It’s the end of the world as we know it, and I feel fine - Public Health Dorset
It’s the end of the world as we know it, and I feel fine
By Dave Lemon
What I want to discuss here is one possible future for public health, specifically public health practice as opposed to organisation. To begin with it’s probably best to examine where public health has come from and where it is now.
Public health has gone through two ideological phases with possibly a third on the way. We are currently in the beginning of the end of the second – that of public health data. The first was the origin of public health as a branch of medicine and was primarily concerned with tackling communicable diseases, and the third one that is starting to take shape is the dominance of environmental public health (built and natural). All three have, or soon will have, reached their limits.
Medically the dominance of communicable disease as a major continuing public health issue has receded (at least in the developed world) and been replaced by non-communicable diseases: obesity, diabetes, and other lifestyle related cardio-respiratory conditions. In any case, from a medical perspective, there is there nothing new to learn that could be of practical use in terms of the main preventable causes of poor health (diet, exercise, alcohol and smoking etc.). However, we are less good at understanding why people make the lifestyle choices they do.
In the second and current ideological phase, (big) public health data is being exploited for all it’s worth, and will continue to have a use in the future in terms of outbreak investigation and intervention assessment. However, aside from incorporating new technologies to speed up data capture, analysis processes and increased accessibility, it can’t tell us anything fundamentally new; just variations on a theme. Patterns of disease across populations are pretty well understood and have been for some time; that is that they are highly correlated with poverty. All the developments around new data models and using technology to streamline processes and improve data-stories might enable a wider understanding of public health by the public and decision makers. But again there is nothing fundamentally new here, just a different way of telling the same old story.
The next phase of public health practice hegemony will be that of environmental public health, or to give it its current preferred name: place based public health. This is already starting to show signs of dominating public health thinking thanks to the current focus on air quality and the acceptance that town planning needs to be linked to public health goals to increase active transport and green spaces.
However, this is fundamentally limited. Once all the cars are off the road, and cycle paths and accessible health encouraging built and green environments are established, all of which will ultimately be dependent on political acceptability, there will be nowhere left for it to go, and some people will still eat poorly, drink too much and not exercise. Health inequalities will still exist, and probably only increase as most of the benefits will be realised by middle class people and those already minded to make a change. We know from experience that the ‘if you build it they will come’ approach simply doesn’t work.
So what is the future of public health thought and practice? I think it will (and probably already should) require a shift in thinking from the public back to the individual, the context in which they live and how that effects the choices they are able to make. This is needed to understand why change is not occurring in some groups. The only way you can start to understand this is through long detailed anthropological studies that examine the external social and cultural structures that influence individual choices. Medical anthropology has been an active field of research for several decades and has helped health care providers understand cultural differences in health behaviours, especially the doctor-patient relationship.
What is needed now is a public health anthropology. This would require a radical shift in thinking from the dominance of large supposed objective ”hard” datasets to ethnographic studies¹. Unlike traditional epidemiological data these ethnographies have a focus on individuals and small groups with a common experience e.g. living in deprived communities, and are derived from observing and interviewing them and often living alongside them for extended periods.
Adopting such an approach in general public health practice could help identify context-specific factors by not only illuminating real world behaviours and exposing the logic behind them, but also in gaining an understanding of local and higher-level processes, all of which contribute to population level public health outcomes.
One practical example of how this has helped was in the Ebola outbreak, particularly around funeral practices. Instead of imposing blanket cremation, anthropological investigations into the culture of (proof of) death and burial rituals helped health care workers to learn from the culture, and work with communities to develop funeral practices that would reduce the spread of the virus yet respect cultural norms (http://www.ebola-anthropology.net/tag/burial/).
One final thought is that we also need an anthropology of public health. This would be a self-reflexive undertaking, with the aim to better understand how we got where we are, what the public health workforce culture is, how it interfaces with the public, and how this might need to change in the future. After all there is no point in having a comprehensive view of how people behave if the culture within the public health workforce is at odds with this.
So then, the end of the world of public health data? Well not quite, but neither is it the panacea for all it is often claimed, or hoped it will be. In order to start to deliver on the grand public health objective of reducing health inequalities, a deeper understanding of the choices people make is needed, something which can only be achieved through public health anthropology.
¹Assuming such a thing as a “hard” dataset is possible within health, but that’s a separate discussion for another day.