Editorial – Pulling health promotion and chronic disease prevention from the margins of the global public health agenda—again

One year into the coronavirus pandemic, and with the rollout of vaccines underway, hope of a gradual return to “normal” life grows by the day. However, what normal will really look like is uncertain, as evidenced by the steady stream of publications speculating about our post-COVID lives, from the future of office work to forthcoming changes to the way we design and build our cities, deliver health care services, and deal with climate change and economic inequalities. “Building back better” is a common refrain among governments and international agencies.^{Footnote 1Footnote 2}

There is optimism that the “building back better” mantra will also apply to public health systems, in part through stronger global science diplomacy and, hopefully, new and sustained investments in disease prevention post-COVID. There are calls to reclaim “comprehensive public health” principles,^{Footnote 3} and proposals to further apply and implement a One Health approach^{Footnote 4} and use more integrative thinking by considering how the current pandemic is interlinked with other health conditions and broader determinants of health.^{Footnote 5}  

On that ground, arguments have been proposed that COVID-19 should be approached as a syndemic^{Footnote 6},^{Footnote *} rather than as a pandemic, recognizing that “conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies” and that in the case of COVID-19, “attacking [chronic diseases] will be a prerequisite for successful containment.”^{Footnote 7,p.874} The most recent report of Canada’s Chief Public Health Officer presented well the case for a stronger health equity approach in tackling COVID-19, and noted that “the COVID-19 pandemic has jolted our collective consciousness into recognizing that equity is vital for ensuring health security.”^{Footnote 8,p.2}

But there is an air of déjà vu. These calls for renewing our approach to noncommunicable diseases (NCDs) and implementing a more integrated global health agenda have intensified since the first United Nations High-level Meeting on NCDs in 2011, but progress is slow. In 2018, Time to deliver: report of the WHO Independent High-level Commission on Noncommunicable Diseases concluded that, globally, we are not on track to reduce, by one-third, premature mortality from NCDs by 2030 (Sustainable Development Goal 3, target 3.4).^{Footnote 9} The Commissioners noted that “there is still a sense of business-as-usual rather than the urgency that is required”^{Footnote 9,p.4} and that, consequently, national and international investments have been insufficient.

If COVID-19 is to bring a new lens or sense of urgency to tackling chronic diseases and the broader determinants of health, what principles or strategies might guide our next steps? A starting point could include the following.

• We must reframe the conversation around chronic diseases and their underlying causes, and do away with the artificial divide between chronic and infectious diseases. This is clearly a long journey. The fact that the United Nations Sustainable Development Goals are deeply interconnected is already well recognized, at least among scientists. Increased investments in infectious diseases prevention and control—and these investments are necessary—should not end up causing a decrease in funding for addressing other conditions and the broader determinants of health. A zero-sum game approach would be shortsighted. Promoting and using the term “syndemic” to describe COVID-19 may take us a little further.
• We need better data. This statement requires qualification. While we do have data showing that chronic diseases are one of the critical factors associated with COVID-19 deaths and demonstrating the severity of the disease, the gap in the availability of quality disaggregated data about vulnerable populations (e.g. lack of ethnicity-based data) to inform decisions has been exposed. In investigating the wider impact of COVID-19, including the impact of public health measures (e.g. on mental health, problematic substance use, etc.), the importance of longitudinal studies to answer complex research questions has also been on full display. Raised awareness about current gaps may provide momentum to address these shortcomings head on.
• We can’t let the quest for innovation be a distraction from the old, tried-and-true of public health. While we clearly need vaccines to help us get out of the current COVID-19 crisis—and we should celebrate vaccine innovation in the era of COVID-19—we are also being reminded that vaccines are a vital tool, but not a silver bullet.^{Footnote 10} The same advice holds true in the field of health promotion and chronic disease prevention. A slew of strategies based on mobile technology—under the umbrella of “innovation”—have been used to help people improve health behaviors. These strategies are part of a toolkit, but they must not detract from adopting evidence-based policies for chronic disease prevention. A stronger focus on individual behaviours and responsibility can sometimes detract attention away from addressing more upstream and structural determinants of health. 
• We should be solutions-oriented. The COVID-19 crisis lends itself to natural experiment studies, for example, on the effects of nonpharmaceutical interventions on the incidence of COVID-19, the wider effects of public health measures or the effects of interventions designed to mitigate the negative consequences of these measures. Natural experiments are still an underused tool to improve public health evidence. The vast majority of the manuscripts submitted to the HPCDP Journal aim to describe the “problem”—measures of disease burden, economic cost of disease, etc.—and this is, of course, of critical importance. What is still lacking is more rigorous studies about the impact of natural policy experiments and population-level interventions. Public health research efforts in the era of COVID-19 may help to solidify the field of population health intervention research.

This is by no means a full and comprehensive assessment of how to ensure that the field of health promotion and chronic disease prevention evolves as part of a wider movement to strengthen public health systems. The COVID-19 series of the HPCDP Journal (with an online-first publication model) remains open. This is a renewed invitation for colleagues in Canada to send us additional manuscripts related to COVID-19, from forward-looking editorials and commentaries to original research papers about the wider impacts of public health measures.