Sarah Chan: Defining public health

Public health: it’s one of those things, like free education or saving the giant panda, that we all pretty much agree is a “Good Thing;” and not just a good thing but one of the fundamental social goods that most of us expect the state to provide.  But what, exactly, is public health; and perhaps more importantly, what measures are justified in pursuit of it?  For example: should we introduce compulsory food labelling, the “traffic light” system and educational campaigns about nutrition as ways of reducing obesity – or should we ban fat people from restaurants?

Harald Schmidt, in the opening paper of the Think About Health conference, held in Manchester on 4-5 April 2008, defined public health as “the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society”.  Schmidt is the Assistant Director of the Nuffield Council on Bioethics, which last November released a report entitled “Public Health: Ethical Issues” that attempts to address these questions and develop an ethical framework for public health.  In presenting the findings of the report, he highlighted two key elements of this definition of public health: that it involves the promotion of health, and that this takes place through communal involvement.  These elements between them define one of the most pressing questions in public health ethics, that of the role of the state in public health – what should the state do, and what may it legitimately do, in pursuit of improving the health of its citizens?  The essential tension between state-driven measures designed to promote population health, and protection of individual freedoms that may be threatened by the introduction and enforcement of such measures, lies at the heart of public health ethics.

Another important point raised was the difficulty of assessing the effectiveness of public health measures, both in terms of what the “good” that such measures are intended to promote is, and the metrics selected to assess that good.  I was somewhat surprised to learn, for example, that the people who cost the health system the most, who incur the biggest public health care bills, are not (as one might guess) smokers, or obese people: it is actually the healthy people who are the most expensive!  Closer examination reveals the reason for this: unhealthy people are more likely to die prematurely, while healthy people live long, fulfilling and health-care-cost-incurring lives.  In terms of a public health system, however, if effectiveness is measured by minimising costs, we might consider encouraging everyone to take up smoking.  Another example is the use of QALYs and other health care metrics that discount the value of lives lived with disability or illness.  It may be true that individual health and individual lives are improved by being freed from the burden of disability; but if these metrics are applied across the population to determine which public health measures are most effective, we may conclude that it is better not to treat disability or disease, since saving a disabled life “counts” less than saving a healthy one. 

Public health also forces us to rethink the ethical framework associated with individual health care.  Consent, for example, is one of the pillars of health care ethics at the individual level; but what role does (or can) it play when determining the legitimacy of introducing an intervention across the entire population – such as fluoridation of the public water supply?

The case studies discussed in the Nuffield report and presented in Schmidt’s paper serve to illustrate the particular difficulties associated with public, as opposed to individual health, and the need for a different approach to public health issues.  This, indeed, is part of the purpose of this conference: to “Think About Health” in a new way and to form a network of academics, practitioners, policy-makers and other stakeholders to continue this discourse. 

Sarah Chan (Research Fellow, Institute for Science, Ethics and Innovation, University of Manchester)
Conference organiser: Dr John Coggon
Sponsored by the Institute for Science, Ethics and Innovation and the Cardiff Centre for Ethics, Law and Society.

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