July 12, 2020
Written By: Jenna McHugh
Populations are more aware of their respective public health authorities at multiple governing levels because of the COVID-19 pandemic that swept people into their homes and away from their friends, families and regular life. Due to the evidence-based methodologies that public health put into place to save lives and flatten the curve, many countries are beginning to return to some levels of normalcy, remaining careful about hygiene practices. The Western world should consider itself lucky to have access to robust information, relatively quick (arguably not quick enough) research and a long-history of respectable public health units that can enact population-based safety protocols that are taken-up by the population. However, my quiet concern about how long this respect for public health can last reached its pinnacle. Over the last 30 years, for multiple of reasons that will be outlined, public health strayed from its original function and succumbed to the ideological hypnosis that is disrupting academia, government, businesses and other important facets that uphold our individual-driven civilization. What I mean is, instead of using evidence informed decision making to propel methodologies to promote population-based health outcomes, group identity, oppression, and intersectionality have become the mainstream explanations for health disparities in a population. This discipline now seeks to prove health disparities amongst arbitrarily identified group populations based on oppressive ideologies instead of seeking explanation for health disparities across populations.
The Center for Disease Control in the United States endorses Charles-Edward Amory Winslow’s definition of public health, “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” The discipline takes a macro-level approach to enact lifestyle changes. In theory, the easier it is to lead a healthy lifestyle, the more likely individuals are to practice those habits. The discipline prides itself in using evidence-based methodology to inform policy recommendations, using the hard sciences and social sciences to make holistic recommendations that consider an individual experience alongside the structural setting. In practice, public health takes many forms. At the local level, program implementation can include: immunizations, nutrition programs in schools, smoking cessation, dietary management, mental health initiatives, and informing planners on the built environments to encourage walkability and greenspace for general health. At provincial and federal levels, public health advises on policies to combat the spread of infectious disease, leading research for improved health outcomes, and advocating for funding for preventative health measures. As one can imagine, its broad definition leads to insistence on expanding the capabilities of public health. All of the deeds public health makes claim to are in hopes of promoting health amongst populations, which can have important impacts on economic growth in a civilization. It is difficult to find fault with these goals, but like all good things, too much can lead to disastrous effects.
I’ve considered where things began to go awry in public health and it seems to begin at the first International Conference on Health Promotion on November 21, 1986 with 38 countries signing the Ottawa Charter for Health Promotion. Wherein lies a list of prerequisites for improvements in health: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Health promotion was dubbed the “process of enabling people to increase control over, and to improve their health.” Responsibilities to advocate, enable and mediate were coined to achieve this. Advocacy would improve political, economic, social cultural, environmental, behavioural and biological factors conditions. To enable all people to reach their health potential, health promotion aims to, “reduce differences in current health status and ensure equal opportunities and resources” (applying equally to men and women, as specified). Lastly, health promotion calls on all sectors to establish coordinated action in the pursuit of health. A move towards a new public health frontier insisted that health promotion would ‘Build Healthy Public Policy’ by using an advocacy strategy to support communities. This all seems to be done with the best of intentions to improve health outcomes in all forms. Incorporating health into policy making would create a health conscious state, which could reduce health disparities and promote lifestyle changes. It is possible that health should be considered in almost all decision making, but the language used is problematic because it establishes an agenda for social justice that’s ideological. The Charter also does not answer the questions of how far equity should go or what the methods are to advocate, enable or meditate, to reduce the differences in current health status amongst groups.
Following the Ottawa Charter, came the birth of the social determinants of health (SDH) in the early 2000’s by the World Health Organization (WHO). These are “the conditions in which people are born, grow, live work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.” The language of power used to describe the distribution of resources is reminiscent of oppressive doctrines. The WHO includes the effects of the social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transport in hopes of enacting change in policy at all levels for communities to take a wider responsibility for creating healthy societies. The SDH manner to change unhealthy behaviours is to enact structural-level policies. However, because public health expanded its own identity the SDH of health made the discipline susceptible to concept creep. These SDH have expanded vastly in the Western world to include items like: food, housing, economic and social relationships, transportation, education, income and income distribution, unemployment and job security, employment and working conditions, early childhood development, housing, social exclusion/inclusion, social safety network, health services, Aboriginal status, gender, race and disability. I congratulate you if you didn’t skip over a single determinant in that list, as it’s quite expansive. Since 2003, the structural and social environment has become the explanation for health disparities. The WHO claims, “The social determinants of health are mostly responsible for health inequities- the unfair and avoidable differences in health status seen within and between countries.” The SDH removes individual behaviours from the equation for poor health outcomes. Considering the Ottawa Charter, it is no surprise that the list of SDH is impossibly long. Because of the Charter there are no limitations, allowing the SDH to follow a similar path. It became the responsibility of public health to advocate, enable and coordinate within these loosely defined factions, urging social justice and equity to reduce disparities.
Public health had worked to establish its importance at decision-making levels. Armed with a Charter prompting advocacy, the SDH, and having tasted the sweet flavour of ideology the discipline began to shift more drastically alongside academia. I was told in my Masters of Public Health program that governments, Canada in particular, began to take the importance of public health more seriously after the first worldwide epidemic of the new millenium, SARS. The original Coronavirus pandemic, emerging almost 20 years ago, was a health scare that public health was seemingly unprepared for with outbreaks occurring in Toronto, leading to 44 deaths. This may seem relatively small when thinking about COVID-19, but it confirmed a susceptibility to community and hospital spread and the need for surveillance to stop transmission. After the SARS scare, undergraduate and graduate public health programs were set up across Canada in haste. I’ve hypothesized that the establishment of the academic public health programs, such as a Masters of Public Health (MPH) program in Canada, with its special interest in structural, macro-level implications for health disparities and solutions further propelled a move away from empirical evidence, towards ideological theories. The influence of social science disciplines that teach critical race theory, intersectionality, and theories of oppressive societies became an easy reach for health professionals to explain disparities in health amongst populations. This was a perfect storm, as the Ottawa Charter had already included social justice and equity in 1986 as a fundamental resource for health and the distribution of power was an explanation for health disparities. Oppressive ideologies were readily available on campuses to lengthen the list of social determinants at the time of academic public health program expansion. Speaking from personal experience, MPH programs are not overtly ideological and the discipline prides itself on being interdisciplinary. The core subjects of Epidemiology, Biostatistics, and Research Methods are present and considered foundational to conduct future public health work. Scanning through the course listings for the programs at the graduate level doesn’t indicate that a student would spend time defining ‘intersectionality’, ‘white fragility’, or learning about Karl Marx. These theories are an undertone, with emphasis on group identity and structural oppression because of the constant links to the SDH and the distribution of power and wealth. Those who study public health are taught that marginalized populations experience discrimination due to unequal social, political and economic power distribution, leading to increased health disparities. In public health, marginalized is almost always synonymous with minority.
To reiterate the noble ideals of those who study, teach and practice public health we can discuss the work of Jonathan Haidt and infectious disease expert political affiliations. It further explains how altruistic moralities have sought ideological social justice initiatives and structural explanations. In 2016, Hersh and Goldenberg published an article that highlighted the political differences of physicians and healthcare professionals. Hersh and Goldenberg then shared their data with The Upshot (a newsletter for the New York Times), where the data was considered further. Infectious disease experts are the least right-wing affiliated of all medical specialties with only 23% having registering as Republican. These are the doctors who study and inform on pathogenic microorganisms, such as bacteria, viruses, parasites or fungi, including the diseases that can be spread, directly or indirectly, from one person to another. This is important because Haidt and his team discovered 5 foundations of morality that create connections and divisions amongst groups. These foundations are: 1) Care/harm, 2) Fairness/cheating, 3) Loyalty/betrayal, 4) Authority/subversion and 5) Sanctity/degradation. According to Haidt’s research, left-leaning liberals are much more likely to value the first two foundations, Care/harm and Fairness/cheating, over the others. Conservatives are more likely to value all 5 foundations equally. Care is the cherishing and protecting others; the opposite of harm. When we look at the political affiliations of infectious disease experts through Haidt’s morality-coloured glasses we can infer that infectious disease experts are morally inclined to care more about Care and Fairness than any other medical profession. Infectious disease experts are the backbone of public health.
Furthermore, Haidt’s morality research also plays into the explanations of equality and equity. Haidt claims that conservatives and liberals view fairness differently, “Everyone cares about fairness, but there are two major kinds. On the left, fairness often implies equality, but on the right it means proportionality—people should be rewarded in proportion to what they contribute, even if that guarantees unequal outcomes.” Equity is defined as the quality of being fair and impartial, but public health seeks to move the needle on fairness and have developed their own terms, like health equity:
the absence of systematic, socially-produced (and therefore modifiable) and unfair differences in one or more aspects of health across populations or population groups; defined socially, economically, demographically, or geographically.
This jargon is widespread across the Western world. The definition of health equity that is used in Ontario, Canada was pulled from a resource developed for the WHO by a collaborating centre at the University of Liverpool. The Ontario Public Health Assosciation recommends the use of Health Equity Tools, like the Health Impact Assessments that are derived from Australia and Europe to ensure that equity is used to, “identify both the positive and negative consequences of non-health related proposals on the health of the community.” This methodology determines the “potential differential and distributional impacts of a policy, program or project on the health of the population (as well as specific groups in the population) and assess whether differential impacts are equitable.” Of course, avoiding potentially harmful policy implementation on particular populations is virtuous, but is there a disadvantage to continually considering marginalized populations before the larger group? Perhaps. Public health professors, colleagues and students continue to seek equality of outcome between different group populations rather than equality of opportunity because of equity. Instead of measuring equality of opportunity by comparing where a marginalized population group was, to where they were currently, public health is focused on comparing marginalized groups to broader populations. By doing this, public health neglectfully weaponized equity, by altering its meaning to suit an agenda that promotes provisions based on group identities such as race and gender and abandons individual behaviours.
The introduction of social justice and equity in the Ottawa Charter, the SDH and power, and the use of academic disciplines that promote ideas before evidence has been detrimental to public health responses and its long-term credibility. The morality of infectious disease experts aids in understanding, but due to ideologies disrupting the importance of seeking empirical evidence public health embedding itself in a world that caters to identity politics. In recent years, the WHO shifted its language to promote a sense of urgency on social issues with statements like, ‘Social justice is a matter of life and death’. Public health’s references of a structural power imbalance, while negating the importance of individual behaviours have created tensions between logical and ideological explanations in health disparities. These tension have become visibly mainstream over the last months after the #BlackLivesMatter movement went global and public health got political.
COVID-19 was a global health crisis that could have solidified the importance of public health, epidemiology and population-based healthcare. Social distancing measures were heeded, businesses were closed, masks became the norm, and borders were closed when public health said so. However, after the horrific death of George Floyd, many public health officials saw an opportunity to amplify the discipline’s presence in ideas of oppressive culture, with health boards publicly announcing anti-black racism as a public health crisis. Over 1200 U.S. public health officials supported large group gatherings after having denounced them for the months prior to serve a left-wing political purpose by signing a letter in support of Anti-black racism protests stating, “This should not be confused with a permissive stance on all gatherings, particularly protests against stay-home orders. Those actions not only oppose public health interventions, but are also rooted in white nationalism and run contrary to respect for Black lives.” Public health lost its credibility when they flip-flopped on their recommendations for social distancing to support a political movement. A global pandemic with strict social distancing measures in place should take precedence over a protest movement regardless of the political leanings. Because advocacy, equity and social justice are embedded in public health frameworks officials risked an increase of COVID-19 cases to support a cause for socio-structural change. What authority does public health now have moving forward when they have forgone previous evidence-based, social distancing recommendations in support of #BlackLivesMatter protests? What’s the real public health crisis? The empirically evidentiary pandemic or the ideas of systemic racism? Those who signed the letter justified the protest by describing white supremacy as lethal and theorized that racism is linked to increasing COVID-19 related deaths. How can we develop healthy countries in our societies when those who are responsible for our health forgo their own recommendations to support a cause that is political and ideological, while condemning previous protests that were deemed right-wing and anti-lockdown? How frustrating.
After the historical evidence has been laid out, it is easier to see why public health would make unproductive claims of racism as a public health crisis. It is time for public health to revert back to its roots of evidence-based practices, infectious disease control and rigorous research methodologies that coincide with the scientific disciplines. It’s unnecessary to expand the list of SDH and conflate these influences with societal power imbalances based on group identities when there are more persuasive, well documented reasonings. Socioeconomic status is perhaps the only social determinant of health that is needed as it considers social standing, measured by occupation, education and income. The WHO continues to use the social gradient (income distribution), stress, early life, work, and unemployment in their SDH measures. I am certain the solution to health disparities is more closely linked to education, income and occupation than identifying racialized minority groups and theorizing how oppressed the group might be with intersectionality theories. There are many examples of SES being a common denominator amidst some of the other SDH listed. Here is one, Aboriginal health status is listed in Canada as a SDH and one of the many health concerns regarding this population is the infant mortality rate. Canada as a nation had 4.3 infant deaths per 1000 in 2019. The Indigenous infant mortality rates are twice as high as the general population in Canada. However, studies have shown First Nation women are much more likely to live in neighbourhoods of lower SES and low neighbourhood SES is associated with an elevated risk of infant death among First Nations. In fact, low SES are associated with elevated risk of infant death regardless of First Nation status. Does this unfortunate circumstance exist because the mothers are Aboriginal or is the disparity more closely linked to SES? The latter seems more plausible to me. We should not conclude that being born First Nations is the reason for greater health disparities. We need to offer solutions to individuals within groups that may propel better health outcomes through education and employment. I would expect similar outcomes for other SDH like, race, housing, and food insecurity where SES would provide more of an explanation for health disparities than these factors. It’s a mistake to deem every social problem as a health problem when there is determinant that transcends the rest. Why are we decrying that racism is a public health crisis when there are more reasonable, evidence-based explanations for health disparities?
It is useless to perpetuate ideas of power, race, intersectionality to discuss health outcomes. Coleman Hughes has pointed out repeatedly that group differences in health are all around us. Health outcomes between races, or other group identifiers, cannot be explained by systemic oppression. The Ottawa Charter, the SDH coupled with academia, feeds into a theoretical narrative of oppressive structures. The good-hearted leftist thinkers who value Care and Fairness disproportionately are advocating for health equity across all sectors, at multiple levels of governance. The social determinants approach has expanded group identity politics, provided a simplified and ideological answer to group identified health disparities, and necessitated public health officials to advocate social justice based on health equity ideals. Public health has stopped looking beyond structurally oppressive doctrines to explain health disparities in marginalized populations. There are explanations for social structural causes of health disparities and it is not a surprise these answers are rooted in income. Structural changes do aid in the development of healthier communities, but it is a mistake to extrapolate these issues in frameworks that are based on group identity and systemic oppression. When public health attempts to stand for theoretical explanations for health disparities and neglects explanatory evidence, it ends up standing for nothing at all. There are epidemiologists, biostatisticians and public health officials who are implementing public health practices daily who recognize the importance of an epidemic response and are doing their part to assist communities. I have not forgotten the many public health doctors, nurses and officials are working diligently in truly dire situations to help communities access primary care, overcome outbreaks of Ebola, the spread of HIV/AIDs, Malaria and more. This is the work of public health and some of the real crises to solve.
Jenna McHugh is the Founding Editor of Vigor. Follow her at @jennoratorr