International public health is a mess. Once seen generally as a public good, the focus of the World Health Organisation (WHO) now more closely resembles a scheme for extracting private profit from the public purse. Wealthy corporations drive a ‘public-private partnership’ agenda, the foundations of the rich determine global priorities, and a propagandised public are ever more removed from decision-making regarding their own wellbeing.
There was a time when things were different and public health promoted genuine equity and decentralisation. However, decades of naïvely swapping public control for private money have dismantled the decolonising, community-based model on which institutions such as WHO were ostensibly built. Recent policies have promoted impoverishment and centralised control, and WHO is now seeking power to entrench these.
While WHO remains mainly publicly funded, and defunding bad ideas is sensible, simplistic solutions to complex problems are seldom a good idea. Replacing net harm with a vacuum will not help the people who need substance. Knee-jerk reactions can satisfy those who are unaffected by collateral harm but want ‘something done’ (such as the privileged Zoom class who decided in 2020 that wrecking the livelihoods of others might protect them from a virus), but we should be better than that. Public health, like our personal health, should remain a responsibility of us all.
Some argue that ‘public health’ is a false construct, and only personal health really matters. Those who believe this should clarify what they will do when a factory upstream on their local river starts releasing mercury or cyanide into their water supply. Without a structure to monitor this, they won’t know until people around them get sick or die. If they want to walk outside, they probably prefer clean air. These require considerable communal effort.
We also live far longer than our forebears principally due to improved sanitation, living conditions and nutrition. Antibiotics play an important role, and some vaccines have contributed late in the game. While some of these improvements grew organically, many required communal action (i.e., a public health action). If the road has now led us into the bog, better to back up and re-route the road than destroy it altogether.
What public health is
The WHO was designed in 1946 to help coordinate international public health. It was to be called upon by countries when needed. WHO’s remit was primarily to address high burden diseases that cause avoidable sickness and death where countries lacked the resources or technical expertise needed. Although non-communicable diseases such as diabetes or obesity – or cancers and degenerative diseases such as dementia – kill most frequently, WHO sensibly prioritised the unavoidable results of poverty or geography, predominantly infectious diseases, that strike younger and so shorten life far more.
‘Life-years lost’ is an extremely important concept in public health. If we really believe that equity is important – a reasonable chance of all having a roughly equal lifespan – then addressing diseases that remove the most life years makes sense. Most people would prioritise a five-year-old with pneumonia before an 85-year-old dying with dementia, if the choice had to be made. Both lives are of equal value, but one has more to lose than the other. When truth was important, preventable diseases such as malaria, tuberculosis, HIV/AIDS and the effects of under-nutrition were the priority of the international health community.
COVID-19 is therefore an obvious anomaly. It kills at an average age older than most people even live to and predominantly affects those with severe metabolic or lifestyle diseases. It is notable that from the start of the COVID-19 outbreak, only raw death rates were quoted by those who stood to gain from lockdowns and mass vaccination. Conventional public health metrics that consider life-years lost (such as disability-adjusted life years, or DALYs) would have allowed the public to realise that things were not as serious as some needed them to believe.
What public health is not
In terms of equity, it would be ludicrous to divert resources from African children dying of malaria in order to vaccinate them against COVID-19. Such a resource diversion would be expected to kill more children than could conceivably be saved – mass Covid vaccination is far more costly than malaria management. Less than 1% of Africans are over 75 years of age, half are under 20, and nearly all had immunity against Covid before Omicron immunised the rest. So, the fact that such a vaccination program was run by WHO, and is still underway, says everything we need to know about the current intent of WHO and its partners.
Mass Covid vaccination, though clearly a public health negative in low-income countries, was not a mistake but a deliberate act. The people in charge knew the age at which people die of COVID-19, they knew most people already had immunity, and they knew the worsening of other diseases that resource diversion would drive. In the same way, they had known that closing schools would entrench future poverty and increase child marriage, and that closing workplaces in crowded cities would enforce poverty whilst having no impact on virus transmission.
It is therefore rational to conclude that those driving such policies are acting incompetently from a public health standpoint. Calls for their organisations to be defunded and dismantled are fully understandable. In wealthier countries, where organisations such as WHO provide minimal value-added beyond career opportunities, the benefit of demolishing international public health may appear obvious. However, those born by good fortune into countries with strong economies and health systems must also think more broadly. An example will help explain the issue.
Where international cooperation saves lives
Malaria has had a huge influence over humankind. It has killed enough to change humanity, selecting for mutations such as sickle-cell disease that, while deadly in themselves, killed less often than the malaria parasite they protect against. Malaria still kills over 600,000 children every year. Good diagnosis and treatments exist but they die because it is often unavailable. This is mostly due to poverty. The parasite is naturally spread by mosquitoes throughout the tropics and sub-tropics but is only a major issue in poorer countries. As example, there is no malaria in Singapore, very little in Malaysia, but a lot in Papua New Guinea.
A concerted effort in development of better malaria drugs, diagnostics and insecticide-impregnated bed nets (to stop and kill the mosquitoes) has reduced risk for many, but many low-income countries cannot procure and distribute them without external support. As the COVID-19 response demonstrated, some people and corporations are willing to risk the lives of others for profit – so without international regulatory support malfeasants would also send sub-standard and fake products to these countries.
A similar picture applies to many other diseases, including tuberculosis, HIV/AIDS and schistosomiasis (a very nasty worm infection). So, while it may be reasonable to state that WHO and partners have been a net public health negative over the past few years, not all the actions of such institutions produce net harm. Not all their work is configured to benefit the rich. If we permanently eliminated all international health effort, then history suggests we would kill far more than we save. That is not an outcome to strive for.
Recognising institutional realities
Somehow, we must retain the benefits whilst removing the ability to sell out to the highest bidder. A penchant for injecting pregnant women with mRNA medicines that concentrate in ovaries and liver, crossing the placenta to enter the dividing cells of the foetus, does not mean honesty or competence are beyond reach. It simply means people can be bought or brainwashed. We already knew that. Public health, like plumbing or selling cars, is a way by which ordinary people make money. Therefore we need ordinary restraints and rules to make sure they do not abuse others for self-enrichment.
The current mess is also society’s fault. Because these institutions deal in health, we pretended they were more caring, more ethical and more able to self-regulate. WHO’s version of self-regulation over the past 20 years has been to cast aside longstanding norms regarding conflict of interest and cozy up with Pharma and high net worth individuals in Davos. We should have expected this and prevented it.
Because WHO is staffed by humans, and humans have a natural desire for more money, it will keep prioritising its corporate benefactors and their investors. Car salesmen don’t succeed by giving customers the best deal, but by gaining the best deal for themselves and their paymasters.
Who and what to fund?
It is irrational to support corrupted institutions, but rational to support improvements in health and well-being. It is rational (and decent) to help populations who, through accidents of history such as past colonial exploitation or other misfortune, lack the means to fully address their own basic healthcare. While bilateral arrangements may address much of this, it also makes sense to coordinate more widely. Multilateral institutions can provide efficiencies and benefits beyond those achievable on a bilateral basis.
A sensible model would recognise human frailty and greed, ensuring international health institutions can only act when and as requested by each country. It would exclude private interest, as the priorities of population health are simply incompatible with maximisation of corporate profit (which WHO’s corporate donors are obligated to prioritise). The tendency of humans to put loyalty to an institution (and their own salaries) above a cause also necessitates strict staff term limits. Equity would demand the same.
International institutions, supported by our taxes, must never be in a position to undermine democracy, curtail freedom of expression or override our fundamental right to work, education and normal family life. Doing so would be the antithesis of bodily autonomy and human rights. It would be the antithesis of democracy. And it would be the antithesis of good public health. Institutions seeking power to impose their will on ordinary, free people must be dealt with accordingly.
The COVID-19 response of the international health industry, led by WHO, impoverished the public and degraded health. The current rush to transfer greater powers to WHO should therefore not be confused with public health. Publicly funding the further erosion of freedom and basic human rights would be self-harm, while funding access to basic healthcare is a global good. The public and the politicians that claim to represent them should be clear on the difference.
Dr. David Bell is a clinical and public health physician with a PhD in population health and background in internal medicine, modelling and epidemiology of infectious disease. Previously, he was Programme Head for Malaria and Acute Febrile Disease at FIND in Geneva and coordinated malaria diagnostics strategy with the World Health Organisation. He is a member of the Executive Committee of PANDA.
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