A RE-DEFINITION OF PUBLIC HEALTH
It is therefore important to include a social understanding of public health. Beauchamp and Steinbock have Commented “ …….that public health must pay careful attention to the larger horizon of the community and to justifications for promoting and protecting the health of the people if it is to prosper and persuade. While there may be a notion that public health refers to communities as opposed to individuals, the relationship between those who have come to represent the discipline and the members of those communities is not well defined. How is the profession that works in and for “public health” accountable to the public?
Indeed does the world ‘public’ in public health have any meaning at all? Is the word perhaps :
• Merely ideological or decorative – perhaps used by its founders in a previous era to edga a medical movement in language that would commend it in the political climate of the times.
• Used to legitimize population – level interventions by suggesting implicitly that these are somehow sanctioned by the public or in the public’s interest (whether or not the public have assented to them).
• A way of denoting the profession’s scope so that it is the public which is the object of this profession’s attentions, whether or not the public it self is interested or has assented to the profession’s interests, concerns or actions.
• An essentialy private word pertaining to identity that allows inhabitants of a particular group to recognize each other while having little to do with other’s undestandings of the word.
• A political endeavour, hence accountable to the public, rather than a professional practice.
Each of these usages is politically laden and important in terms of determining needs for consultation and accountability. A book on the ethics of pulbic health suggets :
‘as a perspective, public health is about facing health problems as a group and using organized community approaches to resolve those problems. Its roots lie in the public health campaigns of the 19th and early 20th centuries. Its core method is epidemiology, which is the study of diseases that strike the community or the people’s as a whole. The good it promotes is a common good, one that is aggregate in its nature. However, (…….) public health as a method does not provide first principles.
It is disturbing that while a public, philosophical dimension is recognized here, the work of public health is basically taken to be a matter of technique, with the wider horizons of publicness kept at some distance from the work of public health practioners. The core method of public health ( a population – orientated discipline) is actually mainly focused on researching causes of disease in individuals and evaluating interventions at the individual – level rather than exploring the value of population – based interventions. While population science techniques are used to evaluate individual level interventions, there os adearth of methods to evaluate population – level interventions. Questions of the common good are assumed rather than properly discussed or consulted upon. This may have the effect of making public health in character and function a reasonably uncritical handmaid of an implicitly bureaucratic, rational and ultilitarian approach.
There seems also to be an unwillingness to recognize that if public health is a movement and a community, then it has its own ethics and interests that it will try to progress, possibly in opposition to other movements or communities. In other words, recognizing politics and debates while refusing to engage with them makes public health disingenous and somewhat self – deceived. Implicitly then, public health could be considered to be an interest group or stakeholder itself in public debates at the same time as continuing with partices and assumptions which it adopts and ‘inflicts’ on other members of society ‘for their own good’. In this sense, public health claims and implicitly defines the word public, but its actual self-conception is a very private, professionalized one.
An analysis of the NHS plan gives some insight into the problems that current public health structures have in relating to public concerns or delivering health outcomes :
‘ it was back in 1974 when public health (community medicine as it was then know) came within the embrace of the NHS. Far from influencing the NHS agenda, public health allowed it self to be captured by a narrow, managerial agenda focused exclusively on healthcare. It seemed to lose sight of its core business and became proggressively focussed on the NHS agenda rather than that of the wider public health. How can a public health delivery system be made to work? How can it add value and demonstrate this?’
One of the reasons this narrow managerial agenda happened is that after the 1974 NHS reorganization, public health doctors became part of the NHS, and hence part of the goverment machinery, where as before they had a much more autonomous existence within local authorities and a greater breadth of responsibility. So in some ways, the organizational changes may have dictated the lack of accountability to the public, since public health practitioners now worked within organizations where they were ultimately accountable to the NHS hierarchy rather than to a democratically elected local council.
The recent Select Committee into Health which set itself the task of ‘gauging the extent to which the secretary of State’s pledge to get public health out of the ghetto was likely to be achieved by the policies he has put in place’ gave its verdic that :
‘…… many of the initiatives have been under taken with the best of intentions, but their multiplicity and lack of rigour threatens to undermine them. We have found blurred lines of responsibility leading to disputes over who should have responsibility for the public health function….we found that the present health policy agenda is heavily dominated by the NHS plan with its overwhelming concentration on acute care, hospitals and beds, and numbers of doctors and nurses….we have described the confusion surrounding the leadership of public health at every level……we consider that insufficient attention has been given to the application of knowledge and practice in public health. For too long the public health function has been dominated by a culture, mind set and training scheme which stresses the epidemiology and science of public health, rather than its practice in bringing about chang…’
So public health can be considered to be both conceptually muddled and practically diffuse in its effects, which may reflect similarly unclear thinking among the politicians who require the public health function to be delivered.
Re – defining public health
There have been a number of definitions of public health :
1. The definiton predominately in current use in the UK was coined by the Acheson Committee on Public Health as ‘ the science and art of preventing disease, prolonging life and promoting health through organised efforts of society’. This has subsequently been adopted by the UK Faculty of Public Health Medicine. The House of Commons ‘ Select Committee into Health (which we quote above) felt that this definition, and its interpretation by public health professionals, has been detrimental to the ability to develop the most appropriate public health policies. In our opinion, the definition suffers from being too open to interpretation, not defining the specifically public, as opposed to individual, health component, not allowing those with responsibility for public health functions to know what to actually do to meet this definition, and particularly from not including ‘the public’.
2. The Institute of Medicine in the USA defined the public health function as ‘ to fulfil society’s interest in assuring conditions in which people can be healthy’ which suffers from many of the same problems as the UK definition.
3. Arguably, an improved definition comes from two Norwegian authors : ‘…the organisation and analysis of medical knowledge in such a way that it may be utilised by society in the making of decisions in health related questions’, although this does not imply the use of a specifically population – based approach. It also places too great an emphasis on ‘medical’ knowledge.
We have elsewhere argued the importance of developing an evidence base for public health as have others, which although not the main theme of this paper should be included in any definition.
, need to use evidence and which recognizes the importance of the public :
‘ 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 (teh public).’
This definition clearly recognizes the centrality of the public, distinguishes the population from the individual approach, indicates that evidence is required to improve health and that the population health sciences are required to produce this evidence. Using this definition, any public health professional will recognize that the collection and use of evidence is central to their job, which is to improve the health of the population, and that they are ultimately accountable to the public.
Public health can be condesired to be composed of a multitude of different groups, interests and ‘stakeholders’, all with their own legitimate concerns over health policy. The public (as distinct from individuals) can influence policy makers at various levels. They elect politicans, they may have ‘lay’ reprensentation on fundholder organizations and expert committees such as the community health councils or the partners council of NICE (using examples from the British NHS). In the UK, Community Health Councils appear to have related to individual patient care rather than broader issues of population health and are to be abolished.
Shifting the Balance of Power writhin the NHS makes it clear that ‘ patients and the public will be more involved in the NHS …..’ and involving Patients and the Public in Healthcare – a Discussion Document gives more details of this. There are plans for involving the public as well as patient groups, and it is to be hoped that the statutory bodies – called voice – will take a broader societal view. The public should also be involved in decision making about the determinants of health that go beyond the provision of health services, such as individual and community exposures to education, diet, housing, transport and pollution. There is no easily identified constituency for these wider societal issues, which are such important determinants of the health public of the public. Hence the needs which are not being made explicit through community representation should not be forgetten in any definition, and we have defined these as the ‘implicit’ needs of the public. We hope that the new plans for involving the public will be judged partly against the way they meet the second part of our definition of public health ‘in a way that best meets the implicit and explicit needs of the community’.
If public health practice is to be more focused on being accountable to the public and addressing the wider public health issues, then the population sciences on which the discipline is based need to provide the tools to do so and should shape public health practice in that direction. Training courses should include modules on public health ethics and values, and epidemiology research should focus more on studying the causes of patterns of disease in populations rather than causes of disease in individuals (and evaluation of population – rather than individual – level interventions). We need to derive an evidence base relating to the effectiveness of methods for involving and being accountable to the public.
There is likely to be more than one ‘public’ which comprises a collection of many demographic subgroups and interests, and more than one way of relating to the ‘publics’.
1. Krieger N, Birn A-E A vision of social justice as the foundation of Publich Health : commemorating 150 years of the spirit of 1848, Am J Public Health 1998 ; 88 : 1603 – 6
2. Beauchamp DE, Steinbock B. New ethics for the public’s health. Oxford : Oxford University Press ; 1999
3. Hunter D,The NHS plan : a new direction for English public health?
4. House of Commons ‘ Select Committee into Health Second Report, 2000.
5. Acheson D. Independent inquiry into inequalitie in health.
6. Faculty of public health medicine.
7. Departement of Health ; Shifting the Balance of Power wthin the NHS
8. Galssziou P, Longbottom H. Evidence-based public health practice. Aust N Z J Public Health 1999 ; 23 ; 436 – 40
9. Heller RF, Page J. A Population perspective to evidence based medicine – evidence for population health.2001