Editorial in Canadian Journal of Public Health, 2000, 91 (1), 9-12.
Putting the Population into Population Health
Dennis Raphael,
Department of Public Health Sciences
University of Toronto
Toba Bryant
Faculty of Social Work
University of Toronto
Correspondence to: Dr. Dennis Raphael, Department of Public Health Sciences,
University of Toronto, McMurrich Building, Toronto, Ontario, M5S 1A8. Tel:
(416) 978-7567; fax: (416) 978-2087; e-mail: [log in to unmask]
Putting the Population into Population Health
Population health is challenging health promotion as the dominant discourse
in Canadian health policy. Its influence is seen in the renaming of government
branches and departments and the numerous documents addressing population
health.1 The impetus for this challenge has come from work by the Population
Health Group of the Canadian Institute for Advanced Research (CIAR), an
international group consisting primarily of health economists and
epidemiologists.1,2 This commentary examines the implications for health
research and action of the CIAR vision of health as presented in the key
document, Why are Some People Healthy and Others Not?3
Population Health is Firmly Rooted in the Epidemiological Tradition
The CIAR definition of health owes nothing to WHO concepts: "For the most
part we simply assume that health is the absence of illness."4, p.24 Similarly,
the CIAR inquiry into determinants of health emphasizes exposures to
environmental stimuli, identification of cause and effect relationships, and
methods limited to experimental designs and quantitative data. It has been
argued that:
There is a growing realization that traditional logical positivist
approaches to health promotion research and evaluation no longer
provide the right questions (or indeed answers) for many health
promotion interventions.5,p.1
In this critique, biomedical approaches are unable to consider lived
experiences of people, a form of knowledge essential to understanding the
origins of health and health-related behaviours.6-8
Population Health Lacks An Explicit Values Base
All health-related research and practice involve values.9,10 This is not
problematic; what is problematic is not making explicit the values underlying
an approach.11 The CIAR approach ignores issues of participation, equity,
community, collaboration, and social justice.12 The result is a reliance on
large-scale data collection surveys that do little to enable or empower
individuals. Indeed, biomedical approaches may reflect conservative values that
serve the status quo.9
Population Health Neglects Political and Sociological Issues
The CIAR vision offers no theory of society.13 It neglects how health
determinants are created and maintained by powerful economic and social forces.
Analysis of the causes of economic inequality and poverty, for example, are not
high on the population health agenda..14 An approach that ignores these forces
is unlikely to be useful for identifying and acting upon the inequities in
health seen among Canadians.
Population Health Leads to Context Stripping
Context stripping occurs when the health of individuals is considered
removed from its community and societal context. Within the health field,
context stripping occurs when studies attempt to identify general determinants
of health across populations. To illustrate, analysis of how societal and
community structures influence individuals' sense of control and well-being
gives way to study of personal coping devices and the biological mechanisms by
which stressors become translated into illness and disease. Critical analysis
of society give way to studies focused on individual-level variables.
Population Health Provides a Model of Research, Not of Social Change
CIAR does not provide a model of change, and there is a hesitancy among its
adherents to suggest health-enhancing policy responses: In 1994, Evans wrote:
We cannot offer a detailed prescription of what is to be done,4,p.24 a
sentiment he repeated five years later.15 Unless research aims to influence,
rather than merely describe the determinants of health, it is unlikely to
improve health. In contrast, the health promotion tradition emphasizes
strengthening communities, building supportive environments and promoting
healthy public policy as means of improving health.16,17
Population Health Minimizes the Importance of Poverty
CIAR writings tend to minimize the problem of poverty -- its causes,
consequences, and solutions. In Why Are Some People Healthy and Others Not?,
Evans stated: Indeed, a focus on poverty can block progress in understanding,
because it can be dismissive of further questions.4,p.5 Poverty is one of the
strongest determinants of health,18-21 but from the CIAR perspective, focus on
poverty -- and working to alleviate it -- distracts from "further questions."
Studying and improving the lives of those in poverty should be a priority for
health researchers.
Population Health Exhibits a Top-Down Emphasis on Expert Knowledge
The CIAR vision of health is not one of working with people in communities
to understand and influence the determinants of health.22 The CIAR denial of
the validity of alternate forms of knowledge, the importance of community
participation, and the value of enabling and empowering people has been ignored
as "population health" has been embraced. In reality, traditional biomedical
approaches to health research can work against health.23
Putting the Population Back into Population Health
Efforts to improve health should be based on clear statements of values and
principles. The validity of various forms of knowledge must be accepted through
a commitment to pluralism in methods. Analysis of determinants should occur at
societal, community, and individual levels, and the political dimension of
health is acknowledged. Finally, providing information for change is a key
element in health research.
These ideas are consistent with developments in health promotion. Such ideas
have seen application in innovative and community-based Canadian efforts such
as the Pathways to Building Healthy Communities in Eastern Nova Scotia and the
Community Quality of Life projects in Toronto.24,25 There, community members
identify and act upon determinants of health by drawing upon their experiences
and developing critical understandings of how societies operate. Armed with
these understandings, they identify policy issues that become the basis of
efforts to influence government actions.26
Such approaches are guided by values of equity, participation, and social
justice; concepts absent in CIAR thinking.27 Without such commitments, the CIAR
vision of population health is unlikely to enhance the health of Canadians. It
certainly will not enhance the health of Canadians most in need; those living
in poverty. Before population health replaces health promotion as health
policy, serious thought must be given to the implications of such a shift on
efforts to maintain and enhance the health of Canadians.28
References
1. Robertson A. Shifting discourses on health in Canada: From health
promotion to population health. Health Promotion International,
1998;13:155-166.
2. Wong D. Paradigms Lost: Examining the Impact of a Shift from Health
Promotion to Population Health on HIV/AIDS Policy and Program in Canada.
Ottawa: Canadian AIDS Society, 1997.
3. Evans RG, Barer M, & Marmor TR. Why Are Some People Healthy and Others
Not?: the Determinants of Health of Populations. New York: Aldine de Gruyter,
1994.
4. Evans RG. Introduction. In RG Evans, M Barer, TR Marmor (eds), Why Are
Some People Healthy and Others Not?: the Determinants of Health of Populations,
pps. 3-26. New York: Aldine de Gruyter, 1995.
5. MacDonald G, Davies JK. Reflection and vision: Proving and improving
the promotion of health. In J. Davies & G. Macdonald (eds), Quality, Evidence,
and Effectiveness in Health Promotion: Striving for Certainties, pps. 5-18.
London UK: Routledge, 1998.
6. Lincoln Y. Sympathetic connections between qualitative methods and
health research. Qualitative Health Research, 1994;2:375-391.
7. Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park CA: Sage,1985.
8. Williams G, Popay J. Social science and the future of population
health. In L Jones & M Sidell (eds), The Challenge of Promoting Health, pps.
260-273. London, UK: The Open University, 1997.
9. Seedhouse D. Health Promotion: Philosophy, Prejudice and Practice. New
York: Wiley,1997.
10. Tesh S. Hidden Arguments: Political Ideology and Disease Prevention
Policy. Rutgers University Press, New Brunswick, NJ and London: 1990.
11. Collins T. Models of health: pervasive, persuasive, and politically
charged. Health Promotion International, 1995;10:317-324.
12. Minkler M. Community Organizing and Community Building for Health. New
Brunswick, NJ: Rutgers University Press, 1997.
13. Poland B, Coburn D, Robertson A, Eakin J. Wealth, equity, and health
care: a critique of a population health perspective on the determinants of
health. Social Science and Medicine, 1998;46:785-798.
14. Coburn D. Income inequality, lowered social cohesion, and the poorer
health status of populations: The role of neo-liberalism. Social Science and
Medicine, in press.
15. Evans RG. Closing Presentation at the conference Population Health
Perspectives: Making Research Work, October 7, 1999, Winnipeg, Manitoba.
16. Canadian Public Health Association. Action Statement on Health
Promotion, 1996. Ottawa: Author. On-line at
www.cpha/cpha.docs/ActionStatement.eng.html.
17. World Health Organization. Ottawa Charter on Health Promotion. Geneva:
1986.
18. Raphael D. From increasing poverty to societal disintegration: How
economic inequality affects the health of individuals and communities. Chapter
to appear in H. Armstrong, P. Armstrong, & D. Coburn (eds), The Political
Economy of Health and Health Care in Canada. Toronto: Oxford University Press,
1999.
19. Canadian Institute on Children's Health. The Health of Canada's
Children: A CICH profile. Ottawa: 1994.
20. Lessard, R. Social Inequalities in Health: Annual Report of the Health
of the Population. Montreal: Direction De La Sante Publique, 1997.
21. Reutter L. Poverty and health: Implications for public health,
Canadian Journal of Public Health, 1995;86, 149-151.
22. Raeburn J, Rootman I. People-Centred Health Promotion. New York: Wiley,
1997.
23. Davies JK, Macdonald G. Beyond uncertainty: Leading health promotion
into the twenty-first century. In JK Davies & G Macdonald (eds.) Quality,
Evidence, and Effectiveness in Health Promotion: Striving for Certainties, pps.
208-216. London UK: Routledge, 1998.
24. PATH Project. Pathways to Building Healthy Communities in Eastern Nova
Scotia: the Path Project Resource.Antigonish NS: People Assessing Their Health,
Suite 204 Kirk Place, 219 Main Street, Antigonish, N.S. B2G 2C1, 1997.
25. Raphael D, Steinmetz, B, Renwick, R. et al. The community quality of
life project: A health promotion approach to understanding communities. Health
Promotion International, 1999;14:197-207.
26. Bryant T. Critical approaches to knowledge development in public
health: a new model of policy change. Paper presented at the session, Policy
Futures at the 50th Annual Meeting of the Ontario Public Health Association,
Toronto, November 17, 1999.
27. Tones K. The anatomy and ideology of health promotion; Empowerment in
practice. In A Scriven & J Orme (eds). Health Promotion: Professional
Perspectives, pps. 9-21. London UK: MacMillan Press, 1996.
28. Raphael D, Bryant T. Is population health a threat to the health of
Canadians? Paper submitted for publication, 2000.
Visit our Web Sites for information and reports from all of our Quality of Life
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http://www.utoronto.ca/qol http://www.utoronto.ca/seniors
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In the early hours I read in the paper of epoch-making projects
On the part of pope and sovereigns, bankers and oil barons.
With my other eye I watch
The pot with the water for my tea
The way it clouds and starts to bubble and clears again
And overflowing the pot quenches the fire.
-- Bertolt Brecht
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Dennis Raphael, Ph.D.
Associate Professor
Department of Public Health Sciences
Graduate Department of Community Health
University of Toronto
McMurrich Building, Room 308
Toronto, Ontario, CANADA M5S 1A8
voice: (416) 978-7567
fax: (416) 978-2087
e-mail: [log in to unmask]
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