Chapter 1: Understanding health: Definitions and perspectives
Health: the clockwork model of medicine
Health defined as the body operating efficiently like a machine, any breakdowns in the body
system mean that it is not healthy (in the clockwork model of medicine)
The clockwork model is the biomedical view of health; isolation (of the body parts/ no
interconnection between environment and the individual), labelling and systematic classification of
disease; disease is not considered within the context of the lives op people with disease, so
predominantly labelling
Health as the absence of illness (clockwork model)
Biomedicine:
-disease a set of signs and symptoms and medically diagnosed pathological abnormalities;
objective
-illness is about how an individual experiences the disease; culturally specific with social, moral
and psychological aspects
Limitations of the clockwork model:
Too mechanistic, ignoring social, psychological and spiritual aspects
When the body is not diseased it must be healthy
Idea of ‘normal’ functioning
Mind-body dichotomy and no emphasis on how mental health might affect physical health
Medical definitions of health reflect its culture (homosexuality, HIV, hysteria)
In the biomedical model has been critiqued for extendinf the definition of disease – this is
linked to pharmaceutical companies seeking new markets – so has the risk factor obesity
become a disease now
Health complete state of physical, mental and social well-being, and not merely the absence of
disease or infirmity
A recent focus on mental health has led to definitions that go beyond the concentration on physical
factors.
Measuring health
Measuring well-being isn’t easy. It is easier to measure the absence of disease. The measures of the
psoitice state of well-being are poor in terms of reliability, validity and techniques of analysis.
Health: ordinary people’s perspectives
Ordinary people define health more in the new terms rather than biomedical terms:
Health is not being ill
It is a necessary prerequisite for life’s functions
Sense of well-being expressed in physical and mental terms
Public and private accounts
Public accounts people present view of health that conformed tot he biomedical view;
moral component and divided causes of illness into those that were or were not the
individual’s fault
, Private account based on their own experiences and of the people they knew
Health in cultural and economic context
The interpretations of health reflect the cultural and economic context op people’s lives. Health
fulfiles different functions for different people:
Health was seen by some as self-control
Middle-class professional people view
Health is something to be achieved through healthy behavior
Fits with moders individualism
Thin personal succes, fat moral failure (expression of dominant values)
Health was seen by some as a release mechanism
Feeling good, distinct from following rules from medical authority
Life is seen as a series of pressures, anxiety, frustration etc where there is no time for
health-promoting activity
Spiritual factors
Lay definitions of health may include spiritual dimension, belief system related to health and disease.
It illustrates that health is not something that can be neatly defined in static categories.
Health: critical perspective
Critical perspectives on health those that seek to explain the purposes that are achieved through
particular means of defining health. They are critical because they look beneath the surface
apperance of a concept or phenomenon and offer an explanation as to why it is this way.
Critical perspectives on health:
Marxist analytical framework
health is defined in such a way by the dominant forces in capitalist society that it becomes a
defining and controlling mechanism
capitalist societies are structured in such a way that they produce illness (maximising profit
intead of health of people) overtime, shifts, monotomy, chemicals
people are forces of production
postmodern perspective
health maintance has become a important aspect of being a ‘good’citizen
in Western society pursuing health is both a right and obligation
political economy perspective
criticises the individualistic definition of health (individualism and perosnal responsibility)
health is seen int erms of its distribution in society (focuses on inequities in health status
especially resulting from claas differences and in terms of structural factors such as:
environment, housing and working conditions
collective health
Health as ‘outcomes’
Health outcomes in the current health system discourse refer to accountability mechanisms and
measures of the effectiveness of particular interventions (the term dosn’t refer to a broader project
of improving helath in a social sense). Only a randomized controlled design can be used to study
clinical interventions (clockwork model). Health in clinical trials is defined as an absence of a
particular ailment the clinical intervention is supposed to cure. This represents more the health
,service provider rather than user perspective ( so crucial factors for personal functioning may not be
covered). The focus on health outcomes demands evidence that it impacts on population health
status rather that evidence concerning a broader apsiration for well-being of society as a whole.
Economic measures of health are used by the WHO whichillustrates the focus on economic
productivity. They use disability adjusted years (DALYS) to determine the value of health
intervention. DALYS are claculated by assigning values to years of life lost at different ages. Very
young, disabled and elderly people get less value in treatment of sickness than people in their early
twenties.
Health and place: defining collective health
‘Healthy city’ project attemps to move beyond a deficit model (how many unemplouyed) to one that
captures more dynamic and positive aspects of health (e.g the availibility of community meeting
places, high health status etc). The idea is that the collective structures of a community form the
crucial determinants of a population health status. Defining health in collective terms is useful tot he
new public health because it appears more likely to focus on positive definitions of health and on
structurally rather than individually driven factors that affect peoples health.
‘Ecosystem health’ healthy ecosystems are characterised by diveristy, vigour, effective internal
organization and resiliance; this approach integrates the overall consideratrion of the environment
and interdependence of systems with the overall ecosystem; holism; health of people is dependent
on the health of the biospehere
Population versus individual health: the heart of public health
Public health focus lies on populations rather than individuals. Treating diseased individuals does not
have much impact on population health levels overall, but changing a risk factor (often clinically
insignificant) across the whole population by just a small amount can have great impact on the
incidence of a disease. Good example would be seat belts: if everyone in the population wears a
seatbelt while driving, the burden of mortality from road accidents will reduce. However, very few of
the individuals doing so will benefit directly-only the few who are involved in an accident.
Example individual vs population:
smoking
individual: how can we stop individuals smoking?
Population: how can we change the social and economic environment so it discourages
smoking?
Diabetes
Individual: how do we encourage people with diabetes tos elf-manage their disease?
Population: how do we alter food supply systems so they prevent rates of diabetes going up?
Individuals are strongly influenced by social norms and rules: proportion of people with high risk
factors is a reflection of the society’s average behaviors (proportion hevay drinkers is a function of
society average alcohol consumption).
Chapter 2: A history of public health
History and development of public health in Australia:
, 1. Era of indigenous control (40000 years ago)
Strong links with land, traditional healers, emphasis on spirituality and integration of
health and life, number of illnesses in these times (prior to colonisation) are mild
compared to the epidemics after colonisation
Typical interventions: practice part of accepted culture handed on through oral tradition
2. Colonial era (from white invasion until 1890s)
Control of infectious disease main aim (public health developed in direct response to
disease threats). Strongly influenced british practices. Emphasis on sanitary measures,
public health legislation, food and hygiene reforms
Typical interventions: quarantine acts, public health acts in colonies, provision of clean
water and sanitation
Theories of disease causation:
‘miasma’ theory belief that disease resulted from inhaling bad smells from the
filth led to cleaning up cities
‘germ’ or contagion theory pathogens are responsible for disease led to
quarantining
Supernatural theories like god’s wrath etc
Two broad traditions of public health activism(19 th century Britain and Australian):
Desire to control disease and the poor who were believed to cause it (Poor Law
Amendment Act 1834) poor had less rights, ‘blame the victim)
More progressive view, where people try to improve
the life conditions of the poor to stop the disease
McKeown and Szreter: Tuberculosis:
Mckeown (1979) believed that improved living
(nutrition) standards have had a significant impact on
mortality while the medical interventions not so much.
Mortality was declining before effective medical
interventions were available.
Szreter (1988) re-analysed McKeowns’ data and
concluded that it wasn’t the improved conditions, but the public health movement
and local interventions through the ministry of health was the most relevant factor.
He argues that it’s not the economic growth that have caused the mortality to
decline but what people do with it. (economic growth doesn’t necessarily lead to to
improvements in health status)
They both agree that the medical interventions played only a small part in the
extension of life expectancy in the 19 th century
3. Nation-building era (1890-1940)
State action to improve the health of the nation, seeking to ímprove the race’ (eugenics),
health linked to ideas of vitality, efficiency, purity and virtue
Traditional interventions: formation of Common Wealth Department of Health,
organized exercise programs to improve national physique, medical inspection of
children, hygiene advice to the population
Public helath was growing state intervention: education, social services, regulation of
industry and labour relations.
Maintaining health was seen as a citizen duty, though nutrition, education, Individual
rather than collective responsibility
Two main strains of thought in nation-building era:
