Decision-Making in Public Health: A Reflection

By Tarun Weeramanthri

Public health is a complex business to be in at the best of times. Most of us work in or with governments, where we need to make and advocate for sensible policy, or with communities or civil society organisations to make a practical difference to people’s lives, or in academia where ideas and theory matter. There is a great temptation to think of public health as simply a set of wholly rational choices, but it is often much more than that – a fierce contest of values, options and priorities, and a struggle for attention, influence and resources. And decisions are most often made around meeting tables, where group dynamics are central, and individual personalities come to the fore.

During my career, I have rarely read a good description of either what it feels like to work in public health inside a big government department, or how decisions are actually made. Jenny Lewis’ book ‘Health Policy and Politics: Networks, Ideas and Power’ comes closest for me, as it captures the sense of possibility inside the bureaucracy, the tangible closeness to actual change, and the need to look beyond the organizational chart (or organigram) to the relationships between the boxes.

These tensions, emotions and difficulties are magnified in times of crisis, and here the literature is a bit more helpful in describing what is actually going on, and what is at stake when decisions are being made. Arjen Boin and colleagues wrote an insightful book ‘The Politics of Crisis Management: Public Leadership under Pressure’ which describes how leaders have a number of challenges in these ‘fog of war’ situations: to make sense of the crisis, to respond in quick-time, to communicate the meaning of the crisis to the public, to be accountable through the crisis, and ultimately to end the crisis and learn from it. Their three key components of crisis – threat, uncertainty and urgency – have been plainly evident during the COVID-19 pandemic, as public health leaders have been brought into the centre of societal decision-making.

A recent literature review by Leah Campbell and Paul Knox Clarke on ‘Making Operational Decisions in Humanitarian Response’ has also resonated with me. It points out that decision-making is not simply a deliberate choice between different options made at discrete points of time, or about following a set protocol, but can also be more naturalistic in style, grounded in experience and intuition. Seen in its widest sense, decision-making in a crisis is a process of solving problems as they arise, and thinking things through as you do so. Perhaps most importantly, the review highlights the impact of stress on decision-makers, and that different individuals will deal with stress in their own ways and in their own style, which can in turn affect the quality of the decisions made.

Even as the COVID-19 pandemic continues, we have now passed into the latter phases described by Boin and colleagues as including critiques of the response up till now, lessons learned exercises, and formal reviews and commissions of inquiry. There will be plenty of finger-pointing and blame games. Mistakes have been made of course, and some will be obvious in retrospect. Hopefully, strengths of the response will also be identified. There will be findings of both kinds, that relate to public health officials and the decisions they made.

Bettina Borisch has recently teased out how the unthinking use of the term ‘crisis’ favours a reactive mode aimed at ‘getting back to normal’, and that this will simply not be adequate after COVID-19. She favours a more flexible, adaptable, and indeed creative response at an international level. Such a new approach to ‘building back differently’, and the reviews of the COVID-19 response that will inform it, will be helped by a greater focus on the reality of decision-making in public health – its complexity, its social nature and the stress that goes with it.

Protecting Health Workforce through Vaccination in Low-income & Low-Middle-income Countries

Protecting people worldwide with the appropriate vaccinations is a priority to save millions of lives. This is even more true for the healthcare and public health workforce, very often on the front lines of caring for patients and communities.

While many countries, including those in less wealthy settings, often have infrastructure and policies to guarantee vaccinations for children, this is not always the case for adults or for health workers. Indeed, in many countries, a lack of infrastructure or appropriate policies undermines access to vaccination throughout the lifespan. This means that high-risk categories like health workers are not protected, creating a huge problem not only for the individual but for the whole society.

On December 08, 2022, at 10:00 (CET), health and public health professionals from low- and lower-middle-income countries presented the real life of a health worker in their country, explaining whether and how this category is or is not protected by immunization in order to better understand the situation on the ground, the needs, and the gaps to be filled.

This webinar is available to view by clicking on the link below.

Has the Pandemic Had an Impact on Your Attitude Toward Vaccination?

The WFPHA is starting a project to analyse if and how the COVID-19 pandemic has impacted healthcare and public health workers’ sentiment towards vaccination. In particular, the WFPHA seeks to understand any sentiment changes concerning the COVID-19 and seasonal flu vaccinations.

The WFPHA invites all health professionals to fill out a short 5-minute survey and share your opinion with us, including but not limited to public health professionals, physicians, nurses, dentists, midwifes, pharmacists, social and community health workers working in any setting from hospital to academia, at the Ministry of Health or with communities, etc.

The WFPHA is conducting this study across multiple countries including Australia, Brazil, Canada, China, France, Germany, India, Italy, New Zealand, Spain, the UK, and USA . If you are from these countries, please share your thoughts with us by clicking on the correct link below!

Deadline April 15, 2023.

Canada (Fr)

India

UK

US

Global Public Health Week 2023

The 2nd edition of Global Public Health Week (GPHW) commences on April 3rd 2023, with the theme “Building a More Equitable, Sustainable, and Resilient Health System”. It will be a hybrid event, combining face to face and digital gatherings worldwide.

During GPHW, the WFPHA brings together institutions, communities, and public health actors from around the world to recognize the contributions of public health and its workforce. This annual event engenders discussion on the best practices and missing gaps fundamental to disease prevention and the promotion of health and wellbeing.

In addition to the week’s theme, each day will focus on a specific theme:

• Monday, 3 April: Preparing Public Health Professionals & Associations for the New Challenges
• Tuesday, 4 April: Tackling the Climate Crisis
• Wednesday, 5 April: Empowering Our Communities – Protecting Minorities & the Most Vulnerable
• Thursday, 6 April: Making Health a Human Right
• Friday, 7 April: A World in Turmoil: A Discussion to Be Continued

Get Involved

• Hosting Event

Whether you are a public health association, a health organization, an institution, a health professional, a student, or an ordinary citizen interested in one of this year’s five GPHW themes, you are invited to:

1. Choose one or more of the themes above.
2. Mobilize your team to organize your own event(s) such as workshops, conferences, webinars, interviews, social media activities, contests, exhibitions, and many more in different formats such as in-person, online, or hybrid. Events can be big or small, local or global. Events can be organized in any language.
3. Submit your event by 1st March 2023 using this link.
4. The WFPHA will dedicate all its platforms, such as its website and social media, to give visibility to your events.

• Participating

If you are unable to organize your own event, joining GPHW events and activities contributes to the success of events. Several events will be planned for each day of the week. Pick your favorite(s) and join us there.

Keep up to date with all the activities and news relating to GPHW by following #GPHW & #GPHW2023 on social media.

For more information, please send an email to: secretariat@wfpha.org

Statement on Protecting Ecosystems & Supporting Nature-based Solutions for Improved Public Health

The interconnectedness between natural and human systems is well documented and is observable in the sheer breadth and scope of our interactions with nature for procurement of food, water, shelter, and virtually all critical resources we need to survive and thrive. The health benefits we derive from ecosystems are delivered as a consequence of the world’s rich biodiversity, species composition, and complex interwoven ecological processes performed by natural systems. Such processes, in turn, enable ecosystems to perform essential functions that have been collectively grouped as ecosystem services under the categories of provisioning services, regulating services, supporting services, and cultural services, and more recently as Nature’s Contributions to People.

A failure of ecosystems to perform optimally in any of these four categories has direct and dire implications for the health and well-being of humanity. When the microbial richness of soil is depleted due to human intervention, ecosystems cannot provide nutritious food products through agricultural yields. Without adequate animal/insect pollinators, processes of pollination seize to regulate the populations of pollinator-dependent plant species from which we derive essential foods and medicines. When large swathes of forest are destroyed, ecosystems cannot support robust habitats for plants and animals. And when oceans are polluted with garbage or excessive carbon dioxide, marine and coastal environments fail to uphold the cultural value that otherwise renders beaches an important setting for cultural and social gatherings and mental relaxation.

Whereas the great acceleration of the past 70 years has lifted millions from poverty and extended life expectancy, this has wrought devastating impacts upon our natural environment. As public health is fundamentally intertwined with the health and functional performance of ecosystems globally, such devastation represents a reversal of long-sought progress. Ecological breakdown, for example, has been shown to diminish yields and nutrient content of foods, and consequently detriment population health and agriculture-based livelihoods. Degraded ecosystems have profound negative impacts on mental health, particularly amongst indigenous populations. Through multiple impact pathways, anthropogenic interruption to planetary geophysical systems necessary for climate stability amounts to ‘species suicide’. The combined assault on humanity that environmental degradation represents is thus incompatible with a future conducive to human survival and wellbeing.

Examined in isolation, each attack renders massive harm to global health. For example, widespread insect decline is a growing concern, and a complete loss of animal/insect pollinators globally is estimated to place an additional 71 million people at risk for vitamin A deficiency and 173 million people at risk for folate deficiency, while contributing to 1.42 million additional deaths per year from non-communicable and malnutrition-related diseases. Urban environments lacking adequate greenspace suffer from greater air pollution, more frequent heat waves, higher rates of stress and anxiety, and increased non-communicable diseases. Similarly, cutting down trees has been linked to heightened waterborne disease spread due to reductions in flood control and resulting contamination of surface water bodies. Most recently, tropical deforestation, by increasing the frequency of interactions between humans and wildlife species, has proven to be a direct contributor to emerging infectious diseases which can trigger devastating epidemics and pandemics.

As global dialogue on climate change is underway at the 27th Conference of the Parties to the United Nations Framework Convention on Climate Change (COP 27), it is essential to acknowledge and raise concern on the impact of climate change, amongst other anthropogenic disturbances, on ecosystem health and biodiversity worldwide. The IPCC’s Sixth Assessment Report unequivocally articulated the adverse impacts, both current and projected, of climate change on marine and coastal ecosystems, terrestrial and freshwater ecosystems, and production of food, fibre, and other ecosystem products. This is already harming global health.

Due to loss of food production alone, the IPCC projects that climate change will increase the number of people at risk of hunger mid-century by 8-80 million, with rates highest in Sub-Saharan Africa, South Asia, and Central America. Meanwhile, projected increases in extremes of temperature and rainfall variability, droughts, flooding, and sea-level rise are projected to strongly increase the risk of frequent and severe aquatic human pathogen outbreaks in populated coastal areas. Due to changing terrestrial ecosystems and vector ranges, involving species expansion into warmer highland regions, the global burden of vector-borne diseases is also anticipated to rise substantially under various climate modelling scenarios. In essence, increasing parts of the globe will become uninhabitable.

As both the environmental and social determinants of health remain strongly practically and politically linked, the driving forces underpinning many of the social determinants of disease match the socio-economic influences that drive environmental degradation. Thus, injustice permeates all layers of the current socioecological crisis; those least responsible suffer the greatest and the world’s children—and future generations—lose their right to a habitable planet. Delaying action is not an option. Ecosystem-mediated impacts are clearly ubiquitous, and represent the multitude pathways through which climate change will increasingly erode public health if rapid, massive-scale action is not taken to protect biodiversity and imminently restore eroding ecosystem functions. A biosensitive approach requires that we structure our lives respectfully in tune with the natural world, other species, and the ecosystem processes on which our wellbeing stands. Transitioning to a nature-positive economic framework through this approach need not undo those gains as the World Economic Forum projects such a transition could generate US $10.1 trillion in annual business value and create 395 million jobs by 2030.

The WFPHA supports the United Nations’ stance when recognizing that “we are losing our suicidal war against nature” and stressing that “we have a choice: collective action or collective suicide”. It is in this light that the WFPHA affirms the human right to a clean, healthy, and sustainable environment and, in keeping with its commitment to protecting and promoting public health globally, calls upon delegates to COP 27 to:

• Prioritize (health-promoting) nature-based solutions to climate change adaptation, including but not limited to reforestation and afforestation, habitat protection, restorative agricultural practices, mangrove conservation, growth of urban green spaces, and expansion of natural carbon sinks like oceans, forests, peat bogs, and wetlands; and
• Champion the thought leadership and knowledge potential of indigenous groups when identifying best practices for community-based conservation, ecosystem restoration, and sustainable environmental management in the long-term

It is the WFPHA’s deeply held conviction that heeding this call to action is in the best interest of the global public’s health and is fitting with recently hailed principles of One Health that the COVID-19 pandemic has sharply illuminated the need for. While taking this stance, the WFPHA urges other public health bodies to follow suite and to affirmatively echo the WFPHA’s call to action on this matter.

Welcoming Our New Members

On October 13, 2022, during the Special General Assembly of the World Federation of Public Health Associations, member organizations have welcomed 2 new members; the Philippine Society of Public Health Physicians (PSPHP) and the Agency for Public Health Education Accreditation (APHEA).

We look forward to working together towards our shared goals of protecting and promoting health & wellbeing worldwide.