The public health paradigm in research and practice
A significant re-framing
In December 2022, the (then still relatively new) director of homelessness policy, Jeffrey Olivet, announced a significant shift in the approach that the US federal government was to take, towards our understanding of and response to homelessness. In future, this was to be seen as an issue falling within the compass of public health.
A re-frame in terms of public health places the emphasis now not just on explicit healthcare provision and funding, but on wider systemic issues, calling for local strategic and operational co-ordination, and involving a greater range of relevant agencies. In a country where healthcare provision as such is largely in the hands of private and insurance funded agencies, this seems a useful new direction to pursue.
Complex interactions
The definition of public health may seems, at first sight, fairly straightforward. It is a concern for the general health of the public at large - as distinct from the health issues of those who, as individuals, may be patients of any specific clinical service – and action to be taken to address more systemic issues, addressing the social determinants of health.
In practice, however, this must then be translated and incorporated into specific policy and funding streams and administrative arrangements that may vary quite significantly from country to country – and even from place to place, and from time to time. These in turn are deeply enmeshed in the economic and social fabric of everyday life.
In the ‘origin story’ of public health, the iconic image of public health was the famous cholera pump (pictured) , a single intervention to intercept a single identified disease vector, with immediate results. Yet the 19th Century was also the heyday of major public works for sanitation, air quality, and protective legislation to limits the hazards of working life. Many analyst now argue that the improvements in public health and life expectancy in that ear owed far more to such activity than to any innovations in healthcare.
As the 20th and 21st centuries unfolded, the picture of public health action has therefore moved on, from an aspiration for a single interception to a far more complex picture. The iconic image of contemporary causal influences is the obesity map, produced for Public Health Scotland. It shows a bewildering array of factors all influencing obesity – and all, in research terms, confounding any attempt to identify single interventions and outcomes. The issue is essentially systemic.
Visualising these 'illusive interactions'
We have other examples of expressing this complexity visually. In a conceptual mapping of possible interactions between well-being and environment-based interventions, Ruth Garside of Exeter University shows an equally complex picture – closer to a circuit diagram than a single switch.
In an infographic prepared for the UK Cabinet Office, Robin Johnson shows the range of levers available or needed to implement just one specific policy on ‘settled accommodation’ for those in secondary mental health care, of the Labour Government. The mapping shows all possible levels of government, including specialist and regional tiers, regulators, funders, and other significant influencers of policy and practice, through to ‘service providers’ .
In the video on datasets, Grant Shapps shows the results of an analysis conducted on the range of existing local datasets of a multiplicity of agencies where we might, at least in principle, expect to see some difference achieved by interventions to respond to those with the most chronic and entrenched problems.
In other papers in the Library here, we explored the role of social housing in pubic health.
