I can’t count how many times I’ve at least hinted at the phrase in the title of this post.  Following Ison (2010, page 231/232), my stock phrase is something like  “wellbeing and health concerns, are characterized by interdependencies, complexity, uncertainty and controversy and involve multiple stakeholders with different perspectives”.  It’s these type of characteristics that lead us to call health a ‘wicked issue’ or a ‘mess’.

But I suppose I’ve never really taken stock of just how ‘controversial’ health is.  I started thinking about this the other day and realised that a lot of the time the ‘multiple stakeholders with different perspectives’ can’t even agree how to word the questions, let alone any of the ‘answers’.  What’s more when people want to illustrate the ‘wickedness’, they often don’t even take on ‘health’ in its entirety they break it down into example issues or more focused concerns like obesity or sexual health – it seems that ‘health’ is so wicked you have to chunk it up.

So I thought I’d try and summarise my thinking on this controversial concept – in doing so I hope that I will bring into focus the nature of what makes the territory so difficult to negotiate through.  By the way, I’m making no attempt to ‘hide’ where my own perspective lies!

What is health?

There is a widely quoted definition of health, embedded in the constitution of the World Health Organisation

Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease of infirmity

(WHO, 1946)

Public health writing quotes this continually, but is it ‘lived’?

In practice, the discourse and action around health is focused on reducing/eliminating disease and infirmity i.e. getting rid of the negative condition.  This drowns out any attempts to focus on creating ‘complete physical, mental and social wellbeing’ i.e. the positive state.

There is a reason for this.

Public Health historically formed as a branch of medicine – with a biomedical approach to health focused on positivist research methods developed in the natural sciences and a focus on individual level interventions.  Working in this way is very tempting – you can decide on an evidence-based intervention (‘proven’ through randomised control trials), you can count the number of people you ‘treat’, and you can monitor the difference you made to those people – and you can explain the value of this activity in terms of preventing demand for higher cost interventions. In a world where performance management and evidence based practice shapes our behaviour towards needing certainty and predictability – this model wins.

This emphasis is so dominant, that it influences discourse in the media, it influences policy and it influences citizen perspectives of health and what it is to be healthy (therefore perpetuating the discourse)….

The other lineages of modern day public health are the inter-related practices of health promotion and community development – they are so much more interesting – but disappear behind that clinical model coz they seem fluffy and find it hard to ‘guarantee’ improvements.

What then is ‘public health’?

The prefixing of the word ‘health’ with the word ‘public’ is a bit of a mystery – why ‘public’?   Aren’t other forms of health to do with the public?

Generally, people seem to emphasise that public health is about the health of whole populations or communities (rather than individual level ‘health care’).  It starts with epidemiological information about disease distribution (yep that hegemony again) and health inequalities in a society and uses these to guide what it does.  It emphasises ‘population-level’ action, but that seems to be  interpreted in two ways:

• making an intervention at population level (with the intention of that helping the health of a whole population) – a current example is the debates about minimum unit price for alcohol or campaigns about income inequality/fairness.  These are broad, structural, policy level changes – hard to predict the health-enhancing (or health-harming) impacts.
• making an intervention at an individual level but making sure you ‘scale it up’, make it universal enough so that all of the individual benefits add up to a population benefit – an example would be childhood MMR jabs or wide availability of stop-smoking services or NHS health checks programme or weight management.

Needless to say, in a world of wanting certainty and appeasing big business – the latter always seems more attractive – which is another reason why that biomedical model flourishes.

Those working in the first of these recognise that public health is inherently political – caring about public health requires political action.  Some people involved in public health excel at this but a lot are very uncomfortable with it, preferring to be the ‘objective expert’

What ’causes’ health?

This is the first question that was hard to frame – it’s a broad banner for a range of questions that could be asked from different perspectives

• What factors lead to a disease or illness?
• What places you at risk for a disease or illness?
• What factors harm your health?
• What factors keep us healthy?
• What factors enhance health?
• What creates health?

Of course, the way you pose the question affects the nature of your answer.  Crudely, public health has two ‘traditions’ of research

• The pathogenic approach – the etymology gives it away – ‘producing disease’.  In essence you take a ‘disease’ and work backwards to the causes, the causes of the causes and so on.
• The salutogenic approach – ‘creates health’.  You focus on what enhances and maintains health as a positive state (irrespective of disease categories).

But these two ‘approaches’ have traditionally been answered from different scientific perspectives

• The biomedical/positivist approach – seeking deterministic or at least a probabilistic relationship
• Social sciences – understanding ‘health’ as something that is socially constructed

but guess what the Systems sciences are also beginning to play a key role – in helping to unravel the perceived interdependencies between a whole range of ‘factors’ or determinants of health or ‘ill-health’.  It often gets referred to as an ‘ecological’ approach with a focus on both the physical and social aspects of the human ‘habitat’.

What is the relationship with wellbeing?

In the WHO ‘definition’ cited above, health is defined in terms of wellbeing…but a lot of the time the two go around hand in hand ‘health and wellbeing’.  It seems that even though health tries to escape the clutches of a ‘medical’ feel that association is too strong so we have to use the word ‘wellbeing’ too.

I know the WHO definition of health is old – but I’m very interested in the fact that they chose just ‘three’ dimensions of wellbeing – physical, mental and social.  I spent a short time on google today as well as having a good think about all the dimensions of wellbeing I see mentioned in documents I read.

Here is the list of ‘dimensions’ of wellbeing I have found…(I’ve tried to cluster them into what is similiar – to me)….

• social wellbeing
• relational wellbeing
• cultural wellbeing
• environmental wellbeing
• physical wellbeing
• medical wellbeing
• mental wellbeing
• emotional wellbeing
• psychological wellbeing
• cognitive wellbeing
• intellectual wellbeing
• material wellbeing
• economic wellbeing
• financial wellbeing
• occupational wellbeing
• work-place wellbeing
• informational wellbeing
• digital wellbeing
• spiritual wellbeing

There were also lots of different ‘levels’ of wellbeing:

• individual wellbeing
• community wellbeing
• organisational wellbeing
• societal wellbeing
• global wellbeing
• planetary wellbeing

So if wellbeing is such a broad concept, it’s kind of like when we say ‘health and wellbeing’ – we mean ‘health and other dimensions of wellbeing’.

Recently the WHO European Region’s annual report acknowledged that to date much work had focussed on disease and disability and in the process had ignored wellbeing – maybe wellbeing’s time is here!

Who is responsible for improving health?

You often see phrases such as “through the concerted efforts of society”.  You could say that via taxation, paying for the NHS and other services provided in the name of health is an illustration of the ‘concerted effort of society’. But health doesn’t come from service provision – service provision steps in when health goes wrong, when there is a ‘need’.

So there is the more structural perspective – that government creates policies that help or hinder health of people.  They can choose to take actions that increase or decrease income inequalities.  They can choose to take actions that favour the tobacco, alcohol or food industries or favour health of the population.  Lots of controversy comes here – do businesses have the freedom to make a profit from something that is known to be ‘bad’ from society?  When do the markets need to be regulated? Does ‘social responsibility’ go far enough?

It’s easier then to turn the focus onto ‘individual responsibility’ and ‘choosing healthy lifestyles’.  The difficulty with that discourse is that it assumes that once ‘educated’ all members of our society live in response-able circumstances.   That they do have access to affordable healthy food, that they can ‘resist’ social norms to have friday drinks with colleagues, that they can be ‘resilient’ in the face of work-based stress and work-life imbalance; that life is not so stressful that you turn to a cigarette or chocolate or coffee for the instant (but short-lived) ‘ups’ they bring.  It assumes ‘choices’ are there just for the taking, but actually do we really have free choice?

But then come the politics of ‘nudge’ – should governments act to ‘steer’ people towards healthy lifestyles? Should we think, like supermarkets do about ‘choice architecture’?  At what point does that get seen as limiting freedom or the nanny state?  Once upon a time some people argued against seat belt laws.  Once upon a time some people argued against bans against smoking in workplaces.  Those things seem so normal now, but they were the ‘social engineering’ of their time.

How do we improve health?

Another one of those questions that can be phrased in different ways to lead to different answers:

• How do we improve health?
• How do we promote health?
• How do we prevent disease or disability?

First issue – there are different ‘levels’ of intervention.  So do you intervene at the level of the individual or a community or society as a whole.

There is also a whole way of working that seeks to create ‘health promoting settings’.  That could be a street, a neighbourhood, a workplace, or a school, or a hospital or a university or a city.  There are whole movements and networks around these approaches.  For example, Newcastle is part of the WHO European Healthy Cities Network (I’m the named coordinator).  The idea is that you think about the different economic, environmental and social dynamics of that ‘setting’ and seek to make them as health promoting as possible.  Sometimes however this too gets seen through the lens of providing individual interventions in a setting (e.g. a stop smoking service in a workplace) rather than truly working on creating a health promoting setting.

Then it comes to the ‘type of intervention’ – all of these can be done ‘in the name of public health’

• Medical interventions – like controlling blood pressure
• Behaviour change/lifestyle improvement – focussing on behaviours that place a risk to person’s health
• community based interventions – interventions done in community settings rather than ‘health’ ones
• community development – focussing on empowerment and building social relations
• communication campaigns – using mass media.  This could be done for the purpose of ‘health education’ (such as Change4Life) or more ‘critical conscientisation (such as the work of the Equality Trust).
• specific health policy, regulation or legislation (such as the bans for smoking in public places)
• testing all policies (such as transport policy or economic development policies) for their potential health impact (known as the health in all policies approach or healthy public policy).

 

That seems like I am just looking at the tip of the iceberg.  There seems like ample opportunities to fall into the trap of reductionism – picking the factors that can easily be worked with such as individual level, behaviour change, rather than the bigger harder more contentious stuff.  Equally there seems like ample opportunities to fall into the trap of dogmatism – emphasising the view of the ‘good healthy citizen’ from a white, middle-class perspective.

No wonder it is hard doing jobs like mine 😉