Offline: The case against (and for) public health

Abstract

When you walk into the atrium of WHO in Geneva, and if you look carefully, you will discover the head of Andrija Stampar. His face is strong, dignified, and wise. He commands your respect. His presence is rightly prominent. Stampar was the first President of the World Health Assembly in 1948. He dedicated the final decade of his life to WHO, and to what we now call global health. His contribution was inestimable. Through his work as a young district medical officer in Croatia, and then as director of public health for the new Kingdom of Yugoslavia, he showed how nations could build effective public health systems around a common vision for health and wellbeing. He also put what The Lancet described as his “alarming temper” to good use in addressing the injustices he saw. We could do with more of that “alarming temper” in public health today. For if Stampar was with us now, I think he would be both pleased and disappointed by the state of public health. Pleased, because public health, or social medicine as he preferred to call it, has matured into a powerful field of inquiry with a long list of respected achievements to its credit. But disappointed because public health has failed to take advantage of the full range of opportunities before it. It has privileged technical success over political struggle. Too often, public health has retreated from urgent engagement in the public sphere. It has seen its capacities and capabilities constricted. Its objectives have been reduced to the mindless metrics of academic output. Its social impact has been blunted. Its professional workforce is enduring a profound crisis of contraction. Its divorce from medicine has deepened. Its organisations have been weakened by broken leadership. And its vision has been corrupted by collusion with conservative regimes and states. We may therefore ask: what is public health today? Does public health live up to Andrija Stampar's hopes and expectations? These questions come at a moment of emergency in the idea of the global: a period of social, economic, and political disruption unseen since World War 2; peoples enraged by anxiety, alienation, and discontent; political norms shattered; economies plagued by unemployment and low growth; societies jeopardised by terrorism and insecurity; migration as one of the most powerful—and feared—social forces of our times; an unexpected fear of knowledge; attacks on the independent institutional foundations of nation-states—such as the judiciary and the press; a media withered and partisan, a megaphone for plutocrats; governments paralysed by the threat of populism; and the conditions for fascism—let us call it what it is—flourishing: unbridled nationalism, authoritarianism, violence, the demonisation of minorities, belligerent foreign policies, and the application of power to extinguish criticism. The world has faced similar moments before—for example, in the early 19th century, at the time of The Lancet's birth. The 17th-century Enlightenment promised much. In d'Alembert's introduction to Diderot's Encyclopaedia, knowledge was to contribute “new advantages to society as a whole”. But by the beginning of the 19th century, that certainty had been destroyed. The Industrial Revolution brought poverty and workhouses, inequality and deprivation. Science had accelerated, not ameliorated, this terrifying fracture. The reaction came to be called Romanticism—a movement that expressed itself in literature, art, music, philosophy, politics, and science. Romanticism, lasting from the late 18th to mid-19th centuries, was about improving the quality of society. It was about reconnecting Humanity to Nature, rewriting the purpose of politics, and creating a new philosophical radicalism—one dedicated to a progressive realisation of justice and a reinvigorated humanitarianism. Romanticism would address, in Byron's words, the “endless torments and perpetual motion” of the world. The Lancet was part of this extraordinary moment. The revival of a radical tradition succeeded in the early 19th century because of uncontainable social pressure: unprecedented levels of rural poverty and urban hardship. It also depended on a new generation of remarkable young men and women. Science, medicine, and public health in the hands of this new generation was distinguished by an unappeasable social commitment translated into political action. So what are the lessons for today? Nothing less than to grasp the necessity of re-evaluating the entire purpose of public health in the 21st century.