Category Archives: Public Health

Defining (global) public health and its challenges

19th century remedies

Creative Commons license via Flickr: http://www.flickr.com/photos/aussiegall/309391023/

 

 

An outfit called “Thought Economics: Interviews With the World’s Leading Thinkers” recently posted an interview with some leading members of the public health enterprise: Dr. Julio Frenk (Dean of the Harvard School of Public Health, and former Minister of Health of Mexico), Sir Richard Thompson (President of the U.K. Royal College of Physicians), Baron Peter Piot (Director of the London School of Hygiene and Tropical Medicine) and Dame Sally Davies (The United Kingdom’s Chief Medical Officer).

The questions were, at times very broad (e.g., what is public health; to what extent should health be considered a human right?).  In other cases, the questions were almost predictable (e.g., What are the key challenges and opportunities in the sphere of communicable disease?).

All very useful for a very high level overview of the challenges facing contemporary public health.  Of particular interest was Peter Piot’s answer to the question, “what is global health?”.  His pithy answer was interesting:

Many of our health problems challenges cannot be solved within one specific border. In the old days, we had ‘tropical medicine’ which was a colonial approach. This led to international-health during the cold-wars which simply meant the health of those far away. Now we have the concept of ‘global health’ which reflects the globalisation of the world.

global health

Source: BMC Medicine

Alas, I think that too much of what is written under the rubric of global health remains in the style of “the health of those far away”. There are good and bad reasons for this.  On the one hand, there is just the continuing interest in investigating the health of people in other countries.  On the other hand, what is perhaps new in the last 10-15 years is an acceleration of research that is written from a more normative perspective.  On this account, we need to be concerned about the health of those far away because all too often their health status is very poor indeed and this is, quite simply, unacceptable.

Perhaps this is simply an expression of life in a globalized world.  We are very much connected one to the other, not just by the speed at which infectious disease can travel, but also by the fact that we have a shared humanity and it is unacceptable to turn a blind eye to the plight of others.  And of course, in a globalised world what we do in our own backyard can have such a large effect on the health of people in far away places.  The migration of highly skilled health professionals is but one example of this.

All of this may be self-evident to specialists in global health but for a more lay audience, these distinctions are interesting and important.

Inside the black box: science, politics and healthy public policy Notes for an address to The Ontario Public Health Convention, April 1, 2014

tophc_ca

 

Yesterday I had the honour and the pleasure of speaking to The Ontario Public Health Convention.  The title of my talk, “Inside the black box: science, politics and healthy public policy” gives a good sense of the themes developed in my presentation.  I specifically made an argument about the limits of evidence for making public health policy, presented some key ideas about the policy process arising from political science theories of policy making; and ended with a short defense of “politics”.

A copy of the notes for my presentation is available here.

Policy as Values

In July 2012 I published a short piece entitled “Policy as Values” in the newsletter of the Institute for Science, Society and Policy. While this was a response to an earlier item by my University of Ottawa colleague, Scott Findlay, I think my contribution stands on its own and may have continuing interest to a wider audience.

I am reproducing the piece here since it is no longer avaialble in its entirety from the ISSP.

ISSP logo

Policy as Values

Patrick Fafard

June 2012

Long ago and far away I took a course in philosophy of the social sciences. Surprisingly, this philosophy course involved a field trip and a very peculiar one indeed. On campus there was a small office in a bit of commercial space that housed, if memory serves, Technocracy Inc. The organisation was committed to advancing the cause of a rational and scientific approach to life in general and government in particular.

I have repeatedly encountered variations on this desire for a scientific approach to government, most recently in the blog post by my University of Ottawa colleague Scott Findlay provocatively entitled (at least for me) “Policy as Science”. To summarize and oversimplify, he advocates a rational policy process that selects among candidate policies in a rational manner, using the scientific method. My first inclination was to discount if not dismiss the argument by simply asserting that in real life things are not so simple and grumble about the hubris of scientists.

But the very fact that the desire for a rational approach to policy making is always present and, at first glance, quite seductive, demands a more fulsome response. There are any number of possible objections: much has been written on why policy making is not rational and indeed cannot be so. In fact, I have argued, as have many others, that policy making should not be reduced to rational problem solving.

But for the moment I want to focus on one aspect of the argument for a more rational or scientific approach to policy making. To reduce policy making to problem solving, as Scott suggests, assumes that we can agree on the nature of the problem and on the desired outcome. Let us consider each of these claims in turn.

Before there can be a policy choice there has to be agreement that there is a problem to be solved or at least one that government can do something about. In effect then, the art of governing is to choose the problems that will be addressed and which are to be more or less ignored. However, among the many challenges of governing is the simple fact that we do not always agree on the nature of the problem. I say Canadians eat too much salt, which causes widespread high blood pressure. Others say that there is no scientific consensus on the matter and scoff at the idea that there is a problem to be solved. In effect, fighting over how to define the problem and the science underlying problems is often a big part of the policy process – witness the debates about climate change or drug addiction.

Assuming we can agree on the nature of the problem (or at least most of us can, at least for a time) according to Scott a rational policy process would see us choose the option that is most likely to achieve desired outcomes. However, we are confronted by the reality that we are unlikely to agree on what is desirable. Policymaking is never only about solving a problem. It is addressing a problem in a way that is acceptable to at least some citizens some or most of the time. It is making decisions that advance a broader overall agenda if not a broader philosophy. It is addressing public concerns in a politically prudential way.

To return to the case of dietary sodium, we have no way of demonstrating unequivocally whether what is required is social marketing, industry self-regulation or government regulation of the food industry. And even if it could be shown that government regulation of the food industry is the optimal way to reduce the amount of salt in our diet, small-c conservative governments are unlikely to want to do so on broadly philosophical grounds.   Government regulation of food raises concerns about undue government influence in the lives of citizens. The latter objection cannot be resolved with reference to science alone. It is a normative claim and requires a different kind of reasoning altogether.

In effect, most of the truly interesting and non-trivial policy issues do not lend themselves to rational decision-making. Why? Because they involve disagreements over values and such disagreements, as Hume reminded long ago, cannot be resolved with reference to science alone.

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.