Interesting new article in the latest Journal of Epidemiology & Community Health. The article is entitled How Political Epidemiology Research can Address why the Millennium Development Goals have not been Achieved: Developing a Research Agenda. The abstract is less interesting than the following excerpt:
Public policies, and their relation to health, are still not part of mainstream epidemiology, which continues to consider health as apolitical, and applies a definition of health that is centred on the individual illness rather than on society health problems. As a result, health policies are equated to healthcare services policies, and inequalities in health distribution are considered to be the result of individual problems (chosen lifestyle) or of how healthcare is implemented. This perspective has the effect of directing political attention towards the most manageable variable, the healthcare services. However, health inequalities have a political basis.10 Information on health inequality is not sufficient in order to decide what is inevitable and what is unjust, and such a decision does not depend solely on logic and empirical research, but also on an assessment of politics and ideology.
(footnotes omitted)
This paragraph should be required reading (& reflection) for any health policy scholar.
My reaction to reading Deborah Stone's Policy Paradox (Stone is as fine a health policy scholar as there is, and is always required reading, IMO) was to express astonishment at the to-me ludicrous idea that policy -- health or otherwise -- can be conceptualized coherently outside of politics. I could not understand why Stone had undertaken to write a book exploding the duality, and it was only as I began to do my active policy work that I began to see just how pressing was the need for her book.
One of the most basic classical insights (Plato, Aristotle) is that humans are political animals. There is no such thing as a human enterprise in which socialization and political practice is absent. This is in part why I find the discourse bemoaning the "politicization of science" tiresome and even bizarre. What does this even mean? Scientific practice is irreducibly political. Leigh Turner, whose work is also always required reading for me, addresses this issue in detail in a recent article, and argues that if we want to complain about a poor policymaking process, in which conclusions are predetermined, discourse is silenced, and stakeholders ignored, that is perfectly justifiable. But those specific complaints have little to do with a nonsensical complaint that scientific practice and policy ought not be politicized. News flash: scientific practice, like medical practice, like any human endeavor, is inherently political.
This observation is important for a variety of reasons, not least of which is the implication that if we want to improve public health policy, political considerations are inextricably linked with the process itself. It cannot be avoided. It cannot be ignored.
Second, the authors note that mainstream epidemiology still focuses on individual illnesses rather than population health problems. This is absolutely correct, IMO, though the tendency is certainly not limited to "mainstream epidemiology." I am going to quote again and highlight the following two sentences, because they seem so important to me:
As a result, health policies are equated to healthcare services policies, and inequalities in health distribution are considered to be the result of individual problems (chosen lifestyle) or of how healthcare is implemented. This perspective has the effect of directing political attention towards the most manageable variable, the healthcare services.
Health services research and discourse is extremely important. It is vital to understand how we are and are not utilizing health services. But I am more convinced than ever that to reduce health policy, and the normative problems contained therein, to analysis of our utilization of services, is to make a grievous mistake. Health and illness are not exclusively functions of health care utilization. Health is not exclusively a function of health care. The two are related, but the evidence that the former flows from the latter is, as I have noted before on this blog, not particularly strong. The health policies we do and do not support are discursive products; they are results of a series of nonlinear dynamical systems, of social and cultural processes that combine to shape what policies do and do not get implemented.
Changing culture, of course, is just about the hardest thing to do in the world. So we focus on the variables we can do more about in the short-term: utilization of health care services. This, as far as it goes, is fine. But the widely assumed inference, that if we do the latter, improved population health and decreased health inequities will ensue, is quite implausible, to me.
As such, the authors note:
However, health inequalities have a political basis. Information on health inequality is not sufficient in order to decide what is inevitable and what is unjust, and such a decision does not depend solely on logic and empirical research, but also on an assessment of politics and ideology.
This too cannot be overemphasized. It is entirely fallacious to infer what we ought to do -- what distributions of health are and are not unjust -- from a descriptive analysis of how we utilize health care services. We desperately need information on health inequality. But that information is not self-executing, from either a moral or a policy perspective. The decision on how to act virtuously -- what kind of a society do we want to be -- in context of health does not follow from an analysis of how we consume health care services. Political, social, moral, and yes, historical analyses are crucial.
Hence, I continue to believe that an interdisciplinary approach, medical humanities or otherwise, is a promising avenue for addressing health and health inequities.
Thoughts?
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