SEE ALSO activism; advocacy; power; social entrepreneurship; social movements
Historically, public health has played an important role in influencing legislation on sanitation, housing, human rights and working conditions. These actions were also influenced by the desire of government to reduce its own responsibilities and to improve the efficiency of the nation’s workforce. Public health reform was as much due to the discourse of economic production as it was with empowerment and good governance. The period around 1848 was especially pivotal because of a number of key social movements that pursued an agenda of social justice including the socialist and trade union movements in Europe, the anti-slavery and women’s rights movements in the United States and resistance to imperialism in India. Europe saw the revolution in France and in 1848 the first public health act was sanctioned in Britain (Krieger and Birn, 1998).
Social and political reforms such as improved sanitation, improved working and living conditions, improved nutrition and family planning did not come easily. Employers often opposed reforms because they reduced profits. Working-class organization for improved wages and better working conditions was often brutally repressed by elite groups whose interests were challenged. Public health reformers have provided the courage and a direction on issues that may not at the time have been considered to be mainstream, even subversive. The work of Rudolph Virchow, Rose Kushner and Margaret Sanger help to illustrate how reformers have provided the passion behind the public health action.
In 1847, the Prussian province of Silesia was ravaged by a typhoid epidemic. Because the crisis threatened the population of coal miners in the area, and thus the economy, the Prussian government hired a young pathologist, Rudolf Virchow (1821–1902), to investigate the problem. One of the first points he made was that typhoid was only one of several diseases afflicting the coal miners, prime amongst the others being dysentery, measles and tuberculosis. Virchow referred to these diseases as ‘artificial’ to emphasize that, while they had their origin with a particular and naturally occurring bacterium, their epidemic rates in Silesia were made far worse by poor housing, working conditions and lack of sanitation amongst the coal miners. Virchow’s solutions to the typhoid epidemic over the longer term included improved occupational health and safety, better wages, decreased working hours and strong local and regional self-government. Virchow argued for progressive tax reform, removing the burden from the working poor and even suggested hiring temporarily unemployed miners to build roadways making it easier to transport fresh produce during the winter. His views did not fit within the mainstream thinking of ill health and he was promptly fired. On his return to Berlin, Virchow joined others to demonstrate for political changes that he believed were essential for health because to him there was no distinction between being a health professional and a health activist (Taylor and Reiger, 1985).
Rose Kushner (1929–1990) was a 45-year-old American journalist when in 1974 she was diagnosed with breast cancer. The standard procedure at that time was to perform a tumour biopsy and radical mastectomy in a single surgical operation in which muscle tissue and lymph nodes were removed along with the breast. Rose Kushner objected to this very invasive procedure and it took her a long time to find a doctor who would perform a diagnostic biopsy and a modified mastectomy. She was deeply affected by her experiences with breast cancer and embarked on learning more about treatment options. She fought for the right of women to make decisions about their own bodies and openly challenged the medical profession. Kushner established the Breast Cancer Advisory Center to promote patient self-help and in 1979 the National Institutes of Health concluded that radical mastectomy should no longer be the standard treatment for suspected cases of breast cancer and recommended a total simple mastectomy as the primary surgical treatment (Lerner, 2001).
Margaret Sanger (1879–1966) was a key advocate for birth control at a time when it was illegal for any woman, even those that were married, to use these methods. Sanger argued that women would not be fully able to participate in life outside the home until they could control when, and if, they became pregnant. In 1916, Sanger opened a family planning and birth-control clinic in Brooklyn, the first of its kind in the United States, violating laws concerning the dissemination of information for the purposes of birth control. Sanger was arrested and imprisoned where she continued to give lectures to the inmates on hygiene and reproduction. Sanger founded the American Birth Control League in 1921 and in 1923 established the first legal birth-control clinic in the United States. It was not until 1960 that the birth-control pill became available to the general public and in 1966 the birth control was legalized for married couples in the United States (Randall, 2007).
Historically, what has defined a contemporary public health practice has been its willingness to work with others to address the causes of social injustice and health inequalities in society. Public health reforms occur through the prolonged and entwined struggle of organized civil society groups, health professionals, activists and political reformers.
KEY TEXTS
•Crosier, S. (2012) ‘John Snow: The London Cholera Epidemic of 1854’. Center for Spatially Integrated Socially Science. Available at http://www.csiss.org/classics. Accessed 14 May 2012
•Laverack, G. (2013a) Health Activism: Foundations and Strategies (London: Sage)
•Lerner, B. H. (2001) ‘No Shrinking Violet: Rose Kushner and the Rise of Breast Cancer Activism’, Culture and Medicine, 174: pp. 362–365
SEE ALSO advocacy; capacity building; communicable disease; epidemiology; risk factors
Risk communication is an interactive process of exchange of information among individuals, groups and institutions about the nature of risk, and which expresses concern, opinions or reactions to risk messages, or to legal and institutional arrangements (Committee on Risk Perception and Communication, 1989).
Risk communication is viewed as an essential and integral part of risk management. Risk management is a cyclical process with risk communication as a core component which underpins the entire process of identifying hazard, assessing risk, developing, implementing and evaluating policy (Health Protection Network, 2008).
The importance of risk communication has been particularly highlighted since the release of anthrax in the United States in September 2001, the outbreak of severe acute respiratory syndrome in Asia and North America in 2003 and the H1N1 pandemic influenza in 2009. Such public health events have shown that a lack of planning, communication and engagement can make an emergency or disease outbreak even more stressful and potentially dangerous to public health (PREVENT, 2011).
Crisis communication, also known as emergency communication, is organization, analysis, planning, decision-making and assignment of available resources to mitigate, prepare for, respond to and protect property and the environment when an emergency or disaster occurs (O’Hair, 2004). This differs from risk communication which concerns an event that has occurred, whereas crisis communication is a projection of what might occur.
Risk communication is most effective if undertaken in a systematic way and generally starts with the gathering of information on the risk issue of concern. Once the available information has been used to fully identify the hazards, and decide on and assess the appropriate risks, then the preparation and dissemination of this information is required (WHO, 1998). Risk communication has traditionally been interpreted as a top-down process, one in which the collective and individual decision-making is the prerogative of those in authority in public health. New risk-communication approaches have ushered in a shift towards open-ended communication, using language the public understands to transmit messages and that motivates people to participate in the decision-making process. The shift, which began in the 1980s, has occurred due to the development of a new paradigm of risk communication, one which requires partnerships and dialogue between authorities and citizens. New approaches to risk communication also emphasize the requirement for early planning, the establishment of process and procedure and a well-trained multi-sectorial team with different levels of responsibility (Health Protection Network, 2008).
A variety of approaches for risk communication have been developed for the public health sector. Guidelines for risk communication by the US Environmental Protection Agency, for example, involve: accept and involve the public/other consumers as legitimate partners; plan carefully and evaluate your efforts with a focus on your strengths, weaknesses, opportunities and threats; listen to the stakeholders’ specific concerns; be honest, frank and open; coordinate and collaborate with other credible sources; meet the needs of the media; speak clearly and with compassion (Covello and Allen, 1998). This approach actively involves the primary stakeholders and public health service users and people are viewed as an important part of the engagement in the risk-communication process.
Risk communication should be a two-way process. Public health organizations communicate with the public, not to or at them, but through constructive partnerships (Health Protection Network, 2008). A guiding principle for effective risk communication in public health is building, maintaining and, where necessary, restoring public trust in those responsible for managing risk. Only when trust and credibility have been established can other communication objectives, such as protection, education and consensus, be achieved. Trust and credibility, which are demonstrated through empathy and caring, competence and expertise, honesty and openness, will therefore always be essential elements of the risk-communication approach (Reynolds and Crouse-Quinn, 2008).
Effective risk communication aims to encourage a working relationship that develops the public’s understanding of risk, enables them to make informed choices as to how best to protect their own health and that of their families and promotes their ability to collaborate with agencies in identifying solutions to risks and problems (Covello and Allen, 1998).
KEY TEXTS
•Brennan and Gutierrez (2011) Field Guide for Developing a Risk Communication Strategy (Geneva: PAHO/World Health Organization)
•Centers for Disease Control and Prevention (CDC) (2012) Crisis and Emergency Risk Communication. 2012 edn (Atlanta: Centers of Disease Control and Prevention)
•Covello, V. and Allen, F. (1998) Seven Cardinal Rules of Risk Communication (Washington DC: Environmental Protection Agency)
SEE ALSO communicable disease; health; injury; lifestyle; non-communicable disease; prevention paradox; upstream and downstream
Risk factors refer to social, economic or biological status, behaviours or environments and are associated with an increased susceptibility to a specific disease, illness or injury (WHO, 1998).
Understanding the risks to health is key to preventing disease and by quantifying the impact of risk factors on diseases, evidence-based choices can be made about the most effective interventions to improve public health. However, a particular disease is often caused by more than one risk factor, which means that multiple interventions are needed to target each of these risks. For example, the infectious agent mycobacterium tuberculosis is the direct cause of tuberculosis, but overcrowded housing and poor nutrition also increase the risk of infection, which presents multiple paths for preventing the disease. In turn, most risk factors are associated with more than one disease and targeting those factors can reduce multiple causes of disease. For example, reducing tobacco smoking will result in fewer deaths and less disease from lung cancer and chronic respiratory diseases (WHO, 2009).
The leading public health risks are high blood pressure (13% of deaths), tobacco use (9%), high blood glucose (6%), physical inactivity (6%), and overweight and obesity (5%). These risks are responsible for raising the risk of chronic diseases such as heart disease, diabetes and cancers across all income groups. The leading global risks for the burden of disease as measured in disability-adjusted life years (DALYs) are underweight (6% of global DALYs) and unsafe sex (5%), followed by alcohol use (5%) and unsafe water, sanitation and hygiene (4%) (World Health Organization, 2002, 2009a, 2013). The DALY is a measure of overall disease burden expressed as the number of years lost due to ill health, disability or early death. The DALY quantifies the gap between a population’s current health and an ideal situation where everyone lives to old age in full health (World Health Organization, 2009a).
The existence of risk factors – for example, living and working conditions can increase poor health – is unequally distributed and can change over time. Psychosocial risk factors describe individual cognitive or emotional states such as self-esteem which are often reactions to risk conditions and which also influence our desire and ability to create social networks. The stress, for example, created by economic insecurity and structural inequality can become physical pathology. People living in risk conditions experience distress with the unfairness of their situation (their low status on some hierarchy of power or authority, indicated in part by wealth) and internalize this unfairness as aspects of their own failure. This internalization adds to their distress, if not also to their loss of meaning and purpose, with measurable effects on their bodies, or physiological risk factors. This situation is more likely when the dominant social discourse on success is competitiveness, individualism and meritocracy, where people are presumed to succeed or fail purely on the basis of their own ability (Lerner, 1986).
People who live in risk conditions, and internalize this as psychosocial risk factors, are also more likely to have unhealthier lifestyles. This is seen in the associated behavioural risk factors, for example, smoking and alcohol consumption, which can serve as stress-coping rewards. Even if people living in poor and unequal conditions can change their unhealthy behaviours, without any change in their risk conditions, their self-reported health can actually worsen (Blaxter, 2010).
Health behaviours can be distinguished from risk behaviours which are associated with increased susceptibility to a specific cause of ill health. Health behaviours and risk behaviours are often related in clusters in a more complex pattern of behaviours referred to as lifestyles. People caught in the cycle of risk conditions and risk factors usually experience less social support and greater isolation and are often less likely to be active in groups concerned with improving risk conditions in the first place. This then reinforces their sense of isolation and self-blame, reinforcing the experience of disease or a lack of well-being (Laverack, 2014, p. 168).
Public health professionals may begin their work with an individual or group around a physiological, behavioural or psychosocial risk factor, or around a risk condition. Once risk factors have been identified, these can become the entry point or focus for a public health intervention. But health professionals must also identify the risk conditions otherwise they will forever be treating the symptoms and never preventing the cause of the health problem. The task is to locate these disease and behavioural risks in their psychosocial and socio-environmental contexts, for example, powerlessness, poverty and isolation, and to recognize these contexts as independent health risks in their own right.
KEY TEXTS
•World Health Organization (2002) – ‘Reducing Risks, Promoting Healthy Life’. The World Health Report (Geneva: World Health Organization)
•World Health Organization (2008) ‘Closing the Gap in a Generation: Commission on Social Determinants of Health’. Final Report (Geneva: World Health Organization). Available at www.who.int/social_determinants. Accessed 6 May 2012
•World Health Organization (2009a) Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks (Geneva: World Health Organization)