Political perspectives in public health

For several years now I have been pondering the intersection between public health and political science and between public health and politics.  How, where and with what effect the two intersect is manifest in a number of dimensions, some scholarly, many decidedly practical and real (my earliest effort in this area was published in 2008).

One of the perennial debates in public health generally and health promotion in particular is the role of “individual” vs. “societal” changes in improving the health of populations.

The “individual” perspective on public health (let’s call it IPH for short), emphasizes the importance of each of us making small and not so small changes in how we live our lives as the key to improving our own health and, collectively, the health of the population overall.  As my University of Ottawa colleague Yoni Freedhoff recently put it “what we choose to do with our forks and our feet” has significant implications for our health.

The “societal” or “structural” perspective on public health (let’s call it

John Locke

John Locke
Source: Wikimedia Commons

SPH for short) argues first, that societal or structural changes are required to improve population health, and second, that absent these structural changes, it is difficult if not impossible for many people to make the individual changes required to improve their own health (e.g., the poor cannot eat well if they live and “food deserts” and do not have access to health food choices where they live).  There are various versions of SPH from those that emphasize changes to our built environment (e.g., how we design and build cities) all the way to those that argue that the structural changes required go much deeper and point to the design of the welfare state.

My working hypothesis is that there is a set of relationships between these different perspectives on what matters for public health and different ideological if not philosophical positions.  IPH clearly has it roots in traditional liberalism with an emphasis on the central importance of individual choices about the good life.  Conversely, an SPH perspective is linked to a more social democratic interpretation of what makes the world go ’round.

In contemporary politics the IPH perspective is by far the stronger of the two (or at least something that most governments can agree on) and gives rise to the bureaus, agencies and departments devoted to health promotion.  The SPH perspective is not completely absent but pops up more selectively (e.g., the largely ineffectual interest of the government of Tony Blair in health inequality; the WHO Commission the Social Determinants of Health – which itself has been accused of being excessively liberal in its orientations).

Krieger

Source: Oxford University Press USA

This is by no means a novel observation, at least in public health circles. Nor is it anything close to a complete account of the different perspectives in public health (for this you would be well served to read Nancy Krieger’s magisterial survey of public heath theory).

I draw attention to it because it would seem that there is a growing awareness in the broader population that health is more than health care (a truism among students of public health).  Yet, when a well-intentioned citizen or politician wishes to take the claim seriously, she or he is immediately confronted by quite different accounts of what it means to tackle public health using tools beyond the health system.  In other words, perennial debates inside public health are being moved into a broader arena.  This means that the usually polite disagreements between proponents of different flavours of both IPH and SPH accounts of what keeps up healthy risk being transformed into a more partisan, and therefore more heated and perhaps partisan discussion if not debate.

And this could be a good thing.

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