Public health is a failed ideology. Lot's of people are dead because of this failure. But nothing will change.

 

Among all the endless models and graphs it is sometimes difficult to get a strategic handle on the response to Covid-19. In one respect it is characterised by a depressing league table of actions and outcomes – comparing Britain to Spain, the USA to Germany, and everywhere to little old New Zealand. But underneath all this is something else – the complete and abject failure of public health authorities. Not just those in the UK but pretty much everywhere – from the World Health Authority downwards to the little local public health functions in cities and local councils.

Current debate isn’t about this failure but rather about the extent to which different parts of the public health response have failed to different degrees. We are presented with a debate about tiers of lockdown rather than whether the strategy of locking down worked. And meanwhile the public is regaled with a steady dribble of anecdote – shocking stories of poorly people presented as undeniable evidence that we have to, once again, hunker down in our homes until the bad virus goes away.

Let’s start by saying that the problem here isn’t with “the science” – in truth there’s precious little science involved in the models and graphs, mostly different variants of arithmetic. There is, however, an ideological failure that all this supposed “science” simply ignores. The dominant practice in public health – it’s ideology, if you like – is that the problems it faces affect all the population and therefore the responses to those problems must similarly affect all the population. We see this most clearly (despite evidence to the contrary) in how public health campaigners respond to “non-communicable diseases”. These aren’t actual diseases but rather conditions or lifestyles choices – obesity, drinking, smoking.

Public health ideology treats these NCDs as all-population problems – we are fat because of an ‘obesogenic environment’, some people drink too much because alcohol is too cheap, to strong or sold in the wrong places, and smoking persists because of a dark, secretive marketing programme poisoning the minds of ‘our kids’. Ill-health is never the consequence of genetics, personal choices, or bad luck and always environmental, a feature of the whole population.

Presented with a pandemic involving a contagious virus, starting with the whole population would seem to be the right approach. After all, as we were told, the virus doesn’t discriminate meaning we are all (equally) at risk of contracting it. Those anecdotes (“I have a friend and she told me about her friend who is only 21 and was nearly dead”) help to sustain the view that this is an all-population problem and therefore we need an all-population solution. Forget about targeting, ignore the medical evidence, let’s just shut everything down to “prevent the spread”. So, we were locked down, all of us (well except for the key workers we needed to keep things running) despite not all of us being in serious risk.

And maybe those lockdowns worked (we don’t really know the answer here) and maybe they didn’t. At no point did anyone ask a different question – given that the risk of dying from Covid-19 increases with age and prior medical condition, is it really an all population problem? Although we’ve heard the anecdotes about children and young people dying, the truth is that the virus isn’t going to kill young people (and probably won’t kill anyone under 50 who doesn’t have some other serious condition or disablement). Yet public health ideology dictates that measures must address all the population, that targeting is wrong.

Imagine for a moment a different ideology, one that doesn’t see the challenge as all-population but rather as an extension of existing strategies aimed at reducing excess winter deaths (much of which is about protecting the very elderly from infection). So, instead of locking down the whole population, we do some different things – secure the care homes, isolate hospital wards, advise the most vulnerable in the community to shield themselves. Imagine too that these strategies are things we do every winter not special measures in response to pandemic. Add the isolation of people who are exposed to the virus and those who arrive from places where it is not under control. With good hygiene advice (wash your hands, wear a mask if you’re ill), we have a set of strategies targeted to the problem rather than blanket, essentially panic, lockdowns.

The reason we don’t have these sort of strategies is because of the dominant public health ideology – not only do its advocates believe responses to public health problems have to be all-population but they also believe that people cannot be trusted to comply. Controls must be regulatory and enforced – simply advising (strongly) good behaviour will not work. The public health ideology also insists that ill-health is a consequence of lifestyle and, importantly, that these bad lives aren’t the fault of the individual and his or her choices but rather a consequence of ‘marketing’ and the wider social environment. People, especially poorer and less well-educated people unlike those working in public health, simply don’t have agency, they are sad victims of environmental manipulation by sinister capitalists.

We have conducted the debate around Covid-19 on the basis of vast spreadsheets (some of them accurate) carefully curated to present the best – or worst – impression so as to suit the advocate’s chosen position. This overlooks the more fundamental ideological question as people assume that, for example, the Great Barrington Declaration presents merely a different all-population response to the dominant public health position when it really takes us towards an approach based on risk-assessment and targeting instead of blanket geographical lockdowns or restrictions. And it is this ideological challenge (somewhat late in the day but welcome none-the-less) that results in a defensiveness verging on ad hominem among fans of the dominant public health viewpoint.

It is depressing that, given the almost complete failure of this dominant public health ideology, we are in the position where the preferred response is to double down – talk of circuit breaks or fire breaks accompany bans on alcohol, closed hospitality and ever more draconian policing. If only we’d locked down harder, longer, and tougher it would all have been fine. This despite the evidence telling us that such a response probably wouldn’t have made a great deal of difference. Public health failed us but politicians and the media (each, as comedian Geoff Norcott put it, with their own favourite virologist) still treats its failures as if they have something to offer – professor this and doctor that pop up again and again to present the latest iteration of their numbers all still clutching to that disastrous ideology.

Nothing will change. There will be a review and an enquiry (it will spend most of its time trying to find politicians to blame, of course) but it will start and finish within the bounds of public health’s assumptions, constrained by its failed ideology. There won’t be a fresh approach, any attempt to look at how we improve our response to winter excess deaths, protect care homes better or prevent the spread of infection within general hospitals. There will be a new mythology around eating and drinking with pubs and fat people singled out as the vectors for ill-health. The media, bored by dull technical discussions about infection management or risk profiles, will leap onto the government’s obesity strategy with glee as they find another set of bossy ideas from the putrid pit of public health’s ideology. And, when the next pandemic arrives, we won’t be ready.

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