When politicians instruct senior public health bureaucrats to ban language used in developing policies this opens the door for change management which creates opportunities to introduce new approaches into the business process. Peter Drucker (1909-2005), the famous management guru, made his name by asking his clients two questions: “What business are you in?” and How’s business?” The business of public health is to transform lives with an expected outcome while supporting people so they can reach their full potential of good health. The answer to “How’s business?’ is not as positive as it could be. Evidence of the need to address health inequities has been present for over 30 years but has not been incorporated into interventions. During this time policies incorporated language such as evidence-based, science-based, entitlement and vulnerability into reports sent to policy makers. For Nietzsche everything is in flux – ideas should change as soon as information and input changes.
Evidence-based public health (EBPH) action was launched following a 1984 report from US Preventative Services Task Force. EBPH “is the development, implementation, and evaluation of effective programs and polices in public health through application of principles of scientific reasoning, including systematic uses of data and information systems, and appropriate use of behavioral science theory and program planning models.” The Ottawa Charter for Health Promotion (WHO 1986) established that while changing behaviors was indeed a crucial aim of health promotion, bringing change at that level involved a complex interplay of policy and strategy, creating supportive environments, encouraging community action and reorienting health services. Policies aimed at the individual foster the illusion that a person’s health status is entirely under his or her control, as a consequence, health problems are assigned solely to the individual. In the end the individual becomes a victim, being blamed for what are socially-produced health problems.
The 1986 report, Achieving Health for All, introduced an expansion to the traditional use of the term ‘health promotion’ for Canadians. Three major changes were identified as not being addressed by the current health policies and practices: poorer people have significantly lower life expectancies, poorer health and higher prevalence of disability than the average Canadian, preventable disease and injury are undermining quality of health and the quality of life of many Canadians, chronic disease and disability co-exist with emotional stress, and a lack of community support to help cope and live meaningful and productive lives. In summary the report broadened health determinants to include environmental determinants such as income. In the challenge to reducing income inequalities, poverty did not appear, the discussion was about addressing groups who were disadvantaged. Examining the intersection of poverty and health is crucial to understanding the full impact of income inequality on overall well-being.
In the 1990s public health developed under the rubric of population health. Population health includes strategies that address the entire range of strategies that determine health, and strategies designed to affect the whole population. A consensus emerged to support the need for evidence-based policy development and decision making. Emphasis was placed on the use of the most solid information available to make health decisions, and to ensure these decisions reflect the values and principles of citizens regarding health and health care. This means that every decision should be justified by reference to the available evidence and reasoning. It involved increased upstream investment. The population health approach is grounded in the notion that the earlier in the causal stream action is taken (the more upstream action is taken) the greater the potential for population health gains and health-related cost savings for the system. Income and social status was identified as the most important determinant of health.
Social determinants of health (SDH) are understood as the conditions in which people are born, grow, live, work and age, that is, their whole life cycle, encompassing not only the social, but also economic, political, environmental, cultural and individual determinants. It refers to the social conditions of each individual, their characteristics, lifestyle, socioeconomic and demographic conditions, permeated mainly by social inequalities. Public health must point out policies and activities that when implemented in other sectors, including medical care, can help improve health and reduce disparities. This is important as many agencies do not participate with respect to cross-cutting issues. For example, effective tobacco control required the use of fiscal policies to reduce tobacco consumption, allied with labour and environmental laws to reduce exposure to smoke, and regulation of marketing practice. None of these activities are the primary domain of the health sector. An SDH approach may identify and address issues that are not feasibly addressed through individual or interpersonal behavior change approaches.
Neglected infections of poverty are a group of chronic and debilitating parasitic and other infections (including congenital infections) that disproportionately affect people living in poverty. Major neglected infections of poverty in the United States include toxocariasis, trichomoniasis, toxoplasmosis, cysticercosis, Chagas disease, and congenital cytomegalovirus infection. Neglected infections of poverty tend to be concentrated in areas of extreme poverty, including the Mississippi Delta, the border with Mexico, Appalachia, tribal lands, and disadvantaged urban areas, where these diseases perpetuate poverty because of their adverse health impact on child development, pregnancy, and worker productivity. The economic toll from these infections are substantial because they cause poor school performance, young adult disability, premature death, and hospitalization; in some cases, the costs of therapy are also high because correct diagnosis is delayed.1 It is necessary to develop health impact assessments in order to help other sectors understand how their action can help improve health and reduce disparities.
The 1992 Declaration of the Rio Conference on Environment and Development, Principle 15 reads: “In order to protect the environment the precautionary principle shall be widely applied by states according to their capabilities. Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation.” To mitigate against harmful toxins one could take the precautionary approach, even with the lack of science-based certainty one takes action in the face of potentially serious risk without having to wait for completion of further scientific research. When evidence gives us good reason to believe that an activity, technology, or substance may be harmful, we should act to prevent harm – to protect public health, environment and the future of our children. If we always wait for scientific certainty, people will suffer and die and the natural world may suffer irreversible damage.
Health should be understood as a state of complete physical, mental and social well-being, and not merely as the absence of disease. Vulnerability has three important dimensions: individual, social and programmatic. These are interlinked and one influences the other. Individual vulnerability refers to biological, emotional and cognitive aspects of the individual. Social vulnerability is characterized by cultural, social and economic aspects that determine the opportunities to access goods and services, whereas programmatic vulnerability consists of the social resources that are necessary for the protection of the individual in relation to risks and integrity, as well as to physical, social and psychological well-being. Surveillance of social determinants of health inequalities identifies the following groups in the US where findings indicate that unemployment has a greater adverse effect on the mental health: male manual workers, single mothers, main earner women, and manual workers without unemployment benefits for both sexes.
Since the turn of the 20th century, there has been a belief that technology and reason would make us masters of our environment. By the end of the 20th century, individualism, happiness and capitalism were core values of the Western world. In the second decade of the 21st century we face three deficits: current fiscal imbalance of various levels of government, the need to reverse epigenetic harms from the toxins in the air, water and food, and the debt to future generations as the growing economic gap will ensure them poorer health as adults, which will affect their economic status as they earn lower wages (the false promise of the neoliberal economics). Our expanded understanding of the wider determinants of health and disease suggests that significant advances in health could be achieved if policy makers, program developers, and implementers address these broader influences on health outcomes while maintaining excellence in traditional disease control approaches.
Social determinants are understood as the conditions in which people are born, grow, live, work and age, reflecting positively or negatively on their lives. Social and economic conditions (and their effects on people’s lives) determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs. We need to ban making public policy decisions through the lens of individualism (which oversimplifies complex and multifaceted problems) and switch to filter social and economic policies through the lens of the social determinants of health before they are implemented to ensure they support actions that reduce inequities in the system. Words like evidence-based, science-based, entitlement and vulnerability can then be relegated to the reference papers used to develop reports destined for policy makers, that address the key main social determinants of inequality: unemployment and the working poor. We need to close the gap in health-care policies – between the declarations of social determinants of health, and actions and deliverables.
1 Hotez, Peter et al. National Summit on Neglected Infections of Poverty in the United States https://wwwnc.cdc.gov/eid/article/16/5/pdfs/09-1863.pdf