This is an exciting and challenging paper1 that covers many important aspects of public health in an illuminating way. The historical background (‘the origins of public health’) is particularly useful. I do not want to disagree with the author, but rather extend his argument at one level, primarily around neo-liberalism. I also want to argue for a yet greater strengthening of the involvement of the community in public health policy.
There are many different interpretations of public health. To my way of thinking, while not neglected, not enough mention is made in this paper of social justice and inequalities, especially in the work of Navarro2 and Wilkinson.3 The divides between rich and poor are increasing internationally and in Australia. Where the responsibility for these divides might lie does not get addressed.
A large part of that responsibility, in my view, might be laid at the door of neo-liberalism. This, however, is played down in the paper in two ways. First, it is argued that “we need to be careful that we do not make extravagant claims about the evil empires of global commercial interests”. Second, it is suggested that: “The heyday of globalisation is not today. It was in 1914.” The issues here are dismissed: “We’ve been there and done that.”
On the first point there is no need to make “extravagant claims” but just to look at the evidence. On the second point, the issue is not globalisation per se; it is neo-liberal globalisation, which has only existed for the past three decades.
Poverty creates problems for population health. These problems are then fed by neo-liberalism's individualism, which leads to loss of social cohesion and social solidarity and in turn greater population health problems. There are various analyses of these phenomena. Navarro,4 for example, shows that redistributional policies for income, employment and services are the keys to improved health status for populations, especially for those most disadvantaged.
It is also noteworthy that industrialised countries, by and large, have continued to prefer publicly funded health care. However, at the same time – and hypocritically – these same countries, together with the World Health Organization (WHO) and the World Bank, have encouraged the commercialisation and privatisation of health care in developing countries. This is evidenced by data that show that, in general, the lower the income of a country the higher the proportion of health care spending that is private.5
Another problem that arises through neo-liberal globalisation and the freeing up of trade is the movement of labour, especially doctors and nurses, from developing to developed countries. It has been estimated that poor countries are subsidising industrialised Western countries by about $500 million a year through the migration of health care workers.5
In the context of public health, neo-liberalism's philosophy of individualism represents, as the Canadian philosopher Charles Taylor6 argues, a major source of The Malaise of Modernity. He writes of what he calls “the dark side of individualism”, which “centres on the self, which both flattens and narrows our lives, makes them poorer in meaning, and less concerned with others or society”. While Taylor does not write as specifically about culture, this flattening and narrowing must also reduce diversity of culture. Individualism encourages us to look inwardly and introspectively at ourselves, which then affects our capacities to see ourselves as part of a society or community and to recognise the importance of the culture in which we live. There is a prospect of creating a world of free-floating atoms, not caring about others, not caring about culture. We risk ending up behind the veil of ignorance of Rawls7 not just as a philosophical construct but in the real world, with, in Thomas Nagel's telling phrase, The View from Nowhere.8
With respect to the impact of neo-liberalism on income inequality, there is evidence from a number of sources9 that neo-liberal societies tend to be less equal. Further and contrary to popular belief, it seems that neo-liberalism does not promote faster economic growth. Navarro takes the starting point of neo-liberalism as being 1979-80. He compares growth rates in a number of countries over the 1960s through to the 1990s. He shows that the rate of economic growth was higher in the 1980s than in the 1970s.9 Just four countries stand out as bucking this trend – and these four were protected by highly regulated labour markets and other such non neo-liberal policies.
Vandana Shiva10 expresses concern about the threat to cultural diversity as a result of the move to the global monoculture of neo-liberalism. Where people are comfortable in their own cultures, where their cultures breed self-respect and are respected by others, then population health is more likely to flourish. Where, as in many Indigenous cultures such as in Australia, cultural self-respect has been lost in the wake of colonialism and neo-colonialism, neo-liberal globalisation is destroying cultural diversity. In the wake of that, it is adding to the problems of social self-respect and in turn of public health.
The paper1 also points to the way in which we organise our lives – how we eat, the urban environment, etc. – as being the cause of certain risk factors, such as obesity. Yes, but why do we eat as we eat? Is there not some link here between the profit making of the fast food industry and our eating habits?
I agree that “society – the public – needs to be more closely involved with the public health agenda and politically supportive of it”.1 But that is not enough. An informed public through, for example, citizens’ juries11 needs to set the public health agenda. Public health professionals can assist in saying what the impact would be of a tax on fast foods, of banning advertising of junk food on TV, of subsidising jogging shoes, etc. But it is the community's values, within relevant resource constraints, that should determine the ‘constitution’ or set of principles on which public health policy should stand. The community should also be able to check periodically that what they have asked for, they are getting.