Ecological Public Health

Reshaping the Conditions for Good Health

Geof Rayner, Tim Lang

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136482700
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

What is public health? To some, it is about drains, water, food and housing, all requiring engineering and expert management. To others, it is the State using medicine or health education and tackling unhealthy lifestyles.

This book argues that public health thinking needs an overhaul, a return to and modernisation around ecological principles. Ecological Public Health thinking, outlined here, fits the twenty-first century's challenges. It integrates what the authors call the four dimensions of existence: the material, biological, social and cultural aspects of life. Public health becomes the task of transforming the relationship between people, their circumstances and the biological world of nature and bodies. For Geof Rayner and Tim Lang, this is about facing a number of long-term transitions, some well recognized, others not. These transitions are Demographic, Epidemiological, Urban, Energy, Economic, Nutrition, Biological, Cultural and Democracy itself.

The authors argue that identifying large scale transitions such as these refocuses public health actions onto the conditions on which human and eco-systems health interact. Making their case, Rayner and Lang map past confusions in public health images, definitions and models. This is an optimistic book, arguing public health can be rescued from its current dilemmas and frustrations. This century's agenda is unavoidably complex, however, and requires stronger and more daring combinations of interdisciplinary work, movements and professions locally, nationally and globally. Outlining these in the concluding section, the book charts a positive and reinvigorated institutional purpose.

PART I

Images and models of public health

1

INTRODUCING THE NOTION OF ECOLOGICAL PUBLIC HEALTH

This chapter introduces conventional understandings of public health. It explores some images of what is meant. It concludes by laying out some characteristics of what a twenty-first-century public health entails. Public health is literally the health of the public, but to protect and promote it requires recognition of the complexity of the task. It is rare for there to be any simple ‘silver bullets’ for public health. Improving public health today requires: recognition of the scale of change dynamics and societal transitions; political involvement and leadership; interdisciplinary collaboration; commitment to democracy and progress; and an ecological framework of thinking.

Making the invisible visible

This book is about what is meant by public health. It explores various traditions and ways of thinking about health. It argues that public health is sometimes completely marginal to mainstream thinking and lives, yet they depend entirely upon the population having a modicum of good health. The key notion of public health is that good health flows from the population level to the individual rather than the other way round. No one, however rich, however well-endowed with ‘good genes’, living in any circumstances, can outweigh the impact of the collective experience or poor conditions threatening their individual health. Public health literally means ‘the health of the public’. Calling it a field, a profession, a task, a set of interventions or a set of laws or technologies comes after that founding perspective that health is a public and not just personal phenomenon. Public health is ultimately about all of humanity – how we live together, our shared circumstances and infrastructure (air, water, soil, food, housing, work, etc.), the causes of our illnesses, the quality of our lives and the causes and quality of our deaths. For us, public health is a synecdoche, an indicator of progress both for and of human society.

We set out a critical assessment of public health, arguing that the notion of health-as-public or public health suffers from cultural invisibility. It lacks a good story for modern politics, and therefore suffers too much from a deficit of highlevel championship. While it has successes, which are discussed in this book, these are seen as episodic, the resolution of crises, or occasional moments of action. Public health is associated with the drama of threat. Few politicians will ignore a crisis, not least since they do not want their names associated with failure to respond. Equally, they are content to marginalise public health when concentrating on conventional political aspirations such as job creation, growing the economy, or getting re-elected. Then, public health is too often painted as a drag on lively economies, what ‘we can or cannot afford’.

A different interpretation of public health and its invisibility points to a paradox. Successful societies are those which embrace public health principles but often, in the act of applying these principles and investing in their implementation, lose sight of the rationale for why the actions have been pursued. Success in preventing ill health quickly breeds collective amnesia. Sight is lost of causation and what went into its resolution. Political memories fade. The result may leave changed daily behaviour but lacks rationale. The rules of driving cars on the road, for example, came about because the number of people killed on roads by motor traffic was considerable. Traffic lights, rules of how to drive, and collective awareness of other drivers transformed the ‘freedom’ of the individual early driver. Civility, law and good sense worked together to discipline what otherwise was initially a free-for-all, symbolised by Mr Toad’s driving behaviour in Kenneth Grahame’s Edwardian novel Wind in the Willows – a mad individualist who hogs the road, threatening others and endangering himself.¹

Mr Toad, apart from his clammy green skin, eccentric language and dress sense, represents the twenty-first-century not just early-twentieth-century individualist, everything reduced to his needs, no one else’s. His counterparts today might be the presenters of television series celebrating the interests of the motorist, such as the BBC’s successful Top Gear programme, whose motoring stunts and light humour draw 350 million viewers worldwide. In contrast, public health seems killjoy, imposing rules, stopping individual motorists putting their foot down in pursuit of motoring freedom.

Public health thus easily represents a rather sober case for investing in and accepting the need for measures which are designed to improve the lot of the public. If so, who does it? Whose interests triumph? Hence the accusations that public health is the killjoy. Yet public health provides the rationale for creating healthy, sustainable transport systems and, for that matter, also decent water supplies, or setting minimum wages or cleaning up food adulteration or preventing children dying prematurely from preventable diseases. This positive image of public health is easily swamped by the individualist perspective which too often tacitly encourages young people to see road rules as against their interests. In fact, the more people survive road carnage, the better road safety has become. In 1926 Britain, there were 2.9 fatalities per 1,000 vehicles on the roads. By the end of the century, the ratio had fallen to 0.1.²

Behind this public health success story lies huge investment in road safety, car design, driver regulation, skills and policing, all of which generated a culture of civility, based on thinking and negotiating with one another. Rules on alcohol use and seat belts, for example, were successfully injected into motor car use, transforming social norms of accepted behaviour. On the other hand, the less pleasant news is that, over this period, cycle use has plunged and parents have become increasingly wary of their children using bicycles. Children are car-driven to school, to parks and to parties, insulating them from knowledge of where they live and from necessary but stunningly ordinary means of gaining physical exercise such as walking and cycling. Improving safety in one mode of transport has thus compromised another. From a public health perspective, critics of motorised transport also rightly point to its contribution to obesity, disconnected social life, changes in the physical environment, and wasteful use of finite energy resources.³ It needs to be said that the positive trends in Britain and other developed economies may not be the case elsewhere. Approximately 1.3 million people die each year on the world’s roads, and 20–50 million sustain non-fatal injuries. Roughly half of the victims are pedestrians.⁴

Part of the invisibility of public health, such examples suggest, is that societies come to rely on the investments championed in the name of public health. Those improvements are then taken for granted and even attacked as unnecessary or ‘nannying’. Part of the challenge for twenty-first-century public health is to articulate the principles by which this century’s health can be improved. In this book, we explore the principles and institutions of public health, and how they are or are not providing the necessary new clarity. Making a healthy society requires institutionalisation of investment, commitments, and rules of civil engagement and everyday life. If movies of car-driver mayhem divert people away from poor driving on the road, so to the good, but the effects have to be understood and acknowledged. Mangled bodies or frightened pedestrians are not ultimately topics of entertainment.

We are not alone in seeing this paradox – success leading to silence leading to underemphasis on the centrality of public health – as the denial of a civilising force. The philosopher John Searle has highlighted the way humans think they are acting in freedom and spontaneity but how in reality behaviours are contextualised by a hidden framework of prior decisions, laws, institutions, habits and tacit everyday rules which guide our behaviour and mental reflexes:

I go into a café in Paris and sit in a chair at a table. The waiter comes and I utter a fragment of a French sentence. I say, ‘un Demi, Munich, à pression, s’il vous plaît.’ The waiter brings the beer and I drink it. I leave some money on the table and leave.

Searle points out that this simple everyday episode – ordering and drinking a beer in a café – is more complex than it appears to be at first:

[T]he waiter did not actually own the beer he gave me, but he is employed by the restaurant which owned it. The restaurant is required to post a list of the prices of all the boissons, and even if I never see such a list, I am required to pay only the listed price. The owner of the restaurant is licensed by the French government to operate it. As such, he is subject to a thousand rules and regulations I know nothing about. I am entitled to be there in the first place only because I am a citizen of the United States, the bearer of a valid passport, and I have entered France legally.⁵

Everyday exchanges, he argues, have behind them a vast number of hidden institutional rules and conventions, built up over time, and negotiated between and within cultures, which guide our behaviour and actions. In similar manner, public health is more than individual genes or the size of bank accounts. Public health is part of the fabric of how society operates. Who could be against public health, the right to live in a state of health? Most people desire health for themselves, their families and their fellows. But for this to come about requires collective action.

Some argue that public health merely needs better public relations. We think its problems are more profound than can be resolved by spending on publicity. Certainly, public health, when compared to other aspects of health provision, is often low in the list. David Hemenway, a US public health specialist working in the field of violence and firearms, has asked why this is so, and he suggests that its lack of profile is systemic, not least because it sits alongside medicine, which has a far higher profile and funding.⁶ Unlike medicine, where the linkage to patients is immediate and direct, the benefits of public health programmes often lie in the future, and whereas the beneficiaries of medicine are easily identified – and at some time it will be us – the beneficiaries and even benefactors of public health may be unknown. When lives are saved and when the population’s health improves, it is unclear whose lives they are, and people may not even recognise that they have been helped. They become anonymised in mass statistics, the health profile of a nation or group. To complicate further, some lines of public health effort encounter not just disinterest but out-and-out opposition. For Hemenway, firearms – less of a feature in Europe than in some parts of the world – are a case in point.

The invisibility of public health is not recent, but has dogged its history. In 1937 Richard Shryock (1917–72), a US historian of public health, observed that, ‘by the simple process of forgetting’ its past efforts, the public health movement had become irrelevant. He expressed a worry that ‘indifference to the past’ might promote ‘complacency in the present’.⁷

There are also powerful intellectual reasons why public health is such a thorny issue. The process of identifying problems and solutions is often furiously difficult, whether the problem is death due to famine or infectious disease, or death due to firearms or tobacco. The case for public health always has to be built, argued and won. And, once won, it continues to need to be argued for. Thus public health requires a movement which champions it. The more people are engaged in thinking about public health, the more their health is likely to be improved and/or maintained. That is why this book and the model of public health that we elaborate here – Ecological Public Health – see social engagement about health as so important. The health of the public is actually a measure of societal progress. Indeed, public health is the health of societies and is the ultimate yardstick by which most people value existence for themselves and their loved ones.

So why is there such opposition to public health, and why is it frequently presented as unwarranted intervention or busybodying? Arguments offered against public health include that public health measures:

• come at too high a price for the taxpayer;

• interfere with private decision-making;

• act as a restraint on trade and economic growth;

• impose an unnecessary burden on business;

• disrupt moral or religious norms (e.g. between the sexes, parents and children);

• are expressions of self-interest by State-funded interest groups;

• represent an overextension of legitimate public health action into unnecessary terrain;

• are not evidence-based or are based on insufficient evidence for benefit;

• infantilise the general public by assuming our need for paternalism and oversight;

• result from the manipulation of moral panics;

• are a smokescreen for social engineering; and

• are ultimately self-defeating.

Again, these arguments are not new. A similar list of potential objections to his plans for the promotion of public health in Boston, USA was compiled by Lemuel Shattuck (1793–1859) in the late 1840s. Objections frequently voiced against measures to promote the public health, said Shattuck, were that they were:⁸

• too complicated;

• ‘not applicable to us’;

• too statistical;

• interfering with private matters;

• interfering with private rights;

• creating an unnecessary expense;

• promoting quackery;

• alarming the people;

• interfering with Providence; and

• a diversion of time.

These arguments are essentially that public health is overweening and self-aggrandising. But they also expose how health interventions are moral and societal dilemmas. They are sometimes the result of the collision between social conservatism and progressivism, the precedence of the short term over the long term, or powers held by the few over the many. While we speak of public health being aligned with social progress, it would hardly be of surprise if these and other dimensions of philosophical disagreement were not also reflected within public health. While we argue that the discussion and promotion of public health by its nature represents social progress, acknowledgement also needs to be made of the fact that public health interventions can be received as oppressive, retrospectively irrelevant, or interest-laden. A serious critique of public health is that its manifestation may result from or ignore long-standing injustices. Too often the history of public health is written as a continual line...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• List of Figures
• List of Tables
• Preface: From the History to the Future of Public Health
• Acknowledgements
• List of Abbreviations
• Part I Images and models of public health
• Part II The transitions to be addressed by public health
• Part III Reshaping the conditions for good health
• Notes
• Index