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Disease

A set of signs and symptoms and medically diagnosed pathological abnormalities

Illness

primarily about how an individual experiences the disease. Illness can be culturally specific and may have social, moral or psychological aspects

You are not healthy according to the clockwork model

if there are any breakdowns in the body system

The WHO defintion of health has been criticised as being too …

utopian and unachievable

Three main domains relating to the definition of health are found when asking what the publics definitionof health is:

health is not being ill, it is a necessary prerequisite for life’s functions and it is a sense of well-being expressed in physical and mental terms

Critical perspectives on health are those that …

seek to explain the purposes that are achieved through particular means of defining healt. They are critical in the sense that they look beneath the surface appearance of a concept or phenomenon and offer an explanation as to why it is this way.  

A concern for the Healthy Cities movement has been to move beyond a deficit model

(for example, for a city, how many unemployed, how many households without running water) to one that captures the more dynamic and positive aspects of health (the number of trusting people, the availability of community meeting spaces)

Defining health as the Healthy Cities movement does is useful for the New Public Health, because 

it appears more likely to keep a focus on positive definitions and on structurally rather than individually driven factors that affect people’s health

Ecosystem health

integrates an overall consideration of the environment and the interdependence of systems with the overall ecosystem

The new public health is innovative because:

• it puts the pursuit of equity at the centre of public health endeavours 

• it is based on the assumption (supported by considerable evidence) that social and environmental factors are responsible for much ill health  

• it argues for health-promoting health services that are based on a strong system of primary health care  

• it stresses the role of all sectors in impacting on health and the importance of health in all policies  

• it stresses the importance of participation and involvement in all new public health endeavours 

The ottawa charter

1. The development of healthy public policy

2. The creation of supportive environments

3. Strenghtening community action

4. The development of perosnal skills

5. Reorientation of health services

1. The development of healthy public policy

recognises that most of the private and public sector policies that affect health lie outside the conventional concerns of health agencies, such as eduction, welfare, taxation

2. The creation of supportive environments

in which people can realise their full potential as healthy individuals. The Charter recognises the importance of social, economic and physical environmental factors in shaping people’s experiences of health

3. Strengthening community action 

those activities that increase the ability of communities to achieve change in their physical and social environments through collective organisation and taking of action

4. The development of personal skills

acknowledges the role that behaviour and lifestyles plays in promoting health. The skills called for are those that enable people to make healthy choices

5. Reorientation of health services

is a call for health systems to shift their emphasis from (in most industrialised countries) an almost total concentration on hospital based care and extensive technological diagnostic and intervention to a system that is community based, more user-friendly and controlled, which focuses on health

The Ottawa charter stresses the importance of, and recommends:  

• advocacy for health  

• enabling people to achieve their full health potential  

• mediation between different interests in society for the pursuit of health

Evidence suggests that the amount of overall expenditure on health is not the key determinant of …

population outcomes but that the proportion of public expenditure (as part of total expenditure on health care) is more important

Health systems based on the principle of universal coverage achieved through public financing are generally … 

cheaper, more efficient and more equitable → runs aigainst the general belief that services in the private sector are more efficient

Three disturbing trends that have a negative influence on population health outcomes and equity and undermine primary health care:  

• a disproportionate focus on specialised curative care  

• a command-and-control approach to disease control, focused on short-term results  

• in some health systems, an unregulated commercialisation of health, which has been allowed to flourish 

The challenge for the twenty-first century is for states to invest in a health system and governance system that sees health as a measure of …

the outcome of all activities of government and the private sector

Health systems equipped to promote health in the twenty-first century must be prepared to take on a stewardship role for the health of the population they are responsible for

monitoring the state of population health and the extent of equity, and being a facilitator and advocate for all sectors to see health as an outcome of their actions

Walt cites Blondel’s three basic criteria for the classification of political systems as reflecting points on the following dichotomies

• democratic/undemocratic  

• liberal/authoritarian  

• egalitarian/inegalitarian 

he new public health philosophy appears to assume a society that conforms to …

the left-hand side of Blondel’s dichotomies: democratic, liberal and egalitarian

Paternalism

practices that restrict the liberty of individuals, without their consent, where the justification for such actions is either the prevention of some harm they will do to themselves or the production of some benefit for them that they would not otherwise secure

Consequentionalism

holds that most ethical decisions are based on calculation of the good that derives as a consequence of a given decision

Deontologism/non-consequetialism

the view that decisions should be guided by a set of inherent moral principles that one has a duty to follow, regardless of context or consequence

…  has been an important philosophy behind the health education and health promotion movements

individualism → often concentrate on changing individual behaviour rather than the conditions that create ill health in the first place

social-structural perspective on health

is concerned with how society is organised (economic, social, cultural and power issues) and its impact on health and illness

Key issues from the social-structural perspective on health

the construction of social risk, the exercise of power on participation in society and the effects of income and wealth distribution on the pattern of health

The social-structural perspective is less evident in public health literature, because:

1. Social structures are abstract and elusive while biological and psychological evidence is more tangible and obvious 

2. Western societies have a bias towards explaining social events in terms of personal characteristics

3. Recognition of the importance of social-structural factors in the creation of health and illness can lead to a sense of powerlessness. Explanations located in individual behaviour can lead to far more manageable policies and plans. 

Economic gloablisation

the process of trade liberalisation, tariff reduction, standards harmonisation and deregulation → accelerated growth in international trade

Political globalisation

the creation of global institutions that are establishing global forms of governance → weakens capacity of national governments

Technological globalisation

the rapid breakthrough in communication technologies, such as satellites and the internet, which have made worldwide communication so much more rapid

Cultural globalisationo

involves the fast transmission of ideas, images, fashion and information through new communication media → breaking established social orders

Ideological globalisation

the way in which political and corporate leaders sell a view that there is no alternative to the neo-liberal package of reforms. The argument is that citizens, companies and whole societies have no option but to accommodate these reforms, despite the negative consequences.

Neo-liberalism

progressive reliance on economic factors as the basis for organising society and making government decisions, the free market should determine all economic transactions

Many governments around the world base their economic policy on neo-liberalism, which means they put …

economic considerations ahead of those of social policy and health and well-being of citizens

The justification for neo-liberal policies lies in the belief that …

policies that encourage economic growth will be beneficial for human health and well-being

It is only when growth is combined with state action to ensure … that health improves

redistribution of resources and the direction of the benefits of economic growth to public projects for the communal good

Inequities in health relate to:

• SEP

• Gender

• Ethnicity

Townsend et al. put forward four possible explanations for variations in health

1. artefact explanations  

2. theories of natural or social selection  

3. cultural/behavioural explanations  

4. materialist or structuralist explanations 

Artefact explenations

based on the notion that the ways in which social class has been measured in the UK may be unreliable and artificially inflating the size and importance of observed health differences. The argument hangs on the claim that the classification and nature of occupations have changed so much in recent decades that any comparison with earlier decades is meaningless

Theories of natural selection

inequities arise as a result of social mobility—healthier people rise to higher social classes. Those in poor health are less likely to be socially mobile

Cutural/behavioural explenation

differences in how the various social groups make lifestyle choices. They maintain that people in less well-off groups typically adopt lifestyles that are likely to be damaging to their health

Materialst/structuralist explenation

focuses on the material conditions under which people live, maintaining that health inequalities stem from the less affluent social groups being the victims of unhealthy environments

The behavioural explanations see the cause of greater burdens of illness lying within …

the individual

The structural stresses the impact of the …

collective on the individual

Wealth

things people own and use to (1) produce goods and services, and (2) enjoy directly without consuming them in the process

Direct effects of climate change on human health:

• Thermal extremes

• Ozone layer depletion → skin cancer

• Natural disasters

Indirect effects of climate change on human health

• Communicable diseases increase

• Sea level rise → salt water will enroach upon fresh water

• Food security → some areas may become drier, while others will get more rain

People with … will suffer more from climate change on human health than people with

low SEP, high SEP

In warmer climates people suffer from air pollution from

burning fossil fuels in houses with poor ventilation → particularly a problem in low-income rural and urban slum settings

In colder climates people suffer from air pollution from

buildings are designed to reheat and people spend a lot of time indoors, pollutants trapped inside can reach dangerous levels

Coastal ecosystems are deteriorating because of contamination from inadequately controlled… 

industrial, agricultural and domestic waste disposal → water with higher concentrations of cyanobacteria report more health effects

Three factors that have increased the stress on water:

1. Population growth 

2. One-third of the world’s population lives in areas suffering water stress 

3. Climate change, which has brought increased drought to many arid or semi arid regions

What is most hopeful is that the environmental health problems we face are largely a result of

social and economic arrangements → this means they are, therefore, open to change and adaptation

Why don’t we take action to stop climate change?

• Vested interests interests in the corporate sector are likely to obstruct changes that reduce consumption and pollution

• Our global system of economics has no way of valuing the environment unless it is developed and exploited

• Strong political lobbying from the fossil fuel and forestry industries to protect their commercial interests, which are likely to be most affected by any move to reduce greenhouse gas emissions or to curtail logging

• Most of the environmental threats are happening over long time scales → the public health challenge is to respond to long-term and gradual danger.

WHO notes that the health impacts of climate change will be felt most by those in …

low- and middle-income countries (mainly because of the underlying social determinants of vulnerability)

Around the world, whenever there is conflict over an environmental threat, the onus is on the community to prove that an environmental hazard is dangerous rather than on …

the industry or developer to prove that it is safe

The precautionary principle

once there is reasonable evidence, but still some level of uncertainty, that a particular practice might be harmful, it is advisable to take preventive or ameliorative action

Rapid urbanisation can also produce damaging combinations of health determinants, such as

infectious diseases (HIV), non-communicable diseases (from poor diets, pollution and lack of excercise) and injuries (including road traffic accidents and violence)

Living conditions in … are far superior to those in …

industrialised countrie, the developing world → where the problems faced are similar to those tackled in the industrialised cities in the nineteenth century

The epidemiological evidence at the time of the Industrial Revolution led to the assumption that high-density living was a health hazard. A more likely explanation is that …

the lack of the most basic public health measures, such as sewerage, solid waste collection, water treatment and control of air pollution, was the real culprit

The density of populations within cities makes them particularly vulnerable to …

man made disasters

Crime and vandalism are more common in urban designs featuring …

anonymity, lack of surveillance and availability of alternative escape routes

Well-managed high-density urban environments have the potential to …

minimise their ecological footprint

Cities and suburbs, in particular, have been accused of …

encouraging isolation and not providing a sense of community

Much community development work aims …

to create closer communities in which people know each other and can work together towards collective goals

Increasing social capital cannot be expected to solve problems that are essentially those of …

poverty and deprivation

On the face of it, the solution to the world’s growing population seems obvious:

encourage those countries with high birth rates to introduce contraceptive technology that reduces the fertility of the women

Moves towards gender equity are a key to effective population policy

Women need access to contraception, integrated reproductive health care, access to educational and employment opportunities and freedom from violence

Poor countries have a valid argument that the problem of overpopulation is as much one of …

overconsumption. Poor people in developing countries have large families mainly because it is to their benefit

Five main areas in which the current economic system needs to change to achieve healthy and equity have been identified:

1. the need to challenge the assumption of economic growth  

2. the need for new indicators of economic and social development

3. the need to restrict the domination of the international economic system by multinational corporations and for the development of smaller scale locally controlled economic systems  

4. the need for a fair taxation and income system within countries  

5. the need to create fair terms of global trade and especially fair trading conditions for poor countries 

Neo- liberal economics was founded on growth as the means by which wealth is produced, and wealth production is assumed to be …

good for well-being

Economic growth and the resultant wealth production are only possible because of …

the exploitation of non-renewable resources, especially fossil fuels. Systems that consider social and environmental impacts may lead to very different assumptions about the value of economic growth

Criticisms of the GNP:

• Not good for health.
  Increase in road accidents → more need for crash repairers → production is up

• It does not cost in ‘externalities‘ (= when an activity affects poepel or the environemnt external to that activity)

• Does not allow for any calculation of the distribution of wealth and income

• Undervalues activities that are not part of the formal system of production
  Unpaid work, emotional caring and unpaid caring for sick people

A further key concern of those promoting an alternative or new economics is to develop systems that …

prevent manufacturers and others from externalising their environmental costs. → policies that encourage the polluter to pay the costs associated with the pollution it creates would discourage the activities that create it

A society geared to consumerism is unlikely to …

be sustainable

Taxation cuts to the heart of creating a society based on the principles of …

solidarity and fairness

Taxation is also vital to creating a society that has the ability to …

control and regulate the private sector and its profit-seeking motives, which so often win ahead of questions of public health and environment

A healthy global economy would also ensure a much fairer distribution of …

income and wealth than the current one

… is at the heart of the aspirations of a public health for the twenty-first century

Ecological sustainability

What characterises attempts to create healthy and sustainable cities and communities? Three factors stand out:

1. The complexity of sustainability. Sustainable cities and communities will only evolve with multidisciplinary, lateral thinking and cooperation across sectors 

2. The constant tension between the desire for economic growth and development and the need to protect and maintain the viability of the physical ecosystem and the social, welfare and health needs of people. Sustainability requires a shift to development that is not dominated by short-term economic decision making and which stresses hope rather than fear. 

3. Effective management and leadership capacity within communities. Leaders will have to juggle the different values and politics in determining acceptable strategies and principles for tackling problems in both urban and rural contexts

Convivial neighbourhoods that promote health will:

• Encourage interaction

• Make people feel safe, because people are evident in the streets and public spaces

• Ensure that the needs of the car do not dominate

Lindheim and Syme stressed three factors that appear to be important for healthy environments: 

• Building social relationships that include support, social ties and family relationships. They note that urbanisation and industrialisation have decreased the likelihood that supportive social relationships can exist. 

• Minimising hierarchal relationships that include support, social ties and family relationships. They note that urbanisation and industrialisation have decreased the likelihood that supportive social relationships can exist

• Encouraging connection to people's cultural heritage and the natural world because most people relate to these factors. Similarly a sense of history and culture is important to self-esteem and well-being. These links of cultural heritage are under significant stress in the cities of the world that are growing rapidly—often development wins over cultural preservation

Energy policies at federal, state and local levels need to move towards …

sustainability

The most efficient way to reduce the disease burden associated with poor health behaviours and psychosocial characteristics is to improve the …

socioeconomic conditions that generate them

The main barriers to GP’s involvement in health promotion aside from the limited basis for its effectiveness are:

• Structural factors (lack of initial and continuing education and training in health promotion, non-standardised guidelines and low financial incentives

• office organisation (lack of time in consultations, lack of support staff and sheer forgetfulness)

• patient reluctance and competing priorities for the time available in the consultation

• low confidence

• frustration from doctors because they do not receive rapid feedback

Immunisation depends on

creating a sufficient pool of immunised people to prevent outbreaks from spreading more widely among the population = herd community

If immunisation levels in the population are not sufficiently high, it will not be possible to …

control acute, vaccine-preventable diseases

Dahlgren and Whitehead note that although all European governments make statements about the need for justice, equity and solidarity in their health care systems, in practice the actual experience of low-income households …

does not reflect these commitments

There may be some frustration among health bureaucrats and service providers that they can do little to reduce inequities, given that the crucial factors are outside the health sector. This is reinforced by the tendency for social factors to be regarded as epidemiologically fixed and unchangeable. Health policy makers need to be reminded that … 

these factors are not inflexible because they are socially created, they are amenable to change through social and political actions

Primary health care services are particularly effective at working with …

disempowered, poor communities by using community development strategies in addition to clinical work → try to change the conditions thate create inequities