Category Archives: Politics

From my point of view, this is big “P” politics of Nation States or Provinces within Nation States.

Es ist ernst! [It is serious]

Chancellor Angela Merkel, 2019 (source: wikimedia)

There are truly great, rousing political speeches. President John F Kennedy’s Inaugural Address on 29 January 1961 comes to mind: “ask not what your country can do for you — ask what you can do for your country.” Prime Minister Winston Churchill’s, “We shall fight them on the beaches” speech, during World War II.

The defining political speech of the COVID-age will surely be that of the German Chancellor, Angela Merkel: “Es is ernst!” It’s in German. There are subtitles. Watch it!!

The power of the speech lies in no single phrase and no single idea. The power lies in the gestalt. It lies in the thoughtful, measured, and compassionate speech to a nation from someone who holds the idea of democracy dearly, and needs to ask 83.1 Million people for patience, sacrifice, and forbearance; for a great community good — because no one is expendable.

In her speech, brilliantly, she thanks the forgotten cash register staff and shelf packers for their tireless efforts, as well as the easily remembered healthcare and public health workforce for theirs. She suggests that people might even consider writing a letter to a friend or loved one because, of course, the German postal service continues to work. She constantly plays between the culture of the German people (what it is to be a German), their expectations of Government, and the task of managing SARS-CoV-2.

Like many countries, Germany has instituted measures that are anathema to democracy, but necessary to slow the spread of the virus. As she explains, all we are doing now is buying time. Stretching it out. The longer we stretch it out, the more time researchers and healthcare workers have to find measures of prevention, management, and cure. The longer we stretch it out, the more person-ventilator-time (PVT) and person-ICU-time (PICUT) there will be to allocate. If you are acutely ill, PVT and PICUT are the most precious commodities available at the moment (excepting toilet paper), and the best way to make more of this commodity is to stretch out the length of the pandemic.

Do not watch or listen to the blather and buffoonery of the likes of Trump and Johnson. Whether they do not understand or do not care is irrelevant. Their “ideas”, their politics and their speeches will be lost in the waste-paper basket of history, to be picked over by pimply, undergraduate students in response to the essay topic: “Political leadership is important in times of crisis. Discuss”

Merkel’s speech is the most hopeful, rational and caring political message I have heard since the outbreak of the SARS-CoV-2 pandemic. Sitting at my desk in Dhaka, I found it enormously comforting to know that there was leadership like Angela Merkel’s out there. There has been considerable discussion about the lack of global political leadership. It is there. Turn your eyes and face the light.

This is serious.

Covid Economics

“Governments will not be able to minimise both deaths from coronavirus disease 2019 (COVID-19) and the economic impact of viral spread.” [Anderson et al.]

A soup kitchen during the Great Depression. Apparently it was only men who were hungry

It is easy to see that the economies of the world are being affected by the COVID-19 pandemic. Share-markets have tumbled. Airlines are flying empty. Except for bizarre panic buying of toilet paper, malls and shops are more deserted. And if you have an employer with a large cash reserve and a bit of heart, you will be OK. There are many companies, however, that are at the margins and they are already failing because of the impact of COVID-19. Households are hunkering down: not spending, not going out.

These are the consequences of containment.

Now think about the daily wagers and piece workers, the sex workers, couriers, garbage pickers, rickshaw drivers and maids. Who will pay their bills, put food on their tables and ensure the same for their children?

Workplaces are instituting attendance rules based on health guidelines. Fevers, coughs, headaches and myalgia? Stay home! Recently been with someone who tested positive. Stay home! Etcetera.  That’s fine for me. I will apply for sick leave. In all countries, but disproportionately in Low- and Middle-Income Countries, large numbers of people in the workforce are in the informal sector. They are vulnerable. Even in the formal sector, many workers have no financial protection.

Think again about the daily wagers and piece workers, the sex workers and couriers. Their capacity to pay the bills and keep food on the table is proportional to their capacity to keep working. No matter what.

Death is not everything.

The obligation of countries who have committed to sustainable development goals is to “leave no one behind”. Governments should implement their public health measures to limit the effects of the COVID-19 pandemic, but the poor should not have to carry an unfair burden.

A street sweeper in Mokhali

To share power, someone has to give up power

Over the past few years I have been peripherally involved in various discussions with male colleagues about gender equity. The conversations have had a predictable ebb and flow.

Women’s empowerment. It’s great in theory, but who wants to give up power? Not these men. [source: reddit; https://bit.ly/2wd2AJC]

The consensus, at least among my colleagues, is that gender equity is a good idea. In the abstract, we fully endorse it. The practice is another matter. It is not that we don’t want to share power. We’re enlightened! We know there is a problem, but can it be someone else’s power that is shared?

The reasoning goes something like this. I should not have to share power. I’m talented, I got here on merit, and I deserve everything I achieved. It is an absolute social good when I have power. For me to give up power would not be good, because I wield it benignly and actively promote gender equity. It would be great if another man gave up power because that would support gender equity.

At a fundamental level, power is a zero-sum-game. There are only so many seats around the high tables of power, and if someone gets a seat at the table, someone loses a seat. Sure, we can squeeze an extra seat in here or there — but there are limits. If someone sits on a panel, someone else cannot sit on the panel. If 50% of the world’s population suddenly achieved fair access to power, power that had been largely controlled by the other 50%, competition would increase sharply.

In 2017, the World Health Organization Director-General Tedros Adhanom Ghebreyesus, tried to fudge the arithmetic [it has since changed]. He appointed a substantial number of women to senior positions in WHO. He did this by increasing the pool of senior positions, and he appointed women to the new positions. Unfortunately, many of the new positions were without substantive portfolios, and without real power. In effect he dragged some extra stools to the table. Chairs for men. Stools for newly appointed women.

The strategy had all the right visuals without the structural capacity to support gender equity; i.e., the fair distribution of power.

Gender equity is a good idea. It will be achieved through structural changes that share power and resources, not through appeals to people’s better nature nor through empty gestures. The test of whether one person’s power has increased is whether another person’s power has been diminished.

Public Health is not a specialisation of medicine

Medicine saves lives one at a time. Public Health saves lives by the millions.

In many countries, the guilds of the medical fraternity provide for specialist membership. Attached to membership is prestige, promotion, and increased earning potential. In almost all cases, membership or fellowship of one of these guilds, typically titled “Colleges”, indicates increased expertise in the management of classes of disease in individual patients.

If you have diabetes, atrial fibrillation, Parkinson’s disease, major depression, etc., or you need more or less specialised surgery, you may well want to consult a member of one of these guilds of medicine.

 

Vaccination programs are critical to Public Health, but they do not require a medical specialisation in Public Health. [Image source: pixnio.com]

The focus of Public Health is the protection and improvement of the health of populations. The breadth of public health practice is enormous with individuals working in disease specific areas (e.g., HIV, TB, or mental health); settings (e.g., schools, workplaces, markets); social policy areas of the social determinants of health; health systems; health financing and market regulation; urban design; and health data analytics, to name just a few. Although there are commonalities between them, Public Health may be contrasted with Community Medicine and Social Medicine by the fact that Public Health practitioners do not spend their time treating individual patients, although they may guide services for the better and more efficient treatment of populations of patients.

The most significant distinction is that Public Health draws its expertise from a wide range of disciplines: behavioural sciences, nursing, management, geography, history, politics, anthropology, environmental sciences, urban planning, sociology, pharmacy, economics, biostatistics, microbiology, ecology, mathematics, parasitology, computer science, entomology, engineering, veterinary science, … and medicine. Some of the best public health people I have ever worked with have come from history and geography. It is not that history and geography are peculiarly crucial to Public Health. It is that good Public Health requires interdisciplinary teams that can bring new perspectives to problems. It is relatively unusual to find historians and geographers in Public Health, so they bring novel solutions that are quite different from those one might otherwise see.

Postgraduate Public Health training, such as a Masters of Public Health (MPH), is a useful way of providing the diverse disciplines involved in Public Health a common language with which to share problems, ideas, and solutions. There is no one best discipline for Public Health, and there is no reason that one has to study Public Health formally to make a valuable contribution to Public Health practice. I speak here as a person who has no formal qualification in Public Health but one who has been a Professor of Public Health, has lead Public Health teams, and has advised governments, UN agencies and international NGOs on Public Health.

I return to my titular point. Public Health benefits enormously from the input of people with a diverse range of qualifications. What then is the purpose of a medical specialisation in Public Health, if Public Health is not a branch of medicine?

The answer is historical and political. The historical answer is that Public Health is traditionally located within the Ministry of Health (MOH). There is a logic to this. So much of the practice of Public Health is about the coordination, regulation and efficient delivery of health services that it must be coordinated with MOH activities. The obvious down-side of this historical location of Public Health is that, as it has become increasingly evident that population health problems require whole of government approaches, any attempts to transcend the departmental pillars of government are regarded by other Ministries as a MOH power-grab.

Politically, power within MOH is typically vested in people with membership in one of the specialist guilds of medicine. The only way for Public Health to have status in MOH (and let’s face it, Public Health has never been as sexy as clinical medicine) is for it to be lead by people with a medical qualification and membership of a specialist guild. Thus, specialist guilds of Public Health medicine were born.

This historical and political strategy protected the status of Public Health within MOH. It provided a career pathway for medically qualified personnel interested in pursuing a career in Public Health. Unfortunately, it also limited the capacity of Public Health practice to deliver the best population health outcomes.

Governments need to improve the way they approach the protection, promotion and improvement of the health of their populations. A good start is to recognise that medicine is a part of the practice of Public Health (just as history, geography, etc. are), but Public Health is much bigger than a specialisation of medicine.