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The state of public health.
Remarks from a dying man.

Eberhard R. Wenzel
(September 2001)

        [H]ealth is something which should be enjoyed, not abused. A long painless life to a ripe old age, culminating in a death replete with life, is still outstanding, has constantly been planned. As if newborn: this is what the outlines of a better world suggest as far as the body is concerned. But people cannot walk upright if social life itself still lies crooked.
        Ernst Bloch (1995, originally published in German 1959), The principle of hope. Cambridge, Mass. (MIT Press), 471

The following remarks summarize some of my experiences with (international) public health during the past 20 years I have been involved in this area. They are reflections on what I believe are some key topics which public health needs to be dealing with in order to be able to contribute to the improvement of ways of life and living conditions conducive to health. Most programs and projects I know of nationally and internationally have failed regarding the topics mentioned. This is particularly true for one major issue I do not mention here, and that is environmental health (Holgate et al. 1999, Raffensperger & Tickner 1999, Steingraber 1997, Thornton 2000).

Unfortunately, I am no more able to offer scientific references for everything I comment on. Where possible and close at hand, however, I have included references simply to assure you that what I've written here does not refer to myths but to data which have been available for years and years, and which have hardly been taken into account when public health policies and programs have been developed and "implemented". To re-invent the wheel and ignorance seem to be two of our major current mental health problems among politicians and "experts", too.

Personal introduction

Let's get some personal issues out of the way. Yes, I have smoked too much. I have drunk too much. I have probably eaten the wrong diet (what is the right one?). I have worked too much; I have disregarded my body too much. In bio-medical terms, I have done it all wrong, probably.

But I have also been an excellent citizen of the "risk society", which by definition constitutes the globalized society or vice versa, I'm not sure (Beck 1992, 2000). I am a mobility expert in terms of geography at least. I have no home base, I am uprooted, I am mobile as one can be. You can send me to any place in the world and I will work. I can adapt to new environments and my brain works under almost all climatic conditions. In the end, I put almost 18.000 km between the place where I was born and the place where I will die. I am a good boy, ain't I?

Of course, there is a flip-side to this good boy. I was exposed to manifold stresses and strains. I suffered from not knowing where I belong to, and I only came to grips with what I have done in the past 30 years now that I am dying. While some have expressed their deep appreciation for my contributions to public health for which I am very grateful, they may not have been able to realize at which cost those contributions have been made.

The following remarks are written without being affiliated to any governmental or non-governmental organization. I can speak out as I have done in the past 6 years at least and be only responsible to what I call the truth.

Time and growth

Public health deals with human lives. Life means growth and growth happens in time. To be able to grow as a human being we need time. We assume that people are learning life-long, in other words, we assume that they change over their whole life-span.

We know from personal experience that change comes slowly and mostly it may happen after many detours. Our European concept of time and growth being linear and having become almost a commodity of planning and management, is unrealistic and violates all our knowledge about ecological processes of which humans are one part (Barker 1968, Bronfenbrenner 1979, Goffman 1986).

Take for example one of our favorite strategic terms "participation" or even "empowerment". Both refer to activities people need to adopt in their everyday-life in order to make them practical. They cannot be imposed on them by short-term projects of 2, 3 or even 5 years. Participation needs to be learnt, and this learning process takes many years during which we will have to find out where we wish to be and how to get there. It requires freedom of speech as much as freedom of choice, both of which seem to be resources, which are not available everywhere and in adequate qualities (Lyon 2001). The result of participation may be empowerment (Alinsky 1969, Minkler 1997, Rogers 1990).

Recently, a friend asked, how can I empower people in this project, and I said within 6 months you cannot empower anyone. It's ridiculous not to understand the dimensions of time and growth, which define the context within human development takes place over long periods of time.

Listen to what Indigenous people can tell you in this regard and you may find out how terribly limited the idea of rationalism in all its variations is, which European philosophers set into the world only 400 years ago (Cajete 2000, Lambert Colomeda 1999, May et al. 1998, Trudgen 2000).


The language of public health has taken up some Orwellian flavor when the term partnership was introduced. How can opposites like public health and private commercial interest groups ever become partners? The realities of our societies tell us that this fatal construction means that we contract out public responsibilities to the private sector. The result is a public health cash system where powerful corporations make money and the population, particularly those who can hardly afford it, have to pay for it with money and lesser services.

I have observed that in Australia there has been almost no resistance among public health experts against this development. The Medicare campaign of the Public Health Association of Australia seems to have gone nowhere. Political and economic interests seem to prevail including the Labour Party, who still claims to represent those who are not rich.

There are of course alternatives to this development, but there is no public discourse about them because there is hardly any public discourse in Australia, and I mean discourse, not mutual accusations, misinformation and other means of discrediting potential alternatives and their public debate.

International health / WHO

In January 1998, I sent out a personal comment on the electronic list-service that I have maintained from 1997-2001. The comment dealt with the nomination and the acceptance speech of Dr Gro Harlem Brundtland to become the Director General of the World Health Organization. In my analysis of her speech I came to the conclusion that she would open up WHO to the multinational vested interest groups. I warned that this would change international policy and practice fundamentally.

I received e-mails from two staff working for the Australian Government, which indicated to me that I might have gotten a little bit paranoid.

Three years later, in the year 2001, my paranoia has became political reality, not only on the international level of WHO (see for example Lerer & Matzopoulos 2001, Navarro 2001) but also with regard to national developments in Australia and elsewhere. One of the major political consequences is that the connection between health and human rights is not recognized (Mann et al. 1999).

It seems that we are selling public health to commercial interests (Kim et al. 2000) and it also seems that there are only few people worldwide who recognize and resist these developments. One exception may be the Peoples Health Assembly, which can be reached via their web-site at:

The latest shock I got was when I saw a paper published in Health Promotion International (September 2001) by one of the leaders in health promotion, the research of which was sponsored by the multinational pharmaceutical company Pfizer.

Non-governmental organizations

During the past years I have become increasingly concerned about the status of non-governmental organizations, nationally and internationally. I have observed that in many cases their budgets are heavily subsidized by governments.

The Public Health Association of Australia can only survive financially and thus organizationally because of the subsidies it receives from the Federal Government. As we all know those who pay decide about the music. Or at least they decide upon the music they don't want to listen to. The influence of governments on NGOs in terms of policies and statements of NGOs has become obvious, not only in Australia, of course, but elsewhere too (Edwards &.Hulme 1995, Satterthwaite 2001) Is that what we call partnership?

None of us is probably entitled to claim independence as a public health expert. Almost all of us are connected to the money infusion provided by the governments and which nicely fills our research, consultancy, or even private bank accounts. In this process, I believe we have lost our fundamental credibility as advisers to the people on public health matters. Rather than being advocates for public health, which we love and claim to be, it looks to me that many of us have become public health mercenaries.

If we want to regain credibility and confidence amongst the people we need to re-organize ourselves. We need to cut down expenses. Our conferences have become so exclusive that field workers can not afford to attend. It is simply obscene for a non-governmental public health organization that overall expenses to attend its national conference in Australia exceed more that A$ 1.000. Of course, it becomes worse with conferences of international NGOs, which can easily exceed U$ 1.500.

NGOs by definition are fora for everyone working in this area. To neglect those who do the hard work in the field displays a level of arrogance which only those can afford who do not care anymore.

Health policy formation

A friend told me about a theatre play, which was produced in Melbourne sometime between 1910 and 1920. I have forgotten the correct title of the play but it goes somehow like this "It's not about time yet". The play deals with policy development. Whenever the workers and trade unions asked for the improvement of housing, education, health care, occupational health and safety, etc. and demanded substantial policy changes the governmental response was "it's not about time yet"!

My friend saw the play again a few weeks ago in Brisbane. We looked at each other and I asked him: "so - when does the time come that these demands will be addressed and responded to properly?" We did not find an answer, we went silent, and after some time we were talking about some lighter issues.

Health policy formation these days seem to focus on preventing diseases of which we assume they are preventable in the first place. By "preventable" we usually mean that they are based on human behavior. The question is, isn't everything happening in any society based on human behavior? Does it then make sense to single out a handful of diseases, declare them "preventable" and neglect the underlying causes for these and other diseases? This may be the strategy of behavior change experts like psychologists, but does this constitute a reasonable, let alone effective policy for public health? I have my serious doubts about it. This type of policy formation is looking for a quick fix when there is none because the development of human ways of life is as much a long term process as would be the change of these lifeways. Since they are based on the specific living and working conditions of humans, it seems to me that policies need not only to address these conditions, but to change them to ones, which are conducive to health (Wenzel 1983, Wilkinson 1996, Raphael 2000).

Education and teaching

I find it utterly irresponsible that in many cases that I have seen, senior staff at schools of public health is not doing the actual teaching anymore. They give their names as course-convenors, but the teaching of the courses is often carried out by junior and sessional staff.

If we do not dare to send the best people to our students teaching and guiding them through the complexities of public health we loose the case. If we do not teach them to learn how to read and to listen to texts, to raise questions, to question questions, I believe we do not teach them critical public health. If we do not learn to listen to our students, to respect their attempts to come to grips with what public health may mean conceptually and practically, we are bad teachers. To be able to listen and practice mutual respect are essential skills of teaching in general (Dewey 1938, Michie 1999) but even more so when it comes to such human conditions like public health.

These considerations do not seem to be popular in times when governments and political parties become increasingly obsessed with the World-Wide Web, "flexible learning" and distant education and their assumed potential to teach students via computers and written material. It is claimed that the "new technologies" will improve education and professional training, but this assumption is of course nothing else but a rather weak hypothesis. I doubt that face-to-face communication and interaction between teachers and students can be successfully replaced by these approaches. I recall educational research from the 1970s, which indicated that this would not be the case. Perhaps, we are re-inventing the wheel again, spend billions of dollar for something, which cannot be generated with any amount of money, and that is human learning and human growth. Learning and teaching are times of reflection, too, reflection on the content and reflection on the self in relation to the content. Reflection needs communication with others in settings, which are conducive to reflection. I have my doubts whether the computer screen or print material are able to constitute these settings.


Well, it's time to go now. But I'll be with you for a long, long time. Once I am dead, I will be registered as another cancer death in the local, state, federal, and even international statistical cancer yearbooks. I will become a number. Looks like this is the fate of human life with modern public health research, isn't it?


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Copyright © by Eberhard Wenzel 2001