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CHAPTER SIX: TRADITIONS OF PUBLIC HEALTH

6.2 Generic Global Public Health

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initiative, 2000-2007 by Pan American Health Organization, 2008, p.2. Washington DC: World Health Organization.

Within this section I examine the origins of generic public health and influenced by Baum’s (2008) conceptualisation, I outline the origins of generic public health.

I then examine medical, behavioural and socio-environmental traditions of public health.99

Origins of Generic Public Health

Early public health decision-makers were concerned with where and how to bury the dead, isolating people with leprosy and quarantining ships suspected of carrying diseases (Rothstein et al., 2003). There were two rival theories as to how disease was spread. Miasma theory suggested disease resulted from inhaling bad smells from filth. The germ or contagion theory held that pathogens caused disease. These different understandings impacted on approaches taken to public health interventions. Experiences in early nineteenth century Europe, combating the waterborne sanitation diseases of cholera and typhoid brought on by rapid industrialisation and urbanisation led to the development of more systemic approaches.

Baum (2008, pp. 18-19) identifies several distinct stages within the early development of generic public health: the colonial, nation-building, affluent and medicine eras. The emergence of epidemiology, the study of disease patterns across populations, rapidly became a dominant consideration in public health decision-making. The ability to quantify mortality and morbidity, identify disease and isolate injury enabled a plethora of insight into how to prevent and manage disease.

Environmental reforms and learning to manage the threats of epidemics and pandemics was the primary focus of the colonial era. Reynolds (1989) argues legislation became the main instrument in enabling these reforms. For instance Snow, a London physician utilised the Public Health Act (UK) 1848 to remove the handle from a water pump on Broad Street as he believed it was a source of cholera infection. During this era the poor were often constructed as the cause of diseases. The writings of political theorists, Engels and Virchow as early as the 1840s challenged this discourse, speculating changes to working and living conditions were likely to be influential in preventing disease (Waitzkin, 1981).

Baum’s nation-building era refers to the beginning of last century when British colonies such as Australia and New Zealand were establishing their public health bureaucracies. This was a zealous time of assimilation with compromised health outcomes for indigenous populations, in the wake of the assumption of white

99 Note this broad brush précis does not attempt to address the complexities of public health delivery within third world contexts, but rather privileges public health as delivered within the affluent west.

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sovereignty. Baum (2002, p. 24) contends maintaining health for white people was seen as part of a citizens duty and encouraged by state health checks and the encouragement of open-air exercise. Being healthy contributed to a nation’s efficiency and was therefore considered a legitimate concern of governments. The health of indigenous peoples was a lesser priority.

The affluence and medicine era focussed around the post-war abundance when significant medical break-throughs occurred. At this time it was expected that clinical medicine, during this its “golden age”, would conquer disease through more and more sophisticated medical technology, including organ transplants (McKinlay & Marceau, 2002). There was little attention and/or investment in public health through this period. Baum (2002, p. 26) maintains, public health resources were focussed on policing standards for clean air, water and food. Major emphasis was also on immunisation campaigns and the screening of populations.

Medical Traditions

Practice nurses and general practitioners are the cornerstones and first point of contact for most people engaging with the wider health sector. Medical approaches to public health focus on the prevention of disease and interventions usually occur within primary care settings. These interventions often focus on individual level behaviour change through lifestyle advice and health education programmes. Health screening and immunisation are also areas where medical interventions have influenced public health through population-based interventions. Table 10 below illustrates the relative position of primary care led interventions in a wider continuum of core generic public health activities.

Table 10: Public Health Continuum Individual

focus

Population focus Screening &

immunisatio n

Lifestyle advice Health education

Social marketing

Community development

/action

Economic &

regulatory activities

Primary care Public Health

Note: Reproduced from Integrated health promotion: A practice guide for service providers by Department of Human Services, 2003, p.44. Melbourne, Australia: Vic Health. Reprinted with permission.

A key marker in the intersection of primary healthcare with public health is the Alma Ata Declaration (World Health Organization, 1978, September), which introduced the notion of health as a community asset and identified access to health as a social justice issue. The ultimately unsuccessful challenge to mobilise attending state parties to achieve health for all by the year 2000 was embraced by both public and primary health practitioners.100 The Declaration emphasised global co-operation through the involvement of other sectors and community participation. It also championed health education as a formal measure to enhance

100 In much the same way the millennium development goals continue to inspire some (United Nations, 2000).

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knowledge, raise consciousness around health and thereby enable behaviour change around lifestyle factors (Ritchie & Short, 2000).

In the wake of the Declaration, Tannahill (1997, p. 169) argues health education become a cornerstone of primary and generic public health practice. Bonevski, Sanson-Fisher and Campbell (1996) in their review of international evidence around the effectiveness of lifestyle advice delivered within primary health care settings concluded there “...was unrealised potential for disease prevention in primary healthcare”. Structural barriers to general practice participation in public health are considerable. Baum (2002, pp. 314-315) identifies the fee-for-service structures within practices, short consultation times, a significant focus on curative interventions and lack of public health expertise generally within primary healthcare as obstacles to effective practice.

Population based screening programs involves the early detection of whether an individual is at risk of a particular disease through testing for risk factors and early physiological indications. Successful detection particularly within national breast and cervical cancer screening programmes, for example, can enable often life-saving early treatment. Screening programmes for cardiovascular disease that address behaviour risk factors are more complex and require more intensive follow up and ongoing engagement. Baum (2002) and Goel et al. (2003) suggest there is strong empirical evidence that uptake of screening opportunities is most prevalent with the healthiest section of the population and those most vulnerable do not engage at the same rates.

Since the discovery of the smallpox vaccine, immunisation has also been a key public health tool. Successful immunisation programmes achieve ‘herd’

immunity.101 On a global level, immunisation has seen the eradication of smallpox and reduced polio, measles and diphtheria down to manageable levels across much of the developed west. As with screening, analysis by indigenous and non-indigenous health researchers such as Crengle, Pink and Pitama (2009) and Grant, Turner and R. Jones (2009) suggest there is evidence that the uptake of immunisation is most prevalent within the healthiest section of the population.

Lifestyle/Behavioural Approaches

By the 1970s, emerging understanding of the impact of lifestyle choices on health considerably influenced public health activities. These insight entered the public discourse through what became known as the Lalonde Report (Lalonde, 1974) commissioned by Health Canada. Baum (2002, p. 32) maintains, healthy lifestyle traditions focused on individuals taking responsibility for their health, were awakened by both health professionals and social marketing campaigns.

Significant amounts of public health activity at this time focussed on how to reduce disease risk factors through changes in diet, exercise and tobacco use.

101 Herd immunity occurs when the vaccination of a significant proportion of a population provides some protection for those few whom have not developed immunity.

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During this period behavioural change models, such as the health belief (see Becker, 1974) and the stages of change models (see Prochaska & DiClemente, 1984), based on social learning and reasoned action theory were widely utilised within the sector.

The first international conference on health promotion, held in 1986, saw the development of the influential Ottawa Charter for Health Promotion (World Health Organization, 1986, November). It became a template for generic public health, building from a base of health education and behaviour change, it emphasised the importance of community action, creating supportive social environments, building healthy public policy, and included the bold ambition of re-orientating the health sector. The Charter presented an ecological approach to strengthening health status that recognises the validity of advocacy as a public health tool and within its preamble recognises everyone’s entitlement to the core prerequisites of health. These fundamental conditions and resources for health include peace, shelter, education, food, income, a stable eco-system, social justice and equity (World Health Organization, 1986, November, p. 1).

The Charter also consolidated a shift in emphasis in public health practice to community participation, policy change, strengthening social capital and the importance of equity. Intersectoral approaches were favoured with medicine being only one of many contributing professions. Activity often occurred in specific settings or domains as in school-based and/or healthy city programmes, moving beyond disease specific interventions. The Ottawa Charter remains widely used across Australasia as a planning and evaluation tool for public health interventions.

Critics of behavioural traditions such as Syme (1996) assert that there is too much emphasis on individual responsibility within the tradition and structural systemic impacts on health are ignored. In his 1996 review of a multi risk factor intervention on coronary heart disease Syme is adamant that context is critical to the efficacy of behaviour interventions. Wilkinson (1996, p. 64) concurs from his review of the evidence that health behaviour is clearly related to the social context in which people live, and that to change behaviour it may be necessary to change more than lifestyle.

Baum (2002, p. 338) concurs that interventions which focus on the provision of information and resources to facilitate behaviour change, tend to ignore the structural circumstances which put people’s health at risk in the first place. The Australian Minister of Health, Hon. John Cornwell (as cited in Raftery, 1995, p.

35) explains some of the challenges of looking beyond the individual:

At a political level, the public policy approach lacks support because it produces results in the long term and less visibly than the short-term crisis intervention of heroic medicine. Coronary bypass surgery and level-three

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intensive care for very low birth weight babies are newsworthy.

Addressing questions of poverty, education, housing, nutrition and income maintenance to overcome the problem of very low birth weight babies is not possible in a 60-second television news segment.

Socio-Environmental Approaches

Labonte (1992) explains that socio-environmental approaches describe the broad social, environmental and economic strategies to promote health beyond medical and behavioural traditions. They emphasises the interwoven relationship between individuals and communities and their social, cultural and physical environments.

Lifestyle choices within this approach remain the responsibility of an individual but it recognises that largely the wider social environment determines these choices, by community norms and values, harmful and healthful regulations and policies.

Connections between environment and health were introduced to a wider audience through the landmark British Black Report102 on social inequalities (D. Black, Townsend, & Davidson, 1982). Determinants of health authorities, Marmot (2004), Wilkinson, (2003) and Whitehead (2007) have since identified the existence of a social gradient in health; in that the lower an individual’s socioeconomic, position is the worse their health. Chaudhuri (1998, p. 27) explains how environmental factors can influence child health:

Poor children often live in social and low rent housing located very close to industrial areas, high-density traffic corridors and interchanges and sites previously used for toxic waste disposal. Housing is often inadequate due to its age, chronic poor maintenance and faulty design leading to a variety of indoor air quality hazards including mould growth or the presence of toxic substances such as lead paint or asbestos.

Research into the determinants of health has had a profound impact on generic public health practice, confirming that both societal and lifestyle factors influence health status. Figure 12 developed by Labonte (1990a) diagrammatically depicts how physiological, behavioural and psychosocial risk factors in combination with risk conditions such as poverty can intersect and influence health status.

The core of a socio-environmental approach is to mobilise communities to affect change on both risk factors and conditions that threaten and strengthen health.

This approach opens up a variety of spheres for public health activity both within and outside the core health sector such as working with local government, education, employment, economic development and welfare sectors on policy and collaborative programmes.

102 Which was subsequently ignored by the Thatcher government.

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Figure 12: Social Environmental Approach to Health

Adapted from “Heart health inequalities in Canada: Models, theory and planning” by R. Labonte, 1992, Health Promotion International, 7(2), p.122. Reprinted with permission.

The socio-environmental tradition also emphasises the importance of active participation in public decision-making and what political commentator, Cox (1995) calls “social capital” and Muukkonen (2009) calls “an engaged civil society”. Baum (2002, p. 343) contends that the existence of trust and reciprocity in relationships are key indicators of the existence of social capital and the ability to cooperate to achieve common goals. She maintains that the active engagement of people in the planning of health initiatives improves their quality, relevance and effectiveness. Participation also helps communities overcome powerlessness and leads to people being healthier. An inter-related concept is the notion of empowerment. Israel, Checkoway, Schultz and Zimmerman (1994, p. 153) defines empowerment as “…the ability of people to gain understanding and control over personal, social, economic and political forces in order to take action to improve their life situations”.

Within the next sub-section, I examine two elements of the socio-environmental tradition community development/action and social, economic and cultural determinants of health approaches.

Community Development/Action

People need the basic material prerequisites for a decent life, they need to have control over their lives, and they need political voice and participation in decision-making processes. Although individuals are at the heart of empowerment, achieving a better distribution of power requires collective social action – the empowerment of nations, institutions, and communities

(Commission on the Social Determinants of Health, 2007, p. 15).

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Community development advocates (see Green & Raeburn, 1988; Raeburn &

Rootman, 1998) hold that community lies at the core of public health interventions. A community is often defined as a geographic neighbourhood or a sub-population or social grouping (Goodman et al., 1998). Communities, assert medical anthropologists, Wayland and Croder (2002), are made up of various competing interests vying for attention and resources. The strengths and potential weaknesses of a community influence its ability to respond to challenges and environments that compromise health. Labonte (1990b, p. 69) argues that not all communities are equal, and that a social justice approach demands prioritising working with communities whose circumstance place them at the greatest risk.

Community development/action is a process of community empowerment.

Community development the broader of the two terms refers to an open-ended approach where communities identify and prioritise issues that they wish to address. Bryar and Fisk (1994, p. 203) define community development as a

“…radical process which seeks to redistribute knowledge and skills through active involvement of those usually excluded from such participation”. Minkler, Wallerstein and Wilson (2008) identify several elements they hold as critical to this approach, empowerment, community competence, starting from where people are at, participation, how issues are selected, and creating critical consciousness.

Raeburn and Rootman’s (1998) model of community development, the PEOPLE103 system is similar but includes the additional elements of people-centeredness, organisational development, life quality and evaluation.

Community action is more specifically focused on affecting change within a specific area. Greenaway, Milne, Henwood, Asiasiga and Witten (2004) in their meta-analysis of community action projects identified empowerment, equity, collaboration and consensus as key elements of such an approach. Laverack (2004, p. 64) in his health promotion text, criticises community action approaches, noting that such top down programmes in both their design and delivery can be disempowering to the intended beneficiaries. He explains:

Such programmes can reinforce people’s feelings of powerlessness by ignoring their concerns, over-riding their needs and by giving out the message that their problems are not relevant to those who hold power, the outside agents and health promotion ‘experts’ (p. 64).

Oakley (1991, pp. 17-18) in his study of rural development identified a variety of advantages of a development approach including, efficiency, effectiveness, self-reliance, coverage and sustainability. An ‘evidence of effectiveness’ review commissioned by the WHO (Wallerstein, 2006, p. 14) found development approaches consistently achieved outcomes at psychological, organisational and community levels, and across populations. The specificity of those outcomes

103 The mnemonic stands for Planning and Evaluation of People Led Endeavours.

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varied based on what public health issues were being addressed and the social and cultural contexts where the program took place. These outcomes were achieved after long-term investment Baum (2002) contends such an approach is not a quick fix to improving health status.

Social, Economic and Cultural Determinants

The devastating health inequities we see globally are man-made. The causes are social – so must be the solutions. A global society in which millions of children and adults are unable to lead flourishing lives is not sustainable (Commission on the Social Determinants of Health, 2007, p. 3).

A determinants approach to public health recognises that a range of influences from age, sex and ethnicity determines health and hereditary factors, through individual behaviours to the social, cultural and economic context in which people live (see Figure 13). The Commission on the Social Determinant of Health (2007, p. 14) argue that social hierarchies in which economic and social resources including power and prestige are distributed unequally, impacts on people’s freedom to lead lives they have reason to value. This inequity in turn has a powerful impact on health and its distribution. Health inequities, maintains Whitehead (1992), are differences in health that are unnecessary, avoidable and unjust.

Figure 13: The Determinants of Health

Reproduced from Policies and strategies to promote social equity in health: Background document to WHO strategy paper for Europe by G. Dahlgren & M. Whitehead, 1991, p.11. Copenhagen, Denmark: World Health Organization. Reprinted with permission.

Whilst some determinants of health can be modified, others cannot. In their review of the international evidence the New Zealand National Advisory Committee on Health and Disability (NACHD) (1998, p. 8) argue that income, primarily influenced by participation in paid employment, is deemed the most

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important and modifiable determinant. The primary driver of a determinants approach is promoting equity and reducing power differentials and inequities between population groups. Advocates for this approach argue the right to the highest attainable level of health is enshrined in human rights conventions and in the constitution of the WHO (United Nations, 1976b; World Health Organization, 1948).

Action on the determinants occurs both within the health sector and outside it, through local networks and national advocacy coalitions. The Ministry of Health (2002g) commissioned a reducing inequalities framework to advance work on the determinants of health, which identifies several key sites for interventions. These include i) structural approaches to tackling the root causes of health inequities; ii) intermediary pathways focussing on targeting material, psychosocial and behavioural factors that mediate the impact of structural factors and iii) interventions within health and disability services to minimise the impact of disability and illness. A substantive review undertaken by the NACHD (1998, p.

61) of ninety-eight publications into interventions to reduce health inequalities found structural measures to be most effective.

One of the emerging tools of the determinants tradition is also the use of social and health impact assessment tools (see Ministry of Health, 2007e; Public Health Advisory Committee, 2005). Health impact assessment “...is a combination of procedures, methods and tools by which a policy may be assessed and judged for its health effects across a population” (World Health Organization, 1999, p. 4).

This process of critical review identifies both potential intended and unintended impacts of policies, plans and regulation and the distribution of those impacts on communities. It can be used at project level to decide about a new skate park or at a strategic policy level about public transport policy. It can be used by policy-makers and affected communities together or separately to provide evidence to inform policy development, implementation and/or evaluation.

In summary, generic approaches to public health have been shaped and adapted to changing political environments and to new evidence about what influences health status. Early emphasis was placed on using legislation to address poor water, sanitation and housing, to tracking disease patterns through epidemiology, to medical break-throughs enabling health screening and immunisation. The 1970s brought emphasis on healthy lifestyles and behavioural models. New insights about the impact of social and physical environments on health lead to interventions addressing psychosocial risk factors and emphasis on the importance of equity, community engagement and empowerment. Emerging determinants approaches highlight the role of healthy public policy and multi sector collaboration to achieving health gain.

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