International Perspectives on Public Health and Palliative Care

Libby Sallnow, Suresh Kumar, Allan Kellehear

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136631993
• Edition: 1
• Topic: Medizin
• Subtopic: Gesundheitswesen, Verwaltung & Pflege

Public health approaches to palliative care have been growing in policy importance and practice acceptance. This innovative volume explores the major concepts, practice examples, and practice guidelines for this new approach.

The goal of 'comprehensive care' – seamless support for patients as they transition between home based care and inpatient services – relies on the principles of health promotion and community development both to ensure services are available and importantly appropriate for patients' needs. In developing contexts, where hospitals and hospices may be inaccessible, a public health approach provides not only continuity of care but greater access to good end of life care. This book provides both a historical and conceptual overview whilst offering practical case examples from affluent and developing contexts, in a range of clinical settings. Finally, it draws together research-based guidelines for future practice.

Essential reading for public health researchers and practitioners with an interest in end of life care and global health as well as those involved in developing palliative care provision, International Perspectives on Public Health and Palliative Care is the first volume to present an overview of theory and practice in this emerging field.

1	Public Health and Palliative Care
	An Historical Overview
	Allan Kellehear and Libby Sallnow

What is Public Health?

The twentieth century has seen dramatic improvements in mortality rates and life expectancy; an achievement widely attributed to ‘public health advances’ rather than to clinical medicine. But the ubiquitous use of the term ‘public health’ can cause confusion, as much public health practised today bears little resemblance to that practised by the founders of this movement in the mid-nineteenth century. Public health is concerned with the health of people on a population level. It aims to reduce mortality and morbidity and improve the health of communities, cities or nations. As public health focuses on major killers or disease burdens, it must evolve as they change.

Health is influenced by more than just biomedical factors and thus public health is linked to the prevalent social, political and economic influences on health. Public health is usually defined in terms of its aims: to reduce disease and improve health. As public health does not adhere to a particular theoretical framework or specific methodology, tensions can exist between different areas. It is currently said to be facing a crossroads (Beaglehole and Bonita 2004) but, in order to understand the current tensions, it is important to acknowledge the history of the movement, as the struggles and successes of the past inform many of the current conflicts.

The History of Public Health

The importance of maintaining the health of a population has been recognized by governments and doctors alike since the time of Hippocrates. Although some changes implemented by the Romans and Greeks would now be classed as public health measures, the concerted study of public health as a discipline can be traced to the time of the Industrial Revolution. Rapid urbanization and the development of industry on a large scale presented sudden threats to health and new disease burdens. In addition to this, the traditional means of coping with illness, injury and dying were stripped away as people left their rural communities where strong support networks for the needy and vulnerable had been built up.

Governments began to focus specifically on threats to health, primarily as they were seen to have an influence on economic productivity and social order. The first public health studies were broad demographic studies of mortality rates in different districts and from these an appreciation of the social and environmental determinants of disease grew. In France, in 1821, a surgeon, Rene Louis Villermé, examined the health implications of a large study of mortality rates carried out in Paris.

Searching for a factor that correlated with the high rates seen in certain districts, he found that the strongest by far was income (Porter 1999). In the UK, at approximately the same time, people were becoming increasingly dissatisfied with the Poor Laws, a set of measures devised to support those who could not work. It was felt they were an unnecessary expenditure and in 1834 a report was commissioned into the causes of poverty and the need for the Poor Laws. This enquiry was chaired by Edwin Chadwick, a committed follower of the emerging school of thought of Utilitarianism. The link was made between poverty and ill health but it was believed that disease caused poverty, rather than poverty influencing disease (Hamlin 1994). It was felt that if you removed causes of disease, resolution of poverty would follow. In accordance with the established theories of disease, such as the theory of miasma, the idea that diseases are spread by the gases emitted from rotting matter, the recommendations were narrow in scope and reflected the prevalent reductionist approach to health. New sewer systems and waste disposal schemes were installed but no attempts were made to address the other causes of poverty. The revolution heralded by the germ theory later in the nineteenth century served only to compound this reductionist approach and the remit of public health was narrowed further.

In 1847, a typhoid epidemic broke out in the Prussian province of Silesia. The government was concerned as it was impacting on the profits from the mining industry and Rudolf Virchow, a young doctor, was sent to investigate the causes. He had been influenced by the work of Chadwick and Villermé and produced a report detailing the social causes for the outbreak and recommending better pay and working hours, housing and diet and a joint committee of lay people and professionals to monitor and organize the relief efforts (Waitzkin 2006). He was dismissed after his report was filed but the experience shaped Virchow’s view of disease and he maintained that every disease has two causes: the pathological and the political.

Public health in the eighteenth and nineteenth century is often referred to as the ‘Golden Age’ of public health, when rapid improvements in mortality rates were made and control over many diseases was achieved. Sanitary reform and legislative action were the basis for public health measures in the mid- to late eighteenth century, with dramatic improvements in mortality rates seen in many areas (Szreter 1988). The germ theory heralded a new era, which over-shadowed the older, environmental approaches. A focus on transmission, isolation and targeted antimicrobial therapies caused public health to become colonized with medical professionals and the social reformers were gradually squeezed out. Public health slowly became a specialty allied to medicine. The twentieth century posed a dramatically different set of challenges to public health. The previous century had been dominated by conditions such as cholera, tuberculosis and malaria exacting a high death toll. The epidemiological transition to non-communicable diseases in the twentieth century in the developed world meant public health needed to find new methods to approach the health problems presented by these diseases. Aetiologies were not easily elucidated and were multifactorial. A single biological factor was not responsible, meaning prevention strategies had to look outside the contemporary scientific sphere.

The New Public Health

The broadening of the ‘host-agent’ paradigm that had long dominated public health prompted those in public health to again re-examine the causes of disease. In the UK, a report was commissioned in the 1970s to look at inequalities in health. The Black report, written by Sir Douglas Black, found that a gradient favouring the higher socioeconomic classes existed in most health indicators. This disparity persisted despite the National Health Service providing medical care free at the point of delivery (Davey Smith et al. 2001). This and other similar realizations around the world meant that the social determinants of disease were once again considered when looking at causes and prevention of disease.

In Canada, this appreciation of the wider social determinants of disease was formalized in 1974 with the ‘Health Field Concept’. The then health minister, Marc Lalonde, argued that four elements were involved in determining health outcomes: human biology, environment, lifestyle and health services (Lalonde 1974). This prompted an examination of lifestyle and environmental factors that individuals could control that would then influence health. Although useful in broadening the scope of public health, this was later criticized as creating a culture of ‘blaming the victim’, as many of these factors were in fact beyond an individual’s control.

The Alma-Ata Declaration of 1978 by the World Health Organization (WHO) took this a step further. In order for comprehensive primary care services to be successful in improving the health of communities, the services needed to be appropriate and sustainable. The key part of this was participation of the local community. Services should be developed in partnership with local people, meaning they would be able to accurately address the needs of the people they were serving. This suggestion of health interventions being done with people rather than on people is one of the central themes of the new public health. The Alma-Ata Declaration was followed in 1986 by the Ottawa Charter for Health Promotion (see Box 1.1). This was again put forward by the WHO and it proposed a new model for addressing health, defining it in a positive way, rather than simply the absence of disease. In addition to individual lifestyle factors involved in determining health, there were other, more structural or eco-logical factors that also need to be tackled in order to see any real health gains. For example, health education and empowerment needs to be followed by legislative action such as seatbelt laws or a ban on cigarette advertising.

Box 1.1 The Ottawa Charter

1. Building healthy public policy
2. Creating supportive environments
3. Strengthening community action
4. Developing personal skills
5. Re-orientating health services

Source: adapted from WHO (1986)

The new discipline of health promotion was built on the participatory notion of health, namely that the very people whose health was affected often had the answers about how to solve the problems. The professional dominance of those from outside assuming they knew best for a community was challenged and this set the new public health apart from previous initiatives.

Hospices, Poor Houses and the Development of Palliative Care

The adoption of the term ‘hospice’ by the early workers in palliative care in the 1960s both acknowledged the history of institutions caring for pilgrims, travellers and the poor when sick, but also reflected a new philosophy. The significant historical, cultural and religious overtones contained in the word ‘hospice’ mean it is not a neutral term and it has been used to describe widely different, if not contradictory, institutions over time. The history of hospices through time reflects the parallel developments in scientific, religious and political arenas.

In the early uses of the term, in the Middle Ages, ‘hospice’ was synonymous with ‘hospital’, as places for the sick to reside. The lack of any formal medical presence meant the distinction between investigation and treatment or supportive care was not made. In the affluent classes, medical care was provided in the home and thus the majority of the patients in the early hospices were the poor and homeless. With the advent of the Crusades and religious pilgrimages, large numbers of people were displaced from home. They required shelter and support when they became unwell whilst travelling, and these were met by the early religious hospices. Often run by monks or nuns, they were based on the Christian ethic of care for the needy and there was an emphasis on meeting spiritual needs (Saunders and Ross 2001). With the Reformation, many of these religious hospices were disbanded and, as the profession of medicine began to develop, a distinction between hospices and hospitals developed. Many hospitals instated a policy of not admitting incurable or dying patients, emphasizing that they were places of cure (von Gunten 2005).

The Industrial Revolution caused great social upheaval. The large number of people living in the newly created cities had left behind their communities and traditional means of support. When they became ill or homeless they needed to look for new, alternative means of support. The workhouses provided the employment for the majority of the new inhabitants of the cities. Living in slums and working in dangerous conditions, the mortality and morbidity rates were high and traditional family roles changed as all were required to work in the factories.

New provision was required to house the poor who could no longer work or who were dying. The workhouse infirmaries or poor houses were the solution to this problem. Created simply to house this section of society, there was little medical provision and no ethos of care of the individual. In Spain in the eighteenth century, the Royal Hospice in Madrid was said to act as both an alms house and a jail. Legislative change aimed to contain poverty, and undesirable elements of society were sent to the hospice and kept there under armed guard. These associations have been maintained, with the current meaning of a hospice in-patient, hospiciano, still denoting extreme poverty (Nunez Olarte 1999). Thus the old understanding of the term ‘hospice’ centred around ideas of containment (Humphreys 2003) – containment of disease, undesirable aspects of society and pollution, as this was seen as synonymous with disease. This institutionalized view of end of life care – to view death and dying as polluting experiences to be ‘contained’ – reflected the prevalent ideas in public health at the time.

The theories of contagion and miasma suggested that pollution and poverty should be kept away from the healthy, to protect them, and there was no consideration of more inclusive strategies to address the root causes and integrate the different aspects of society. The development of the modern hospice movement has its roots in this tradition – a commonly unacknowledged insight into the sociology of health policies for end of life care. Institutions were built to house the dying, to set them apart from the community (Abel 1986). Although they were intended to serve the terminally ill of the community, they were not involved with it and this could also be seen as an effort to ‘contain’ the dying from the wider society. The paradigm is now gradually being shifted to take a broader view of the dying and terminally ill.

Influenced by the ideas of new public health and community empowerment, the boundaries between institutions and communities are being broken down and a more participatory, interactive collaboration is being developed: moving away from the focus on disease to a more positive understanding of health; away from containment of pollution and poverty to emphasizing social and collective responsibility. A public health approach to palliative care today includes all these elements and is part of the broader and global health promotion movement.

The Emergence of Community Development in Health Promotion

As mentioned earlier, in 1986 the WHO released the Ottawa Charter for Health Promotion. This charter became a watershed of ideas for the ‘new’ public health. Though new ideas of public health had already made the association between the idea of physical settings and environments to social settings and environments, the mode of working in these quite different ecologies was largely unknown or unprecedented. There were many public health workers who merely felt that social environments – individuals and groups going about their everyday business of work, play or worship – should be ‘targeted’ and changed with ‘interventions’. The problem of cancer, for example, like the problem of polluted drinking water or poor sanitation, should simply be subject to the same interests in surveillance, education and then appropriate health services.

The Ottawa Charter was among the first modern public health documents that challenged this didactic, professional dominance model. Its five principles advocated the building of public policies that supported health (as opposed to only disease intervention) but it was clear that this meant the need to ‘create supportive environments’, to ‘strengthen community action’, as well as to develop personal skills and re-orient health services. In meeting these new and somewhat radically different goals, the new public health was to be ‘participatory’. This was no set of public health initiatives that added to the list of things that we, as professionals, do TO others. The new approach to public health was that health and social care was a collection of changes to enhance health and safety that we do WITH others.

In this subtle change of policy language, a new and rather novel set of assumptions had crept in. It had long been assumed in the ‘old’ public health model that professional health workers knew best. People who were not ‘trained’ in health knowledge characteristic of academic subjects such as medicine, nursing or public health were ‘lay’ people. Lay people were largely ignorant of their own health because their knowledge about anatomy, biology, patho-physiology or clinical pharmacology were minimal or absent. The expertise, and therefore the authority and responsibility for surveillance and change, must emanate from professionals. It became rapidly apparent in the 1960s that there were severe limits and constraints on this approach and these assumptions.

Furthermore, public health research in diverse areas from occupational health and safety, sexual and mental health to cardiovascular and gastrointestinal medicine were uncovering the fact that many dimensions of an individual’s health were not entirely under that individual’s control. Moreover, individuals and groups had extensive experience concerning the barriers that needed to be overcome to access better health in their own work, family or sexual circles and environments. In other words, so-called ‘lay’ populations enjoyed their own ‘expertise’ because only they knew best HOW better health might be obtained because they were often more knowledgeable about what they were personally up against to achieve this. People often recognized the barriers to their own health goals, and were able to identify the supports needed to help...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• List of illustrations
• List of contributors
• Preface
• Acknowledgements
• 1. Public health and palliative care: an historical overview
• 2. “But we’re already doing it!”: examining conceptual blurring between health promotion and palliative care
• 3. Illness trajectories and palliative care: implications for holistic service provision for all in the last year of life
• 4. Public health approaches to palliative care in Australia
• 5. Public health and palliative care: a perspective from Africa
• 6. Public health developments in palliative care services in the UK
• 7. Public health approaches to palliative care: the Neighbourhood Network in Kerala
• 8. A public health approach to palliative care in East London: early developments, challenges and plans for the future
• 9. The campaign to build a dementia-friendly community
• 10. Discovering options: an Australian initiative in the care of the dying
• 11. ‘Let’s talk about dying’: changing attitudes towards hospices and the end of life
• 12. Public health approaches to end of life in Ecuador: avoiding suffering at the end of life – a health service issue?
• Appendix 1: Palliative care policy for Kerala
• Appendix 2: Charter for the normalisation of death, dying and loss
• Appendix 3: Practice guidelines for palliative care
• Appendix 4: An action plan for the initiation of a palliative care in the service in the community
• Appendix 5: Model of Palliative Care, Lothian, Scotland
• Appendix 6: Survey questionnaire for HOME Hospice for Chapter 10
• Index