Public health or political health?

John Lunstroth

To triangulate a meaning for public health, three "public" entities that can be said to be healthy have to be identified: 1) patients, as reflected and exemplified in the doctor patient relationship; 2) populations described by epidemiologists (orthodox public health); and 3) political collectives (states, etc.). The boundary between 2 and 3 is ambiguous, and in my opinion, the source of much difficulty in pinning down a definition of public health, since the idea of a "healthy" political collective is ancient. Is the social determinants movement a political movement?

For the purposes of this blog I assume there is a conceptual break at some point, that the "health" of the populations studied by epidemiologists is not the same "health" that is postulated by political scientists. It is not the same because it is described in different terms. Epidemiological health is related primarily to medical health, whereas political health is measured in philosophical, demographic and other measures, such as whether the population can be said to be flourishing. It is wholistic, whereas epidemiological measures are in a relevant way reductionistic. Political health is demographic, whereas public health is epidemiologic. Epidemiology is a species of demography.

There is another limitation and prioritization that is important and involves the institutional distinctions between 1 and 2. Public health is in some ways a residual category (re)created by the medical profession as it, the medical profession, assumed the mantle of its social authority. Public health became all the health related disciplines that were not profitable or glamorous in some way. That is why, at least until the bioterrorism funding explosion following 9/11, public health as an institution was perpetually underfunded and considered the poor step-sister or hand-maiden of medicine. Its chiefs were all doctors, and public health students and practitioners aspired, in some cases, to be doctor-like, to have that utopian level of social authority.

The foregoing describes some features of the institution of public health as seen in and about its schools. However, where the rubber hit the road, in the state legislatures, where public health is primarily regulated, public health looked a little different. All health matters in the legislatures, whether uni- or bicameral, were first considered in the public health committees. They have different names, but their function is the same. From a regulators perspective all regulation of health construed as a medical matter is focused through one committee. Of course, insurance, and other institutions that bear on the health economy may be dealt with primarily in other committees.

From a legal perspective Larry Gostin got it right in his book Public Health Law: Power, Duty, Restraint. Public health includes medicine, and all kinds of other policy issues that have to do with medical (including mental) health. That is, as a legal matter, the social authority of medicine is a nullity. Medicine is simply another profession to regulate, another group of lobbyists to deal with, another set of interests to consider.

Public health is a comprehensive concept that ranges from biochemical models of disease to social determinants, from doctors and other health workers to policy-makers. It is everything to do with health that is not definable as political health. Public health is part of political health, but political health includes norms with which to evaluate political structures, e.g., constitutional design (and theory); fit between the government and the constitution; human rights; international law; and other concepts.