Have the three domains of public health practice had their day?

As part of the introductions for my current PhD module, we were all asked to introduce our job roles through the lens of the ‘three domains of public health’.  We all did so – but it was only when I was chatting to another student, that I dared to say that I didn’t really like them and was pleased when she agreed.  But before rejecting something outright on the basis of an emotional reaction – it is perhaps best to look where they originally came from and what they were originally for…and explore the thoughts behind my emotional reaction.

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Equity, social determinants and the ‘usual’ public health suspects

WHO Publication I’ve just familiarised myself with WHO’s publication “Equity, social determinants and public health programmes“.  It was written in 2010 with a view to drawing lessons from the WHO Global Commission on Social Determinants in order to think further upstream than the traditional public health programmes.

I have to say I struggled to start with.  I always groan a little when I see documents about ‘public health’ where the chapter headings are the ‘usual’ suspects – diseases such as cardiovascular disease; diabetes; mental disorders and ‘lifestyle behaviours’ such as alcohol; tobacco; diet.  My worry is always that this silos people into thinking of the determinants of each of these ‘usual’ suspects without considering the crossovers between them – what you then get is practitioners fighting for the attention of different stakeholders on a disease by disease or risk by risk basis.  Just recently I was at a WHO European Healthy Cities Network conference where there were calls to move away from that perspective to think more holistically about what creates health.

But I thought I’d persevere, after all – equity and social determinants were in the title.  And I’m glad I did.  In essence the introductory chapter introduces a common analytical framework to consider inequities in major public health priorities i.e. usual suspects (more later).  Then this framework is applied in each of 11 chapters to all those ‘usual’ suspects.  Then in the final chapter – yeah – they synthesise the findings across the whole lot and highlight those social determinants that should be addressed in order to have an effect across a substantial number of all those ‘usual’ suspects.  In other words, they recommend working upstream in an integrated, holistic way – rather than a disease by disease or risk by risk way.

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