Definitions in public health
Use of definitions in PH
Before any study is conducted, before any intervention is designed, a condition to be targeted needs to
be defined. We need to agree on what counts as a particular health condition and how we will
differentiate it from other things.
Uncertainties in definitions
Trying to decide where the boundaries of a particular health condition lay and to distinguish normal
from pathological, we face much more uncertainty than some might expect.
Problems of definitions
Human-made definitions and classifications create the hardest realities--> channel our attention and
segment the world for us and if we're not aware of the limits of classification we may overlook
something
Classifications simplify our world to allow strategies , make things doable BUT very important to think
beyond them
Examples
ADHD in children
How is ADHD defined
- Behavioral problem deviating from normal behavior--> what is normal?
- School and teachers play a role in detecting ADHD
- ADHD is individual for each child--> many factors
How was the definition established
- First the director of psychiatric hospital for children integrated psychoanalytic, mental and
behaviorist principles
- WW2--> mental health as a matter of national security
- Distribution of methylphenidate to calm children
Consequences
- Teachers are the one diagnosing--> frustrated and advise Ritalin rather than pedagogical
resources
- Medicalisation of education
- Misdiagnosis--> line between normal and abnormal?
Autism
What's autism?
- Mental disorder in infants and children
- Current def: autism refers to a broad range of conditions chracterized by challenges with social
skilles, repetitive behaviors, speech and nonverbal communication
How was the definition established
- 1911-20: linked to schizophrenia and psychotic behavior, hallucinations
- 1940's: children not engaged with external environment
- 1959: desinstitutionalization of mentally retarded homes
- 1960s: psychiatric epidemiology--> determining causes
- Research: detaching it from hallucination--> communication disorder and developmental
disorder
Consequences
- Relying on only one definitions--> misinterpreting and misdiagnosis bc different dimensions of
autism
Cholesterol levels among adults
What is normal/abnormal/pathological level of cholesterol
- Changed from 300mg/dL-->280-->250-->200 and now <150 is optimal
How was the definition established
- Collection of data on cholesterol in the 50s
- National institution of health-NCEP international cholesterol education programm
- Pharmaceutical companies and physicians linked to those companies and NIH
Consequences
- According to the new optimal level most people are unhealthy
- Higher medicalisation of society
- Higher profits for pharmaceutical companies
,Measuring isn't innocent
Use of metrics in Public Health
They are used to establish magnitude and location of health problems, make inequalities visible, guide
action, and evaluate effectiveness of interventions. Public health metrics are convenient because they
enable comparisons between vastly different settings and attractive because they look reliable and
objective
Limitations of Public Health metrics
- Not a straightforward task to quantify human suffering, count years of life lost or conceptualize
quality of life.
- Disregarding structural conditions behind health problems, hiding uncertainty behind layers of
numbers, and rendering certain "aspects of life invisible
- Life expectancy used to tell us about state of health in country but it is linked with social-->
income, government, equality to produce good or bad health
Ex: collapse USSR --> drop in life expectancy has to do with social-->novel situation,
disorientation, expectations put on men (breadwinner)
Ex: tuberculosis in Russia--> societal conditions can facilitate it's spreading , who has access to
treatment, social protection
Measuring isn't innocent
Seems objective, value free, clear cut
BUT
Different definitions: here what counts
as murder?--> statistics change based
on the definition
Behind this map: value based work,
human made definitions/
classifications create the hardest
realities
Examples
Maternal mortality ratio
Creation of the metric, by whom and why
- Gap in maternal mortality in wealthy nations and poorer nations is greater than any other health
indicator
- Created for research purposes and to reduce it as part of millenium development goals
- Created by the WHO and IHME publications
How is it calculated
- Ratio of maternal death total live births
- Ideally one would count every maternal death and every live birth to produce ratio
- MMR=maternal deaths/live births *100'000
- Other factors not considered: health issues, deaths in prison
How is the data collected and consequences of this
- Malawi: estimated as a proportion because detahs of reproductive-age women are generally
underreported
- Creates issues with registering/lack of data
- What counts as a maternal death isn't clear
- Difficult to know the reason of death
- Some factors cannot be translated in numbers
- Numbers convert people in abstractions
How is it being used, who supports it, why?
- Indicator of gender or economic inequalities
, - Indicator of health system overall functioning
- Supported by politicians (health is a political issue), advocates, researchers (need data)
QALY
Creation of the metric, by whom and why
- Not clear how it was created because history written by non-historians
- Term QALY first used in the late 60s by US and Canadian article
- Emerged bc need to analyse cost-effectiveness after economic shock in UK
- Measuring QoL and healthiness
- Creted through negotiations btw clinicians and economists
How is it calculated
- Measure of the state opf health of a person or group in which benefits in terms of length of life
are adjusted to reflect the quality
- Brings together morbidity and mortality in a single ratio to evaluate the outcome of health
interventions
How is it being used, who supports it and why?
- Used by economists and health care managers to ensure viability of healthcare systems by
calculating the cost effectiveness of treatment
- Central to healthcare decison-making
Consequences
- Values one's life over another --> economic value of life
- Overly utilitarian
DALY
Creation of the metric, by whom and why
- Conceptualized in work carried out with the WHO and World Bank--> Global Burden of Disease
Study
- Created in the 1990s
- 1 DALY= 1 year of lost healthy life
- Purpose: indicator of disease burden resulting from diability and early death
How is it calculated
- Sum of years of life lost(YLL) due to premature mortality in populations and years lost due to
disability (YLD) for people living with the health condition
- YLL: number of deaths multiplied by standard life expectancy at age of death
- YLD: number of incident cases multiplied with disability weight multiplied by average duration of
the case until remission
How is it being used, who supports it and why?
- Maximizing productivity
- Cost-efficiency analysis --> achieving value for money in health spending
- Used in social circumstances or in reserach to estimate the relative value of competing health
interventions
, Responsive interventions and what stays beyond calculations
Public Health interventions
- After defining and measuring certain health conditions, public health professionals need to make
decisions and develop health interventions to address problems associated with these health
conditions
Ex: lung cancer defined to be caused by intensive smoking and calculated to be prevalent
among middle-aged man living in urban settings-->develop an intervention targeting the
smoking habits of this population group.
Limitations
- Health definitions and health metrics never simply neutral but reflect social, political and
economic contexts--> may overlook or even silence other types evidence that could lead to
alternative public health knowledge and interventions.
Public Health interventions have multiple unexpected impacts
Ex: Universal access to AIDS therapies in Brazil= first high-income country that instituted access to
AIDS therapy (since end of 1990's)--> mortality fell down // success
BUT beyond statistics programm created new inequalities and new underclass of people left behind-
selective provision of therapy so if you're traceable and have stable home/ life --> homeless, drug
addicts left out
Pharmaceuticalised so other aspects left out--> poor people can't afford good nutrition or other
medications
Whole group who need additional support left out --> dichotomy ( availability of medicine vs availibility
of care)
Examples
Health care standard and the politics of singularity
What aspects and who's voices were not part of the prevailing PH knowledge
- Singularity// patient disregarded
- Disregards combinations of variables (profession, family, age)
- Common interpretation //generalizytion of all Alzheimers sufferers
How is evidence understood, defined and calculated
- Patients and their perception of outcomes of medicalization --> surveys
- Used a QALY
PH consequences of exclusion and inclusion
- Exclusion leads to not everybody receiving medication
- Exclusion prevents getting entangled with the interest of particular groups so they don't get
sucked into politocs of singularities
- Not every variable is accounted for while providing care
- Relationship btw generalization and singularization is dynamic --> case stories are resources for
that
Polycystic ovary syndrome
What aspects and whose voices were not part of the prevailing PH knowledge
- Race: ghost variable in science
- Hirsutism varies by race
- High levels of androgens could lead to hirsutism
- Link btw testosterone and race
How evidence is understood, defined and calculated?
- Claims on racial variation in hirsutism
- Lack of reserach
PH consequences of exclusion and inclusion
- Exclusion of race --> PCOS risk factor for other health conditions
- Incclusion of race--> impact on PCOS prevalence and PH intervention
Depression in men
