|Year : 2010 | Volume
| Issue : 3 | Page : 580
In the News! An Opinion - Health for, or Health of the People?
J van Dalen
Associate Editor, Education for Health
|Date of Web Publication||28-Dec-2012|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
van Dalen J. In the News! An Opinion - Health for, or Health of the People?. Educ Health 2010;23:580
Public health has become the domain of health care professionals. They pretend to know what is good for us. But the public turns its back, not taking the professionals seriously...
On 25 June this year Klasien Horstman was inaugurated as Professor of Philosophy of Public Health at Maastricht University, the Netherlands. At that occasion she presented a lecture that contained many messages relevant for a wider audience. Below I will address some of the points she raised. Although focused on the Dutch or European situation and, therefore, perhaps not applicable to many other countries, Horstman's messages may help others avoid some of the pitfalls she describes. I have used the transcript of her presentation as well as her summary in a Dutch daily national newspaper article as sources1,2.
Public health is in trouble. The many successes achieved in extending life-expectancy notwithstanding, governments as well as the health care professionals have shifted their attention from the prevention of illness towards the promotion of health. Campaigns for weight reduction are seen in Europe and the USA. These activities, however, have not led to much change in people's health and health care behaviour. The average weight of the population still increases, with consequent diabetes globally on the rise, and a HPV vaccination campaign in the Netherlands for twelve-year old girls to reduce rates of cervical cancer yielded a large, emotional national debate when a mother claimed in the Internet that her daughter had died from such an injection. After that, only less than half (47%) of the girls accepted free vaccination. Apparently, such nationwide interventions, which are aimed at improving the populationï¿½s health, have only very limited success.
This limited success of such large campaigns, or in some cases their downright failure, can be remedied in a number of ways. According to Horstman's diagnosis of the situation, those responsible for crafting a population-wide health intervention see the problem they are addressing as a 'technical' issue, so if the intervention 'did not work' it evidently wasn't pursued far enough. What they believe is needed is a more intensive intervention so that 'people's knowledge about risk-behaviour will be increased'. Health care professionals and academics acquire more data to 'prove' the intervention's value, and they attempt to develop more strategies to convince the people.
So far this approach has not worked. The people in my country are in general well informed, and still we continue to behave in ways that are bad for our health. We know we should move more - our TVs provide us information on the health advantages of an active life - and still we take the car to do our shopping and bring home more food than is good for us. The Ministry of Health, advised by health professionals, has no other answer than to push still more information at us on TV. The officials assume they know what's good for us, but simply delivering more of these messages to people does not help us to change.
Interestingly, the tendency to rely on increased information to affect changes in people's behavior has been influenced by an increasing democratic process. Previously, health care professionals had the public's confidence: they were afforded status and their work and opinions were not challenged. In the second half of the 20th Century this confidence eroded with the public's increasingly rationalistic style: the relation between politicians and professionals on the one hand and citizens on the other became more characterized by guidance and control than by reflexive acquiescence. Since the 1970s the government has issued guidelines for good practice, (e.g., setting maximum size of a General Practitioners' practices, codes of professional conduct with sanctions for those who do not comply, requirements for informed consent) and verification processes assured that guidelines were followed. The people also faced more guidelines, like children's screening centers that appeared to monitor our children's health, growth and cognitive development and to refer for further care when needed. Public health information was increasingly influenced by scientific 'objectivity' and interconnected with bureaucracy. The people became better informed, and consequently demanded 'value for their money' from health care professionals. The professionals were held accountable. The people did not uncritically accept that the health advice was in their best interest, they started to suspect the professionals and assume other mechanisms, like increasing profits for pharmaceutical companies.
The increase in information resulted in a widening of the gap between the public health officials and the public. Epidemiologists and health scientists determined the relevant risks and attempted to inform the public, but the people didnï¿½t accept the messages. Paradoxically, this process of adding information increased their distance from the public whose health they were trying to improve. The people became dissatisfied with the rules that were imposed on them, and they questioned the professionals: "Who do you think you are, interfering with how I eat or raise my children..??" Professionals' evidence was challenged and they were asked to respond publicly.
Horstman advocates thorough reflection on this process and renewed attention to the relationship between science, politics and society. She recommends what she calls a pragmatic perspective: the relationship between public health professionals and the public should be based on experimentation and learning from the public. Public health professionals should actively seek the opinions and perspectives of overweight individuals, smokers and drinkers to learn about the factors that influence their behaviour. Health care professionals should learn from their patients who maintain unhealthy behavior. Only by knowing what causes unhealthy behavior despite sufficient personal knowledge can we develop ways to address the causes. Such an approach is already practiced in psychiatry in the Netherlands, where professionals are assisted in their approaches to improve therapeutic interventions by input of current and former patients. The public should be seen as co-constructors, rather than as objects of public health. This, Horstman advocates, will be the only way by which researchers and public health professionals can regain status and confidence in a society in which they are no longer worshipped and their word no longer automatically heeded.
Jan van Dalen
Associate Editor Education for Health
1. Horstman K. Mobiliseer de dikkerds, de rokers en de drinkers [Mobilise the fatsos, the smokers and the drinkers]. De Volkskrant, 10 July 2010.
2. Horstman K. Dikke kinderen, uitgebluste werknemers en vreemde virussen [Big children, burned-out employees and strange viruses]. Inaugural Address Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands, 25 June 2010.