Like other aspects of medicine, public health is about dealing with life and death. In the international sphere, this involves big numbers. If, as a group, a few million dollars is allocated here, it may save thousands of lives. Actual people living rather than dying, or grieving. If it’s allocated there, it may even promote death – diverting other resources from a more useful approach or causing direct harm.
Dealing with such issues affects people’s egos. Humans are prone to think themselves important if they seem to have power over the lives of others. With international public health staff this is reinforced by people they meet and the media glorifying their work. The public hear little of the high, often tax-free salaries or the travels and five-star hotels that boost these egos still further, but instead are fed pictures of (usually brown) children lining up to be saved by people in (usually blue) vests with nice logos. It all feels good.
The result, inevitably, is an international public health workforce that has a very high opinion of itself. Possessing values that it considers superior to those of others, it feels justified in imposing its beliefs and values on the populations who are the target of its work. As their role seems to them more important than bringing up kids in some random village or working at an airport check-in counter, they can feel virtuous when seeking to impose their superior opinions on others. The WHO’s insistence that countries globally embrace certain Western cultural values supporting abortion on request until time of delivery are a powerful example, irrespective of what one considers its ‘rightness’. All the more as the WHO also claims to support ‘decolonisation’.
Things get tricky when the ultimate source of funding has its own commercial or geopolitical priorities. As example, expenditure of the World Health Organisation (WHO) is now over 75% specified by the funder, including those who stand to gain financially from such work. Large organisations that helped WHO run its COVID-19 response, such as GAVI (vaccines) and CEPI (vaccines for pandemics), were jointly set up by private and corporate interests who are now represented on their boards and directing them.
The interface between these self-interested funding sources and the populations upon whom they seek to impose their will is where the self-righteousness culture of the public health workforce becomes so important. They need enforcers whose culture renders them willing to impose harm and restrictions upon others. Apologists and sanitisers who are in a position of trust.
A captured but willing workforce
If you are going to sell a product, you can advertise it and hope potential buyers are interested. This carries a commercial risk. If a product can be mandated – essentially force the market to buy it – then this risk is eliminated. If you can then remove any liability for harm done, you are simply printing money with no risk at all. This is such a ridiculous and indecent approach that it would never fly in a normal commercial context. You would need a workforce capable, en masse, of putting aside the moral codes that prevent such practices, a shield between the people being managed and the commercial or political interests standing to gain.
Historically, public health has often provided such a shield – a way of sanitising vested interests that would otherwise appear repulsive to the public. In the United States, ‘public health’ was used to implement racist and eugenic policies to sterilise and send into decline ethnic groups deemed inferior, or individuals considered to have lesser mental capacity (or to be socially inferior). The Johns Hopkins University psychology laboratory was founded by proponents of just such an approach. The fascists in Italy and Germany were able to extend this to active killing first of the physically ‘inferior’, then whole ethnic groups claimed by governments and health professions to be threats to the purity of the majority. Examples such as the Tuskagee study show this attitude did not stop with World War Two.
Most of the doctors and nurses implementing eugenics and other fascist policies will have convinced themselves they were acting for the greater good rather than demons. Medical schools told them they and their kind were superior, patients and the public reinforced this, and they convinced each other. Having the power to directly save or not save lives does that, while carting trash and repairing sewers (equally important to public health) does not. It enables people to tell others what to do for a perceived greater good (even sterilisation or worse) and to then stand together as a profession to defend it. They will do this for those who direct them, as health professionals are also trained to follow guidelines and superiors.
The hardest thing for anyone conscientious serving in what now passes for public health is accepting that none of the above is actually for the public’s health. It is about unleashed human ego, a large helping of greed and a trained and frequently reinforced willingness to bow to authority. Hierarchies feel good when you are near the top.
In contrast, real health depends on mental and social wellbeing, and all the multiplicity of influences from within and without that determine whether each person experiences, and how they deal with, disease. It requires individuals to be empowered to make their own choices because mental and social health, and a large part of physical health, are dependent on the social capital this agency enables. Public health officials can advise, but once they step over the line to coerce or force, they cease to be an overall positive influence.