Effect Measure

Public health: what is it?

A couple of ideas are floating around in the comment threads as part of an initial conversation about public health. I’m not surprised they seem to be on different topics and have the feel of talking past each other. We are not used to discussing basic assumptions and have an immediate tendency to talk about what we know, what interests us particularly, what bothers us most or what is our particular preoccupation. Many of those things turn out to be really important for public health and there are plenty of reasons for talking about them.

Annie, for example, is frustrated with other medical and public health professionals. From appearances she is herself a dedicated public health professional and feels alienated from her peers. Like other professions we have become guild-like, with all the usual tendencies to draw lines around what we do, lines that keep others out. The Association of schools of Public Health is now promoting certification exams, a very bad idea in my view. Who should get certified? As commenter/economist floormaster squeeze observes, the community’s health is tightly tied to the general state of the society, both economically and socially. By that definition there are a whole lot of people “engaged in public health” that don’t fall under the usual disciplinary titles and even more who do day to day work that contributes significantly to public health (like the RotoRooter guy or the water treatment plant operator or the cop on the beat). I’m not advocating expanding the definition of public health so far that virtually everyone falls under that heading, but I am suggesting we start to think hard about what could properly and usefully be brought under the ambit of public health and what should not.

For example, commenter rotatingmass (RM) remarks that a major change from the early days of modern public health is the inclusion within public health of access to care, its financing and its administration . It is not a minor point. Health services has become the preoccupation, resource hog and motor of much going under the name of public health today, and RM wonders if public health might not benefit from a divorce. Question: what would that leave, what should be included that isn’t, what should be further amputated from public health? Maybe it would be useful to shuffle some things like bioterrorism response into public safety, keeping pandemic response for public health and acquiring meteorology. Maybe not. There are trade-offs here and we should be discussing them openly and honestly, including the pros and cons.

As usual, DemFromCT makes an important point. We need new models. But a model of what? New models aren’t likely to come only (or at all?) from within public health. We are inviting another kind of engagement in public health, the engagement of the hivemind. If you don’t think of yourself as a public health expert, you can still help think this through. Our thinking in public health has become ossified. Don’t worry if you think your ideas are stupid or off topic. On the basis of blogging daily for four years (during which time I’ve had plenty of practice saying stupid and off-topic things), I’ll predict most of the ideas that will wind up in the comments will be at least uninteresting or off topic. Try again. But some of them won’t be. It’s the job of all of us to find the diamonds in the rough, separate them from the dust, cut some gleaming facets and polish the result. A little bit at a time.

What, then, is this project we call “public health”? One useful formulation of public policy is that it is what the community chooses to do for each other. By that definition, if, as MRK expressed it in his comment, your objective is only to look out for yourself, then you aren’t engaged in public health (although someone else may be, on your behalf). But maybe it’s not a good definition. What would be a better one?

A lot of people have no patience for this kind of abstraction. My advice is to come back later when we might have some of this sorted out. But the difference between a conception of the bottom line that it is everyone for himself and one that says there are some things we will agree to do for each other is not trivial and deserves to be discussed, along with still other radically different views. I strongly disagree with MRK on this (as on many other things), but I like very much that he decides to go directly for the jugular, what he sees as the core of the question.

What do you see as the core of the question? And what question?


  1. #1 rotating mass
    December 17, 2008

    -Should we change the name to population-based health or will that make our job of educating lay people more difficult?
    -I think that part of what we need to do is develop (re-develop?) our brand, as revere and at least one pump handle commmenter have noted. The public perception of the need for what we do in public health has waned. This is about social marketing of public health (what has public health done for you?) but also becomes a discussion about health literacy levels and personal responsibility.
    -A major question that we must answer as a society regards government responsibility for public health. What must government public health agencies do and what can we leave to the private sector? Depending on our answer(s) to this question, we might need to change state and federal laws.
    -I believe that one main purpose of community is to take care of each other so think that a government role in public health is necessary. I also understand that not everyone agrees with that point of view. Finding a compromise here would be helpful for consistent future funding.

  2. #2 Lea
    December 17, 2008

    Or revere some of us don’t really have the time to contribute what we believe is important, so don’t let the momentum fall away, keep it going. As Catherine said it is better left up to the professionals however, we can take the time to read what’s posted here and then when time allows contemplate the subject and remember what it is that’s important to us and share that with you.

    If you were to talk to Michael S. Rockwell, D.D.S., in Tooele county Utah he would tell you that proper and preventative dental care will heal many a physical ailments. He would tell you that heart disease has been linked to poor dental hygiene.

    If you were to talk to Kip C. Porter, Chiropractor – Palmer Graduate in Tooele county Utah he would tell you that the fluids in the spine are the life blood of skeletal and over all health within the body. That one must keep the autonomic nervous system functioning properly for other parts of the body to work properly.

    So, and with that said, if it were me running this exercise I’d put away the computer screen and models, purchase a huge blackboard / whiteboard and begin a family tree type of diagram. From that diagram I’d list the top 10 or 20 most common concerns here and then bullet what falls below that. Then when the diagram is near complete, in your mind, I sit back and begin to combine what goes together.
    I wouldn’t rush it, unless your constructing a proposal for Obama, and then just stare at the dare board. Then the answers and solutions could well begin to flow.

    My increasing focus is on medicinal marijuana and the freedom to use it as a medicine, rather than pharmaceuticals. There is no freedom of choice if I cannot chose what medicine works best for this body, and I would know as I’m living in it.

    While I’ve enjoyed reading what you write Catherine I can’t agree with the mother – child scenario as being the most important. Maybe because it was never an issue or even discussed when I was young, it is a new development.
    What matters to me most is the above mention and relief from physical pain. What matters to me most is dignity, love and care for our senior citizens.

  3. #3 Farmer
    December 17, 2008

    I agree with RM that public health is population health. It is defined as public policies, regulations and approaches that contribute to human health with an emphasis on the population as opposed to the individual doctor-patient relationship.

    Clear examples (clear to me at least!) include:
    Food, drug, consumer product and drinking water safety.

    Regulation of air, water pollution, toxics in the environment (cross boundary issues).

    Control and tracking of communicable disease, outbreak investigation.

    Vaccination – recommendations and schedules (to develop and preserve herd immunity)

    Health education via public schools and health messages delivered nationally. Some examples of educational topics include: safer sex practices; smoking cessation/smoking risks; injury prevention messages; healthy hygiene habits and practices (including safe food handling); dietary guidelines; radon awareness, etc.

    Maintenance and analysis of vital records.

    An area I see as on the line between public and private, but an area that has become necessary due to the structure of our health care delivery system- Public clinics that deliver basic preventive care to underserved populations (prenatal care, cancer, STI screening), vaccinations, chronic disease screening/education. However, I agree that health services in general support the doctor- patient relationship, not public health.

    I do not consider disaster response/preparedness as a core public health activity. I see this more as a first responder community /law enforcement responsibility that needs to be coordinated with public health practitioners, but I believe that it diverts energy and attention from the core areas of public health that I have listed above.

  4. #4 pft
    December 17, 2008

    Public health should mean access to quality health care for all without forcing people into bankruptcy or face economic hardship for being sick, treating it more as a right than a service for those who can afford it (like a good masssage).

    It should limit public health risks from water, food, medicines, vaccines, consumer products and the environment with adequate regulations, and be free from conflict of interest that is within the current system. And it should have plans for emergencies such as pandemics or other disasters.

    Debt free money that is legal tender w/o exception created by government for the general welfare of the people will pay for it, subject to price controls/agreements to prevent greed in the system from taking advantage of unlimited funding.

    This would stimulate an economy already paying for these services out of private funds (actually 50% is already paid by government), leaving people and corporations with more money to spend into the economy or reduce debt.

    It would of course be harmful to the insurance companies, but they would be able to offer supplementary insurance for those wanting special treatment like their own room during a hospital stay, and they deserve what they get.

  5. #5 attack rate
    December 18, 2008

    For me, public health as a concept is actually too narrow. I like the concept of One Health, which in very basic terms describes that the health of humans is interdependent on and interacts with the health of animals (both domestic and free-living) and the health of the environment.

    This take on things encompasses a lot of the traditional “public health” areas such as zoonotic diseases, vector borne diseases, food and water safety, environmental/occupational diseases – but puts them into a broader and integrated context.

    I think that there will be gains in understanding of where to target problems deemed as important, as well as gains in efficiency, by using this approach. By its very nature, it requiress collaboration between those in human health, animal health, plant health, ecology, anthropology/sociology, meteorology and probably other fields as well.

    One Health even access to health care, because access to health care can have effects on behaviours which then interact with other areas. I’m personally tempted to try to put health care access into a different (but closely related) basket, which could either be ‘Ethics’ or ‘Health Policy’, because while there is an effect on the rest of the model, it’s something that we can ourselves directly intervene in (unlike some of the other effects that we may not be able to).

    Disaster preparedness is a border area (interacts with the model, has some common goals) but is probably not what I’d consider in the tighter scope.

    However, I think the benefit of this way of looking at things is the reminder that actions (or inaction eg lack of planning) will have consequences down the line. It’s a holistic approach.

    The main problem is ensuring we get started instead of getting bogged down in how big the whole process is.

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