2020 saw competing approaches to COVID-19. Sadly, the dominant one was bio-medical, top-down, command-and-control oriented, and, in many cases, actively militarized.
Society was told it was “at war.” To defeat the virus, a range of bio-security measures were imposed to protect citizens against harmful pathogens. Key workers were sent to the front lines as warriors and — rightly — valorized; borders were closed to protect against attacks from invisible enemies; wider society was put under lockdown. In that approach, citizens and civil society were largely locked-out of meaningful decision-making, as in many cases were local leaders.
And while many, if not most, countries performed woefully in surveillance of their local epidemics, mass surveillance of their citizens escalated almost everywhere.
Just months into the pandemic, new laws and rules increasingly enforced behavior change. Around the world, as people and communities were disempowered, alienated, and criminalized, trust between leaders and those at the sharp end of restrictions dissipated.
Emergency powers often removed checks and balances on leaders. With diminished accountability, many leaders resorted to overcentralized responses that excluded the public, paradoxically undermining confidence, and voluntary compliance with necessary public health measures.
Only a science-based public health movement rooted in public interest, based on the values of participation, transparency, and justice, and grounded in strong linkages with health and other sectors will enable us to tackle the complex challenges of our time.
—There is a better way. This approach brings people to the center of shaping pandemic responses. It draws on rich traditions of participatory development and directly from AIDS activism and struggles for disability rights — including the mantra of “nothing about us without us.”
There is ample evidence that responses to COVID-19 need not instill fear; they can be inclusive and creative by involving civil society. By putting the “public” back in public health, more effective, equitable, and compassionate policies can be enacted. Measures supported by communities are much less likely to fall away due to “pandemic fatigue” — something we are facing right now.
To support community-friendly pandemic responses, we join a group of public health practitioners and academics in an open call to action to world leaders meeting at a special session of the United Nations General Assembly this month.
The call sets out 10 principles and approaches, starting with a recognition that communities and civil society have been a source of resilience, innovation, and mutual aid during the pandemic.
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By having a seat at the COVID-19 policy table, better policies will be implemented, informed by more diverse expertise and experience, and adaptable to local realities. Public health systems, hollowed out by decades of austerity and defunding, must be revived. Transparency will enable greater oversight of the use of public resources — as well as the use of public office more generally.
The call seeks measures that place restrictions on people to adhere to International Human Rights Law. Such restrictions must be scientifically sound, proportional to risk, non-discriminatory, least restrictive, time-limited, and subject to independent oversight.
When the intended and unintended effects of public health measures are beset by uncertainty, asking people to comply with these restrictions is expecting them to place their faith in their leadership. To retain public trust, leaders must lead with good communication, transparency, and humility.
Where leaders have acted in accordance with these principles, such as in New Zealand and Kerala in India, they have often succeeded in limiting the health and socioeconomic consequences of the pandemic. Where they have not, we see loss of public trust, repeated and protracted use of restrictive control measures, and unnecessary deaths and economic suffering.
In making the call, we are not only seeking to challenge world leaders to rethink their pandemic responses. We are calling for a revitalized, neo-public health movement. A renaissance of tried, tested, and proven approaches that put civic participation at the center and privilege bottom-up approaches — even during times of crisis.
Indeed, engaging the public is likely the antidote that is needed today given increasing public hostility and weariness with official dictates.
Engagement mechanisms, for rapid consultation with local leaders and organizations representing front-line workers for example, as well as procedures for emergency citizen assemblies, must be developed and hardwired into systems in advance so that leaders do not fall back on top-down approaches during emergencies.
Great crises test our resolve but they also provide opportunities for transformation. The COVID-19 pandemic has reinvigorated the conversation on what a 21st-century public health system should look like. Only a science-based public health movement rooted in public interest, based on the values of participation, transparency, and justice, and grounded in strong linkages with health and other sectors will enable us to tackle the complex challenges of our time.
The views expressed in this article are those of the authors and do not necessarily reflect the official position of their employers.
About the authors
Kent Buse
Kent Buse is co-founder and co-CEO of Global Health 50/50. He is a political economist who served as head of strategy and policy at UNAIDS for 13 years. He is an honorary professor at The George Institute for Global Health at the Imperial College London.
Wafa Aftab
Wafa Aftab is a physician, and health policy and governance researcher at the Aga Khan University, Pakistan.
