The future of public health: the lessons of modernism

The paper by Hanlon et al. sends a signal to our profession about the need to rethink the nature of our discipline and our training in the face of global, meteorological, cultural and economic developments. I agree with the general tenor of the argument and suggest that we already have to hand the conceptual apparatus to do this. The idea of modernism is critical. Two concepts associated with modernism are particularly germane to Hanlon et al.’s thesis—the creation of the biological and psychological individual as the dominant unit of analyses in the medical and social sciences (as well as for the purposes of political administration) and the tendency of all scientific disciplines to continually fragment into sub-disciples with narrower and narrower foci of interest. Contemporary public health manifests both tendencies. Although public health is a population science, much of its conceptual apparatus treats populations as aggregates of individuals rather than as units of analyses in their own right. The corollary is a pathogenic approach culminating in for example very close attention to various risk factors or individually focussed behaviour change strategies. The sciences that make up our discipline, from medical microbiology in health protection to health psychology in behaviour change to take but two examples, speak little to each other and across the compass of public health subdisciplinary specialization proceeds apace. This becomes the more obvious when we take the kind of holistic global approach advocated by Hanlon et al. The big picture will forever be out of our grasp if we stay inside our internal sub-disciplinary silos. One example illustrates the point—the wider determinants of health and their impact on patterns of health inequalities. To take effective action requires acting on the causal pathways from the wider determinants to the individual and social patterns of mortality and morbidity. This requires the elaboration of a causal pathway that begins with the socio-economic, geo-political and meteorological determinants and plotting them to individual and collective health outcomes. This requires transcending disciplines as diverse as climatology, sociology, through economics and politics to psychology and biomedicine. This is difficult to do because of the dominance of the individual in our models and trans-disciplinary work takes most of us outside of our comfort zone to places where we are forced to confront the fact that there are vast swathes of this fundamental public health problem, which our training has given us little and about which we know next to nothing. The big picture requires that we be prepared to generate genuinely trans-disciplinary questions, that those questions are answered using a variety of disciplinary perspectives in an integrated fashion and acknowledging the different levels of analysis involved in what we do, without privileging any single approach or method. So I endorse the argument proposed by Hanlon et al. and hope that it will start a debate in the pages of this journal about the paradigms we use in public health and what a public health approach will look like in the future.