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Public Health in an Open Society: how society and language shape prevention

Introduction by Croakey: When public health physician Dr Tarun Weeramanthri resigned as Western Australia’s Chief Health Officer last year, Health Minister Roger Cook issued a statement acknowledging his wide-ranging contributions over many years, across Australia and also globally.

The statement noted his work on many national disaster and health responses including the influenza pandemic, Ashmore Reef disaster, Mumbai bombings, Pakistan floods, and earthquakes in Indonesia and Papua New Guinea. He also worked with the World Health Organization in Sierra Leone and Iraq, co-ordinating the activities of foreign medical teams after the 2014 Ebola outbreak, and co-ordinating trauma services around the Mosul offensive.

In an interview last year about his experiences of leadership, Weeramanthri discussed the importance of active self-reflection, and revealed that he enjoys meetings “because they’re little exercises in social observation”.

He also described the importance of the “conversational culture” in advancing the work of public health:

I spent a long part of my career with no control of resources, trying to influence change by good argument.

So you live and die on the quality of your advice, not on the resources you control, and that really sharpens you up. But, as I say, even the President of the United States doesn’t get everything he wants.”

In delivering the Gordon Oration at the Public Health Prevention Conference in Melbourne earlier this year, Weeramanthri provided an eloquent argument for the importance of an Open Society in the face of rising populism and related threats to public health, drawing on the work of the philosopher Karl Popper.

His Gordon Oration, which grows ever-more timely, was published recently in the Australian and New Zealand Journal of Public Health and is cross-posted below with permission.

Now an independent public consultant and adjunct professor in the School of Population and Global Health at the University of Western Australia, Weeramanthri is currently chairing an inquiry into the impacts of climate change upon health and healthcare in WA.


Tarun Weeramanthri writes:

I’d like to begin by thanking the Public Health Association of Australia conference organising committee for inviting me to give the Douglas Gordon Oration today.

I respectfully acknowledge the Traditional Owners of this land, the Wurundjeri peoples of the Kulin Nation, and pay respect to their Elders, past and present.

Like many of you, I have spent perhaps too much time in the last three years following not just Australian politics but Trump, Brexit, and the rise of authoritarian and populist governments across the world. As a result, I am more worried than ever before about the vulnerability of democracy and the level of public support for its institutions, about the erosion of a rules‐based international order, and the gathering implications for public health.

We do live in an era with much to be outraged about, but outrage alone is unlikely to be effective as a response, and is personally corrosive. So, greater mindfulness aside, what’s the alternative?

I have recently been asked by the WA government to conduct an Inquiry into the Impact of Climate Change on Health. More on that later, but in Sharon Friel’s excellent new book, ‘Climate Change and the People’s Health’, there is a foreword by Nancy Krieger, one of the legendary figures of social epidemiology, and she urges us, paraphrasing Raymond Williams, to ‘make hope practical, not despair convincing.’

So, in this Oration, I will attempt to do that in three parts.

In the first part by stating some fundamental questions of political philosophy, for which we may have assumed answers for too long. The answers we all come up with and live by, form part of the societal determinants of health, which shape, or are part of, the more frequently discussed social determinants of health.

In the second part, we will use Brexit as a case study in how language frames and creates problems, but also draw on two recent West Australian examples, to show how we, as a public health community, might use language to offer solutions to complex problems in Australia.

In the third and final part, we’ll look at two as yet unaddressed global issues of the utmost importance, namely attacks on health workers in conflict zones, and climate change, seeking clues on how to better organise a cooperative response, and how to ‘make hope practical’ in solidarity with others around the world.

Douglas Gordon was appointed the foundation Professor of Social and Preventive Medicine at the University of Queensland in 1957. He defined public health as “prevention practised by a community collectively”  and published a seminal text ‘Health, Sickness and Society’ in 1976. His focus in that textbook was on society, environment, epidemiology and the organisation of health care. One of the final chapters is titled ‘Social Duty and Social Concern.’

So, I don’t think he would have found anything particularly new about the fundamental questions I will pose, or the discussion of societal and social determinants. He might have been surprised though at the context in which we need to restate them and re‐argue them so many decades later.

In 2019, indifference to these questions is turning into hostility. The Monty Python question, ‘What have the Romans ever done for us?’ has morphed into the Brexit question, ‘What has the EU ever done for us?’ and is increasingly part of a global libertarian challenge, ‘What has public health ever done for us?’

Part 1: An Open Society

My first question to you all: would you prefer to live in a society governed by a benign dictator or live in an imperfect democracy?

This is a perennial and non‐trivial question that goes back to Ancient Greek times, and is as important now, as it ever was in the past.

Think modern America, where the most fundamental criticism of Trump is that he was elected President, but sees himself as a King.

As in all societies at every time in history, some will be fine with the protection of a powerful leader, perhaps drawn more to certainty and security, and a release from fear, than to civic responsibility and the uncertainty that goes along with that.

In my former government role, I was often lobbied to ban this or mandate that. I did wonder at times if some of my erstwhile public health colleagues would have preferred dealing swiftly with a benign public health dictator with a rubber stamp, rather than face the frustrations and delays inherent in a parliamentary democracy!

But the answer must always be to plump for an imperfect democracy with its checks and balances. The 20th century surely taught us that. Extreme ideological positions that infringe individual liberty and rights, end up costing lives in their thousands and millions. Benign dictatorships turn into malign dictatorships, as night follows day.

So, if we are agreed that a messy democracy is better than other alternatives, let’s put a second, harder question about the place of public health in society, namely: can public health and prevention only succeed in an Open Society?

The Austrian writer, Karl Popper (born 1902, died 1994), is famous as a philosopher of science, but it is his work of political philosophy, ‘The Open Society and its Enemies’, written in exile in New Zealand, and published in 1946, that I will mainly draw on. In it, he provides a strong philosophical argument, via a critique of Plato and Marx, for avoiding extremism and the imposition of any kind of abstract ideology, secular or religious.

He also cautions against historical determinism, or the idea that we can accurately predict history, or assume its inevitable progress towards an ideal state. This quote appears in his book: “… progress is not a law of nature. The ground gained by one generation may be lost by the next.”

An Open Society is “an association of free individuals respecting each other’s rights within the framework of mutual protection supplied by the state, and achieving through the making of responsible rational decisions, a growing measure of humane and enlightened life”.

For Popper, the state should serve its subjects, not the other way round.

The attraction for scientists, I think, is that such a society is oriented to problem‐solving, and incremental change. In Popper’s view, all public policies are hypotheses to be tested and corrected in the light of experience. Unintended consequences must be looked for. Ideally, everyone should be free to criticise and government policies should change accordingly. His is a pluralistic, meritocratic vision.

But note, his general guiding principle for public policy was, “Minimise avoidable suffering.”

Not for Popper the utilitarian aspiration of maximising happiness, but rather the more modest goal of minimising unhappiness, and remedying specific social evils.

He took Plato’s question ‘Who should rule?’ (choose answer from the Good, the Wise etc.), with its implications of a possible Utopia, and Popper asked instead how we can minimise misrule.

Specifically, ‘How can we so organise political institutions so that bad or incompetent rulers can be prevented from doing too much damage?’

A first part of the answer is for people to be able to change governments without recourse to violence, a second part emphasises the role of the law and the media, and the third lies in the richness of non‐government institutions, as part of an overall system of checks and balances.

And it is well to reflect for a moment, that we are citizens in a society where those three conditions are met, and power transfers peacefully through the ballot box.

Popper also identified a number of enemies of an Open Society, particularly those vested interests that seek not a voice within civil society, but assured power and dominance, aiming to tilt the political system sharply in their favour.

As public health professionals, we are already on familiar ground calling out undue commercial influence. It may make sense to advocate on the more general theme of making society more open.

Transparency of political donations, media diversity and independence, the need for Indigenous empowerment, gender equality, and codification of human rights are some other examples where Australia could arguably improve and move closer to the ideal of an Open Society.

PHAA is particularly important here. Its diverse membership, range of special interest groups (including the long‐standing Political Economy of Health SIG), and suite of policy positions has led to a broader and deeper engagement with fundamentally important issues that impact on health, but are not ‘owned’ by health.

PHAA’s recent media release (May 13th, 2019) in support of an increase in the age of criminal responsibility is a good example of that. Many other groups would not view that as a public health issue, but PHAA to its credit does.

In all countries, there are uncomfortable trade‐offs when speaking truth to power. There are some countries where societies could be described as more closed than open, and public health professionals will have to consider putting themselves and their organisations at risk.

Can you, for example, simply promote vaccination, tobacco control and cancer screening, without ever talking about stigma, discrimination and treatment of minority groups? Can you be healthy if you are not free? Or is talk of an Open Society simply code for Western values and dominance? These are all fundamental issues for the global public health community, and a closer reading of political philosophy, in addition to traditional political economy or political science, may help us.

I have emphasised Popper’s views on an Open Society, because they have so strongly influenced my personal approach to public health and public administration, and they are not often discussed these days. I have not mentioned other theories: for example, John Rawls’ well‐known theory of Justice as Fairness, where we decide principles of justice blind to our own situation; or Philip Petitt’s views on ‘freedom from domination’, which Michael Moore, the former PHAA President has championed.

Put Popper, Rawls and Pettit together, and you have a powerful philosophical underpinning for public health advocacy and action. A triad of Open, Fair and Free.

Part 2: Language and Society

Brexit

In the second part of this talk, I will turn to a recent example of how language can mislead and distort, and why it matters for public health.

The best book I have read this year is the Irish historian and writer, Fintan O’Toole’s withering analysis of Brexit as psycho‐drama, called ‘Heroic Failure’. He asks, ‘How did a once‐great nation bring itself to the point of such wilful self‐harm?’

He points to the irony – Indigenous Australians take note – that the nation once built on colonising others, has managed to appropriate the pain of the colonised, in a crucible of self‐pity, that combines a sense of grievance with a sense of superiority.

He shows how some slogans make us stupid. ‘Brexit means Brexit’, ‘Take back control’, ‘The Will of the People’ are all meaningless. (You can think of your own three‐word slogans in the Australian political context.) Events in Westminster show that language can lead us in circles, and entrap us in very practical ways. You now have the phenomenon of the Brexit Party, not just a single‐issue party, but a single‐word party without a policy to match.

Brexit means Brexit … means … Brexit.

O’Toole writes, “Perhaps the most brilliant linguistic manoeuvre … was the renaming of the welfare state as the nanny state. The helping hand was transformed at a stroke into a pointing finger. The things that enabled people to be free of drudgery and want were re‐defined as barriers to their freedom”.

The European Union has been characterised not just as the Nanny State (a term and critique obviously familiar to public health people) but as the Nanny Superstate.

Does any of this matter right now to public health? Yes, absolutely.

There are strong links between nationalism, populism, and hostility to science, underpinned by a mistrust and dismissal of experts and/or ‘outsiders’. The leader of the Brexit Party champions smoking and has warned his followers that the World Health Organization is “just another club of ‘clever people’ who want to bully and tell us what to do”.8  The former Mayor of London, and prime ministerial aspirant happily portrays himself as a beer‐drinking glutton, and Brexiteer media commentators have turned junk food into a symbol of English freedom.

And such attitudes are not confined to Britain. There is a growing worldwide scepticism towards arguably the most successful public health intervention of all time, namely vaccination.

Exhibit A: rising measles cases and falling vaccination rates globally after decades of progress. And Italy and Indonesia are good examples of countries where the falling rates are explicitly linked to either nationalist political ideology (in Italy)  or religious views (in Indonesia). There are links between the anti‐vax movement and populist parties across Europe, and the Vaccine Confidence Project showed that countries where populists performed well in the 2014 European elections had higher levels of vaccine hesitancy.

Public health cannot be complacent and cannot take previous public support for granted, even for the most evidence‐based and successful policies and programs. As Popper reminded us, there is no one historically determined path for society, we can fall back or move forward, depending on our efforts.

Fighting back through language

So how can we fight back, what can we draw on?

Let’s go back to 1946, when George Orwell wrote his essay ‘Politics and the English Language’.

Orwell wrote that the “slovenliness of our language makes it easier for us to have foolish thoughts” but also, “the point is that the process is reversible”.

He wrote “political language is designed to makes lies sound truthful and murder respectable” but he also wrote, “To think clearly is a necessary first step towards political regeneration”.

His essay has inspired an army of writers since to use shorter sentences, unadorned words, the active tense, verbs rather than nouns, the concrete rather than the abstract, as aids to expression and thinking.

Don Watson in Australia is famous for his championing of such ‘plain English’ as an antidote to bureaucratese.

There are also many wonderful public health professionals we can learn from. Over the last ten years, I have listened to a fair bit of talk back radio in Perth. We have had two superb ‘out there’ public health advocates in Terry Slevin and Mike Daube, who would frequently speak on the public health issue of the day – anything from bowel cancer screening to e‐cigarettes.

Both would listen attentively, speak plainly and come across as informed, open‐minded and relatable.

Never as patronising.

Their relatability, their empathy, the lack of distance between speaker and listener – I would like to emphasise how important that is for public health.

Relatability is a key part of the toolkit for inspiring optimism, hope and change, for participating in the public square, not trying to dominate it.

The opening of the Perth Children’s Hospital

Acknowledging that we’ve had our fair share of setbacks to prevention in Western Australia over the last 10 years, and hopefully without sounding too parochial, I’d like to highlight a couple of recent wins, examples where appropriate language played a part in creating a successful outcome.

The first example highlights the difference a reformulation of language can make to an intractable problem.

The new Perth Children’s Hospital is a futuristic, funky green building on the edge of King’s Park. Construction began in 2012, costed at around 1.2 billion dollars, with the hospital due to open in 2016. However, opening was delayed by the finding of high levels of lead in the drinking water supply.

The source of the lead was disputed, whether it was coming from inside or outside the new hospital, there was disagreement between the managing contractor and the government, tension between government agencies and a succession of inquiries. The issue played out regularly on the front pages of the West Australian, and in State Parliament.

To cut a very long story short, and simplify it, after a dozen or so external reports, baseline testing revealed only 74% compliance with Australian Drinking Water Guidelines. At that point, in July 2017, I was asked as the then Chief Health Officer, by the Minister for Health, to conduct a scientific review.

We formed a small team, stepped back from the myriad of confusing test results, and took a simple and traditional public health approach. Our team conducted a series of experiments inside the hospital and identified the probable source of contamination as emanating from brass fittings within assembly boxes, each a metre square, situated next to many of the taps or outlets, in plain sight.

It was a Broad Street Pump moment, as none of the engineers or consultants previously responsible, had realised the significance of those assembly boxes right in front of their eyes.

So, channelling the spirit of John Snow, we recommended that around 1,400 assembly boxes be replaced in their entirety. It took the State Government some months to source and replace them, and then testing was repeated using the same methods and criteria as before. Everyone held their breath, but thankfully, in March 2018, following replacement of the assembly boxes, the hospital returned 98% compliance with the Australian Drinking Water Guidelines for lead.

The hospital opened in May 2018.

On reflection, one key to the success of the review was the way the problem was re‐formulated from engineering language and its related way of thinking, into everyday language suitable for a public health approach.

The engineering language had provided the basis for a series of unsuccessful trial and error fixes based on rather scattergun testing, whereas the everyday language created a framework for a simple hypothesis, and targeted sampling and testing.

We wrote the following down in plain English before we commenced the Review, on the basis of data already collected by others:

System is water, pipes and fittings. Water is clear coming in and in the basement tanks, so problem is not in the incoming water and must be distal to the tanks … Stainless steel does not contain lead. Only source of lead is brass – fittings, valves, joins etc. We have data that can point to outlets where lead levels are particularly high, so we can now target those brass fittings proximal to the outlets and examine them. We can also test piping in the walls and check … lead levels … prior to (the water) entering the brass fittings around the outlets.”

That is exactly what we did over a four‐week period in mid‐2017, sampling from different parts of the piping, testing sequential aliquots of water as they emerged from taps, utilising high powered spectroscopic analysis provided by Curtin University, and re‐analysing old and new data to test our hypothesis. Our team’s approach drew directly from our respective training in public health, epidemiology, and environmental science.

All in all, a very traditional public health approach applied successfully in modern times. But getting the initial formulation and language right was the gateway to solving what had been, until then, an intractable problem.

Advocating with Treasury and Government for Prevention

Now to a second WA example where language may have helped produce a good recent win.

In 2017, the WA Government commissioned a once‐in‐15‐year comprehensive review of the health system, the Sustainable Health Review, that was led by Robyn Kruk from NSW.

Its final report was delivered in March this year, and its first recommendation was to increase investment in prevention from its current 2% up to 5% of the health budget over the next 10 years, a recommendation that the WA government has accepted.

This is a big deal for us in the West, and I have to admit the outcome was a pleasant surprise, after many years of talking with Treasury and Government with less success about the benefits of investment in prevention and public health. Clearly, there is no one easy answer and good luck and good timing are critical!

In hindsight, the key to the submissions and papers put forward to the Sustainable Health Review team, may have been that no‐one over-promised on short‐term savings. Public health investment will not save dollars from this or next year’s acute care budget. Hospital beds cannot be closed behind such an investment, and we need to admit that, as other priorities simply come to the top of the queue.

But based on a wealth of ‘best buys’, cost‐effectiveness literature, program evaluations, and detailed case studies, a range of submissions did make the argument that the return on investment (a favoured Treasury term) from a diverse range of public health programs is fantastic, in terms of quantity and quality of life; and that the arc of the cost curve can be bent favourably over the longer term, not just for health but for a broad range of social care costs.

The review team concluded in their wisdom that prevention is, therefore, critical to sustainability of the whole health system.

I think there is a subtle but important difference between saying that ‘every dollar spent in prevention saves over five dollars in health spending’, with its implication of a short‐term saving, and arguing to Treasury there is a fivefold long‐term return on every dollar invested in prevention.

As PHAA argues for an investment of 5% of national health spending into prevention, not raising unrealistic expectations and tailoring of language to your audience may matter.

Part 3: Achieving UN Sustainable Development Goals

In the final part of this talk, I’ll mention two issues that bear directly on the world’s potential to achieve two of the 17 UN Sustainable Development Goals, goal 16 (Peace, Justice and Strong Institutions), and goal 13 (Climate Action).

Health Care in Danger

Imagine this – you are a health worker at the Royal Melbourne Hospital a few kilometres from here. In the middle of your shift, a military aircraft targets that hospital and drops a bomb precisely onto it. Certain carnage. Inconceivable here, but a fact of life in many parts of the world.

Health Care in Danger describes the escalating tragedy of direct and deliberate attacks on health care personnel and facilities in conflict zones. It includes attacks on health centres, ambulances and field workers, such as those delivering vaccines. As a result of such attacks, health workers leave, health centres close, and whole communities are deprived of basic health services. People’s need for health care is thus turned against them, causing populations to lose hope and flee.

The UN Security Council passed resolution number 2286 in 2016 condemning such attacks, but the situation has not improved in the three years since.

The latest report from the Safeguarding Health in Conflict Coalition titled Impunity Remains, documented a total of 973 attacks on health in 23 countries in 2018.

At least 167 workers died, and a further 710 were injured. The highest number of deaths occurred in Syria, where the scale of attacks is unprecedented, and Afghanistan.

Vaccination workers were attacked in 6 countries in 2018.

In the Democratic Republic of Congo, there have been over 40 attacks on health centres, frustrating attempts to bring the current Ebola epidemic under control, and creating agonising ethical dilemmas for responders and employers.

Picture again the Red Cross or Red Crescent. They are meant to be symbols of protection, not targets in crosshairs for militias and governments.

This year marks the 70th anniversary of the modern form of the Geneva Conventions, under which attacks on hospitals and health staff are plainly outlawed.

The Australian Red Cross is trying to raise awareness of this issue, through its international humanitarian law or IHL committees in each state and territory.

I’m the health sector representative on the WA committee, hence my raising of the issue today.

It is easy to despair and condemn as precious norms erode in front of our eyes, but to ‘make hope practical’ we need to bolster the impact of words written into law through other concrete actions; education of civil and military forces, on‐the‐ground protection, and ultimately sanctions and enforcement of accountability, through international mechanisms and the courts.

Dr Tedros Adhanom, Director General of the World Health Organization, has said simply that there is no health without health workers. An attack on one is an attack on us all.

But what can we personally do to bridge the distance between our work and lives here in Australia, and this issue, if we want to show solidarity with our fellow public health workers in other countries?

Firstly, we can start by recognising that though not exactly the same, violence against staff, particularly in Emergency Departments, is an issue here in Australia, and we have strategies in place to address it.

Having made that connection, we can learn more about the international issue, by going to websites hosted by the ICRC, WHO or Safeguarding Health in Conflict Coalition.

An easy, practical thing you can do immediately if you have a mobile phone, is to download the ‘Emblem Protection’ app developed by the Red Cross, and learn more about the Red Cross emblem, and its meaning.

Lastly, recognise that global solidarity is important, and health workers in the field in affected countries appreciate and value your support. Mobilisation of health workers internationally, and the use of our moral authority through our professional organisations is a key policy lever.

Climate change

And, finally, to climate change. The WA Government has recently announced an Inquiry into the Impact of Climate Change on Health.  Like the increase in funding for prevention, this was a recommendation of the Sustainable Health Review.

This is the first inquiry using powers laid out in the new Public Health Act of 2016, and recommendations for a path forward will cover both mitigation of health sector emissions, as well as public health adaptation.

We will call for written submissions in the next 1–2 weeks, hold open public hearings later in the year, and report by early 2020. It is clear there is a wealth of evidence that demonstrates the direct and indirect links between climate change and health, and highlights specific practical options for climate action.

We need to bring all that information together, emphasise the particular environmental and health impacts for Western Australia, and tap into the strengths, leadership, networks and success stories in the current health system.

The inquiry team are not the experts, but the means of synthesis and alignment, and the bridge between the science, the sector and the public. We therefore need to create a process, and report in a language, that connects with the public as well as current health sector employees.

We are optimistic, based on the level of expertise and commitment in the community, that the Inquiry can contribute to the momentum for change.

But we also need to recognise that the health sector has to this point been slow to act, despite contributing 7% of all emissions in Australia, and think harder about why more concerted action on climate change has been delayed.

What are the barriers? There are obviously structural, economic and political barriers, but there are also intersecting psychological and linguistic ones.

Per Espen Stoknes, in his book ‘What we think about when we try not to think about Global Warming’, emphasises psychological factors, which he names Distance, Denial, Doom, Dissonance and iDentity.

Let’s just take the first factor, Distance. People can’t see climate change easily, it feels distant from everyday concerns, and even 2050, let alone 2100, seems a long way away.

We need to reduce the distance between the ‘now and the never’, making it the ‘now and the near’. The slogan ’12 years for Climate Action’ is cutting through, and is based on excellent science in the Intergovernmental Panel on Climate Change (IPCC) 1.5 degrees of Global Warming 2018 Special Report. Accordingly, we will focus the Inquiry on what the health sector can do and contribute in the ten‐year period, 2020 to 2030.

It’s also possible to construct an imaginative bridge to the future. Damon Gameau, the Australian actor and film‐maker, has done just that in his recently released film ‘2040’, in which he speaks to his 4‐year old daughter, and paints an optimistic canvas for her in 2040, drawing on approaches to energy, waste etc. that are in place somewhere today, on the assumption that what is already possible, will be more widely adopted.

Another way to deal with the time frame issue is to draw on Indigenous knowledge, perspectives, experiences and frameworks of environmental and generational care. 60,000 years equates to 3,000 generations of stewardship.

Indigenous knowledge is critical to ecological science. Indeed, the IPCC 1.5 degrees Special Report stresses the importance of strengthening the capacity of Indigenous peoples and local communities for climate action.

There is already active discussion of climate change in the Aboriginal community‐controlled health sector, who are on the frontlines of natural disasters, extreme weather events and environmental change. There was a First Nations Climate Summit held in Queensland only two weeks ago. So, I have committed the WA Inquiry (as a matter of necessity, not nicety) to seek to engage with Aboriginal people and organisations across the state in coming months.

Conclusion

In conclusion, at a time of crisis for democracy across the world, I am grateful to live in Australia, where we may not have produced that many visionary political leaders, but the community can still find ways to organise and lead, and we can get rid of would‐be tyrants peacefully.

As I get older, I’d still like to change the world, and minimise unhappiness, but I don’t want to aim for a Utopia. I admit it’s a fine balance, better or best. My heartfelt wish is for a more Open Society, that navigates that tension. Not a closed society, succumbing to a populism that closes minds, and sees all experts as tall poppies to be dismissed or cut down. If we close ourselves off, and turn inwards, we then risk turning on each other. An Open Society is a bedrock determinant of health, critical to a fairer world, a freer world and a sustainable environment.

We should be mindful that there will always be defenders of a particular status quo. It’s part of public health’s ‘strategic operating environment.’ The clue to working out who simply holds a genuine conservative view, and who might be called in Popperian terms, an enemy of an Open Society, is whether or not they are committed to greater transparency and accountability themselves.

Brexit and Trump are the latest in a long line of morality tales, and important, because they arise from countries that created the forms of parliamentary and constitutional democracy, that we drew most heavily on in drafting our Australian Constitution.

To unpick the lessons from the tales, we need to relearn the lessons of history; in particular, revisiting closely the period after the second world war. The consequences of political extremism and nationalism were then painfully recent, and the world had to be remade through decolonisation on the one hand and international cooperation on the other.

The United Nations, the World Health Organization, the Universal Declaration of Human Rights, and the Geneva Conventions all came into being between 1945 and 1950. That period also saw philosophers like Karl Popper, and writers like George Orwell, publish their most enduring works and imprint in indelible ink the links between politics, populism and language.

In public health, we are both products and influencers of society and language. Currently facing rising levels of distrust and doubt, by careful attention to our philosophical roots, and ways of speaking, we can, as Orwell pointed out, reverse the process and fight back.

This is no time to rest, as we are currently going backwards in some areas globally, and some norms are being eroded – I have mentioned falling vaccination rates, and attacks on health care.

And we are at risk of inaction on the most difficult and pressing challenge of our time, climate change, unless we quickly change our approach in the next ten years.

But we have much to be proud of and to draw on, as we seek to make progress and help restore trust in science.

The public health approach to prevention, including its core of epidemiological methods, and its commitment to meaningful equal partnerships, has been spectacularly successful and continues to be applicable, even to the building of shiny new hospitals.

We have a great track record in Australia of ‘practising prevention as a community collectively’, as Douglas Gordon put it, though it most often takes time and persistence.

The returns on public health investment are simply compelling. Just look at PHAA’s publication ‘Top 10 public health successes over the last 20 years’, and be amazed at the range of achievements – on tobacco, road deaths, gun control, HIV, prevention of neural tube defects with folate – the list goes on.

But it’s also how we communicate that success, and what underpins it, that counts. We know how important it is to close the gap between society and the individual, the public and experts, and build bridges to others and the future.

Conscious of the political, societal and social determinants of health, we can promote a philosophy of Open, Fair and Free as a strong positive vision and counter‐argument against Nanny State critics.

We are at our best when we are relatable and our language is plain and fit for purpose – whether talking to each other, to the community or to power.

We can act in solidarity with our public health colleagues worldwide to negotiate pathways to more open societies, relevant to each country, and find ways to meet the UN Sustainable Development Goals.

We also know none of this is easy, and we need to help and support each other to be our best selves through organisations like PHAA.

Wherever and whenever the question comes ‘What has public health ever done for us?’, we will be ready to answer.

Acknowledgements

I would like to thank Professor John Mathews, now at the University of Melbourne, for introducing me to the work of Karl Popper in the early 1990’s, when he was Director of the Menzies School of Health Research in Darwin. And I also acknowledge the helpful comments from both manuscript reviewers, encouraging me to clarify my belief that a political philosophy approach overlaps with and is complementary to a more traditional political economy or political science approach. Interested readers may find the podcast ‘Public health and the Open Society’ broadcast on Radio National’s The Philosopher’s Zone on 23 June, 2019, helpful in further exploring the philosophical basis of this Oration.

*** Read the article in the ANZJP ***

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