Announcing ‘The Philosophy of Public Health’ by Benjamin Smart

It is a delight to share the publication of The Philosophy of Public Health by CPEMPH co-Director, Professor Benjamin Smart of the University of Johannesburg. This is an important and timely book which exemplifies the best of applied philosophical thinking: it identifies deep conceptual problems that arise in real-world contexts, and uses rigorous philosophical tools to reach conclusions that can guide public health practice.

At its core, the book develops a powerful account of health as a property of complex systems. Rather than treating health as a feature of isolated organs or discrete individuals, Ben argues that health is an emergent, capacities-dependent property instantiated at multiple biological and social levels: cells, organs, organisms, and—crucially—populations. This move allows him to dissolve familiar puzzles about “population health” and to provide a framework that aligns far more closely with what public health professionals actually confront.

A second major contribution concerns the goal of public health. Ben rejects the simplistic idea that public health should merely raise aggregated individual health scores, noting that such metrics neglect inequality, autonomy, and the broader social determinants of health. Instead, he argues that public health should aim to increase the capacities that matter for individuals’ ability to realise the goods of life—capacities that range from access to clean water and functioning healthcare systems, to education, mobility, and the structural conditions required for dignified living.

The book also provides a philosophically grounded defence of Evidence-Based Public Health that is sensitive to context, values, and the limitations of traditional hierarchies of evidence. Ben engages seriously with recent failures in global pandemic response, arguing for a more nuanced and context-aware understanding of what it means to “follow the science”.

In the final chapters, he turns to ethics and the question of decolonising public health, offering a principled but pragmatic framework for navigating public health decision-making across profoundly unequal societies. Throughout, the book is shaped by his decade of experience living and working in South Africa, but its arguments travel far beyond this context.

The result is a work that will influence both philosophers and practitioners. It is a rare example of philosophy that is simultaneously conceptually rigorous, policy-relevant, and deeply humane. I could not be more pleased to see it in print, and I recommend it warmly to anyone working in public health, philosophy of medicine, or the conceptual foundations of health policy.

Congratulations, Ben. 

Negligent Racism in COVID-19 Lockdowns

We are pleased to announce the publication of a new article by CPEMPH members Alex Broadbent (Durham University) and Pieter Streicher (University of Johannesburg), titled Was Lockdown Racist?”, in Ergo: An Open Access Journal of Philosophy.

In this paper, the authors introduce the concept of negligent racism—a form of racism that does not require intent but arises when policy choices foreseeably cause disproportionate harm to certain racial groups, and alternatives are available but ignored.

Focusing on the impact of COVID-19 lockdowns in sub-Saharan Africa, the article argues that these measures, regardless of intention, were ill-suited to the region’s socio-economic realities. The authors contend that the adoption of lockdown policies, modeled after responses in wealthier nations, led to significant harm in African contexts, where factors such as overcrowded housing, reliance on informal economies, and limited access to essential services made strict lockdowns particularly detrimental.

The paper challenges the notion that the adverse effects of lockdowns were merely consequences of existing inequalities. Instead, it posits that the global implementation of such policies, without adequate consideration of their suitability for diverse contexts, exemplifies negligent racism.

This publication contributes to ongoing discussions about equity in global health policymaking and underscores the importance of context-sensitive approaches.

📄 Read the full article here

Or listen to an AI-generated podcast about the article here…

Methodological Pluralism in Epidemiology: Lessons from Covid-19

We are pleased to share a commentary published in Global Epidemiology by CPEMPH members Pieter Streicher and Alex Broadbent, with co-author Joel Hellewell (EMBL-EBI), titled The need for methodological pluralism in epidemiological modelling.”

This paper examines two high-profile failures in Covid-19 forecasting by the UK’s Scientific Advisory Group for Emergencies (SAGE), during the Delta and Omicron waves of 2021. In both instances, projections proved not only inaccurate but too vague to be practically useful—hospitalisations were overestimated by an order of magnitude, and deaths by even more.

The authors argue that a key contributor to these failures was SAGE’s reliance on a single modelling approach: mechanistic simulation. By contrast, the South African Covid-19 Modelling Consortium adopted a pluralistic strategy—combining mechanistic and descriptive methods, learning iteratively from outcomes, and achieving far greater predictive accuracy despite far fewer resources.

The commentary makes a strong case for adopting methodological pluralism in epidemic modelling, highlighting the value of multiple, complementary perspectives when dealing with uncertainty in high-stakes contexts. The paper calls for diverse methodological inputs, critical evaluation of past performance, and more open-minded engagement with data from a variety of global contexts.

📄 Read the full article here

Pandemic response strategies and threshold phenomena

Delighted to share the publication of “Pandemic response strategies and threshold phenomena”: https://www.sciencedirect.com/science/article/pii/S2590113323000081 by Pieter Streicher and I. Really proud of this one. Abstract below.

This paper critically evaluates the Suppression Threshold Strategy (STS) for controlling Covid-19 (C-19). STS asserts a “fundamental distinction” between suppression and mitigation strategies, reflected in very different outcomes in eventual mortality depending on whether reproductive number R is caused to fall below 1. We show that there is no real distinction based on any value of R which falls in any case from early on in an epidemic wave. We show that actual mortality outcomes lay on a continuum, correlating with suppression levels, but not exhibiting any step changes or threshold effects. We argue that an excessive focus on achieving suppression at all costs, driven by the erroneous notion that suppression is a threshold, led to a lack of information on how to trade off the effects of different specific interventions. This led many countries to continue with inappropriate intervention-packages even after it became clear that their initial goal was not going to be attained. Future pandemic planning must support the design of “Plan B”, which may be quite different from “Plan A”.

Was lockdown racist? Lecture in Princeton Center for Human Values, Boston SPH

Delighted to be giving a talk called “Was lockdown racist?” at the Princeton Centre for Human Values (2 Nov) and the Boston School of Public Health’s Department of Global Health (7 Nov).

Princeton: 2 Nov @ 4.30pm, Center for Human Values

Boston SPH: 7 Nov @ 1pm, Dept of Global Health

Abstract

In 2016, South African learner Zulaikha Patel argued that a school rule requiring hair to be neat was racist, despite applying equally to pupils of all races. This paper argues that suppression strategies deployed against Covid-19, especially in the early stages of the pandemic, were racist in the same way. The suppression strategy was motivated by science done in traditional seats of colonial power. Local factors shaped (as they normally do) both the methods used and the recommendations arrived at. These did not adequately consider the situation of many people globally living in various contexts of poverty: including on those in Africa. Notwithstanding, the recommendations were promulgated by the World Health Organisation and others, with no regard for local context. Feasibility of implementing “lockdowns” in breadline conditions, effectiveness in overcrowded conditions, local priorities, and the age of the population (in Africa, median 19.7) were not contemplated. Local political and financial interests were aligned with this neglect, and local scientific capacity was in any case lacking. When a regulatory package is implemented in an African country with high costs and low benefits, and originates in a strategy conceived in Europe and promulgated by European-based international organisations, it is impossible to ignore racial dynamics. I show that the trope of “lockdown” as enacted for Covid is a central difference between the responses to Covid and other epidemics in Africa, and I show that one cannot adequately explain this contrast without reference to race. Therefore lockdown was racist.

‘Can you lock down in a slum?’ published in Global Epidemiology

Delighted that this paper co-authored with Pieter Streicher has now been published in Global Epidemiology.

Broadbent A, Streicher P. Can you lock down in a slum? And who would benefit if you tried? Difficult questions about epidemiology’s commitment to global health inequalities during Covid-19. Global Epidemiology. 2022;4:100074. doi:10.1016/J.GLOEPI.2022.100074 (https://www.sciencedirect.com/science/article/pii/S2590113322000049)

Was lockdown racist?

Delighted to be giving a new talk this week in Cambridge and Utrecht.

Tuesday 17 May, 2.30pm BST: Cambridge Moral Sciences Club, Newnham College

Friday 20 May, 16.15 CET: Conference, Covid-19 and Public Policy, Utrecht University

Abstract

In 2016, South African learner Zulaikha Patel argued that a school rule requiring hair to be neat was racist. Even though the rule applied equally to everyone, public opinion swung behind Patel: a rule that imposed a disproportionate burden on Black learners could be racist even if it applied equally to all. The school suspended the rule. Basing itself on this case, this paper argues that global lockdowns in the first half of 2020 were racist. The paper focuses on Africa, arguing first that the lockdown strategy of implementing stringent stay-at-home regulations was externally imposed upon Africa, tracing the origins of this policy to the way that modelling results were presented so as to make just one option feasible. The resulting recommendations were promulgated globally by the World Health Organisation, and geopolitical power relations placed huge pressures on African states to comply. Next, the paper argues that locking down placed a disproportionate burden on Africa, whose population is the poorest in the world and for whom no work often means no food. At the same time, the potential benefit of the policy was small. With a median age of 19.7, much of the population was just too young for Covid ever to be a serious public health problem, and by the same token other threats to life compete for attention. Slum-dwellers cannot reduce their social contact by 75%, which is the figure used in the model upon which the recommendations were based. Most states in the region are unable to afford or implement meaningful food or grant schemes to compensate. Many African countries have no ventilators and low access to health care, so protecting the healthcare system was not a meaningful goal. And the strategy of locking down until a vaccine was available could never have been credible in a region where millions of children die annually from diseases treatable by penicillin. Where a policy originates in Europe and has disproportionate negative effect in Africa, it is impossible to ignore racial dynamics. “Black” is a colonial vestige that does not do justice to the ethnic diversity in Africa. Yet it can be legitimately used as Patel used it: for purpose of internal critique, and as an adjunct identity that does not negate other identities. Lockdown had a disproportionate negative effect on a very large number of Black people, and it was externally imposed. Therefore lockdown was racist.

An egalitarian evaluation of lockdown

I’ve started a new job and in the process not posted anything here for months, nor done a whole lot worth sharing. Now I’m dusting off my “lockdown talk” and updating it, with a view to writing it up soon. It’s now called “An egalitarian evaluation of lockdown” and I feel like it’s matured quite a bit. I also now have the benefit of being able to talk about the global vaccination mess as something totally foreseeable, which matters because awaiting a vaccine is an integral part of the strategy I criticise. Here’s the abstract:

“Lockdown” has come to designate a cluster of non-pharmaceutical interventions intended to slow or stop Covid-19. One familiar line of objection to lockdowns is libertarian: lockdowns restrict freedom of movement, association, and so forth. However, the appeal of libertarian arguments is limited to (a) moral contexts globally where individual liberty rights are a primary dimension of policy evaluation and (b) audiences that see such rights as outweighed by the dangers of Covid. Among the latter are some motivated by egalitarian considerations, who claim that Covid hits poorer people including “minorities” harder than richer people. This paper contends that there is a neglected but extremely powerful egalitarian argument against lockdown, based on the fact that most poor people live outside rich countries in circumstances where lockdowns offer no protection, where the risk posed by Covid 19 is lower both absolutely (due to demographics) and relative to other risks to life (due to these being greater), and that lockdowns greatly exacerbate these risks. This includes racial and other majorities who are routinely referred to as “minorities” by authors in rich countries. The paper argues that neglect of these facts is an instance of epistemic injustice, the victims of which are predominately so-called “persons of colour”. The paper argues further that the unfair features of lockdown are not coincidental, but that it was these very features that led to their endorsement by powerful groups, nations and international bodies, and to the persistent positive attitude to lockdowns. From an egalitarian standpoint, their actions can be interpreted as using the commanding heights of the global knowledge economy, not to reduce the global burden of Covid overall, but to transfer as much of the burden of Covid as possible from the global rich to the global poor.

“Lockdown” has come to designate a cluster of non-pharmaceutical interventions intended to slow or stop Covid-19. One familiar line of objection to lockdowns is libertarian: lockdowns restrict freedom of movement, association, and so forth. However, the appeal of libertarian arguments is limited to (a) moral contexts globally where individual liberty rights are a primary dimension of policy evaluation and (b) audiences that see such rights as outweighed by the dangers of Covid. Among the latter are some motivated by egalitarian considerations, who claim that Covid hits poorer people including “minorities” harder than richer people. This paper contends that there is a neglected but extremely powerful egalitarian argument against lockdown, based on the fact that most poor people live outside rich countries in circumstances where lockdowns offer no protection, where the risk posed by Covid 19 is lower both absolutely (due to demographics) and relative to other risks to life (due to these being greater), and that lockdowns greatly exacerbate these risks. This includes racial and other majorities who are routinely referred to as “minorities” by authors in rich countries. The paper argues that neglect of these facts is an instance of epistemic injustice, the victims of which are predominately so-called “persons of colour”. The paper argues further that the unfair features of lockdown are not coincidental, but that it was these very features that led to their endorsement by powerful groups, nations and international bodies, and to the persistent positive attitude to lockdowns. From an egalitarian standpoint, their actions can be interpreted as using the commanding heights of the global knowledge economy, not to reduce the global burden of Covid overall, but to transfer as much of the burden of Covid as possible from the global rich to the global poor.

It’s bound to be a controversial line of argument in one way, because it’s drawing a normative moral conclusion that’s pretty far-reaching. But in another way, I hope that it might prove more appealing to people who are fed up with “lockdown scepticism” based on libertarian arguments that they just don’t accept (as well as showing “lockdown sceptics” that they might have other intellectual avenues to pursue). It breaks with the familiar left/right and public health/libertarian dialectics, which I regard as rather North/West focused, and as missing an important set of points and contexts. Hopefully many can agree about at least the need for an evaluation that is both global and focused on equality, even some who reject my own evaluation.

I’ll be delivering the talk at a conference hosted by the University of Macau titled ‘The Moral Roots of Lockdown: East Meets West.’ The programme looks really interesting (setting aside my own contribution). See below. Email the organisers for a zoom link: mrqconference@gmail.com

Covid Philosophy Week, 10-13 May 2021 – Registration Open

The journal Philosophy of Medicine, the Department of HPS, Cambridge, and the Institute for the Future of Knowledge, U Johannesburg, bring you a multi-day programme of philosophical discussions responding to Covid-19. There are three events:

10-13 May, Conference: Philosophical Perspectives on Covid-19, hosted by Philosophy of Medicine and the Institute for the Future of Knowledge (UJ)

12 May, Workshop: The Individual and the Population, part of the series Rethinking the Ethics of Vaccination organized by Emma Curran and Stephen John (Cambridge HPS)

13 May, Panel: Philosophy of Medicine on Covid-19, hosted by Philosophy of Medicine and the Institute for the Future of Knowledge (UJ)

These events have been timetabled so that they do not clash and are accessible for as broad a range of time zones as possible.

Registration and further info for all three events available here: https://philmed.pitt.edu/philmed/CovidWeek

Warm regards,

The Editors, Philosophy of Medicine

https://philmed.pitt.edu/