Holst J. When the world depends on effective public health intervention – and public health does not deliver (Editorial). SEEJPH 2020, posted: 23 May 2020. DOI: 10.4119/seejph-3469 P a g e 1 | 7 EDITORIAL When the world depends on effective public health intervention – and public health does not deliver Jens Holst1 1 Department of Nursing and Health Sciences, Fulda University of Applied Sciences, Fulda, Germany. Corresponding author: Jens Holst; Address: Leipziger Strasse 123, D-36037 Fulda, Germany; Telephone +4966196406403; Email: jens.holst@pg.hs-fulda.de Holst J. When the world depends on effective public health intervention – and public health does not deliver (Editorial). SEEJPH 2020, posted: 18 May 2020. DOI: P a g e 2 | 7 Abstract The COVID-19 crisis offers both special opportunities and challenges for Public Health. The ini- tial management of the pandemic was dominated by virologists, supported by epidemiologists who did not always meet indispensable scientific requirements. Interdisciplinary and complex Public Health concerns and expertise, however, did not have tangible impact in the COVID-19 debate. Since social and other upstream determinants of health play a central role, Public Health is universal and goes beyond health security. As an explicitly political concept Public Health must safeguard its broad socio-political approach and obviate all tendency towards biomedical reductionism. Keywords: biomedical reductionism, COVID-19, health security, power, Public Health, public policy, social determinants of health. Conflicts of interest: None declared. Holst J. When the world depends on effective public health intervention – and public health does not deliver (Editorial). SEEJPH 2020, posted: 18 May 2020. DOI: P a g e 3 | 7 The COVID-19 challenge In view of the COVID-19 challenge, analy- sists cannot agree more with the world’s de- pendence on “effective public-health inter- ventions” as stated by José Martín Moreno in the editorial to this edition of the South East- ern European Journal of Public Health (1). However, the long-term outcome for and the effect of the COVID-19 crisis on Public Health - as well as on Global Health - remain uncertain. Instead of strengthening Public Health, which can be seen the national break- down of Global Health, the current handling of the pandemic worldwide rather threatens to become a challenge for Public Health. In any case, the COVID-19 crisis has high- lighted more clearly than ever the complex nature of public health and likewise of global health. But at the same time, it has revealed the extent to which biomedicine and biotech- nology still dominate the debate. For weeks, politicians and the media provided the popu- lations in many countries around the world with a mix of partly meaningless epidemio- logical figures, sorrowful scenarios and dis- turbing images of intensive care units. Apart from “Old” Public Health in the form of mainly national public health services and epidemiologists, the voice of Public Health as theory and practice of protecting and improv- ing people’s health was hardly to be per- ceived during the first weeks of the COVID- 19 pandemic. The Infodemics associated with the global spread of COVID-19 shows that the complexity and transdisciplinarity inher- ent to Public Health failed to achieve suffi- cient impact in the media and general public (2). Even more so, good science in the sense of “Old” Public Health was challenged even by a hitherto respected public-health institution, Johns Hopkins University in Baltimore, by unleashing continuously updated absolute numbers of confirmed COVID-19 cases, deaths and recoveries to the global public (3), and the World Health Organization did not shy away from confronting and comparing absolute numbers among different countries and populations (4). Presenting and publish- ing absolute figures without the slightest idea of what the reference values are, counteracts the most basic concepts and conventions of old public health. Meaningful epidemiologi- cal data require both a numerator and a de- nominator; however, the latter is absolutely missing as there is an unknown number of un- reported cases (5), and data about the number of tests realised were initially unavailable and are still likely to be incomplete. Moreover, even the numerator is doubtful due to a mix of under-reporting (people with or without symptoms who are not tested) and over-re- porting (as not all patients who die with pos- itive tests die from COVID-19). The attempts to address this problem by using the term “deaths in connection with COVID-19” re- duces the meaningfulness of figures while creating another level of incompleteness, namely the under-reporting of collateral fa- talities indirectly caused by COVID-19 (6). Pandemic challenging Public Health In spite of all declarations about the relevance of public health in a pandemic outbreak, it was not public and global health experts other than virologists and epidemiologists to be- come the second group to enter the global and national scenes. Instead, economists and business experts were next on the scene cre- ating awareness of economic consequences of lock-down decisions, and law experts warning about cuts of civil and human rights. Only at a later stage did public health experts make a noticeable appearance. Recent experience during the early phases of the COVID-19 crisis has shown that the rapid succession of epidemic and even pandemic Holst J. When the world depends on effective public health intervention – and public health does not deliver (Editorial). SEEJPH 2020, posted: 18 May 2020. DOI: P a g e 4 | 7 outbreaks does not automatically contribute to shape the awareness of Public Health or Global Health. In contrast, the initial domi- nance of virologists and epidemiologists in media and political crisis management will end up weakening Public Health as a whole rather than strengthening it. It has to be stressed that Public Health comprises much more than health security. The concept of Public Health is per se universal, whereas se- curity-oriented policies tend to focus on safe- guarding the status quo, however inequitable and unfair it may be. This will also apply to innovative vaccines and medicines, which are extremely unlikely to be equally available for all people living on earth. The great importance decision makers attach to biomedical and biotechnical solu- tions compared to the determination with which they address social determinants of health will corroborate the hegemony of the Global North and contribute to release the pressure to address the upstream determi- nants of pandemic outbreaks. The huge amounts of money invested in developing COVID-19 vaccines (7) and the megatrial launched by WHO for accelerating the re- search on medicines to fight the current coro- navirus pandemic (8) will primarily benefit the better-off part of the world’s population. Strikingly, there is and will certainly not be any comparable research fund in sight for in- vestigating the social, political, economic and ecological determinants of the pandemic. The prevailing biomedical reductionism tends to supplant calls for more community health efforts and marginalise the perspective of social medicine and social determinants of health (9,10). The prevalent concentration of Public Health policy on the spread of danger- ous infectious diseases often lacks an in- depth understanding of political, social and economic conditions and requirements. Poli- cies and health strategies in the context of the coronavirus pandemic do not fully grasp the complexity, interdiscipinarity and universal- ity of (New) Public Health since they are in- creasingly determined by cross-border rela- tions, international policy priorities and par- ticularly by often hegemonic security con- cerns, and the securitisation of health is meanwhile considered a key feature of health governance (11). Politicising instead of securitising global health The desire for security is well understandable in an increasingly inequitable, unstable and frightening world. However, it often remains unclear what is meant by security, who de- fines security and how it is to be created. It is not the criticism of the actual causes of global health crises such as the social, economic and political determinants of health that is at the centre of the debate, but the question of how efficiently a crisis can be managed without having to tackle the underlying causes. The prevailing concept of Public Health does not pursue the question of how to combat risks at their origin, but how to deal with future risks in such a way that they do not threaten the status quo or put at risk vested interests. The focus is mostly on how the health problems resulting from the living and environmental conditions can be identified and contained as early and far as possible, instead of changing them. Neither are upstream determinants of health usually high on the health agenda, nor political priorities, power relations or the in- fluence of stakeholders (12). Public Health is by no means immune to be- ing instrumentalised for economic and politi- cal interests, it is rather interspersed with power relations (13), which health-related policies need to explicitly acknowledge (14). Indeed, the existing power relations deter- mine the predominant understanding of Pub- lic Health and Global Health to a much Holst J. When the world depends on effective public health intervention – and public health does not deliver (Editorial). SEEJPH 2020, posted: 18 May 2020. DOI: P a g e 5 | 7 greater extent than usually assumed or often discussed. The whole debate about global health governance, governance for global health and global governance for health (15) falls short in regard of analysing underlying power and power relations (16). The recent COVID-19 reaction has exhibited an interesting policy shift: The short-term re- turn of the strong state. After many years of spreading the neoliberal ideology and in- creasingly evicting the state from its respon- sibilities, the State reasserted its claim to po- litical control with surprising clarity and de- cision. Governments decided to intervene in individual and social life and to restrict eco- nomic and entrepreneurial freedom. For pro- tecting people’s health, the lock-down and the interventions of the reinvigorated state appeared comprehensible, as they were sci- entifically justified. The state's regained strength vis-à-vis the pri- vate sector and even transnational corpora- tions must be maintained beyond the COVID-19 crisis. The state is the only entity capable of guaranteeing and enforcing the right to health as it is ultimately the only one accountable for human rights violations (17). For improving and safeguarding people’s health, public policies must be geared to the rights and legal entitlements of people, as laid down in the Charta of Human Rights and in the WHO constitution. Public Health requires protecting those who are most in need - the poor and the marginalised – from health risks and bad health by overcoming poverty, ineq- uities and social injustice. As important as good medical care is, it has less influence on people’s health than their living, labour, in- come and environmental conditions, educa- tion, equal opportunities and social cohesion. Even in times of pandemic outbreaks, Public Health must consistently follow its broad so- cio-political approach instead of being devi- ated towards biomedical reductionism (12). Conclusion In a world gone upside down due to a pan- demic outbreak, Public Health must not be reduced to the search for medicines and vac- cines. 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