gains elsewhere, and that it reflected what the recipients wanted. In all cases the public would have to drive the agenda, not be driven. The decision would be theirs, rather than belonging to those who gain money or power from implementing such programs.
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 would have to respect the public. Achieving health in the broad WHO definition is incompatible with people being scolded, coerced, or herded.
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 to which they previously claimed to adhere.Insisting on ethical public health may result in the abandonment of certain programs, redirection of certain policies, and corresponding changes in leadership. Those financially profiting would have to be sidelined, as conflict of interest impedes focus on public good. Programs 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 or coerced irrespective of local priorities, or fear and psychological manipulation are used, these should be defined accurately for what they are; commercial, political, or even colonialist enterprises. Those implementing such programs are political operatives, salespeople, or lackeys, but not health workers.
Much of society’s future will be determined by the motivations and integrity of the 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 field have the courage and integrity to do their job.
