Wellbeing Forum 2022

FROM SURVIVING TO THRIVING

WELLBEING FOR THE INDIVIDUAL, SYSTEMS, AND SOCIETY

COURIER

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THANK YOU

THANK YOU TO OUR PARTNERS AND SPONSORS FOR THEIR SUPPORT OF THE WELLBEING FORUM AND THE WORLD IN 2050.

CO-HOSTS

STRATEGIC PARTNERS & SPONSORS

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CONTENTS

INTRODUCTION

BY ANA C. ROLD

WELCOME BY DAVID MOU

THE EMOTIONLESS SOCIETY BY JON CLIFTON

WORLD UNHAPPIER, MORE STRESSED OUT THAN EVER BY JULIE RAY

THE ECONOMICS OF WELLBEING BY DAN WITTERS

PERCENT WHO FEEL EMPLOYER CARES ABOUT THEIR WELLBEING PLUMMETS BY JIM HARTER

REIMAGINING CARE BY ANNE-MARIE SLAUGHTER

WHAT IS THE LONELINESS CRISIS AND HOW DO WE FIX IT? BY KATIE WORKMAN

COVID-19’S UNENDING IMPACT ON THE MATERNAL MENTAL HEALTH CRISIS BY KATIE MILGROM

WELLBEING POST-PANDEMIC BY DERRICK WONG

OWN YOUR HEALTH: HOW PEOPLE LIKE YOU AND ME CAN HELP REBUILD HEALTH SYSTEMS BY DANIELLA FOSTER

HEALTH IS FREEDOM BY KERMIT JONES, MAYA KAHWAGI AND NEEL VAHIL

HEALTH MESSAGING IN THE DISINFORMATION AGE BY WILLIAM A. HASELTINE

HOW TO ENSURE INTERNATIONAL COOPERATION FOR THE NEXT PANDEMIC BY MILLIE BRIGAUD

FIGHTING PANDEMICS THROUGH WASTEWATER SURVEILLANCE BY SADHANA SHRESTHA

THE WORLD HEALTH ORGANIZATION, HEALTHY CITIES, AND AFRICA BY WARREN SMIT

INTRODUCTION

BY ANA C. ROLD

For many of us the year 2020 and the COVID-19 pandemic created stress levels that were normally associated with living in conflict zones or with the immediate consequences of conflict. In addition to the external stress that the pandemic created there is now new medical research that shows that in some patients the coronavirus can actually affect the brain.

As some societies moved from lockdown to reopening, the na ture of our anxiety changed, but the stress remained. Month after month of stress has led to feelings of burnout and despair, cou pled with feelings of guilt at not doing anything properly.

For working parents and caregivers there was also the added complexity of trying to manage working from home with emo tional and academic support for children and longer-term con cerns about the impact of school shutdowns and learning loss on our children’s future. The number of op-ed pieces with titles like “has the economy declared working parents inessential?” seemed to be proliferating. Working mothers in many countries felt they were being pushed out of the economy.

Finally, there is the growing evidence of how different reactions revealed fault lines of inequality — the wealthy and powerful are fine, the less well off, those with additional learning or health needs are hardest hit.

At the same time, we live in an age of major disruption, and that’s a good thing. Healthcare is undergoing massive transformation, and for a very good reason. Doctors spend $210 billion per year on procedures that aren’t based on patient need, but fear of li ability. Americans spend, on average, $8,915 per person on health care — more than any other country on the planet. Prescription drugs cost around 50% more in the U.S. than in other industrial ized countries. And at this rate, by 2025, nearly a quarter of the U.S. GDP will be spent on healthcare.

As you can see, healthcare is massively broken and entrepreneurs are finding new ways every day to make you the CEO of your own health. We are on the cusp of witnessing the biggest break throughs humanity has ever seen. And everyone is in on it.

In 2015, at the United Nations annual General Assembly meet ings, the world’s nations adopted a new set of goals for human ity, the Sustainable Development Goals (SDGs). But the nations’ political leaders were not the only stakeholders — businesses, philanthropic institutions, international NGOs, and a coalition of very diverse constituents vowed to pitch in to make it all hap pen. Goal 3 of the plan aims to improve health systems, health research, and health financing.

But there is more to health than the absence of disease. Some call it happiness. Others call it wellbeing. And others call it quality of life. This is not some elusive concept; it directly affects our perfor mance at work.

We fundamentally agree: everyone wants to be happy. But what we have not figured out yet is how we should do it with policy, education, and community investment. When the discussion goes there, the question becomes: who will pay for all this innovation? My guess: probably not the consumer. Most likely it will be the insurance company, which makes a lot more money when we stay out of the hospital and live longer — so they can collect more fees and pay out less.

But beyond the innovation, the future of health and wellbeing dis cussion centers on our elevated sense of purpose in life. Psycholo gist have found that people who have this tend to live longer and experience less physical infirmity. This also resonates with a trend called “primordial prevention.” While our healthcare has focused thus far on primary prevention — intervening before a disease is developed — or secondary prevention — trying to prevent pro gression of a disease when people are already sick — primordial prevention looks at prevention of the risk factors in the first place. And the best place to start is figuring out what allows people to attain and maintain physical and mental health in the long term. This is where wellbeing and happiness become the factor modern healthcare should begin with.

The essays compiled in this anthology reflect learnings from our key contributors as well as key takeaways from previous editions of the Wellbeing Forum. We hope you find them useful and will reach out to us if you wish to contribute to a future edition. Thank you for being a part of this year’s Wellbeing Forum. We look for ward to learning and creating together.

Ana C. Rold CEO, Diplomatic Courier Host, Wellbeing Forum

WELCOME

BY DAVID MOU

Welcome to the Well-Being Forum! We’ve assem bled leading minds from various sectors to pro vide valuable insights and expertise as we exam ine the key indicators and trends in physical and mental healthcare.

We are in the midst of a mental health crisis. In 2020, 1 in 5 U.S. adults experienced a mental illness, and 1 in 20 experienced a se rious mental illness, yet only 46.2% of individuals received treatment. We need to fix this. We must democratize access to mental health care for all, and remove the many barriers and stigmas in dividuals face when accessing care.

I pursued a career in psychiatry after witnessing friends and family members suffer from mental illness, without getting the care they needed and deserved. As Cerebral’s CEO, I am committed to doubling down on clinical quality and safety and continuing to set the standard for high-quality mental health care.

I hope you find today valuable and insightful!

David Mou, MD, MBA CEO, Cerebral

ESSAYS & FEATURES

THE EMOTIONLESS SOCIETY

BY JON CLIFTON

Singapore is one of the most admired countries in the world — so admired, some countries aspire to be just like it. Global leaders admit to using Singapore’s jour ney as the blueprint for their own countries, including Kazakhstan’s first president, Nursultan Nazarbayev.

The admiration for Singapore might be because its success is so easy to quantify. And a great deal of that success is just eco nomics. When it comes to money, Singapore is rich — ranking in the top 10 of GDP per capita, regardless of whether you look at purchasing power parity or nominal GDP.

But wealth is not the only reason Singapore is so revered.

Singapore is fourth in the world for life expectancy (83.6 years) and tied for 11th for human development, according to the HDI 2019 ranking. It also has an unusually strong jobs market, ac cording to traditional employment metrics. Unemployment has not exceeded 6% in over 20 years of tracking. This is remarkable considering 5% is what many economists consider the natural rate of unemployment (or “full employment”).

Singapore is also one of the safest places in the world. If you have ever walked down the city’s streets late at night, you can feel it. And the data substantiate that feeling.

In 2021, nearly all Singaporeans (95%) said they feel safe walk ing alone at night. While that number is high, it is not unusual for Singapore. Gallup has been asking this question since 2006, and every year, over 85% of Singaporeans say they feel safe walking alone at night. Singapore has ranked No. 1 globally on this metric 11 times in the history of our tracking.

The country is not only rich, healthy, well-educated, and safe — the city even sparkles. First-time visitors are struck by the city’s

cleanliness. Driving from the Changi Singapore Airport to the city, you cannot help but notice how clean the streets are and how perfectly manicured the trees and bushes are. It feels like everything is perfect in Singapore.

But is it?

In early 2012, I flew to Singapore to join my colleagues for a presentation to a large group of government officials. The gov ernment wanted to learn more about what Gallup knows about happiness in the country.

Before the meeting, I looked at our 2011 data for Singapore. Almost all our data corroborated the conventional wisdom — everything was perfect.

We asked Singaporeans whether children had the opportunity to learn and grow and if they felt like children were treated with respect. Almost everyone in the country agreed, and Singapore ranked among the highest in the world on both metrics.

Singaporeans also trust their government. In fact, the Singa pore government received some of the highest confidence ratings globally. And less than 10% of Singaporeans felt like cor ruption was widespread in the government.

Even when we ask questions on basic numeracy, Singaporeans show how smart they are compared with the rest of the world. We once asked, “Do you think 10% is bigger than one out of 10, the same as one in 10, or smaller than one in 10?” (The correct answer is, of course, they are the same.) Only 40% of people globally get it right. In Singapore, 76% get it right, ranking it ninth out of the 141 countries we tested.

But while almost everything looked perfect in Singapore, one thing did not — the way Singaporeans responded to Gallup’s life experience questions.

Before we look at how Singaporeans live life, let’s look at how they see life. About one-third (34%) of Singaporeans rated their lives high enough to be considered thriving in 2011. The global average that year was 24%. Considering Singapore outperforms the world in almost everything, it is no surprise that it also exceeded the global average for thriving.

But now, look at how Singaporeans live life. Here is the Positive Experience Index trend in Singapore from 2006-2011.

The dramatic drop is not the only surprise. Globally, out of the 148 countries we measured in 2011, Singapore ranked dead last.

This decline made me wonder: If positive emotions are plum meting, then negative emotions must be skyrocketing. If people are not having fun, then they must be angry, sad, worried, or at least stressed? Right?

Apparently not. Here is the Negative Experience Index trend in Singapore from 2006-2011.

I should have known better. Norman Bradburn’s research (as I men tioned in Chapter Four) found just how unrelated positive and negative experiences can be. You can feel a lot of positive and negative emotions, but you can also feel very little of any of these emotions — which is apparently what happened in Singapore in 2011.

This finding caused us to rethink how we report our data entirely. We typically report two rankings: one that ranks the coun tries with the highest positive emotions and one that ranks the countries with the highest negative emotions. But what if we combined them? This would allow us to see which countries are most likely to report a lot of emotions, regardless of whether those emotions are positive or negative.

The country that expressed the most emotions that year was the Philippines. People in the Philippines were the most likely

to tell us that they felt a lot of enjoyment, laughed and smiled a lot, felt rested, and felt a lot of anger, stress, and sadness. Latin America dominated the rest of the list, which also included the U.S. and Canada.

But the country that was least likely to express any emotions? Singapore.

When we first launched these results in 2012, they went viral. The findings were covered on the front page of The Straits Times for three days in a row, including a scathing dissent writ ten by former Senior Minister of State for Law and Education Indranee Rajah.

Social media also erupted. “That [poll] is a lie,” commented one person. Another posted several videos on YouTube of a day in the life of an “Emotionless Singaporean,” which simply followed a Singaporean with an expressionless look on his face around Singapore.

Critics of the findings said the underlying methodology was flawed. Maybe they’re right. When someone conducts a survey and says in the fine print, “The margin of error is plus or minus three percentage points with a confidence interval of 95%,” that means that one out of 20 times, the data point may fall outside that range.

But were the results also wrong the year before that? And how about the year before that? In 2010, Singapore ranked 93rd out of 120 countries for positive emotions, and in 2009, 87th out of 115 countries. 2011 was not an outlier — the scores were low for three straight years.

If the data are accurate, why did Singapore have such an emo tions deficit? Here are three possible explanations:

First, a society that relentlessly pursues money does so at the expense of everything that makes life worth living.

Singapore was under British control for over a century and then, in the 1960s, was briefly part of Malaysia. That ended on August 9, 1965, and Singapore became independent.

Although independent, the country was struggling by every objec tive indicator. Most Singaporeans were unemployed, and GDP per capita was low. Singapore had limited natural resources, and the international community had no interest in helping the country.

Under the leadership of Lee Kuan Yew, the country turned to its most valuable resource — its people. Lee’s original strategy focused on manufacturing and bringing in foreign investment. It worked. From 1966-1973, the country experienced double-digit economic growth annually. Singapore continued to invest in its people, and the country went from poor to rich in a matter of decades. Nominal GDP per capita increased from $320 in 1960 to almost $60,000 in 2019 — PPP GDP per capita was $100,000.

Some believe that the country’s work ethic to escape poverty may have become too deeply engrained in the culture. For ex ample, Singaporeans openly talk about the “Five Cs” culture, which stands for your cash, car, credit card, condominium, and country club membership. The concept is so well-known, it even has its own Wikipedia page.

Did “All work and no play,” in the words of Singapore native CheeTung Leong, cause Singapore to be a dull society?

Bobby Kennedy and Bhutan’s Fourth Dragon King would have thought so. They believed that the overzealous pursuit of mon ey causes people to lose sight of what really matters in life. There is merit to this famous observation, but it does not ap pear to apply to Singapore. Singaporeans work hard, but work ing hard does not necessarily make people miserable. Miserable work makes people miserable. This leads to the second poten tial reason for the 2011 emotions deficit.

Singapore was unrivaled when it comes to misery in the workplace.

Singapore’s work ethic is famous. In 2015, Singaporeans worked more hours per week (45.6 hours) than any other developed city in the world except for Hong Kong (50.1 hours). Millennials work even longer. Singaporean millennials worked more hours than millennials in every other country except India (and they were tied with Chinese and Mexican millennials), according to a 2016 report by ManpowerGroup.

Singapore’s Ministry of Manpower has actively worked to ad dress this issue and is making progress. But is the number of hours that Singaporeans work what is taking the life out of Sin gapore? Or is it what happens during those working hours?

In 2011, there was no workplace more emotionally detached than Singapore. Only 2% of Singaporean workers were engaged and thriving in their jobs — the lowest in the world.

Singaporeans not only worked among the most hours in the world, they also had among the highest workforce participation rates. So, everyone worked, everyone worked a lot, and every one hated their work. That could make any society numb.

But here is a problem. Hating your job decreases your posi tive emotions, but it increases your negative emotions. Positive emotions were extremely low in Singapore, but so were nega tive emotions. If workplace misery was a contributing factor, it was only contributing to lower positive experiences.

This brings us to the third potential reason for the emotions deficit: Singaporeans excel in something else globally — modesty.

According to Singaporean psychiatrist Adrian Wang, “We’re less inclined to make a big show of how we feel. It may be be cause we’re a bit more conservative and tend to keep things to ourselves. But when we’re warmed up, we can be quite expres sive — take a look at our National Day celebrations.”

People in many rich Asian societies rate their lives lower than you might think, considering their countries’ wealth. Take Japan, for example. In the 2020 World Happiness Report, Japan ranked 58th out of 158 countries. That put Japan below Costa Rica, Mexico, and Guatemala. Japan’s GDP per capita is roughly 10 times larger than Guatemala’s. Yet, Guatemalans rate their lives higher than the Japanese.

Researchers have established that, for cultural reasons, Latin Americans are more expressive in reporting how their lives are going. On the other hand, Asians appear to exhibit more mod esty when rating many things, especially their lives.

This modesty is often attributed to many Asian societies’ em brace of collectivism, which stresses the importance of the community. As a result, self-ratings are humble because collec tivist cultures focus less on the individual and more on society. This may explain why Singaporeans and people in other Asian societies give higher ratings on societal matters, such as how children are treated or how institutions are performing.

By the way, we cannot minimize the positive ratings of Latin Americans. Latin Americans find a way to experience more fun in life than the rest of the world despite having less money. We should celebrate this and try to understand it more deeply because the world has a lot to gain from whatever they have figured out.

To better understand these cultural differences, Gallup began a project with the Japan-based Well-being for Planet Earth Foundation. The project’s objective is to develop a more allencompassing metric for happiness for the entire world. As of this writing, we are in the field testing to see if we can build sta tistics for concepts such as balance and harmony. Our research is still in the early stages.

But Is it Cultural?

If the results in Singapore were strictly cultural, how did Singa pore reverse the trend on positive emotions?

Singapore went from ranking dead last on the Positive Experi ence Index in 2011 to 67th in 2012. In 2014, it climbed to 14th, and ever since, Singapore has remained in the top quartile for the world.

So What Happened?

Curiously, the only other indicator that improved during this time was worker engagement. From 2011 to 2012, engagement improved seven points (to 9%); in 2015, it increased to 16%, put

ting Singapore 100 spots higher in the global rankings. The sud den increase might make you wonder if something happened nationally. We know that managers are consistently the most significant influence in worker engagement, but the sudden in crease in Singapore may have resulted from government action.

The Singapore government has recently enacted legislation to curb abusive workplace practices. For example, workers cov ered by the Employment Act can work a maximum of 44 hours a week. They also cannot work more than 12 hours per day or more than 72 hours of overtime per month. Prime Minister Lee Hsien Loong also reduced the country’s workweek from fiveand-a-half days to five days. Working hours have indeed de clined consistently since 2010, according to Singapore’s Minis try of Manpower.

But national policy alone will not fix Singapore’s workplace woes. Gallup knows that the adage “People join companies but leave managers” is true and is supported by data. Seventy per cent of a person’s emotional attachment to work is determined by who their manager is. Pick a bad manager, and no matter how good national policy is, workers will still be miserable.

Singapore’s workforce development strategies have been shift ing toward improving engagement since 2011 — including moving away from tenure-based progression to performance-based development. This alone could account for rising engagement because it implies that managers are more effectively support ing Singapore’s workers. For example, in 2015, Singaporeans were significantly more likely to say that they have opportunities to do what they do best at work and that there is someone at work who encourages their development.

Better workplaces may not be the only reason Singapore’s posi tive emotions increased. When Gallup first reported Singapore’s 2011 emotions data, it went so viral that everyone heard about it. Its ubiquity may have even influenced the survey results. When we conducted interviews the following year, Singaporean respondents told us during the survey, “I know what this survey is about.”

Private sector organizations even ran campaigns featuring the findings — promoting how great and how happy Singapore is. Advertisements ran in newspapers, on billboards, and in movie theaters. Since those campaigns, Singapore’s scores have remained unusually high for positive emotions and very low for negative emotions.

So, did Singaporeans’ emotions truly improve, or was everyone simply trying to boost Singapore’s score on the index?

Singapore has figured out the secret to success for almost eve rything. If the country indeed meaningfully improved positive emotions, the world would benefit greatly from knowing what Singapore did.

About the author: Jon Clifton is CEO of Gallup. This ex cerpt is from his new book “Blind Spot: The Global Rise of Unhappiness and How Leaders Missed.” Republished with permission.

WORLD UNHAPPIER, MORE STRESSED OUT THAN EVER

BY JULIE RAY

Emotionally, the second year of the pandemic was an even tougher year for the world than the first one, according to Gallup’s latest annual global update on the negative and positive experiences that people are having each day.

As 2021 served up a steady diet of uncertainty, the world became a slightly sadder, more worried and more stressed-out place than it was the year before — which helped push Gallup’s Negative Experience Index to yet another new high of 33 in 2021.

As it does every year, Gallup asked adults in 122 countries and areas in 2021 if they had five different negative experiences on the day before the survey — and compiled the results into an index. High er scores on the Negative Experience Index indicate that more of a population is experiencing these emotions.

In 2021, four in 10 adults worldwide said they experienced a lot of worry (42%) or stress (41%), and slightly more than three in 10 ex

perienced a lot of physical pain (31%). More than one in four experi enced sadness (28%), and slightly fewer experienced anger (23%).

Already at or near record highs in 2020, these experiences of stress, worry and sadness ticked upward in 2021 and set new re cords. Worry rose two points, while stress and sadness increased one point each. The percentage of adults worldwide who said they experienced pain also rebounded two percentage points, matching levels more in line with previous years’ estimates.

However, there was one bright spot: Reports of anger did not in crease in 2021, dropping a single point from 24% in 2020.

Positive Experience Index Drops for First Time in Years

On top of the increase in negative experiences, fewer people re ported that they had positive experiences the previous day. After several years of stability, the Positive Experience Index score in 2021 — 69 — dropped for the first time since 2017.

The Positive Experience Index is based on people’s responses to five questions about positive experiences they had the day before the survey. Higher scores indicate that more of the population re ported experiencing these emotions.

Last year, roughly seven in 10 people worldwide said they felt wellrested (69%), experienced a lot of enjoyment (70%), or smiled or laughed a lot (72%). Nearly nine in 10 felt treated with respect (86%). People were far less likely, as they are typically, to say they learned or did something interesting the day before the interview; in 2021, half of the world (50%) experienced this.

With more people dying from the coronavirus in 2021 than the previ ous year despite the rollout of vaccines, people felt less well-rested, and fewer derived enjoyment from the previous day. The percentage who said they felt well-rested dropped three points, and the percent age who experienced a lot of enjoyment dropped two.

However, the picture wasn’t entirely bleak. People were starting to smile and laugh again — the percentage who laughed or smiled a lot increased two points — and the percentage who learned some thing interesting ticked up one point.

Afghanistan Is the Least Positive and Leads the World in Negative Experiences

Afghans’ lives were already in a tailspin before the Taliban returned to power in 2021. Most Afghans were struggling to afford food and shelter, few felt safe, and they saw their lives getting worse with every passing year. But as bleak as this picture is, Gallup surveys conducted in August and September — as the U.S. withdrew and the Taliban took control — reveal Afghans were losing the remain ing joy that they had.

Afghanistan has ranked as the least-positive country in the world every year since 2017, apart from 2020, when Gallup could not survey the country because of the pandemic. However, the coun try’s score of 32 in 2021 on the Positive Experience Index represents not only a new low for Afghanistan, but also a new low for any country that Gallup has surveyed over the past 16 years.

Positive daily experiences were already in limited supply before the Taliban seized control, but these emotions largely disappeared from Afghanistan in 2021. The percentage of Afghans who said they

felt enjoyment, smiled or laughed, learned something interesting, or felt well-rested the previous day all dropped to new record lows.

Afghanistan in 2021 displaced Iraq from the top spot on the Nega tive Experience Index that the latter had occupied for the two previous years. Afghanistan’s score of 59 on the index was the highest score on record for the country and the highest score in the world in 2021. However, Afghanistan falls short of having the highest score on record for any country: The Central African Re public posted a score of 61 in 2017.

Worry, stress and sadness soared to record levels in Afghanistan in 2021: 80% of Afghans were worried, 74% were stressed, and 61% felt sadness much of the previous day. Notably, no other population in Gallup’s 16-year trend has ever reported feeling this much worry.

Implications

In the second year of the pandemic, people were living with even more uncertainty than the previous year — with more people dying from COVID-19 despite the rollout of vaccines. Yet, the pandemic is not en tirely to blame for the increase in negative emotions. Gallup’s data show that the world has been on a negative trajectory for a decade.

However, the continued rise in negative experiences in 2021, in tandem with the decline in positive experiences, suggest it is even more imper ative for policymakers to understand why the world is on this course and to look for ways they can change the path it is headed down.

About the author: Julie Ray is Gallup News’ Managing Editor.

THE

ECONOMICS OF WELLBEING

BY DAN WITTERS

Wellbeing matters. Subjective wellbeing — the kind that is measured through survey research — has been linked to a large array of outcomes that are relevant to the economics of both communities and to organizations. In workplaces, for example, well being closely predicts absenteeism, performance, and healthcare utilization as well as turnover and employee engagement. Wellbe ing among residents of communities, in turn, is correlated to health care utilization, crime rates, high-school graduation rates, teen pregnancy, and life expectancy among many other metrics. Well being has even been linked to shifts in voting patterns for the U.S. Presidency across counties. And improving total population health to better realize these outcomes requires a holistic approach, as noted many years ago by officials of the World Health Organiza tion. Health, they noted, was not merely comprised of its physical components and the absence of infirmary, but rather “a state of complete physical, mental, and social wellbeing.”

All of these factors — both large and small — influence the economics of a community. From how much businesses can count on em ployees to show up on time for a productive day at work to how much residents spend on healthcare, today and in the future, the U.S. economy is substantially impacted by the wellbeing of its citizenry.

Since 2008, Gallup has measured the wellbeing of nearly three million randomly selected U.S. adults a part of the Gallup National Health and Wellbeing Index. Gallup defines wellbeing through its five essential elements:

• Career wellbeing: You like what you do every day.

• Social wellbeing: You have meaningful friendships in your life.

• Financial wellbeing: You manage your money well.

• Physical wellbeing: You have energy to get things done.

• Community wellbeing: You like where you live.

In the workplace, wellbeing-related programs are increasing ly common, and it is everywhere in America’s communities and workplaces. The large majority of big employers now offer at least some programs in the workplace that are meant to enhance it. Un fortunately, however, the overwhelming majority of programs are focused only on physical wellness — from back pain to weight loss to smoking cessation to yoga classes and other forms of stress management. Often, little else is dedicated to the remaining elements of wellbeing. And this leaves a very substantial gap be tween the outcomes that workplaces are currently yielding from their wellbeing programs and the outcomes that they could be yielding, even in the presence of widespread knowledge among employees of what is at their disposal and even in the presence of great managers that are engaging them.

Gallup research has proven that addressing wellbeing holistically — as compared to just physical wellness alone — results in substan tially better economic outcomes. After controlling for age, gender, race/ethnicity, income, education, region, and marital status, those workers who are physically fit but otherwise lacking in high wellbeing in the remaining four elements consistently underper form those who exhibit high wellbeing across all five. Compared to employees who are thriving across all five elements, employees who are thriving in physical wellbeing alone:

• Miss 68% more work due to poor health annually. Those who are physically fit miss 3.2 extra days of work each year due to poor health compared to 1.9 days among those with holistic wellbeing. This adds up to an es timated loss of $443,000 in lost productivity due to absenteeism per 1,000 employees per year.

• Are three times more likely have an accident on the job that results in a worker’s compensation claim. This adds up to about nine extra claims per year per 1,000 employees, or about $450,000 per year per 1,000 as suming an average direct cost of $50,000 per claim.

• Are five times more likely to seek out a new employer in the next year and are more than twice as likely to actually change employers during that time.

• Are less than half as likely to exhibit adaptability to change and are 26% less likely to bounce back fully after hardship.

• Are 19% less likely to have donated to charity in the last year and are 30% less likely to have volunteered in the community.

In short, it’s not just about being physically fit; it’s also about all the other things. And those communities and workplaces that embrace this reality and execute on it will lead the nation in build ing cultures of wellbeing that economically thrive and prosper.

Regardless of the quality and reach of wellbeing interventions, the role of leaders — in communities or in organizations — is crit ical in engendering wellbeing among their constituents. Be they politicians, corporate executives, managers, clergy, educators or community activists, a well-informed and active leadership is crucial to a community’s success at building an institutional ized, embedded, and sustained wellbeing culture upon which a thriving economy depends. Included within this culture are certain guiding principles by which these leaders should abide, including a shared and uniform definition of wellbeing, constant and public vigilance in its advocacy, and a clear message that commitment to it will never, ever go away. In this manner, lead ers can fulfill an honorable — and critical — responsibility to the people that they lead and to the constituents that they serve.

About the author: Dan Witters is Research Director at Gallup’s National Health and Wellbeing Index.

WELLBEING AT WORK PERCENT WHO FEEL EMPLOYER CARES ABOUT THEIR WELLBEING PLUMMETS

BY JIM HARTER

Fewer than one in four U.S. employees feel strongly that their organization cares about their wellbeing — the low est percentage in nearly a decade.

This finding has significant implications, as work and life have never been more blended and employee wellbeing matters more than ever — to employees and the resiliency of organiza tions. The discovery is based on a random sample of 15,001 full and part-time U.S. employees who were surveyed in February 2022.

Prior to COVID-19, in 2014, about the same percentage (25%) of employees strongly agreed that their employer cares about their overall wellbeing. Then at the onset of the pandemic in 2020, em ployers responded quickly with a plan, communication, and what many employees believed was genuine concern for them, their work, and their lives. The percentage who felt cared about nearly

doubled, reaching a high of 49% in May of that year. Since 2020, the perception has plummeted to the previous low levels.

This finding is critical for organizations because employees who strongly agree that their employer cares about their overall well being, in comparison to others, are:

• 69% less likely to actively search for a new job

• 71% less likely to report experiencing a lot of burnout

• five times more likely to strongly advocate for their company as a place to work and to strongly agree they trust the leadership of their organization

• three times more likely to be engaged at work

• 36% more likely to be thriving in their overall lives

Gallup’s research has also found that teams who are most likely to feel the organization cares about their wellbeing achieve higher customer engagement, profitability, productivity, lower turnover, and have fewer safety incidents.

Considerations:

• The one-year decline in employees’ perceptions that their organizations care about their overall wellbeing was generally consistent across employee job types — from production and front-line to white-collar professionals. The decline was especially high among manag ers — 11 percentage points.

• Gallup found increases in manager burnout in 2021 and declining employee engagement. The ongoing COVID-19 spikes combined with increased employee resig nation rates in 2021 made it difficult for leaders to de sign and communicate a predictable course of action.

•

The percentage of employees who are extremely satisfied with their organization as a place to work dropped from 23% to 18% from late 2021 to the first quarter of 2022. Perceptions of the overall organization correlate highly with perceptions of leadership.

• “My organization cares about my overall wellbeing” reached its highest point in 2020 following organiza tional changes in response to the COVID-19 pandemic. Of employees who strongly agreed that their employer communicated a clear plan of action in response to

the coronavirus, 73% strongly agreed their organiza tion cares about their overall wellbeing. Of those who strongly agreed that their supervisor kept them in formed about what was going on in the organization, 78% strongly agreed their organization cares about their overall wellbeing. Communication matters.

• Employee expectations of work may have fundamen tally changed after the experiences of 2020 and 2021. Many learned new ways of working and may have an updated definition for what an employer caring about their overall wellbeing means. The work-life intersection has new meaning. Gallup finds those who prefer remote work now cite reduced commute times and better work-life balance as the key reasons. These may be new and more serious considerations for many em ployees, upping the bar for employers.

• Many organizations have built and maintained great cultures where employees do feel their organization cares about their overall wellbeing. In Gallup’s global database, top organizations have six in 10 employees or more reporting they strongly agree their organiza tion cares about their overall wellbeing — two to three times the overall national rate.

What’s Next? Here’s What Some Organizations Did.

Gallup found patterns in organizations that consistently improved their cultures — even during the tumultuous last two years. Some of these patterns include:

• Using their aspired-to organizational culture and val ues to guide business decisions. Employees need to see the intended culture and values lived out daily. It is important to listen to people and act based on employ ees’ work-life needs.

• Embracing flexible work environments while develop ing future-of-work plans. Flexibility can take on different meanings for employees depending on the type of work they do and where they need to be located to have outstanding individual performance, team col laboration, and customer value.

• Focusing on employee wellbeing and acknowledging the whole person. Since work and life are blended for many, consider the demands of life inside and out of

the workplace. Consider career, social, financial, physi cal, and community wellbeing impacts and resources.

• Tailoring communication to reach their team where they are. Transparent and creative omnichannel com munication to employees and customers is more likely to reach and resonate with a wide variety of people in many different work-life situations.

• Enabling managers to manage through times of change with their immediate teams. Consistently up skill managers to coach their employees through their strengths. Every person has a different work-life situa tion and only managers can understand these nuances and make adjustments based on how each person is wired, how they best perform, collaborate, and bring value to customers.

With new variants of COVID-19 emerging in 2020 and 2021, backto-workplace planning included many frustrating starts and stops for organizational leaders. With the rates of COVID-19 now at a low and decreasing rate in the U.S., the removal of many social restrictions and mask mandates affords organizational leaders the opportunity to set predictable workplace plans in motion.

This new freedom may present itself as a big opportunity for or ganizations to differentiate themselves based on what they have learned from the “great forced working experiment” of the past two years. How organizations respond to this opportunity will have a substantial impact on whether employees feel their organization cares about their overall wellbeing.

About the author: Jim Harter, PhD, is Chief Scientist for Gallup’s workplace management practice. Sangeeta Agrawal contributed analysis to this article.

REIMAGINING CARE

BY ANNE-MARIE SLAUGHTER

The recent United Nations Climate Change Conference (COP26) and the ongoing negotiations over US Presi dent Joe Biden’s social infrastructure bill, known as the Build Back Better Act, share an important feature. At the heart of global efforts to mitigate and adapt to cli mate change is a commitment to care for our planet. Similarly, Biden’s bill is a down payment on building an entire infrastruc ture of care — including paid family leave, childcare, a child tax credit, and affordable community and home-based care for an yone else who needs support — in the United States.

The reaction to both of these landmark developments tells us something important about the way many people think about care. In the context of climate change, care for the Earth trans lates into a set of prohibitions, restrictions, and duties: we can not continue living the way we are now without inviting catastrophe. And many justify their support for childcare and eldercare by emphasizing that more of it would allow caregiv ers, still primarily women, to remain in the workforce and thus be “productive” members of society.

In both cases, therefore, care is a means to an end, rather than something to be desired and cherished in itself. Care is a duty: we must take care of our planet and our family members. Or else it is a service to be paid for: we can buy carbon credits to offset our pleasurable consumption, and hire others to feed, bathe, dress, and drive those we love.

But as the British social designer Hilary Cottam and I have written, care is not a service, but “a relationship that depends on human connection.” The quality and depth of our relationships with others are essential to our longevity, well-being, and brain development, and to our very humanity. In a recent lecture at the British Health Foundation, Cottam reminded us of the philosopher Martin Buber’s concept, repeated by Pope Francis in a 2017 TED talk, of how “I become an I through a you.”

Suppose, then, that “We,” the human race, become fully human through our relationship with our environment. Or, put another way, what kind of humans we are depends on how we relate

to the Earth. The British archaeologist David Wengrow argues that recent discoveries of the remains of early societies dis prove the theory that power hierarchies are necessary to civilization. He describes “garden cities” without centers, societies that alternated between hierarchical command and egalitarian cooperation, and cultures that managed land through steward ship rather than ownership. Overall, he concludes, “we turn out to be a playful, inventive species that only recently got stuck in a deadly game of extraction and expansion — ‘you’re either growing or you’re dying’ — and forgot how to change the rules.”

How we relate to the Earth in turn determines how we create economic value. In the agricultural age, we cultivated crops and husbanded animals to feed ourselves and exchange with oth ers. In the industrial age, we extracted material from the Earth and converted it into products that we could use to clothe, shel ter, transport, educate, and entertain ourselves. In the digital age, we extract data from human interactions with one another and with the Earth, and convert these into a new array of goods and (mostly) services.

But if we must now repair the Earth and ensure the continued sustainability of our interactions with it, then care — the skills of nurturing and cultivating land, plants, animals, or humans — becomes a central source of value. Cottam argues that “carers,” for want of a better term, “must be to this technology revolu tion what engineers were to the last. The work of this century is work of repair: of ourselves and of our wider environments.”

We may therefore be entering a new economic era in which value arises primarily from the relationships that contribute to environmental health and sustainability and human flourishing. Call it the relational age. We will deploy technology in the service of a broad range of relationships — teaching, coaching, mentoring, guiding, nurturing, training, developing, nursing, and many others still to be discovered or rediscovered — that enable human beings to reach their full potential and live in har mony with their environments.

Such an economy would move from extraction to investment; from making and building to maintenance and repair; from having to being; and from production and consumption to creation and care. Static individualism would give way to dynamic interdependence.

This vision of human beings as nodes in a vast web of relation ships that can improve or wreck their life chances corresponds to our own biology. After all, an ecosystem is an intersecting set of interdependent relationships. The physicist Fritjof Capra has

written of “the web of life,” referring to the countless interde pendencies of living organisms. Activity in biological networks is a continual process of molecular and cellular repair and renewal.

If we think about care this way, as an essential set of relation ships that allow us to grow and flourish as part of a larger plan etary ecosystem, then care becomes a good in the literal sense of that word. By regarding care as the fulfillment of a deep hu man desire rather than as an obligation, we can turn it into a source of value and thus something to be relished, rewarded, and respected. Above all, care can provide a path out of our current environmental and spiritual crises, a bridge to a new economy, and a deeper understanding of our own humanity.

*****

About the author: Anne-Marie Slaughter, a former director of policy planning in the U.S. State Department, is CEO of the think tank New America. Copyright: Project Syndicate.

WHAT IS THE LONELINESS CRISIS AND HOW DO WE FIX IT?

BY KATIE WORKMAN

As social isolation caused by COVID-19 lockdowns weighs on the public’s mental health, suicide rates in Japan have spiked. In October 2020 alone, more peo ple died of suicide than the entire year’s coronavirus death toll.

Japan is not alone in its loneliness crisis as the pandemic’s fallout continues. They have, however, formulated a unique response: ap pointing Tetsushi Sakamoto as “Minister of Loneliness” to oversee government policy for mental health and isolation. Innovative ap proaches like this will be necessary around the globe to prioritize mental health and overcome the isolating challenges of the loneliness crisis.

The World Health Organization conducted a mental health sur vey with respondents from over 130 countries, and their findings underscored a critical need for additional mental health funding. The report found that the pandemic has disrupted critical mental healthcare in 93% of countries, and that 60% of vulnerable popula tions — such as adolescents and the elderly — who received prepandemic care reported interrupted access to that care. More than one-third of individuals needing crisis care for seizures or substance abuse described disruptions to emergency services, and 30% of re spondents reported disruptions in access for medications. Beyond existing patients, the pandemic has increased demand for mental health services amid the loss of jobs and social isolation.

Trends surrounding suicide are difficult to study and much of the pandemic’s effects are not yet known, but the New York Times suggests that significantly more US citizens considered ending their lives in 2020 than in recent years, with socio-economic pres sures like job losses and isolation acting as possible triggers. Data

from a national survey by the Center of Disease Control found that 40% of Americans reported symptoms of depression, anxiety or substance abuse, and 10% had serious suicidal ideation in the past thirty days. While the Times notes that overall suicides fell in states like Maryland and Connecticut, Black suicides soared, leading some experts to wonder if the racial and gendered disparities of COV ID-19 could be a significant factor in mental health problems.

Regardless of the impacts of the last twelve months, the corona virus has only exacerbated a worldwide and long-term crisis of psychiatric care and loneliness.

The United Nations explains that one in four people will experience a mental health condition in their lifetime, and suicide is the third leading cause of death among young people. The UN re ports that stigma, economic burdens, and inequality contribute to a cerebral crisis which is the number one cause of years lost due to disability.

Supply of mental health care services is often unable to meet the demand for those services. The American Psychiatric Association states that while neuropsychiatric disorders account for 10% of the global burden of disease, mental health workers account for only 1% of the global workforce. They also noted that 45% of the world’s population lives in nations with less than one psychiatrist for every 100,000 people.

Young people are also getting more stressed. The 2020 Deloitte Millennial Health Survey — conducted in over 20 nations before and 13 nations after the pandemic began — found that 48% of Gen Z and 44% of Millennials said they are stressed out most or all of the time. Climate change, familial wellbeing, financial wellbeing, health care, and career prospects were identified as major longterm concerns. Scarred by the economic downturn of 2008 and wounded by the 2020 recession, many young people have been unable to accrue wealth at the same rate as their predecessors and are unable to afford houses or gain stable jobs. Social me dia is also linked with disrupted sleep patterns, and platforms are designed addictively, leaving the most digitally-savvy generations with increased anxiety, depression, and other mental health prob lems. Even as technology connects people, it often leaves them feeling alone.

Finding Solutions Together

In 2018, the Lancet commission on global mental health and sustainable development found that mental illness is increasing eve rywhere and could cost the world $16 trillion by 2030. Decreasing

mental health stigma, the burdens of patients seeking care, and prioritizing mental health infrastructure in the coming decade are imperative in averting the price tag and tragedy accompanying it.

While the field of mental healthcare providers is expanding, the rate of training is expected to cause a shortage of 250,000 nurs es by 2025 in the United States alone. Expanding psychiatric autonomy for Advanced Practice Registered Nurses and increasing telepsychiatry options like videoconferencing therapy that have become vital amid the pandemic are promising solutions to the loneliness crisis. Integrating mental health care under the role of primary care physicians and incentivizing new professionals with student loan forgiveness are also international possibilities.

McLean Hospital, an affiliate of Harvard Medical School, suggests that the technological toll on mental health can be improved if social media platforms curtail mass sharing functions, and if individuals self-monitor their mood as they browse social media and step away if they notice negative effects. Monitoring children’s so cial media and creating a routine for turning off technology and going to sleep were also recommended.

While economic turmoil, global health crises, and political strife have their own complex solutions, the World Health Organiza tion has policy plans for the integration of mental health with health care, the creation of targeting workshops for policy crea tors and health providers, and human resource training for existing professionals.

The crisis of mental health and loneliness are far from over — and government officials like Japan’s Minister of Loneliness have a lot of work ahead of them — but innovative solutions show that people and nations are not alone in seeking help.

About the author: Katie Workman is a Diplomatic Courier corresondent.

COVID-19’S UNENDING IMPACT ON THE MATERNAL MENTAL HEALTH CRISIS

BY KATIE MILGROM

At the end of 2021, many were beginning to feel a shift toward an easing of the pandemic. A more positive outlook with growing vaccination rates, increasing boosters and the seemingly diminishing Delta vari ant brought both relief and a wave of momentum to ward the new year. However, the reality we face in 2022 is that we are still very much in this pandemic as the emergence and transmissibility of the Omicron variant has changed everything.

Many parents are back to facing tough decisions, especially those with children not yet eligible to be vaccinated. As a mom of a 5-year-old and 2-year-old, I share in the fear and uncertainty many parents face as we enter this new year.

We are juggling the calculated yet imperative risk of sending children to school or daycare in hope that our children can have some semblance of normalcy in the classroom. Yet, we feel paranoia with every sniffle and endure the constant risk-benefit analysis over every decision and the mental gymnastics that our child could be exposed to COVID-19 at any moment.

With the spread of the Omicron variant, we are seeing firsthand the unpredictability of this virus. The reality is that de spite how much we want to get back to normal and are looking toward a post-pandemic world, parents are still very much in the thick of it.

Now more than ever, we continue to see the impact this pan demic is having on parents, especially women as we struggle to balance work and family life. Women are struggling to stay in the workforce or at times even being forced to leave. And as we continue to ride out the waves and variants of the COVID-19

pandemic, we must reckon with the current and ongoing mater nal mental health crisis.

Mental Health Burden on Women

There has been a disproportionate impact of this pandemic on the mental health of women and moms — especially women of color. To combat this, we must first have broad acknowledgement and steadfast commitment to address this mental health crisis from companies and society’s institutions alike.

As the pandemic originally stretched from weeks to months, re search published in the Journal of Women’s Health found that women had “alarmingly high rates” of mental health issues like depression or anxiety. Then, as the pandemic progressed to over a year, it was reported that nearly one in 10 women quit a job due to a pandemic-related reason like a school and daycare closure.

Now, as we approach nearly two years of this pandemic, women and moms are straight up tired. According to research done by APCO Impact and the Marshall Plan for Moms, “71% of moms describe being a working mom during the pandemic as very challenging.” Further, 90% of these moms say they need more time off.

So, Now What?

Public Health Mitigation: Broadly speaking, we must continue to focus on all of the public health mitigation tools in our ar senal to fight this pandemic. Public health departments, cities, states and federal entities must continue to focus on wholistic methods for the mitigation of this virus. This includes masking, comprehensive testing programs and of course, vaccinations.

Global Health Equity: We live in a global society. The ongoing spread of this virus in one country is a problem for every coun try. We must work on ensuring equitable access to safe and ef fective COVID-19 vaccines around the world. The continual low vaccination rates in parts of the world due to vaccine inequity are cataclysmic. And abysmal rates of vaccine confidence in other countries like our own where we actually have access to a life-saving vaccine only further hinders strides toward mitigat ing the virus. Ongoing efforts must continue to bolster trust in science and achieve equity in all parts of the globe.

Supporting Mental Health and Women in the Workforce: We can continue to advance federal policies that support paid leave. And we must understand that as much as businesses want to

get back to a post-pandemic world, we are still very much in an unprecedented pandemic and these businesses must show compassion to the impact of this on employees. Outside of leg islative solutions, there remains a critical need for companies to provide flexible schedules to accommodate last minute changes at schools and childcare juggling. Corporations must reevaluate their flexible paid leave policies to prepare for not only employ ees getting sick but having to take care of children and other relatives as well. The implementation of these policies will help moms by alleviating stress and help to achieve balance.

About the author: Katie Milgrom is Deputy Managing Di rector at APCO Worldwide.

WELLBEING

POST-PANDEMIC

BY DERRICK WONG

Rhe COVID-19 pandemic drastically altered the way we operate in society, exposed glaring weaknesses within the healthcare infrastructure, and revealed the lack of preparedness across organizations. The irrefutable in terrelation between work and life became acutely clear as households quickly became domains for office work, childcare, and virtual learning. This sudden societal change, buoyed with a prolonged pandemic, launched mental health, health eq uity, and overall well-being into the forefront of business dis cussions. As the world forges ahead to a new normal, organiza tions need to provide a holistic approach to well-being with an emphasis on restructuring caregiving policies, providing flex ible work schedules, and delivering consistent, affordable, and sustainable avenues for supporting mental health.

One of the paramount concerns is the startling number of laborers, especially working mothers, who face the unmanageable choice of caring for a child or continuing to work. This issue has soared over the last year, with nearly 2.5 million women having left the labor force since February 2020. Prior to the pandemic, women accounted for more than 50% of the workforce. The ongoing pandemic expunged years of progress, highlighting the inequities within our caregiving system. It is imperative for organizations to provide comprehensive caregiving support to employees, particularly women, if the economy hopes to recov er and flourish in a post-pandemic society.

Employers should invest in childcare subsidies as they would in employee benefits. The cost of recruiting and hiring new employees weighed against subsidizing childcare expenses to re tain working parents proves its value. Last August, consulting firm Accenture paved the way by introducing a new school-day supervision for children ages six through twelve through a part nership with Bright Horizons. The organization covered 75% of the cost for its employees’ children to follow remote learning curriculums in supervised locations. Employees opting into this employer benefits program were only responsible for a minimal out-of-pocket cost of $5 an hour; a financial expense that pales

in comparison to the burden of juggling both parental and pro fessional responsibilities at one time.

Flexible work schedules will play an integral part in prioritiz ing human well-being and providing caregiving support for em ployees. According to a survey conducted by global nonprofit organization Catalyst, women with childcare responsibilities are 32% less likely to report intentions of leaving their job if they have access to remote work. Additionally, employees are 30% less likely to look for another job in the next year. The future workplace for many organizations will most likely be anywhere and at any time, with the traditional office location acting as an optional center for social interaction, collaboration, and innovation. This increased autonomy to employees will allow them to fit work around the rest of their lives, enhancing their job satis faction and improving productivity.

As the hybrid workplace model continues to emerge as the preferred post-pandemic standard amongst employees, employers will also reap the benefits of this new industry structure, allow ing businesses to focus on acquiring the essential skills needed to drive economic growth rather than filling key roles. The hy brid model provides an organization to expand its talent pool beyond local expertise, opening the possibility to obtain skilled professionals on a national or global scale.

A November report from McKinsey & Company revealed 62% of global employees considered mental health issues a top challenge during the pandemic. Even as the pandemic begins to wane in 2021, accessibility and affordability to mental health care remain daunting challenges as many therapists are over booked and do not accept insurance coverage. Look for the new normal to transition to non-traditional forms of mental health treatment. Companies such as CVS are leading the way in trying to fill the gaps in access to mental health by piloting a counseling service in some of its retail stores.

The retail corporation is doing its part to reduce the cost of mental health care by negotiating with insurance companies to cover visits. Walmart Health offers a similar retail service mod el that provides counseling as well as diagnostic and primary care. Availability to affordable mental health professionals is not only limited to retail corporations. Online counseling services such as Talkspace and BetterHelp are poised to thrive in the post-pandemic world by offering affordable virtual therapy sessions at a significantly lower cost than traditional in-person treatment. Talkspace is even covered by major insurers, includ ing Cigna, Humana, and Premera Blue Cross Blue Shield. Busi -

nesses should lean on these accessible and affordable avenues to mental health stability when evaluating their comprehensive employee benefits package in a post-pandemic world.

The future of well-being does not only depend on companies, but on state and federal policies as well. The American Rescue Plan Act is a noteworthy start, but industry, state, and federal leaders need to pave the way for systemic change and activism in healthcare; an industry that should be predicated on provid ing empathic, emotional connections with consumers coupled with an emphasis on patient outcomes rather than profits. The foundation for a prosperous future in a post-pandemic economy begins with a holistic focus on the quality of well-being amongst the workforce masses. Only then will society be able to build resiliency and strive toward transformational change.

About the author: Derrick Wong is the head of the em ployee benefits division at Risk Cooperative.

OWN YOUR HEALTH

HOW PEOPLE LIKE YOU AND ME CAN HELP REBUILD HEALTH SYSTEMS

BY DANIELLA FOSTER

One of the most eye-opening transformations that happened during COVID-19 was the increased role of health ownership. Before the pandemic, most people didn’t put the same stock in the care we give ourselves at home to prevent and treat illness. But the pandemic empowered people. The extreme circumstances have shown that people can take more control over their personal health. But they need to be given the right information and ac cess to do this properly.

Helping people understand how they can prevent disease and proactively take care of themselves is one of the key ways we can rebuild health systems. The Center for Workforce Health and Performance in the U.S. believes that if people took care of more of their healthcare needs at home, this could result in $45 billion saved from unneeded doctors’ visits, among other costs. It would also result in an additional 130 million more days worked, which also means more money in someone’s pocket. Other countries have similar statistics.

Embed Self-Care into Public Policy

In conjunction with the World Health Organization, The Global Self-Care Federation* just launched the Self-Care Readiness Index to help countries better understand and create actionable plans against the four key enablers of self-care: stakeholder support and adoption, consumer and patient empowerment, health policy, and the regulatory environment. In assessing per sonal health practices and policies across 10 countries, several key themes emerged. First, self-care legislation is common, but disjointed. Numerous government strategies, plans, and pro grams touch on self-care, but few call it by name or paint a coherent policy vision.

Policies should look at new approaches to behavior change when they are determining future investments in health promo tion, prevention, and self-care initiatives. We need to develop a “whole government” approach to self-care. Think multiple arms of government working together to both educate and embed habits — similar to what we saw when it came to hygiene, social distancing, and vaccination through COVID-19, but a sustained effort. Governments don’t need to work alone on this. The collective action developed through multi-stakeholder partner ships — bringing together the private and public sector — can create an even bigger impact.

Empower People with Information

The second key theme within the Self-Care Readiness Index is that individual empowerment hinges on continued efforts to boost health literacy, having credible, consistent sources of information that’s aligned with healthcare providers. Education is an oftenoverlooked aspect of healthcare, but it is critical. Consider the concerted effort behind the COVID-19 handwashing best prac tices. The efforts were orchestrated, focused and made simple for people to implement — so they did. There’s lots of information available, but it is not always accurate or beneficial. This needs to change. In order for people to feel empowered, they need to be confident in their ability to take the right actions.

These programs don’t need to be complicated, but they do need to be targeted to ensure they are reaching people where they are and how they are most receptive to information.

Rethink Where Health Happens

One of the ways we can help people take better care of themselves is to rethink where health happens. We’re seeing this happen more and more but we need to continue to think of healthcare outside of clinics, doctors’ offices, and hospitals. It needs to happen in homes, pharmacies, grocery stores, and on line — where patients actually are in their daily lives.

There’s still value in traditional healthcare settings, but in many communities, especially underserved ones, people have more access to the local store than a traditional healthcare provid er. Services facilitated by a pharmacist or in-store healthcare provider can often be more affordable and offer 360 solutions — people can get healthcare provider-endorsed recommenda tions for how to take care of themselves, get prescriptions, and shop for over-the-counter solutions all in one place. In order for this to be successful, policies also need to change to enable

access to medical records and the ability to make referrals.

There’s also opportunity for the expansion of digital health. The pandemic certainly encouraged telehealth, but in order to help create health ownership, this should be expanded to other health services. We’ve already started to see a patient’s home becoming the primary site for medical services. We’ll see this centered on at-home medical devices. For example, diabetes is a chronic condition that currently can be monitored with the help of digital remote-monitoring tools like glucose monitors and activity trackers. A patient can sync their devices to track progress, check their health data in real time, send and receive messages from a nurse, and share progress with their doctor. This helps address long periods of ongoing care and allows people to take control of their health.

It’s Up to Us

In order to rebuild health systems, people need to be empowered to take care of their personal health. It requires the lead ership of multiple stakeholders collaborating to do it well, but if we can arm communities with the tools to take health own ership, we can make a huge impact. Not only can we rebuild health systems, but at the end of the day, this approach will help all people lead better lives because they are healthy enough to enjoy them.

About the author: Daniella Foster is Global Vice Presi dent and Head of Public Affairs, Science and Sustainabil ity for Bayer’s Consumer Health division.

*Disclosure: Bayer is a member of the Global Self-Care Federation and helped develop the Self-Care Readiness Index.

HEALTH IS FREEDOM

BY KERMIT JONES, MAYA KAHWAGI AND NEEL VAHIL

The United States has been invested in global health in stitutions such as the WHO and UNAIDS for decades, yet has frequently fallen short of hoped-for population health returns. Fragmented aid, complex procurement regulations, and a lack of long-term strategy all contribute to these failures. While monetary hurdles exist, we argue that the biggest hurdle is one of vision. At home and abroad, the US has a long track record of treating health as a commod ity rather than an essential element of democracy. We argue this is the biggest strategic failure of the last fifty years of U.S. domestic and foreign policy. Looking forward, the U.S. should broaden the concept of health to include climate, sustained so cioeconomic improvement, and a functional political class to ensure that the political and economic gains of the twentieth century will continue for future generations.

Democracy’s Independent Variables

The last four U.S. Administrations State Department Strategic Plans emphasized healthy populations, democracy, and freedom. This is because these variables correlate with economic growth and political rights around the world. It then follows syl logistically that when opposite conditions are present, a local infection in a Chinese province can turn into a global pandemic. Despite rhetoric on global health investments, one need look no further than the USAID organizational chart to see that global health is less than 7% of the agency’s allocated budget. Such scant global health funding is surprising given how the lack of public health infrastructure contributed so greatly to multiple surges of global COVID-19 infections. This anemic approach also ignores the HIV/AIDS crisis just three decades ago, which was so devastating to developing countries that at one point, fighting it consumed half the annual budget of Zimbabwe.

From Policy to Practice

Even before India peaked at over 4,000 COVID-19 deaths a day, its socioeconomic and public health challenges set the stage

for the pandemic to devastate its population. India is not alone. Many of its South Asian neighbors face similar challenges and their citizens have shorter than average life expectancies. These population level challenges cannot be addressed by increasing healthcare capacity or funding alone.

For example, more hospital beds and healthcare workers will help treat cases of tuberculosis but would not address the underlying malnutrition and abject poverty that fuels its spread. Also, antibiotics can treat diarrheal diseases that claim the lives of over 100,000 children annually but does not fix the root problem of unhealthy drinking water. This raises larger ques tions. What policies can be crafted upstream to lower the risk of these diseases downstream? What policies can address the decreased crop yields that result in malnutrition or the runoff of animal waste that pollute the well water?

Donor countries and aid organizations have a solid track record of addressing the end stage illnesses and deploying rapid di agnostics and treatments to plug recurrent holes in the health problems in many developing countries. What is frequently miss ing is a strategy to connect the root causes of these problems to their downstream effects of people being less healthy and less able to fully participate in their democracies. Global health pro grams that only focus on health and U.S. foreign and domestic policy that do not tie poor health to the negative externalities, thus failing to truly solve the problem. Framing Health as essen tial to freedom, however, could make the connection much more tangible in peoples’ and policy makers minds.

Treating health in its broadest sense — as the optimization of one’s relationship and ability to interact with her environment and community — would create a mandate for countries and organizations to focus on root causes of disease to prevent future public health crises. This could give advocacy groups around the globe the rhetorical ammunition to demand action from their governments on those things that negatively affect their healt — from pollution to poor government services.

In the case of India and its neighboring countries, an example of such a policy could be for the U.S. and partner countries to couple healthcare capacity funding with measures to reduce carbon emissions over the near term, crop resilience programs, and access to clean water. All such funding could be linked to trade agreements that incentivize regional over global trade, with broad latitude and economic support given to programs that reduce carbon emissions. Local and regional trade of goods could be incentivized to help reduce carbon emissions. Lower -

ing carbon emissions, ensuring clean drinking water, increas ing crop yields all help to reduce future health problems. The novelty of this approach — tying so many aspects of economic development to health outcomes — is one of many reasons it would be difficult to implement. However, the traditional ap proach — U.S. agencies and institutions providing funding for specific diseases, time periods or categories (e.g., to improve midlevel training or HIV/AIDS testing in developing countries), while beneficial, has not been broad enough for us to ensure the continued promotion, sustainment, and guarantee of our health and ability to exercise our freedoms.

A Healthy Conclusion

The journey to a better, sustainable future begins with one step. The first step here is garnering the collective courage to re imagine our health as something much larger than accessing a healthcare system when we are sick. We should collectively reimagine our health as our freedom and recognize its depend ence on our environment, our communities, our climate, and our safety. This approach accepts health as an essential compo nent of our ability to fully participate in a democracy. The path forward is clear; where our policies and initiatives at home and abroad are not aligned with that reality, we restructure them. We cast aside the shackles of false freedom and work as in dividuals, communities, activists, and public servants to tackle the multiple upstream problems we cannot ignore; problems that are making us less healthy and less free. The goal should be for us to have solved so many of the contributing factors to poor health that our perennial shortage of healthcare capacity will no longer exist; and quite possibly neither will our need for healthcare capacity at all.

About the authors:

Dr. Kermit Jones is a former White House Fellow and candi date for Congress in California’s 4th Congressional District.

Dr. Maya Kahwagi is a family practice physician and geri atrician who has worked in Lebanon.

Neel Vahil is a 4th year medical student at New York Medical College.

HEALTH

MESSAGING IN THE DISINFORMATION AGE

BY WILLIAM A. HASELTINE

As the director of the Centers for Disease Control and Prevention, Rochelle Walensky, recently ac knowledged, poor public-health communication and messaging throughout the COVID-19 pandemic has damaged the public’s trust in health agencies and institutions. This, in turn, contributed to well-known problems such as vaccine hesitancy, noncompliance with mask recom mendations and other protective measures, and general misinformation about the virus and how it is transmitted.

According to a 2021 poll from the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, only 52% of Americans now place a great deal of trust in the CDC, and only 37% have much confidence in the National Institutes of Health or the Food and Drug Administration. State health departments fare little better. They are trusted by just 41% of Americans, with local health departments trusted by 44%, and the same poll shows that positive ratings of the public health system declined from 43% to 34% between 2009 and 2021.

Clearly, public-health agencies need to win back the public’s trust, not just to combat crises like COVID-19 and monkeypox, but also to ad dress a wider range of ongoing health issues. This process must start with a commitment to community engagement, partnerships across other sectors such as housing and education, effective communica tion at every level, and transparency and integrity in decision-making.

Public-health officials often must base their recommendations on incomplete data; as the data evolve, so will the recommen dations. However, in a misguided effort to appear authoritative, public-health officials are rarely transparent about the nuances and fluid nature of what they are communicating.

A perfect example is the early advice on how SARS-CoV-2 is transmitted. The CDC was adamant that the coronavirus was spreading on surfaces and not through the air, rather than acknowledging that airborne transmission was still a strong pos sibility. This approach bred confusion and distrust, because the CDC eventually had to change its advice (as it should have fore seen). After acknowledging that SARS-CoV-2 was spreading through droplets, it finally also conceded that it was spreading through aerosol particles.

As this example shows, credibility often gets confused with in fallibility, resulting in public-health officials who may be slow to admit mistakes—further undermining their credibility. Transparency is key, especially at a time when peddlers of online misin formation will seize every opportunity to discredit public-health officials. Successful public-health communication establishes credibility by being effective, not by being unchanging.

Another cornerstone of sound communication is clarity. Publichealth officials must explain how data and recommendations relate to people’s everyday lives. Whether the information is correct or incorrect is a moot question if the public doesn’t un derstand what is being communicated.

Here, U.S. officials failed the messaging test again when they did not make clear that COVID-19 vaccines’ effectiveness was measured by hospitalizations, not infections. The public be lieved that vaccines would block transmission and infection; but when the Delta and Omicron variants emerged and caused breakthrough infections to surge, distrust and “booster-shot fa tigue” duly followed. As of August 3, only 32% of Americans had received their first booster shot.

In this case, public-health officials could have used the exam ple of the Salk polio vaccine to assure the public that a vaccine doesn’t need to prevent infection or transmission outright to eradicate a disease. Or, they could have emphasized how much the vaccines reduce the burden on our hospitals.

Unfortunately, other historical lessons seem not to have sunk in. Many public-health officials have been committing a grave error by stigmatizing monkeypox as a disease that only threat ens gay, bisexual, and other men who have sex with men. Yet while it is true that this population has been disproportion ately affected by the current outbreak, monkeypox can be transmitted in any situation where there is close skin-to-skin contact with lesions.

By depicting monkeypox as a sexually transmitted infection, public-health officials could give people the false impression that they are not at risk, preventing them from seeking a di agnosis or isolating if they do contract the virus. The situation is not dissimilar to the (incorrect) early messaging about HIV/ AIDS spreading only among homosexual populations.

More broadly, public-health messages are best understood and most likely to be believed when they come from trusted indi viduals within the communities that need to be reached. The messenger is often as important as the message, especially in communities where structural racism and historical traumas have left people disinclined to trust medical authorities.

Rather than issuing authoritative statements and assuming that they will be heeded, local public-health officials should think of their messaging as being part of an inclusive conversation. They should seek out community voices and trusted advocates such as faith leaders, shelter managers, and food-bank directors to collaborate on messaging and reaching populations that may be vulnerable to health disparities.

Another good approach is the one pioneered by the Ryan White HIV/AIDS Health Services Planning Councils. These are commu nity groups appointed by local officials whose members represent the general public, people living with HIV, funded service providers, and other health and social service organizations. Planning Council members work together to identify the care needs of people living with HIV. They then determine which services are highest priority, and how much funding should be committed to each. This model of inclusive decision-making could be applied more broadly to public-health planning and resource allocation.

The current climate of “alternative facts” and rampant disinformation presents many challenges to effective public-health commu nication. But by learning from past mistakes and developing messages that are clear, inclusive, and conveyed by the right sources, we can start the difficult but necessary process of rebuilding trust in public-health agencies before the next big crisis strikes.

About the author: William A. Haseltine, a scientist, bio tech entrepreneur, and infectious disease expert, is Chair and President of the global health think tank ACCESS Health International. Copyright: Project Syndicate.

HOW TO ENSURE

INTERNATIONAL COOPERATION FOR THE NEXT PANDEMIC

BY MILLIE BRIGAUD

With every news article about the outbreak of a new illness, the world is on the edge of its seat. Global leaders are anticipating the next pandemic — and this time they hope to be better prepared. The World Health Assembly has appointed an Inter governmental Negotiating Body (INB) to design an international pandemic agreement. The agreement will aim to shore up the world’s preparedness and cooperation for the next global health crisis, but the INB disagrees on the best mechanism to ensure co operation while still respecting member states’ sovereignty.

The O’Neill Institute for National and Global Health Law and the Foundation for the National Institutes of Health (FNIH) stepped in—pooling together experts in health, trade, and diplomacy to address these concerns. Their recently published report high lights the advantages and limitations of existing international treaties at addressing sovereignty and enforcement.

Lessons from the WHO’s Existing Treaties

The report notes two possible routes for the World Health Organization (WHO) to create a pandemic preparedness conven tion. It may create agreements that member states opt into or out of. The organization’s members are never forced to adopt a treaty, but an opt-out agreement may lead more states to par ticipate purely because opting out takes effort.

Still, this condition does nothing to ensure compliance. The WHO’s International Health Regulations (IHR) — the most significant pub

lic health preparedness agreement in effect today—allows states to use their domestic infrastructure to meet convention require ments and recognizes some of the unique challenges states may have in complying, depending on their national government sys tems. Unfortunately, these sovereignty protection measures have made implementation slow and irregular. A 2005 amendment sought to increase transparency and accountability, but states continue to present information in ways that protect their reputation at the expense of the other WHO member states.

The Framework Convention on Tobacco Control (an opt-in WHO treaty) has been more successful than the IHR. The treaty has both obligations and recommendations, giving countries the freedom to choose which policies to adopt. Member states also receive guidance from the Framework Convention’s Secre tariat. The Secretariat is governed independently, allowing it to work with international and non-governmental organizations. The WHO itself is limited in its ability to work with non-state actors, so the Framework’s structure is strategic. Mimicking the Framework could be useful for pandemic prevention, but the Framework Convention is extremely slow-moving, with some negotiations lasting as long as a decade — far too long to ad dress public health crises.

Shopping for the Best Watchdog Mechanism

In light of the strengths and limitations of the IHR and the Framework Convention, the O’Neill Institute and FNIH report underscored the importance of having both an advising body and a surveillance system. The challenge is to determine how to incentivize countries to comply without being too centralized. The report looks to existing treaties for inspiration. These trea ties reveal what has worked and what has not in managing the sovereignty-accountability trade-off.

The World Trade Organization (WTO) is successful in both guiding and regulating states. Its dispute resolution mecha nism holds states accountable for noncompliance, and specific WTO agreements guide governments on compliance measures, too. But environmental treaties have revealed states’ aversion to ceding regulatory intervention to an external body. We see this with the evolution of climate agreements: the Paris Agree ment is a dispersed system as opposed to the former centralized Kyoto Protocol.

Similar to a pandemic, maritime and nuclear treaties address issues that transcend political borders. What’s more, their moni toring mechanisms are less centralized than trade treaties. The

Boundary Waters Treaty between the United States and Canada turns to a jury of three Canadian and three U.S. representatives to settle disputes. In the event of a tie, a neutral party makes the ultimate decision. The Convention on Nuclear Safety relies on a peer-review system. In the pandemic setting, states could peerreview outbreak assessments or state’s healthcare capacities.

Human rights treaties have weaker enforcement mechanisms, but nongovernmental organizations can increase public awareness of noncompliance and pressure governments to respect treaties as a result. Nongovernmental organizations’ campaigns may motivate individuals to stage protests or bombard noncompliant governments with letters that demand change. These actions — especially when the media catches on — deliver powerful blows to countries’ reputations. As such countries must work with local media and other communication outlets to build trust. An international pandemic treaty cannot function when citizens are skeptical of its legitimacy or effectiveness.

The Treaty Cannot be One Size Fits All

To effectively prepare for the next pandemic, the treaty must account for regional variation. Diseases manifest differently depending on the weather, climate, immunities of populations, and infrastructure of countries. The world expected COVID-19 to ravage the African continent, yet death rates from the virus remained far lower in Africa than the rest of the world. While this is partly due to weaker data collection, data from obituaries and morgues show that the pandemic was truly less catastrophic—likely because of the continent’s relatively young popula tion. Now African governments are wondering if their resources are best spent on COVID-19 vaccination campaigns when ma laria, HIV, tuberculosis, and malnutrition remain the continent’s leading causes of death.

To adapt to local differences, countries should cooperate re gionally in a pandemic. Luckily, a number of existing regional multilateral cooperation treaties are prepared to do so. For in stance, the Association of Southeast Asian Nations adopted an Agreement on Disaster Management and Emergency Response after the 2004 Indian Ocean Tsunami. It now considers pan demic-response as one of its roles.

While the final WHO treaty and INB recommendations may be different, the report from the O’Neill Institute for National and Global Health Law and the Foundation for the National Insti tutes of Health has important items for policy makers to con

sider. The convention can adopt a strong guidance and dispute resolution mechanism like the WTO, or it may imitate the peerreview system of the Convention on Nuclear Safety. No matter what, the pandemic convention must emphasize regional co operation and national communication. With these needs met, it will be easier to motivate states to comply with treaty rules.

About the author: Millie Brigaud is a Diplomatic Courier Correspondent.

FIGHTING PANDEMICS THROUGH WASTEWATER SURVEILLANCE

BY SADHANA SHRESTHA

Our wastewater is much more than waste. The sewage flowing below our feet can provide early warning that diseases like COVID-19 are spreading, help us understand how they spread, and empower us to mitigate their potentially devastating impact. As countries dis cuss a global agreement to tackle future pandemics, they should make the monitoring of wastewater a key consideration in ongo ing negotiations. Wastewater surveillance is cost effective and has enormous potential to strengthen global preparedness as we seek ways to better respond to future health emergencies.

Since the first cluster of COVID-19 cases reported on 31 December 2019, scientists across the globe have been constantly monitoring the evolution of SARS-CoV-2. Omicron was not the first variant, and it will not be the last. Public health organizations are braced for the possibility that future variants could be more infectious and more easily transmissible. Current methods of monitoring have added to the already enormous strain on healthcare systems worldwide. Chal lenges these systems face include scarcity of available medical sup plies, understaffed healthcare personnel, technical and financial re sources, inadequate diagnostic tools, and limited access to clinical testing – especially in developing countries.

Wastewater surveillance could be a powerful tool in helping miti gate this strain. As wastewater surveillance uses pooled samples from the population, it is less expensive than testing individuals. It provides a valuable approach in the toolbox for monitoring COV ID-19 in the general population.

Working like a snapshot of population health, wastewater surveil lance is a strategic sampling and testing of wastewater. It enables scientists to detect diseases and their prevalence within a com

munity in real-time, and track clusters or hotspots. Critically, it even captures the presence of SARS-CoV-2 shed by people with out symptoms. These asymptomatic cases would otherwise be underreported in health surveillance.

In some cities, SARS-CoV-2 has been detected in wastewa ter samples which were collected earlier than the first reported cases of COVID-19. This demonstrates how, if implemented systematically and regularly, the technique can allow early detection of outbreaks which could potentially become future pandemics. Although wastewater surveillance has been used in the past for different purposes (in the 1940s it was used to track polio out breaks in the United States), the COVID-19 pandemic underlines the importance of this cost-effective tool for global public health, pandemic prevention, preparedness, and response.

Due to the current high cost of clinical testing to curb COVID-19, there is a need to implement a cost-effective mass surveillance approach for monitoring the disease in populations. The evidence from a vast number of scientific studies suggests that the inclusion of wastewa ter surveillance in systematic testing strategies at the regional or na tional level will be a solution to complement the healthcare system.

Last year, the World Health Assembly met in a Special Session, the second-ever since WHO’s creation in 1948, and agreed to launch a process to develop a historic global accord on pandemic prevention, preparedness, and response. It established an intergovernmental ne gotiating body to draft and negotiate this international instrument. Given the lessons learned from the current COVID-19 pandemic on the benefits of wastewater surveillance, this powerful public health tool must be a central consideration among Members of the World Health Organization in the ongoing negotiations on a pandemic treaty.

While there is a growing awareness of the value of wastewater to track and prevent the spread of diseases, let us also not forget that water itself is a valuable resource that is increasingly under threat from climate change and we need to work together to pro tect and manage water sustainably.

About the author: Dr. Sadhana Shrestha is a researcher at the United Nations University Institute for the Advanced Study of Sustainability (UNU-IAS) in Tokyo.

Editor’s Note: The views expressed in this article are those of the author and do not necessarily reflect the views of the United Nations University.

THE WORLD HEALTH ORGANIZATION, HEALTHY CITIES, AND AFRICA

BY WARREN SMIT

The ongoing global pandemic has brought cities a distinct set of urban health challenges and has highlighted the challenges of applying universal policies in specific places, as shown, for example, by the lack of success in applying COVID-19 social distancing measures in highdensity informal settlements in the Global South. It is therefore worth reflecting on previous attempts at implementing univer sal health programmes, such as the World Health Organization (WHO)’s Healthy Cities program and its application in the Glob al South, particularly in Cape Town, South Africa.

Like the United Nations itself, the WHO emerged in the after math of the Second World War. It was created as an intergov ernmental agency to exercise international functions with the goal of improving global health. It began with a relatively nar row focus on health care, but from the late 1970s onward, the WHO began to focus on broader health promotion. The period from 1973 to 1988 is regarded as the golden age of the WHO, with Health for All by the Year 2000 a particularly key initiative. This strategy, launched in 1981, advocated that governments were responsible for the health of their citizens and should be active in promoting good health.

The development of this strategy was linked to the rise of the “determinants of health” approach. This growing body of work highlighted that changes in living conditions had a much larger impact than changes in health care on health conditions. In particular, there was a recognition that elements of the urban environment (such as streets, housing, infrastructure, recrea tion facilities, transport, urban agriculture, food markets, and even the spatial form of cities) have an enormous impact on the health and wellbeing of residents. A related shift in the ap

proach to health was the recognition in the Ottawa Charter of 1986 of the importance of participation by individuals, groups, and communities in decision-making (for example, relating to urban planning) in order to increase control over the determi nants of health, and thereby improve their health.

In 1987, the WHO’s European Office initiated its Healthy Cities program “to support integrated approaches to health promotion at the city level.” This ambition, one of the first tangible impacts of the Ottawa Charter, was subsequently adopted in other regions. The Healthy Cities program emphasized the relationship between the urban environment and health, the role of local government in promoting health at a city scale, and the key role of public health officials in local decisionmaking. A healthy city was defined as “one that is continu ally creating and improving those physical and social envi ronments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and developing to their maximum po tential.” Fundamentally, the program centers around public health experts driving participatory processes to make cities healthier using a range of tools, from regulations and plan ning to the implementation of projects.

The introduction of the Healthy Cities program was accompa nied by a series of events to amplify this approach, with the first WHO International Healthy Cities Conference held in Liverpool in March, 1988. The Healthy Cities concept spread around the world and was enthusiastically adopted by governments and civil society. What began with 11 designated WHO cities soon became a widespread, “new public health movement.” By the mid-1990s, several hundred cities around the world, mainly in the Global North, had healthy city initiatives underway.

Although the concept of “healthy cities” was intended to be universal, in practice it was tied to the contexts where the idea originated. The concept of the healthy city was initially devel oped in the Global North and depends on having effective and accountable local governments with sufficient capacity to inter vene in the urban environment. Many of the policy tools identi fied and used did not apply in parts of the Global South, where local government is often relatively under-capacitated and has fewer powers and functions than many in the Global North. Furthermore, many cities in the Global South have a large propor tion of residents living in informal settlements, where the state often does not significantly intervene through service provision or regulation.

As a result, as the Healthy Cities program spread to the Global South throughout the 1990s, implementation became increasingly challenging. Nonetheless, the WHO Regional Office for Af rica held various capacity building exercises around healthy cit ies, and by 2000 most African countries had at least one Healthy Cities initiative under way. Notably, even these programs faced the challenge of having to compete with other global programs (e.g. on sustainable cities) and a lack of resources. In 2002, one set of scholars observed, that “although the WHO healthy cities movement has been widely implemented elsewhere, the Afri can region lagged behind.”

The Cape Town Healthy Cities Project

Cape Town particularly illustrates some of the challenges with implementing the healthy cities program in the Global South. As part of the WHO Healthy Cities program, a healthy cities initiative involving participatory decision-making forums was im plemented in Cape Town in the 1990s. Cape Town was ripe for experimentation, as it had—and still has—a large and complex burden of disease, very high levels of intra-urban inequality, and was undergoing a change in governance structure, with the 56 existing municipalities merging into a new metropolitan author ity, the Cape Metropolitan Council. At the time, South Africa was in the midst of the transition to democracy and experimenting with innovative new policy ideas. The Cape Town Healthy City Project was initiated by the Cape Metropolitan Council (CMC) in 1996 with an extensive public consultation process. The project formally started in 1997. There was an overall steering commit tee that included local government officials from the Environmental Health and Planning Departments, councilors and other stakeholders, including NGOs, academic institutions and a community representative. The CMC employed a full-time coordi nator. Participatory meetings were held at both the city and community scale. In practice, however, public health officials with no experience of community participation struggled to fa cilitate these complex processes with competing interests.

In 2002, the Cape Town Healthy City Project was terminat ed. Although the reasons remain unclear, it is likely that this was linked to the local government restructuring and a large amount of new local government legislation. The introduction of a new intersectoral planning process (which required local authorities to produce Integrated Development Plans) essen tially spelled the death knell of the initiative in Cape Town as it didn’t have political champions. As the Cape Town Healthy City Project drew to a close, there was the potential for the new City of Cape Town’s Integrated Development Plans (IDPs)

to become a vehicle for achieving a healthier city. At first, the signs were promising. The new unified City of Cape Town’s first IDP, drawn up in 2001, included the goal of “a healthy city for all the people.” The contents of the IDP reveal a relatively broad understanding of how a number of activities across different sectors would be required to improve health indicators. But in subsequent Cape Town IDPs, this broad focus on health with ered away. By the 2004-05 IDP, the only mention of health was in relation to stopping the spread of HIV/AIDS and Tuberculosis.

Despite the rapid spread of healthy cities projects around the world, the achievements of the projects have been generally modest, with research suggesting that “progress has been largely incremental or marginal, rather than the radical changes that had been hoped for”. In Africa, although there have been a number of Healthy Cities initiatives that have achieved pro gress with regards to important issues such as the provision of water and sanitation, the challenges have been severe, including insufficient mobilization of financial resources, insufficient monitoring and lack of commitment from municipal authorities. While there are many flourishing Healthy Cities initiatives else where in the world, in Africa comprehensive Healthy Cities ini tiatives have, in practice, largely been replaced by initiatives focusing on healthy villages, healthy homes, healthy schools and healthy food markets.

The modest achievements of Healthy Cities projects are most likely a result of over ambitious objectives and a failure to sufficiently account for the complexity of governance and partici pation processes. The Healthy Cities concept, at least initially, was based on “the modernist belief in the power of science and expertise to solve problems” , and on the belief that “technicalrational solutions can solve complex socio-political problems.” The Healthy Cities program was thus arguably turned from a value-driven movement to “a technomanagerial process.” In ad dition, it is noted that the program was “conceptually contradic tory, because, on the one hand, it claims popular participation; but, on the other hand, is a top-down international program.”

There is still a WHO Healthy Cities program, but it has under gone a shift from implementing participatory health-driven initiatives to trying to get policy makers and urban planners to think about health and incorporate health objectives. he Urban HEART tool for local decision-makers, for example, is used for prioritizing place-based urban health interventions. Since 2016, the 2030 Agenda for Sustainable Development and the Sustainable Development Goals have essentially subsumed much of the Healthy Cities work.

The story is in some ways simple: a global agency with the best of intentions struggled to implement a global program to make cities healthier. The need to make cities healthier is more im portant than ever, and the need for global agencies and global programs to support, through financial resources and technical support, those ends remain. But they should not done through top-down techno-managerial programs; rather, such initiatives require the flexibility to allow for different processes to emerge in different places, including through the use of co-production methodologies that bring together policy makers, civil socie ty and other stakeholders to redefine problems and develop context-specific solutions. Experiences with co-production methodologies show that, although complex and time consum ing, bringing different stakeholders with different perspectives to collaborate on policies and projects can help contribute to more equitable cities that are better places to live in.

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About the Author: Warren Smit is an Associate Professor and manager of research at the African Centre for Cities at the University of Cape Town in South Africa.