The UK Faculty of Public Health defines public health as “the science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society.” The Faculty’s approach is based on the assertion that public health is “population based” and that it “emphasises collective responsibility for health, its protection and disease prevention”. It says so on their website. This conception of “public” health is plainly based on the idea that co-ordinated collective action in the context of health is not only possible, but desirable. This is sociologically interesting because it implies that the general fields of “health” and “wellbeing” are amongst the areas of life where people build, develop and negotiate the relationship between their individuality and their membership of wider social formations.
Specifically, the implication is that, through public health, individuals make decisions and take actions that are not immediately associated with their individual health and wellbeing. Rather, they are set in the context of their membership of a group and designed to bring about whole-population wellbeing, which can only be achieved by mass or collective action. In this sense, the public health ‘mindset’ is a clear expression of simple, old-fashioned utilitarianism.
In terms of collective action ‘Public Health’covers a wide spectrum of activities. These include individual actions such as being vaccinated against a disease, personal abstentions such as not using tobacco, the use of personal equipment like helmets and safety belts, the development and use of public infrastructure like zebra crossings and sewers, and, of course, producing administrative and legal structures such as child protection systems or building regulations. There is, therefore, clearly an overlap (a “synergy” indeed) between individual and collective actions, and it is this that makes public health so interesting to sociologists. It is a field where we can learn a considerable amount about process, structure and agency – in order to better understand and debate how individuals, groups and organisations pick their way through the complex socio-cultural landscapes in which they exist.
We know that a variety of institutions are involved in constructing a social world in which public health can function. Science, in the form of population epidemiology, produces statistical statements about the relationship between individuals and populations. The findings of this scientific work regularly enter the public domain, usually formed around the concept of “risk”. Public, private and ‘third sector’ bodies mount campaigns to inform people about risk and to persuade them to carry out certain actions or to desist from others. Governments regularly pass laws and regulations designed to moderate individual behaviours in relation to risk and sometimes to outlaw those behaviours completely.
These rather different fields of social action have one crucial thing in common. They are predicated on the idea that some individual actions should be taken for the good of the population in general as distinct from an immediate or identifiable benefit to the individual. Indeed, in many public health scenarios there is a chance that a public health choice may be to the detriment of the individual – they may potentially suffer as a result of their participation. This ‘calculus’ is the central tenet of utilitarianism, which prioritises the greatest good for the greatest number. But public health (as a “science and art”, if you will!) is based on the idea that they should participate because the number of people who may benefit is greater than the number who may suffer. This system relies on the individual being effectively ‘blinded’ to which camp they will fall into. Are they one of the future sick/injured who will now be saved? Or do they belong to the previously comfortable/well who will now be damaged?
In recent years public health practice has been changing. It is now more common (but by no means ubiquitous) to exhort individuals to find out about their personal risk and only then choose to participate (or not). This, potentially, presents a problem. What about the individual who, in the light of the epidemiological evidence, chooses not to participate – i.e. not to risk personal suffering for the good of the collective? If a public health campaign puts the concept of individual choice above the utilitarian principle, in this way, doesn’t it begin to undermine its own ‘raison d’ être’.
Apart from observing and debating the end of ‘classical’ public health, social scientists working in the field have a further set of questions to ask. How do these cultural developments within public health fit together with notions of agency? And specifically, how are the knowledge, confidence, freedom and ability to exercise choice over individual participation in public health socially patterned?
For example, are all citizens equally equipped to choose? Or is the ability to participate effectively in “public health a la carte” unevenly distributed? If large numbers of people choose non-participation, does this render the whole public health enterprise redundant? Or is a new version of “New Public Health” being invented? What are the implications in terms of how scientific evidence is related to public policy? Who decides when personal choice is the appropriate way forward in questions of public health or when blanket approaches or even compulsion should be brought into play? If medical sociology has discovered anything in this field, it is that discussions of personal choice in relation to health must by necessity involve an analysis of power, authority, inequality and how freedom of action is socially distributed.
One of the things we can do is to try and build explanations of why and how the same elements of public health (evidence, policy, clinical practice, law, choice, risk etc) become combined and re-combined in different contexts to produce such a wide variety of results. Cycle helmets, motor-cycle helmets, ‘healthy eating’, exercise, alcohol use, tobacco use, drug use, cancer screening, MMR vaccination, coal-burning and car driving all involve individual health-related actions / choices. Yet the cultural, legal and medical arrangements attendant on these public health areas are very different. Explaining why is quite a challenge.
Personally, I suspect that the ability of medical sociology to be sociological about this area has been compromised by the fact that the discipline has gradually (and presumably unwittingly?) been co-opted into a wider public health establishment. From inside the system it is probably rather difficult to see the wood for the trees.
Being “pro” or “anti” individual public health campaigns is not really the issue, nor is it really a social scientist’s job. Rather we should attempt to analyse the whole picture and try to explain why the public health world is like it is. Public Health a la Carte is with us right here, right now – it just doesn’t appear to rule the roost in all, or even most, areas. Why? In my view that’s a sociological question… (in case anyone has forgotten what one looks like!)