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the community want from us. They must set the principles. They must be encouraged to âlay siegeâ to the public health movement. It is then our prime task as public health specialists to help them articulate the value base on which they want public health founded. Consultation must involve listening. It is not enough for us to talk to them. We must ask, listen and act on the responses. My challenges to my colleagues who are being asked to respond to this short note, and to readers more generally, are: How can we as public health practitioners help the citizenry âlay siegeâ to the institution that is public health? How can we help to provide the environment to allow the capacity for autonomy of the community to grow? In turn, how can we then best assist the community to exercise genuine choice over what they want from public health? Finally, how can we ourselves learn to listen? Reference 1. Habermas J. Interview on questions of political theory. In: A Berlin Republic: Writings on Germany. By Jurgen Habermas, Steven Rendell and Peter Uwe Hohendahl. University of Nebraska Press; 1997. Under siege! Stephen Leeder Faculty of Medicine, University of Sydney, New South Wales The Oxford dictionary offers many definitions of the word âvalueâ, but the one pertaining to ethics is the most relevant to this debate: âthat which is worthy of esteem for its own sake; that which has intrinsic worthâ. In relating values to public health, Gavin Mooney first questions whether âhealth maximisationâ is an âuntested assumptionâ in the objective of public health, and whether it is the values of public health professionals that drive efforts in this direction. My answer to that is, yes and no. Second, he is concerned that public health professionals risk becoming elitist zealots, obsessed with quantification (a disease from which he considers clinical medicine currently suffers) to the exclusion of âwhat is important.â Where does the public health professional fit? After Mooneyâs critique I am unclear who, if anyone, remains a professional of virtue! The epidemiologist and neo-classical economist stand criticised for their obsession with quantification and evidence, and for an aura of being value-free; the health advocates for their zealotry; and policy developers for their preoccupation with levels of evidence and for accepting priorities set by themselves and their funders. I do not recognise much either of myself or of my colleagues in Mooneyâs public health roguesâ gallery. I regard myself as a public health professional who enjoys excellence when, rarely, I find it. I frequently make mistakes that I recognise and sometimes I learn from them. I believe the public has paid for my education and training, and gives me a handsome salary from their taxes with a specific goal in mind â that I contribute to the improvement and maintenance of the publicâs health through the application with my colleagues and the community of the professional skills that I have acquired. Those skills and insights convey some authority that I regard as legitimate. But, I do not 2000 VOL. 24 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Editorials exclude the possibility of renegotiating public expectations of me from time to time. I consider myself capable of contributing to the achievement of social justice and I would do this through epidemiological insight with due reference to evidence in the struggle against erroneous, historically inaccurate policy and those professional practices that are dangerous or useless. Given the above, I guess I am part of the problem rather than the solution, as Mooney sees it. Responding to his call, the citizenry will shortly lay siege against me! Should I follow the example of Andreas Vesalius of Padua in 1542?1 He developed blood-going-round-the-body diagrams based on dissection and deduction, but found that he had offended prevailing community values. So he burnt his books and took himself to Rome, and then Spain, where he specialised in diseases of the privately insured. By contrast, Michael Sevetus in Spain in 1553 would not give up his conclusions about the circulation of the blood. This evidencebased medicine offended John Calvin and others as an insult to the Holy Trinity and so Sevetus burned. Thatâs the risk. measles, etc, are surely human rights, and a responsibility of the wider community and public health practitioners. They should exist without awaiting consultation. Decisions about health priorities should and generally must include consultation, but at the same time, ideology should not be an excuse for doing nothing. Both quantitative methods and EBHC are intuitively âgood thingsâ but neither, on its own, is enough. In epidemiological parlance, necessary but not sufficient. Should we, for instance, have waited for the highest level of epidemiological evidence before stopping the prescription of thalidomide to pregnant women? We perhaps need some way of considering evidence that equals compassion + common sense + scientific evidence. We donât need to throw out the need for evidence but rather to consider what is evidence, and not restrict our answers to a probabilistic paradigm of public health. Solutions to Mooneyâs challenges require us, first, to open our thinking to different solutions, not just those that fit neatly into our prior assumptions. This includes broadening of our concepts of evidence. Second, we must consider how we like to be dealt with. Most of us do not enjoy pity, or strangers advising or choosing our solutions unless we ask. We can learn much from our own human reactions. Finally, we must be careful not to let ideology preclude human compassion and doing what we can for our fellow inhabitants on this earth. Reference 1. Jennings G. Sick as: bloody moments in the history of medicine Roland Harvey Books, Victoria; 2000. Letâs change the bath water but keep the baby! Aileen J. Plant Department of Public Health, University of Western Australia Hear my song Penelope Hawe Department of Public Health and Community Medicine, University of Sydney, New South Wales Pursuing social justice, Gavin Mooney challenges how public health priorities are decided, as well as the over-emphasis of quantitative methods and evidence based-health care (EBHC). I was captivated by his article and transported back to an attitude-altering moment when the late Fred Hollows lectured my MPH class. He asked us what were the most important health issues for the Aboriginal community in Town X. I, unlike my classmates, and after many sleepless nights looking after the sick in Town X, knew! Good treatment for pneumonia, diarrhoea and other infections, and fewer children, so that those that were alive would have enough food and medicines. Fred also thought he knew: better eye health. But Fred, unlike me, had then taken the trouble to ask. The local community said their top priority was the number of women who could not have the number of children they wanted, i.e both primary and secondary infertility. The preoccupation with health and illness prevention is a predominantly middle class activity. This is not surprising; if basic requirements such as food, shelter, and physical safety are not met, it is hardly likely that people are worrying about their cholesterol levels. Once basic needs are met, however, many people want to live longer and healthier lives. These two perspectives provide an inevitable tension. If you are preoccupied with obtaining the basics, such as the recent floodrefugees are in Mozambique, the health outcome you are likely to seek is survival of yourself and your family. Basic medicines, treatment for the inevitable diarrhoeal diseases, immunisation against 2000 VOL. 24 NO. 2 By arguing that the community must âlay siegeâ to public health and that communities must be helped to articulate their values and build capacities to pursue their wants economist, Gavin Mooney has arrived at a place occupied by very many players over the past 30-40 years. For example, the links between income distribution and well-being drove the War on Poverty in the US in the 1960s1 and the idea that health promotion is essentially a matter of empowering the have-nots has dominated the community-based practice discourse.2 However, when a new voice joins the chorus, it is a good time to look at the song and its complexity. There is a long history of community voices being ignored or misconstrued by others.3 The assumption that community values can be factored into a broader equation easily is naïve. The community development literature on how to involve communities in decision-making makes the distinction between consensus-based approaches (where values are held to be broadly similar) and social action, conflict-based strategies, where values are held to be broadly dissimilar.4 In increasingly divided societies, with high degrees of power asymmetry between groups, conflict-based strategies are likely to be the most fruitful. These are the messy realities that we will encounter should we take the challenge being presented. I am not trying to spoil the party. I am not saying âitâs all too AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH
Australian and New Zealand Journal of Public Health – Wiley
Published: Apr 1, 2000
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