WFPHA: World Federation of Public Health Associations

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How could public health reimagine ways to protect the population and reinvent itself amid a pandemic?

Before covid-19, only two things were known to influence the course of pandemic diseases—isolation and vaccination. We must now add murderous incompetence, culpable negligence, perfunctory conduct of government response, wantonly foolish ideology-driven reliance on organisations and individuals who conspicuously lacked the necessary attributes to perform their assigned tasks, and so much more. [1]

Abbasi equated the lethal results of political decisions during the COVID-19 pandemic to ‘social murder’ [2]. This term describes what occurs when those in power force the general population to live in conditions that increase, inevitably, their risk of avoidable and premature death [3]. Motivation for such an unusually harsh indictment arises from a large proportion of excess mortality reported during the COVID-19 pandemic that could be attributed to measures put in place by politicians—out of ignorance, incompetence, indifference, negligence, or malice [4,5,6]. As deaths and suffering mounted, public health experts also failed to lead, while witnessing the squandering of an historical opportunity to stop a global plague. In most cases, those responsible for public health were aware of their political masters’ wrongdoing.

Given their dependence on government employment, most public health experts chose to remain silent out of fear of committing career or financial suicide or the belief that, even if they took the risk to speak out, nothing would be done or make any difference. In other cases, they remained quiet due to lack of clarity as to how, where, and to whom to report their concerns [7]. With even more deaths and hardship looming in the aftermath of COVID-19 and expected to recur with new pandemics, it is imperative for the public health community to determine how best to protect people from the effects of harmful political leadership, and to learn how to use the shockwaves of the pandemic as a source of energy in the creation of a brighter future.

Tackling these two apparently divergent challenges simultaneously requires a good dose of what Hearn and Banet–Weiser called ‘scandalous thinking’, or bold mental leaps of imagination to transcend what is presently imaginable [8]. Such a radical approach is essential, as timid variations of the status quo or small incremental steps could aggravate the weak state in which the pandemic may leave the field of public health and increase risk of its relegation to the margins of societal life. Such a risk, perhaps unimaginable before the spread of COVID-19, appears clearly given the role of the political class, as well as the much more assertive medical profession, and the naturally aggressive corporate sector (especially pharmaceutical, e-commerce and telecommunication companies). These three dominated the limelight, pushing public health to the fringes of the decision-making process and public awareness, should and could have outshined the others. In most countries, politicians updated reports and directives for containment and mitigation efforts, with public health officers standing behind them, while physicians and other healthcare providers called attention to the optimization of emergency rooms and intensive care units, and private companies controlled most of the vaccines produced and distributed (or not), worldwide.

Arguably, the precarious state in which public health finds itself, coupled with the traditionally conservative nature of the field and what appears to be a built-in aversion to disruptive innovation, put a damper on what we can imagine within academic institutions, think tanks and professional bodies to transform its future. At the moment, large supra-national organizations are likely to be in a much better position to create the conditions for the audacious, long-range leaps of imagination that public health needs to survive and, ideally, to thrive. In reality, the World Federation of Public Health Associations [9], is the only worldwide non- profit professional society representing and serving the broad areas of public health. It works to boost capacity of more than 130 organizations—serving over five million professionals in 104 countries—to share resources and expertise, and to implement innovative health strategies.

What makes the WFPHA even more special, in addition to its global presence and multidisciplinary membership, is that it decided to form an international Public Health Leadership Coalition [10] devoted to

  • ensuring that the global response to pandemics and to other planetary health concerns is evidence-informed, equitable, and effective; and

  • to providing a strong, independent, and accountable voice to the public health workforce, communities, civil societies, and scientific experts to make governments and organizations accountable for their choices.

In light of this, the WFPHA or any other interested organization, would have at least two possible approaches to make these happen. One approach is to increase the accountability of leaders. It could easily backfire and become ineffective and counterproductive, given their political ramifications and potential clash with powerful interest groups, which either oversee or fund most public health efforts. An alternative, which might yield even more promise for the future of public health, is to imagine new ways to enhance what is directly beneficial to the populations it intends to serve. This second path might face resistance from the most conservative wings of public health, as it requires disrupting the status quo by going beyond the management of diseases at the population level, embracing digital technologies in unconventional ways, and to view health as an ability that could spread, rather than as the impossible-to-achieve “state of complete physical, mental and social well-being” embedded in the outdated definition of the World Health Organization [11].

Increasing accountability

Along this path, efforts could include, for example, actions to lessen risks for whistleblowers, to shame harmful leaders, and to position public health malpractice as a crime against humanity.

Lessening the risks for whistleblowers

Hesitancy by people working inside government or private sector organizations with evidence of wrongdoing by political or corporate leaders to report it is well justified. Even though many countries have laws and acts that protect whistleblowers—with provisions to safeguard their anonymity, as well as their safety and that of their families. Insiders who speak up often face devastating consequences [7, 12]. Often, their identities are exposed, and their employment terminated, and occasionally they are jailed and stigmatized. This, in turn, act as a deterrent to people who might otherwise consider stepping forward to report unlawful or immoral activities—including data falsification, tampering of official documents, bribery or theft—either to media outlets or official bodies within their organizations (such as internal Ethics or Compliance Officers).

The WFPHA or any of its national or regional member organizations would find itself in a strong position to offer additional protection to whistleblowers beyond what is available through the adoption and deployment of easy-to-use digital platforms designed to support the confidential or anonymous filing of whistleblower reports, and their independent review by experts [13]. Some of the most prominent tools, such as SecureDrop and DataLeaks, are free, open source and secure. They are also capable of overcoming the vulnerability of more traditional channels, including techniques used by perpetrators to identify whistleblowers, such as voice recognition to decode hotline calls, handwriting analysis on anonymous letters, and email tracing [14].

Shaming harmful leaders

Despite the growing number of reports describing myriad ways in which leaders failed the populations they were meant to protect during the COVID-19 pandemic, there is a dearth of practical interventions to expose them and to make their misdeeds known to the world.

The international public health community, either through the WFPHA or any of its member organizations, could collect cases of harmful leadership in relation to COVID-19—many of which could be provided anonymously by whistleblowers—and determine what was known and not known, done and not done, when, why, and by whom. This could be achieved easily through strategic partnerships with bodies such as the United Nations Office on Drugs and Crime (UNODC), which developed processes and knowledge products to support countries interested in strengthening their whistleblower protection systems, with emphasis on the COVID-19 response. Findings of validated cases could then be made public—either though public social media outlets or in collaboration with non-profit organizations such as Transparency International or the International Consortium of Investigative Journalists—as a form of social pressure to motivate action [15]. This could also deter other political or corporate leaders, especially those playing prominent roles in future pandemics or responses to other existential threats, such as climate change [16].

Advocating for public health malpractice as a crime against humanity

Even if international organizations document clear cases of mass ‘social murder’, holding those behind them accountable would be practically impossible because of the lack of legal frameworks—within national boundaries or across the world—to prosecute leaders who unleash an infectious disease on their citizens or employees, or on foreigners [17].

The WFPHA, or any of its interested members, could contribute to remedy this situation by lending its support and weight to calls seeking to include public health malpractice in the list of crimes against humanity, as adjudicated by the International Criminal Court. Such an effort, if successful, could also apply to environmental crimes [2].

Enhancing benefit

Options focused on strengthening the positive are illustrated by existing efforts focused on the conceptual foundations of effective leadership; the pursuit of ‘precision public health’; and the completion of a pandemic of health.

Clarifying the concept of effective leadership

Following the recognition of an opportunity to clarify the meaning and attributes of effective leadership in public health, the WFPHA created a task force charged with supporting the Coalition through the identification and distillation of research evidence that could augment the conceptual and operational capacity of public health leaders to incorporate the best available knowledge in their decisions while dealing with COVID-19 and future pandemics, worldwide.

Pursuing precision public health

Analogous to the ways in which Precision Medicine is transforming healthcare, public health could be revolutionized by systematic efforts to map the unique profile of each population of interest with the purpose of increasing their capacity to adapt to challenges such as those posed by pandemics and other existential threats, and to design and deploy large-scale tailored interventions to tackle them.

An example of how this was achieved successfully during the pandemic of COVID-19 was the way in which ‘Big Tech’ could sense the impact of the outbreaks in the working and living habits of their customer base promptly and modified their network of resources to respond swiftly to the changing conditions. As lockdowns incapacitated traditional approaches to working, trading, communicating and entertaining, these large multinationals used their analytical capabilities, e-commerce platforms, online streaming services, and their understanding of human behavior to shift jobs, sales, conversations, and pastimes into people's homes, while turning what constituted the biggest species-wide catastrophe in recent memory into new opportunities to thrive [18].

Completing a pandemic of health

At first glance, the use of the word “pandemic” in this way might seem out of place. After all, it is almost always used in relation to the spread of diseases throughout the world. Etymologically, however, the word pandemic comes from the Greek terms pan (all) and demos (people), and pandemos, which entered English via Latin in the seventeenth century to describe something that is prevalent among people over the whole world, or that pertains to all people [19, 20]. Health fits this perspective, even more than other entities that are regarded as pandemic, including infectious diseases such as COVID-19, or chronic conditions such as diabetes or obesity.

A fact that is often overlooked is that most of humanity, when asked, have rated their own level of health as positive. Of the 36 members of the Organization for Economic Cooperation and Development, for instance, all but four (Japan, Korea, Estonia, and Lithuania) reported that more than 50% of their populations over the age of 15 years regarded their own health to be good or better in 2019. The highest proportion that year, right before the start of the COVID-19 pandemic, was reported by Canada, where 88.8% of the surveyed population was healthy. The data reported for 2020 barely changed [21]. This is consistent with the aggregate findings of the World Health Survey, a cross-sectional study coordinated by the WHO from 2002 to 2004, involving 69 representative nations in the world, and including 271,371 people over the age of 18 years, which revealed that 62% of people reported their own health to be good or better [22]. These figures indicate that positive health is present in more people than COVID-19 or any other condition that has been associated with the word pandemic in the twenty first century, such as diabetes, cancer, or obesity [23,24,25].

To make the notion of a complete pandemic of health—namely that every person on earth could experience positive health, which should be the ultimate goal of public health—even more intriguing, research conducted in France showed that the levels of self-reported health of people who had not been infected by the SARS-CoV-2 in April 2020 had improved twofold during and after the initial lockdown in comparison to previous years [26]. In Germany, 32% of the participants in an ongoing study that had begun in 2014 reported improvements in their levels of self-rated health during the initial months of the COVID-19 pandemic, with only 12% reporting worsening health [27].

Completing a pandemic of health would require, first, a shift in the conceptualization of health, to view it as the ability to adapt to the inevitable challenges people face throughout life [11]. After that, it would be important to position self-reported health as the main indicator, with the plethora of traditional disease-related variables as a complement. Then, it would be necessary to introduce elements that could trigger ‘social contagion’ [28]. This refers to the spread of ideas, affect, attitude, or behavior from one person to another, within a social context, where the person affected does not perceive an intentional influence attempt by the initiator [29]. This is a phenomenon that has been documented in relation to obesity, suicide, smoking cessation, mental disorders, and happiness [30,31,32,33,34]. Only when the public health community embarks in efforts to enable every person to consider themselves to be healthy, it would have a chance to reach its full potential, and to cease playing second fiddle to medicine and its disease-fighting machinery [35]. The main challenge for the WFPHA, public health associations, and leaders in countries around the world is to give themselves permission to believe that this is possible.

Alejandro R. Jadad, MD DPhil FRCPC FCAHS FRSA LLD; Founder, Centre for Global eHealth Innovation, and Chairman, Beati Inc., Toronto, Canada; Member, Public Health Leadership Coalition, World Federation of Public Health Associations.