Introduction by Croakey: A senior public health leader has called on Australian governments to follow the lead of Victoria in publishing the written public health advice that informs COVID policies.
Adjunct Professor Tarun Weeramanthri, president of the Public Health Association of Australia, also said the principle of publishing written expert public health advice should apply to Australian Health Protection Principal Committee advice to National Cabinet.
“We need to commit to the highest levels of institutional and governmental transparency and accountability to sustain trust in public health interventions, particularly in times of crisis or emergency,” he told the opening plenary session of the Population Health Congress yesterday.
The Congress, held every three to four years, brings together Australia and New Zealand’s four leading professional population health organisations: Public Health Association of Australia (PHAA); Australian Health Promotion Association (AHPA); Australasian Epidemiological Association (AEA); and the Australasian Faculty of Public Health Medicine (AFPHM).
The theme for the conference, taking place from 21-23 September, on Kaurna Country in Adelaide, is ‘Towards a just, safe and sustainable future for Australasia’.
Weeramanthri’s presentation, titled: ‘At the gathering of the public health clans – the need for Inclusion, Voice and Transparency’, is published below.
Tarun Weeramanthri writes:
It’s great to be here on Kaurna country. I’d like to acknowledge the Traditional Owners, pay my respects to their elders past and present, and thank Jack [Bucksin] for his Welcome to Country.
Every Welcome to Country highlights the significance of gathering together in a specific place. And this is an important such gathering. The four major professional public health associations meeting for the first time in five years. I am proud to have been a member of three of the associations for many years, and as to the fourth, well, who isn’t an epidemiologist these days?
I’d like to begin by asking a question – who exactly is the ‘we’ in this room? In terms of identity, how do we see ourselves and how do others see us?
If we were bikie gangs, we might choose to play up our differences – the AEA as the technicians in the engine room of epidemiology, the Faculty of Public Health as the guardians of evidence within the inner sanctum of medicine, PHAA as a broad church for multi-disciplinary public health, and AHPA as the torchbearers of community engagement and a new public health.
But we are not competitors, we are kin and collaborators, more Outlander clans than bikie gangs, hopefully. We come together for a purpose, but what is that?
The textbook and WHO definition of public health, as you all know, is ‘the art and science of preventing disease, prolonging life and promoting health through organised efforts of society.’
Such a dry definition causes eyes to glaze over inside health departments, and induces immediate amnesia, so when talking to colleagues and ministers I favour a six-word, functional definition of what we do in public health, namely ‘promote health, prevent disease, manage risk’. Pretty much everything in public health can be organised under those three headings.
But academic lawyer and ethicist, John Coggon, argues it is best to avoid definitional traps altogether (Coggon, 2012). He agrees that public health includes an emphasis on the health of the population as opposed to the individual, and that it is most often conducted and legitimated by government (including through education and legislation) either directly or via the actions of various professional or civil society groups.
He adds that it has important communitarian features (the ‘public’ in public health) meaning that health is shared, not simply a sum of individual benefits.
But instead of asking ‘What is public health’ he asks ‘What makes health public?’
He argues that the practice of public health amounts to a series of claims that are made by various groups, and these claims can and should be tested. Public health is not just what experts say it is.
In terms of who can speak about public health, an expert can certainly state that she has a certain level of training in a discipline (such as epidemiology or health promotion) that relates to the question at hand, or that they have completed an accredited course in public health (such as an MPH), or been recognised as a public health practitioner by a learned college, or have accrued relevant experience working in a specific organisation or through academic research.
However, Coggon argues that no one (not even an ‘expert’, not even, dare I say, a chief health officer or chief medical officer) can claim to ‘own’ public health or speak on behalf of a unitary and uncontested public health view. That does not mean that all views are equal, but it does mean that each view, even say anti-vax views, should be examinable and testable.
Before we attempt to answer the question of how to perform such tests, how to sieve opinions for validity, let’s take a detour, and move from talking about identity, to talking specifically about inclusion.
The founding story of Australia, our Federation, our country, as written in our Constitution, was based on an active exclusion of Aboriginal people.
Section 51 gave the Commonwealth power to make laws with respect to people of any race other than Aboriginal people, and Section 127 said that Aboriginal people shall not be counted in any census.
In other words, in 1901, Aboriginal people were not part of the Australian ‘us’. It was a failure of imagination and inclusion with terribly real consequences, that took until 1967 for the nation to begin to rectify constitutionally.
In 2022, we have a decision to make with respect to what next after that formal inclusion 55 years ago.
The Uluru Statement from the Heart says in part ‘In 1967 we were counted. In 2017 we seek to be heard.’
So, Inclusion is necessary but then the next step is Voice i.e. being heard.
How can we apply that kind of thinking more broadly to public health?
As the HIV/AIDS pandemic of the 1980s reminded us, a human rights approach is fundamental to public health. And the history of human rights can be thought of as the history of extension of those rights to previously excluded groups – to Aboriginal and Torres Strait Islander people as discussed, but also to women, to the LGBTQI population and others.
So, an expansion of the concept of us, as culture and norms are challenged and changed, leads to a greater inclusion in society of the previously marginalised, and extension of their rights, which then underpins a new public health practice. And to complete the loop, public health thinking should also play a key instigating role in challenging current norms, and so on we go.
This kind of thinking underpins our professional identity too, and COVID also demonstrated how contentious but also necessary, progressive inclusion is, even within the public health tent.
Let’s take ventilation as an example. Like many mainstream public health professionals, I was slow to appreciate its importance (see Morawska et al., 2021).
The ‘droplet vs. aerosol’ debate had been raging for some months, but when asked to do a review of hotel quarantine in WA in February 2021, the importance of the airborne route quickly became apparent, and I recommended immediate improvement of ventilation systems in the hotels.
That whole experience made me think about the structure and process of expert advice, about who was inside the tent of recognised experts (infection prevention and control or IPC specialists, infectious disease specialists and healthcare practitioners) and who was kept largely outside the tent even when their expertise was clearly called for (aerosol scientists, occupational hygienists and ventilation engineers), and why.
In an article for Croakey in April 2021, I stated that airborne transmission remained the single biggest risk for transmission in hotel quarantine, and posed three specific questions to improve accountability, one for Infection Control Expert Group (on mechanism of transmission), one for AHPPC (on need for national ventilation standards) and one for national cabinet (on their shared responsibility for building a fit-for-purpose quarantine system).
Questions created to probe into the structure and process of expert advice at each level. These questions went largely unanswered, and in January this year, I again pleaded for greater transparency of advice following easing of COVID-19 restrictions across the country in December 2021, and for the media to be also more accountable for their questioning on behalf of the public.
Returning to John Coggon, we can see these disputes as part of a process of claims. Claims about expertise, claims to power and truth, and claims indeed about human rights.
We think we know in a democratic country how we go about settling claims, not perfectly, but well enough and hopefully fairly. There is a whole structure of institutions, processes and safeguards. But as recent events around multiple ministerial appointments demonstrates, this complex structure with its multiple checks and balances, has to be understood, defended and improved.
There are lessons from COVID-19 about how to create a space for a public health/societal conversation where different claims can be heard and judged, so it’s not just a cacophony of voices, and where the loudest and/or the most powerful do not automatically prevail.
Going back to our original definition, public health is part of the ‘organised efforts of society’. In other words, the conversation needs to be organised or structured, with different views weighed and tested on the basis of data, evidence, experience and values.
But for the outcomes to be believed, and gain community support, we need a far greater measure of transparency, as in the ventilation and quarantine example – of data, of expert processes, of the reasoning behind decisions.
That’s why I firmly believe in the Victorian model of publishing the written public health advice from their CHO pertaining to COVID restrictions, along with the final Government decisions, even or especially when the decision differs from the advice, such as in the case of mask mandates in July 2022. (Just to be clear, I support the right of the elected government to make final decisions based on a variety of inputs, not just the public health advice.)
Other state governments should follow, and that principle of publishing written expert public health advice should also apply to AHPPC advice to national cabinet.
And what should we do beyond COVID? I believe the climate action debate is transformative for public health as it illustrates so clearly the size of what is at stake, and demonstrates the age-old concern of public health with broader societal inequity and injustice.
My experience working on health impacts of climate change in the last few years also highlights the criticality of including different voices (see Godden et al. 2021), as in COVID. Most obviously that of youth, but also that of the Global South.
A quick glance at the world map of countries most responsible for historic CO2 emissions, and countries most impacted by climate change now, serves as a summary of where power is and has been concentrated (Global North, including Australia) and who suffers as a result (the poorest people in the Global South, such as those devastated directly or indirectly by recent flooding in Pakistan).
Someone once said, perhaps a little hyperbolically, that climate action without justice amounts to little more than gardening. But the basic point is correct; to be effective climate-health advocates, we need to be part of a broader justice movement. As one example, in WA, for some years now, the Climate Justice Union has been bringing health professionals working on climate change together with professionals from many other sectors, as well as unions, civil society and academic organisations.
This same attitude to inclusion, not just thinking about networks and partnerships in the traditional way, but moving towards more dynamic coalitions and justice movements, is essential if we are to make faster progress and generate some momentum in climate action.
This changed emphasis has another element too, namely intersectionality. Intersectionality is a kind of a new activist take, exemplified by the #BlackLivesMatter and #MeToo movements, on the overlap or intersection of race, class, gender and other forces on people’s lives. I find this kind of literature eye-opening and essential as it reveals my own biases and challenges my assumptions.
Trying to understand gender perspectives on climate is on the top of my to-do list. Like any critical or radical literature, it’s not a matter of whether you agree totally at any one point in time with the views expressed on one particular issue, it’s what you can learn from reading those views and from analysing your own discomfort, and how those views in aggregate contribute to shifts in culture, norms and power. I’m looking forward to being challenged and discomfited plenty in the next session of this conference on critical Indigenous/Indigenist epidemiology and justice issues.
So, to sum up, it’s a joy to be together at this gathering of the clans.
At any gathering, we should think carefully and explicitly about who is included and excluded, and why.
Innovation from the margins
If we take public health not as the application of expert advice, but as a conversation we have with others about the merits of various claims, then greater inclusion, a broader vision of who ‘we’ are, will enrich that conversation. Many new ideas, much innovation, comes from the margins, not from the mainstream.
Having brought more people in, having put the public back in public health, we need to ensure they have a voice and are heard. And we need to commit to the highest levels of institutional and governmental transparency and accountability to sustain trust in public health interventions, particularly in times of crisis or emergency.
But we then need to go that one step further. Step 1 was Inclusion, step 2 was Voice. But step 3 is about leveling the playing field, it’s about redistributing power and being part of a broader movement for justice. Here’s three final suggestions for us in public health.
Firstly, let’s understand the historical context and our role and power within the broader system, much like the medical research community has done in acknowledging the history of research in and on Aboriginal communities. We and our predecessors in public health have helped design the current system, where public health is part of the engine room of government, to operate in the way it does now, and produce the precise outcomes, both good and bad, that we generate today.
Secondly, let’s then change the way we do our public health work, our structures and processes, to get different outcomes. Let’s embrace transparency more fully, as a form of truth-telling, and reveal any tilts in the playing field. Thankfully, transparency will also allow us to better identify strengths in the system, so we know what to keep as well as what to change.
And lastly, it shouldn’t matter what we are working on in this room and online, whether on traditional public health priorities, or on intersectoral determinants of health, or on the newer intersectional justice issues. Nor should it matter to which, if any, of the four associations we belong.
All doors to the public health house should lead into a common room where claims can be made and heard, a difficult conversation can be held, and new ideas for cooperative action generated.
This conference is such a common room for the next three days. Let’s get talking!
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