Public Health

Policy and Politics

Rob Baggott

• Publisher: Bloomsbury Academic
• Year: 2010
• ISBN:
  9781350311244
• Edition: 2
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Incorporating the latest developments fromthe field, this eagerly awaited new edition once again provides an important andcomprehensive analysis of the key issues in public health. Exploring the underlying political context and policy processes, this textis core reading for all those interested in theessentials of this area.

Public Health Concepts and Frameworks

1

What is Public Health?

There is no commonly agreed definition of public health. This is not surprising as the concept of health is itself multifaceted and contested (Blaxter, 2004). Health can be interpreted as the absence of illness or disease, as fitness or vitality, as an ability to perform certain functions. It can be perceived in terms of social relationships and psychosocial wellbeing. As Ewles and Simnett (2003, p. 5) observed, ‘people’s ideas of “health” and “being healthy” vary widely. They are shaped by their experiences, knowledge, values and expectations, as well as their view of what they are expected to do in their everyday lives, and the fitness they need to fulfil that role.’

Concepts of health are often divided into positive and negative approaches. The conventional biomedical perspective is negative in the sense that it conceives health as an absence of disease in individuals. In contrast, positive approaches highlight the social, environmental and psychological aspects of health (Aggleton, 1990). In modern times, negative concepts of health have predominated, largely because of the combined power of the medical profession and commercial health care interests (Hunter, 2003; Freeman, 2000; Moynihan, 1998). Even so, in recent decades the disease-based approach has been challenged by positive concepts. So much so that the medical profession more readily acknowledges the role of psychosocial factors in health, the importance of quality of life issues and value of holistic approaches to health. Meanwhile, commercial interests have sought to explore market opportunities in prevention and public health.

Perhaps the best-known positive definition of health is that formulated by the World Health Organization: ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 1946, p. 100). Although criticized for being utopian, this definition has been a rallying point for those seeking to shift the balance towards a more positive approach to health. These include Antonovsky (1979, 1996), who called for a refocusing of attention away from the causes of disease (the ‘pathological paradigm’) towards those factors that facilitate health (the ‘salutogenic paradigm’). The salutogenic paradigm is based not on a dichotomy of health or disease, but on a continuum of states between ‘health-ease and disease’. According to Antonovsky, a major factor influencing health, and determining one’s location at the healthy end of the spectrum, is a ‘sense of coherence.’ This is derived from experiences through the life course that enable individuals to make sense of the world and cope with situations as they arise.

Wellbeing

Wellbeing is a key concept in positive approaches to health (see McAllister, 2005; Dolan et al., 2006; Felce and Perry, 1995; Searle, 2008; Kahneman et al., 2003; Huppert et al., 2005). It can be subjective; individuals assessing themselves in how satisfied or happy they are feeling. Alternatively, wellbeing may be objectively ascribed by others on the basis of specific criteria (such as economic resources, education, housing, access to public services). Wellbeing may be measured at the social and individual level. There are two main conceptual approaches to wellbeing. The first looks at the extent to which material, social and psychological needs are met. This is known as the hedonistic approach. Alternatively, the second, eudaemonism, focuses on the realization of potential and seeks to measure the extent to which people flourish as human beings. This may include criteria such as autonomy, personal growth, life purpose, mastery and positive relationships (see Ryff and Keys, 1995, cited in Dolan et al., 2006). Although there is disagreement over the relative weight that should be given to different types of wellbeing, there is much consensus on the domains that comprise overall wellbeing (McAllister, 2005): namely, physical, material, social, personal development and purposeful activity.

The current level of interest in wellbeing is based partly on observations that growing prosperity, as measured by conventional indicators (such as gross domestic product, GDP), has not yielded commensurate improvements in wellbeing (see Exhibit 1.1; Oswald, 1997; Easterlin, 1974; Layard, 2006; New Economics Foundation, 2004; James, 2007). It has also been stimulated by worries about climate change and sustainability (Dolan et al., 2006) and by evidence of the impact of social organization and structure on physical and mental health (Layard, 2006; Marmot, 2004). In addition, there has been specific concern about the wellbeing of children, arising from the increased regulation of childhood, child poverty, lack of protection from consumer capitalism, poor parenting skills and decline in the quality of family life (see James, 2007; UNICEF, 2007a; Bradshaw, 2002).

Exhibit 1.1

Measuring Wellbeing in the UK and Other Countries

There is evidence from the UK and other countries that levels of wellbeing, measured by surveys of life satisfaction, have not increased in line with increases in national income. In the UK, gross domestic product (GDP) doubled between 1973 and 2006 while the proportion of people who were satisfied remained stable. According to the Department for Environment, Food and Rural Affairs (DEFRA) (2007), 73 per cent of people in England rated their overall satisfaction with life at over 7 out of 10. Some aspects of life, however, received lower ratings. For example, although over 60 per cent of respondents said that they were satisfied with their community and their financial security, this was lower than the level of satisfaction with relationships, accommodation and standard of living, which achieved ratings of 80 per cent and over. Differences were found between different social groups (see also Blanchflower and Oswald, 2008). Middle-aged people, particularly men, are less satisfied with their lives than older and younger people. People in unskilled jobs or who are unemployed are also less satisfied with life.

Some have tried to add subjective measures of life satisfaction to other social indicators in an attempt to produce a broader quality of life measure. For example, the Happy Planet Index (HPI), used by the New Economics Foundation (2009), is based on three criteria – life satisfaction, life expectancy and environmental sustainability. Countries that achieve in these areas are given higher ratings and rankings than those that do not. On the basis of this index, the major industrialized countries are rated much lower than their economic wealth might suggest. In the 2009 rankings the UK came 74th out of 143 countries and the USA was ranked 114th. Some industrializing countries also fared badly, with India’s and China’s index falling over time. But this is not always the case: the HPI index for Brazil, which has undergone significant economic development in recent years, increased. There are also considerable differences between European countries, with Germany, Holland, Sweden, Switzerland and Austria ranked highest. Interestingly, among the top 10 countries ranked by HPI, all but one are in Latin America.

Definitions of public health reflect underlying debates about the meaning of health and wellbeing. In a narrow sense, public health refers to the longevity of a population and the extent to which it is free from disease. Public health is sometimes equated with ‘public health medicine’, that is the range of medical techniques, knowledge and interventions that are geared to preventing disease in individuals and in populations (see Chapter 6). Alternatively, reflecting positive perspectives on health, public health is perceived as primarily concerned with population health and wellbeing. According to Baum (2002, p. 14) ‘the distinguishing feature of public health is its focus on populations rather than individuals’. Public health also incorporates a wider range of social interventions and collective action, reflecting Rosen’s (1993, p. 1) observation that ‘throughout human history, the major problems of health that men have faced have been concerned with community life’. This latter approach is captured by Winslow’s classic definition:

Public health is the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organised community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organisation of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. (C. E. A. Winslow, 1920, p. 23)

In the UK context, the Acheson report into public health (Cm 289, 1988) abridged this to ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.’ Subsequently, the Wanless report on public health (HM Treasury, 2004) modified this definition in the context of consumerism, choice, pluralism and the personalization of public services to:

the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organisations, public and private, communities and individuals. (Wanless, 2004, p. 27)

Public health is an extremely broad church. This is problematic because, as Griffiths and Hunter (1999, p. 1) observed, if public health encapsulates so much, it risks being a confusing and diffuse collection of ideas. Indeed, one reason why public health has lacked influence over policy and practice has been its lack of conceptual clarity leading to what some claim is an identity crisis (Hunter et al., 2010; Frenk, 1992). This is not a problem for the UK alone. Indeed, a study of terminology across a number of European countries did not find a common conceptual framework for public health (Kaiser and Mackenbach, 2008).

In an attempt to clarify the meaning of public health, Griffiths et al. (2005) outlined a conceptual model drawing on three distinct but interrelated domains of public health practice identified by the Faculty of Public Health (Griffiths et al., 2005): health improvement – such as information about healthy lifestyles or improvements to housing; health service delivery and quality – for example primary care services; and health protection – including immunization and screening. In another attempt to clarify the concept, Heller et al. (2003, p. 64) defined public health in terms of the types of knowledge required to meet the health needs of the public:

[The] use of theory, experience and evidence derived through the population sciences to improve the health of the population, in a way that best meets the implicit and explicit needs of the community [the public].

Efforts have been made to widen ownership of public health and share a common ethos across agencies and professional groups. Hunter and Marks (2005) promoted ‘public health governance’ which emphasizes the stewardship role of government and the participation of all relevant organizations in public health activities (see also Local Government Association et al., 2004). Similar recommendations have been made in other countries (Institute of Medicine, 1988, 2002; Canadian Institutes of Health Research, 2003). In this context, a distinction is often made between ‘traditional’ public health and ‘new public health’ (Baum, 2002; Ashton and Seymour, 1988; Ewles and Simnett, 2003). This dichotomy is examined more fully in subsequent chapters, but it is sufficient at this stage to note that the new public health (NPH) is perceived as a broader approach that acknowledges the importance of a wider range of environmental, social and personal factors. NPH is also viewed as being focused on promoting health and wellbeing in a positive sense rather than being concerned narrowly with the prevention of disease.

Health Promotion

Another key concept is health promotion (Naidoo and Wills, 2005). It too is a contested concept. It can mean, variously, a social movement, a means of addressing health needs, or a model of health (Bunton and Macdonald, 2002). According to the World Health Organization (WHO) (1986) ‘health promotion is the process of enabling people to increase control over, and to improve their health.’ This reflects the belief that health is a right and endorses a range of ways of improving the health of populations, communities and individuals (Lucas and Lloyd, 2005; Webster and French, 2002; Ewles and Simnett, 2003; MacDonald, 1998; Tones and Green, 2004). It can be contrasted with a narrow ‘health education’ approach, which focuses upon providing individuals with information about reducing the risk of disease, without addressing their wider social and environmental context.

Health promotion is a portmanteau term for a range of activities including health education, preventive health services, economic and regulatory activities, environmental health measures, organizational development, community-based work and healthy public policies (see Ewles and Simnett, 2003, p. 28). Some, however, believe that approach lacks coherence. They call for a more robust philosophy of health promotion to guide policy and practice. Antonovsky, previously mentioned, warned that health promotion risked becoming stagnant in the absence of a clear theoretical perspective. He developed the salutogenic paradigm as a means of highlighting factors promoting health rather than concentrating only on risk factors for disease. Similarly, Lucas and Lloyd (2005, p. 23) argue for a primary focus on ‘improving the quality of people’s day-to-day lives in areas which they have helped to identify’, rather than solely aiming to prevent disease. In so doing, they and others identify the importance of empowerment: for example Tones and Green (2004, p. 3), for whom health promotion ‘is a political endeavour and concerned with addressing issues of fundamental importance – particularly the pursuit of social justice and achievement of equity.’

The concept of ‘health gain’ is also relevant here. Health gain is defined as ‘a measurable improvement in health status, in an individual or a population, attributable to earlier intervention’ (Ewles and Simnett, 2003, p. 336). The relevance of ‘health gain’ lies in its focus on the outcomes of health promotion activities and as a basis for comparing different interventions (WHO, 1998b). Terms such as health improvement or health development are also used in the context of assessing the impact of health promotion activities (Ewles and Simnett, 2003).

Prevention

The focus of public health activities is aimed at preventing problems from emerging, or at least preventing their most serious consequences. The emphasis is on ‘refocusing upstream’, to tackle problems at or near their source (McKinlay, 2005). Prevention can be narrowly conceived as ‘preventive medicine’, incorporating techniques such as screening or immunization, or it may encapsulate a wider range of interventions such as regulation or taxation of potentially harmful products (Yarrow, 1986). It may be targeted at a small ‘high risk’ group or at the whole population (Rose, 1992). Three different types of prevention are usually distinguished: primary prevention – action to prevent ill health before it occurs; secondary prevention – identifying and treating people with early signs of illness; and tertiary prevention – halting or mitigating the effects of ill health already manifested (Cmnd 7615, 1979; Tones and Green, 2004, p. 21). Prevention is often justified with reference to improving welfare or saving budgetary costs (see, for example, Wanless, 2004), reflecting a belief that ‘prevention is better than cure’. However, this is not necessarily the case. As we shall see, preventive interventions may involve significant additional economic costs as well as restrictions on choices and liberties.

So What is Public Health?

Debates about the meaning of public health are essentially political. Different interests favour particular interpretations of public health concepts. The interplay of these forces establishes meanings in policy and practice. Furthermore, these debates are linked to wider political debates, such as those surrounding the role of the state and the individual (Leichter, 1991). Meanwhile, public health policies are shaped by the interplay of political forces in government and in society (Mechanic, 2003; Rose, 1992).

A political analysis of public health is therefore potentially fruitful. This book adopts such an approach and is primarily concerned with political debates surrounding public health and their implications for the emergence, formation and implementation of public health policies. However, to avoid a purely descriptive account, a coherent analytical framework is required. Various frameworks exist (see Signal, 1998, for example). Three seem particularly appropriate: ideological perspectives on the role of the state and the individual; social and cultural theories of risk and expertise; and models of the policy process. Each will now be discussed in turn.

Ideological Perspectives

Public health reflects key ideological debates about the freedom of the individual, the authority of the state, and the balance between individual and collective responsibilities (see Mills and Saward, 1993; Leichter, 1991). The main perspectives are discussed below.

Paternalism and Utilitarianism

Much public health intervention occurred in the period before the era of the welfare state. This was often based on paternalist or utilitarian principles. Paternalism has been defined as ‘the interference of a state or an individual with another person, against their will, and justified by a claim that a person interfered with will be better off or protected from harm’ (Dworkin, 2005). Our main concern here is with state paternalism (also known as ‘narrow paternalism’), but it can apply to employers, professionals, organizations, informal groups and between individuals as well (known as ‘broad paternalism’). Paternalism is essentially a philosophy of intervention that is based on an inequality of power, authority and status coupled with an external assessment of individual needs by a higher authority (Dworkin, 1972).

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