During my internship at the ASPHER’s office in Brussels I followed two main tasks in the broad field of geopolitical health: first, I conducted a scoping literature review to identify Public Health frameworks dealing with the primary prevention of war (still in progress), and second, I did interviews with different stakeholders on the topic of geopolitical health in the context of the Public Health profession.

Why all this? Wars and armed conflicts, e.g., have a major impact on the health of the population. Direct consequences of wars include increased mortality and morbidity, indirect consequences are more difficult to assess but mostly deal with mental health issues and rehabilitation. Wars can also affect the environment, economic and food security which can cause even more deaths in the long run as the war itself. As Public Health aims to increase the health at the population level through, e.g., health interventions and education, Public Health professionals play a significant role in dealing with war. There is a dire need for more research on conflict prevention. Preventing conflicts before they even occur is the greatest challenge.

As the main goal of ASPHER is to strengthen public health by improving education and training of public health professionals for practice and research, it is of great relevance to address their role in geopolitical health. But what is meant by “geopolitics” and “geopolitical health”? Geopolitics in general delas with the analysis of the geographic influences on power relationships in international relations (e.g., climate change, scarcity of resources, disagreements over ownership of land or areas, etc.) (Deudney, 2013). According to Persaud et al. (2021) health is not just shaped by social determinants but also by geopolitical determinants. These are determinants related to governments, geographies, policies, and the interests of countries and the relationship between them. Understanding them can help drive evidence, advocacy, and policy action to improve global health. Therefore, empirical approaches conceptualizing experiences and perspectives of stakeholders can help to identify new levers for advocacy and practical change (ibid.).

Thus, interviews with different stakeholder groups, were conducted on-site in Brussels to get an impression of their thoughts on geopolitical health and the role of public health professionals as well as schools of public health. At this point it should be said that the interviews to a large extent reflect the opinions of the individual partners and are not directly/automatically related to the attitudes of the institution in which they work.

All stakeholders had a health background but work in a wide variety of institutions. Two worked at the European Commission, and one each at the Observatory on Health Systems and Policies, the International Organisation for Migration, Maastricht University, and a pharmaceutical company that will not be named in this blog. Their tasks ranged from administration to the analysis of health systems and policies, and from research to humanitarian work.

The extent to what geopolitical events and/or decisions or geopolitics in general play a role in the stakeholder’s field of work and the way in which they address them differs but still strongly influences their work. The two interview partners from the European Commission see health as a political issue, especially when looking at COVID-19 and other infectious diseases. Particularly the distribution of vaccinations is not scientific anymore (which is seen as one of the main tasks of the Public Health profession). In this respect, health is seen as an instrument of geopolitics as never before. To address geopolitical discrepancies the European Commission can give and raise political attention to this topic, set up regulations, global standards (e.g., regarding medicines and medical devices) and certification and authorization systems. An important role is also to ensure the security of supply chains which became a relevant political topic during the COVID-19 pandemic. The focus here is primarily on secondary and tertiary prevention. At the European Observatory on Health Systems and Policies, geopolitical events influence the work less directly, as they are not a consultancy but provide evidence. However, the most important research in this area concerns the resilience of health systems and thus the preparedness of these systems for new shocks, e.g., war, COVID-19, and AMR. Therefore, they can work on resilience, financial and health support, focus on hospitals and human resources, promote health in all policies, reduce poverty and improve the education system (as it is according to them directly linked to war). Finally, the interview partner stresses the relevance of understanding the root causes of war. Preparedness is also the starting point for the work of IOM, which is concerned with preparing for refugee flows that arise, among others, from geopolitical grievances. In this regard, they work in two dimensions: politically and practically. On the one hand, they do research to advise decision-makers and on the other they directly assist migrants as a reaction to crises. In contrast, pharmaceutical companies have the mandate not to be politically active, at least not in the private sector. Their work in times of crises is to support humanitarian work to maintain supply chains, share expertise, and fund research. In addition to the companies, I talked to one Public Health professional working in the research and teaching field at a university. He says that research and data science are important to conduct, especially regarding mental and physical health outcomes. He argues that at this micro level data is existing and thus ready to be used, while on the macro level it is lacking.

So, in the opinion of all stakeholders, how can the public health profession in general address geopolitical grievances (also looking at primary ways to prevent these)? One interviewee from the European Commission points out that at first, the Public Health profession should raise attention to the topic by conducting research in order to bring challenges and needs in this context to politicians, the public and other relevant stakeholders. Professionals can also offer mental health services, provide food and basic pharmaceutical products, e.g., for people with diabetes or high pressure and it can function as a principal advisor of health. According to the European Observatory on Health Systems and Policies, the strengthening of resilient health systems is most important. Additionally, the interview partner thinks that Public Health has a huge responsibility in advocacy. It has a professional dimension but also a political one: it has to defend especially vulnerable populations which are according to the interview partner most burdened by crises, but also predestined to instigate them due to great inequality. On the other hand, Public Health must be careful to position itself in conflicts in terms of becoming a participant to one of the belligerents. This is also the position of IOM and pharmaceutical companies due to their neutral function. The interview partner from the pharmaceutical company called for health in all policies and emphasizes the political role the Public Health profession has. The person says that many people say that this profession must be apolitical or neutral, but he/she argues that it is close to the health of people and thus must ensure it. This is of great importance, for example, in wars that involve many dead and injured people and destroyed health systems. The Public Health profession wants to avoid this and thus needs to learn how to be political. In his/her opinion, however, it is not the task of public health to prevent wars. The Public Health researcher said that in addition to the obvious research work, public health professionals should cooperate with historians in order to understand past geopolitical contexts and thus be able to recommend courses of action for future events. The biggest challenge – based on own experiences of the interview partner – is the work with data that is losing interest. There is an event occurring, but you have to work at least ten years on it to understand the causes, etc. and you have to ask yourself the question: is this really helping policy makers in the current situation? What is actually needed in his/her opinion is an “emergency” package for future events based on data and lessons learned from former events and the deeply understanding of population structures. Another challenge is that in lots of cases policy makers talk to economists rather than Public Health professionals. Therefore, it is important for these to understand the mechanisms of the event and to be able to communicate it to decision and policy makers properly. The person argues that Public Health is not yet prepared with explicit arguments; economics have a more common language with political leaders and their recommendations and research are most of the time directly applicable, Public Health needs more time for research. The communication with policy makers could, e.g., take place via thinktanks. Public Health has to build bridges to make itself available for the policy area.

After discussing the role of Public Health in general, it is of great relevance to address the role and the involvement of schools of Public Health in this context. Both European Commission experts say that public health professionals need to be familiar with speaking politically, so they need to be trained in political communication and in the interests and functions of the different stakeholders in order to work on an equal footing. In this regard, one of them considers internships in political structures and courses on, e.g., governance and lobbying useful. The other one stresses the aspect of problem based learning as an option for students to directly translate theory into practice. The person also considers the understanding of the complexity of health in all policies and of changes in society relevant. The interview partner from the European Observatory supports the argument of strengthening political communication in school courses. Additionally, he/she emphasizes together with the experts from IOM Public Health’s’ role in advocacy. IOM also recommends a stronger inclusion of refugees in the existing curricula, e.g., cultural factors. From the perspective of the interview partner from the pharmaceutical company, it is important that students of Public Health are aware that their profession is a political profession and there has to be a political understanding. This again supports previous statements on the topic of politics. The Public Health researcher came to the same conclusion. In his opinion, schools have three tasks in this field: first, training of the Public Health work force so that every graduate realizes that they play an important role in geopolitics. Second, there have to be courses on war but also on professional development so students interested in this area could get trained in communicating with and providing information for policy makers. Third, he argues that schools of Public Health are not specialized in/not best suited for cooperation with policy makers and that they currently underestimate the task of education in communicating and advising policy makers and that has to be a competency taught completely on its own.

Another striking aspect emerging in the interviews in this regard was to what extent Public Health should be political. Some stakeholders said that Public Health reached the border during the COVID-19 pandemic, especially when looking at the distribution of vaccinations. Others say that Public Health needs to be more political because health is a political issue, particularly regarding wars and conflicts. One interview partner points out that there is a differentiation between politics and policy in English and Public Health professionals are policy makers, so they play a relevant role in changing the attitudes of patients, citizens, industries on e.g., vaccinations, wars, etc. The pandemic in particular has politicised science, he/she said, and all the international discussions about containment measures of governments have made this clear.

References

Deudney, D. H. "geopolitics". Encyclopedia Britannica, 12 June 2013, https://www.britannica.com/topic/geopolitics. Accessed 15 June 2022.

Persaud, A., Bhugra, D., Valsraj, K. & Bhavsar, V. (2021). Understanding geopolitical determinants of health. Bulletin of the World Health Organisation 99(2), 166-168.