Liberating Public Health from the State

Anarchist Solutions in the Age of COVID


Fifth Estate # 407, Fall, 2020

Most public health concerns are ultimately local. Mutual aid projects and autonomous zones from New York City to Seattle, and from Chiapas and Rojava have shown how democratically controlled, non-hierarchical communities provide not only food and shelter but also health education, training and tools for people to care for themselves and their communities, families and comrades.

During the COVID crisis we have seen that mutual aid workers often function as community health workers who protect the public’s health. With special training and the acquisition of new skills they can become effective public health practitioners. Community health workers who live in and know their own communities are best prepared to educate people about health precautions, to test and do contact tracing, rather than using cops, as they recklessly did recently in NYC to enforce social distancing rules, and low-wage contractors hired by corporations to staff distant call centers.

A young activist recently said she felt like she was living in “1918, 1929 and 1968 all at once.” We are indeed now living through the worst global health crisis in 100 years and the most devastating economic collapse, still unfolding, since the Great Depression. We are also in the midst of a radical, broad and sustained mass social justice movement against structural racism and police violence the likes of which we haven’t seen since the civil rights and antiwar movements of the 1960s. Will this perfect storm ultimately bring us closer to a better world or will it reinforce the worst aspects of nation-states and neoliberalism?

COVID-19 is the deadliest pandemic in a century but it’s unlikely to be the last. The 21st century has already had two officially declared pandemics: the 2009 H1N1 influenza pandemic, and COVID-19. SARS, Ebola, avian flu, and others bordered on pandemic status but were not officially declared. Over the last 102 years there have been 5 pandemics, on average one every 20 years. Crucially, all of these infections were viral zoonotic infections that originated in non-human animals and were then passed to and infected humans.

Zoonoses are spreading with greater frequency because animal habitats are under increased stress due to human activities such as industrial farming and destructive extractive industries like mining, oil, and logging. Building roads and bringing workers to once remote areas increases the spread to nearby and regional population centers. It enables the commercial gathering of exotic animals for consumption by wealthy urban dwellers.

Human-caused climate change can also result in people coming into contact with previously unencountered species, as many animals need to seek new habitats. Increasing numbers of people also enter new areas to farm as rainfall and temperatures drastically change.

The dramatic growth of international travel completes this deadly chain of events that leads quickly as we have seen with COVID to new global pandemics.

There are striking differences in how countries have dealt with the COVID pandemic. Independent of a nation’s economic wealth, countries with well functioning public health systems have significantly lower infection and death rates than does the U.S. Despite decades of warnings from scientists that global pandemics were on the horizon, the US public health and medical care systems were almost completely unprepared for an epidemic of this magnitude.

Despite being the wealthiest nation in the world and having the most expensive health care, at the time of this writing, more than 1,000 people are dying daily. The US, with 4% of the world’s population, has a quarter of its infections and deaths. Four million have been infected in the US and at least 140,000 have died.

The U.S. public health system generally operates behind the scenes and receives little public attention except when there are disease outbreaks or disasters. But with COVID this has changed. It is now very much in the public eye. Technical epidemiological concepts such as herd immunity, R0 (reproductive number) and contact tracing are being discussed in media and at the dinner table.

This is the time for society to understand how public health’s potential has been limited by its subservient role in the US healthcare and political systems and hampered in its ability to prevent and contain COVID.

The discipline of public health is science based but is also a social and political undertaking intended to promote and protect the health of the entire population. Medical care on the other hand focuses on treating individuals who are ill or injured.

Public health applies the scientific methods of epidemiology to study how diseases occur in different groups of people and why. Wide and persistent disparities in health status, such as life expectancy, drug overdose deaths, suicide, chronic disease rates, maternal and infant mortality are strongly influenced by social determinants of health such as socioeconomic status, education, hierarchy, racism, violence, immigration status, the physical environment, employment, and social support networks.

Access to medical care plays a role as well, but not nearly as large as the underlying social and political inequities. By addressing the social determinants of health, public health can be a powerful tool for radical social change.

The World Health Organization (WHO) has played a crucial role in many previous outbreaks and pandemics, and is highly regarded for its high scientific standards. However they are also limited by the political restraints that come from their member states and dependence on funding from governments and the private sector. WHO is prohibited from even working with autonomous non-states such as Chiapas and Rojava.

Also, unlike global organizations such as the WTO, World Bank and IMF that deal with economic matters and can impose trade sanctions or withhold credit, the WHO has no ability to pressure or sanction nations to follow their guidance.

The ongoing threat of pandemics will require a globally coordinated response independent of narrow nationalist interests. We need a science-based, cooperative, non-state, non-hierarchical, democratic, and anti-capitalist worldwide public health movement. Millions of lives might have been saved if such a global system had been in place at the time that COVID-19 first appeared.

Public health is currently a captive of the state. But it is not inherently a state function like the police, prisons, military, and courts that must be abolished along with the state. Public health must be liberated from state control and turned into a democratic, science-based, humanitarian, decentralized movement for human freedom and liberation.

Bruce Trigg is a public health physician and addiction medicine consultant who lives and works in NYC. He worked for three years in the Indian Health Service in Native American communities in New Mexico and Arizona.