Public Health Systems and Systems of Oppression
To prevent the past from becoming prologue, we must first acknowledge how public health institutions can play negative roles in pandemics and epidemics.
The University of Minnesota School of Public Health – where the Center for Public Health Systems calls home – has five core values, the first of which is health is a human right. This value guides the work of many public health scholars. It has also been a driving force behind the careers of many whose work reaches beyond public health. In Pathologies of Power: Health, Human Rights, and the New War on the Poor, the late Paul Farmer emphasized health as a right, further arguing that health inequities result from systems that are fundamentally unjust. Farmer’s words remain a cautionary tale. This must be heeded in public health systems research and practice because fundamentally unjust systems include the systems of public health. Put another way, the field of public health itself can exacerbate health inequities even as we try to eliminate them.
Even before Farmer, Ivan Illich warned of this danger in the 1970s, proposing the concept of medical nemesis. This was defined as the threat that medical professional practice posed to health. Illich wrote that “so-called health-professions have an indirect sickening power – a structurally health-denying effect.” Though Illich’s warning originally was aimed at medical practitioners, it is undeniably applicable to modern public health. For example, he argued that “[m]uch suffering has always been man-made.” It doesn’t take much imagination to understand how this is epitomized in a world where COVID-19 vaccines aren’t public domain but are instead owned by private corporations – a world where 2.3 billion people haven’t received any vaccination against COVID-19 while the United States government debates authorizing second bivalent boosters in an effort to prevent doses with looming expiration dates from going to waste amid low uptake of the first bivalent booster.
More recently, Eugene T. Richardson’s Epidemic Illusions: On the Coloniality of Global Public Health echoed these arguments. Specifically, he noted the widely held incorrect assumption that poor health is primarily caused by biological pathogens. While the proximal cause of disease is, of course, biological, Richardson emphasized the ultimate, social/structural causes and argued that more attention needs to be focused on these upstream factors. In other words, assuming epidemics to be primarily biological hides how colonialism is responsible for their spread. Richardson highlighted Ebola in Africa, noting the history of resource extraction from African countries by European and American empires and how this continues to affect public health infrastructure and emergency response. Another prime example is Haiti, where descendants of enslaved people were forced to pay billions to descendants of French slaveholders until 1947 in compensation for the nineteenth century Haitian Revolution that ended slavery in the country. Haiti was left in a perpetual state of “double debt,” with minimal – if any – funds to support public health. In this vein, Richardson argued that ignoring the history and continuation of colonialism and imperialism to instead focus on the biological causes of disease – the phenomenon that he called the epidemic illusion – prevents us from properly responding to these public health emergencies. Yet again, we turn to Haiti for an example: foreign aid workers responding to earthquakes were responsible for the first cholera outbreak in the nation’s history. Multiple American federal agencies played roles in obscuring the outbreak’s source, slowing mitigation efforts. To prevent the past from becoming prologue, we must first acknowledge how public health institutions can play negative roles in pandemics and epidemics.
But what more can be done? In a previous article, I proposed revising the definition of syndemics to include both biological and social epidemics (previously, it had only been conceptualized as two or more biological epidemics interacting negatively with their social environments). This is more than a semantic argument; it is a change in framing how we see disease and health. Yes, viruses, bacteria, fungi, and other foreign matter are responsible for disease on some level. But so are other, larger systemic actors – and we can’t effectively treat epidemics without addressing all their causes. Defining these phenomena as public health concerns allows us to direct resources, such as funding and personnel, to address and eliminate them.
The takeaway, then: if health is a human right, then poor health is a violation of that intrinsic right. The critique outlined in this post can help us better illuminate – and hold accountable – the systemic actors responsible for poor health, even if the systemic actors are the very public health systems we study.
- Nikki Weiss is a biocultural anthropologist specializing in mixed methods research. She completed her undergraduate education in biology at the University of Wisconsin-Eau Claire, and she earned her master’s and doctorate in anthropology from Ohio State University. Before arriving at CPHS, Nikki worked for the Johns Hopkins Center for Indigenous Health – Great Lakes Hub, as well as for the CDC Foundation. Her research interests include health equity and making health care accessible and attainable for all.
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