Journal of Health Care Communications Open Access

Keywords

Health prevention; Health promotion; Political science; Healthcare; Health issues; Medical science

Introduction

Most, if not all, human endeavours are the pursuit of goals by the use of means within time limits. In this sense it is commonplace to mention that healthcare provision and maintenance systems have health (for a definition see next paragraph) as their goal. Health is sought by the use of resources that are human or technical (from the simplest bandage to the most complicated intensive care unit, or pharmaceutical). On the other hand, goals and resources are set within a certain political and social framework. In other words, healthcare and technology, as well as their combination exist and operate within society and polity, absorbing resources of almost all forms. Therefore questions related to healthcare provision have to be addressed via the lens of political science too.

Commencing an examination of health prevention and health promotion via the lens of political science, it is worth reminding some of health’s definitions alongside their implications. Health according to contemporary approaches and attempts as presented [1], relates to a ‘sound’ or else to a robust condition, which alongside dynamism gives potential for activities and actions. Such a definition is based upon the one set by the World Health Organization Constitution is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [2]. It also denotes at least two issues, that arise when we realize health’s absence: (a) The first is that disease and illness bring upon deprivation of many forms, misery, restriction of activities and therefore are limits to freedom and alongside this, often perform an onslaught to dignity, problems that can be called ‘social’ or ‘political’. (b) The second relates to ‘economic’ problems related to (bi) the cost of treatment (if we decide to tackle illness), (bii) lost working-hours from the workplace due to absence [3], and (biii) Compensations paid (if we decide to pay compensations), the two latter relating to working population.

Therefore, once we (the polity) are informed over the implications of the absence of health, we may decide to take action either ex ante as to avoid, or ex post as to combat problems. These decisions depend upon ideology, resources available and strength of political actors wishing (or not) to implement solutions. In other words, staunch ideological arguments related to concepts such as liberty, dignity, happiness, utility, general will etc. etc. have to be the motive of political actors such as parties and pressure groups that will activate them and lead to political/state action¹.

It is well known that healthcare systems operate upon, and cover a wide spectrum of activities. These are presented fivefold: (health) promotion, (illness) prevention, care (of illness) and treatment (of the diseased), pharmaceutical treatment and rehabilitation.

Referring briefly to care and treatment we observe key involvement of medical personnel at primary, secondary and tertiary level, alongside in- and out- patient care; whilst pharmaceutical care takes place out of healthcare institutions with the patient following an almost ‘normal’ life. Both care and treatment can be either acute or long-term and are usually monitored by medical personnel (that is close to out-patient care and monitoring).

This article wishes to focus upon health prevention and health promotion. The former according to the (Canadian) Institute for Work and Health “includes a wide range of activities—known as “interventions”—aimed at reducing risks or threats to health”. Prevention can be further divided to primary prevention, with primary aiming at preventing problems of any form (accident, illness) before they even occur, via legislation (health and safety), sanitation (infrastructure), immunization, information on healthy living (e.g. anti-smoking information), etc.; secondary aiming at combating problems as early as possible in order to make illness have the minimum (negative) effects possible; and tertiary that goes close to long-term care for chronic cases [4]. Therefore primary prevention relates to health and safety in the workplace and elsewhere, immunity from disease, while secondary to good health checks, screening and monitoring population’s health, advertising and communications. It is self-evident that technology can play a key role in all these.

Primary Prevention: Medicine, Technology and Society and Politics

Medical science can play a key role in all health issues, primary prevention included. But it cannot and should not be left alone. Health depends inter alia upon clean water, swage, elimination of wetlands related to malaria, that are important infrastructure works in the hands of mostly civil engineers who (under medics’ guidance) will use technology and their expertise in it. It also depends on safe roads and vehicles (and safe driving techniques and behaviour), which are also in the realm of engineers (mechanical too), as well as safe workplaces as to avoid both accidents and diseases accumulated over working in a longterm unhealthy environment (e.g. noise, dust, asbestos, other chemicals, radio-active substances).

Primary prevention relates also to vaccination that leads to immunisation. Technology is also useful in this case as to provide vaccines in the one hand, and to deliver them to all population on the other. In this second case distribution depends upon both infrastructure, but information about the need of vaccination (and possible about vaccination centres too).

Dietary and habitual issues play a key role in primary prevention too. Fats, sugar and salt avoidance alongside limited alcohol use and non-smoking combined with exercise (that helps promotion too), assist in illness avoidance. They in their part depend upon decisions of individuals on the one hand, but on information and opportunities the individual has as to make his or her own mind too on the other.

Last, perhaps it relates to education and training (equipment and machinery use, car driving, healthy living) that can be provided through technology too.

It is not for the political scientist to decide what aspects of technology will be used and how! It is however to remind that these decisions are made in certain political frameworks and have political implications, repercussions and connotations.

Secondary Prevention: Medicine, Technology and Society and Politics

Medical science and (medical) technology are paramount in this case since the disease has already occurred but has to be detected early enough, as to be combated. Mammograms, cardiograms, prostate cancer checks, blood checks are easy examples. All need advanced technology on the one hand, but patient involvement too on the other. The latter however depends upon information (both about the need of secondary prevention and its techniques², and specific information about the ability and need to perform the checks on certain time on the other), alongside easy access to the medical facility itself, a fact requiring not just proximity but time allowances (e.g. leave of absence from work) too.

Health Promotion in its turn also needs infrastructure and technology mainly in communication and advertising, but also spare time and access to amenities. This is in our view a social and political issue. It relates to a ‘positive’ action behaviour (not just ‘negative’ that is avoiding exposure to hazards as in prevention) pursuing health in the sense of ‘robustness’. This assertion guides as to two questions.

(a) What does (political) theory have to do with prevention and promotion?

(b) Are health prevention (either primary or secondary) and health promotion individual/private or social and political matters?

Political Theory and Health Prevention and Promotion

It can be claimed that health as a robust condition is one of the components of the purpose of state and state formation in Aristotle’s concept of good life [5]. Similar references regarding healthcare (and in our case prevention and promotion) can be made to a broad spectrum of theorists as Vic [6] has presented in his approach to ‘welfare’, regardless of as he himself mentions incompatibilities in the use of the term among theorists. Health (and therefore prevention and promotion) is in the paper’s view an either implicit or explicit ‘golden thread’ that connects the spectrum of theorists on the one hand, and polity’s activities and healthcare and technology on the other. Or else, as Mill [7] puts it “[q]uestions of ultimate ends are not amenable to direct proof. Whatever can be proved to be good must be so by being shown to be a means to something admitted to be good without proof. The medical art is proved to be good by its conducing to health; but how is it possible to prove that health is good?” Similarly, Erasmus claims [6] that human life on earth should not be a vale of tiers, an idea in this paper’s view not far from Mill’s ‘utility’ or else ‘greatest happiness’. Utility is “the absence of pain [… that alongside pleasure] are the only things desirable as ends” [4]. It is worth reminding (with reference to the importance of healthcare) that Thomas More (1478-1535) in his Utopia refers to sanitation and free medical care. Moreover our spectrum of classical and key theorists may include more such as the radical Thomas Paine (1737-1809), who set issues of universal coverage of needs, T.H. Green (1836-82) who reformed liberalism by referring to positive freedom as the ability for self-accomplishment and fulfillment of hopes and aspirations and self-realization under the proviso of assistance in the covering of necessities and social minima with the assistance of polity. Green’s idea is not far in this paper’s interpretation of JS Mill too, should we take Mill’s concept of dignity into account also. ‘Dignity’ is of particular importance with reference to health care. For Mill, ‘Dignity’ is unalienable and equally vulnerable to (among other calamities) to disease that should be eradicated [7], whilst one should not forget that such an approach is kept by Sir I. Berlin in his ‘Two Concepts of Liberty’ too.

The spectrum of theorists is almost endless, and can be further expanded (even with the danger –self diagnosed in our case-of ‘cherry-picking’) to Rousseau’s ‘General Will’ [8]. Despite Rousseau not referring directly to health or healthcare (his subject is other in any case) the aim of his Social Contract is the common good that is useful for all as individuals and as a polity, including their preservation [8].

Turning to approaches that have greatly influenced if not even shaped the academic discipline of social policy (mainly in the ‘golden years’ of the welfare state, not in the current crisis) we observe that social policy (that includes healthcare) is society’s response to identify and combat problems, something that involves moral and political values [9,10], to achieve welfare, that is alleviation of need be it physical or emotional [11].

It becomes apparent that healthcare and prevention and promotion in particular can claim being based upon political theory and social policy theory too, further to the assertion that they (prevention and promotion) conduce in cost containment, alongside primary care that is considered cheaper [12]. Should an approach restrict itself in this latter issue it would face criticism from Miller [7,13] that “the cost efficiency approach relies on the quantification of everything. Not only is Oscar Wilde’s commend on those who know the price of everything and the value of nothing appropriate but the quantitative goal approach biases the choice of policies towards the quantifiable. What cannot be measured tends to be ignored or downplayed…”

We, both as a polity and as academics involved in the study (and occasionally also planning and managing) of health care, should always keep in mind that technology is a tool and prevention and promotion are means towards the goals of welfare, dignity, (positive) freedom etc. [14].

The question concerning prevention and promotion becomes now on an issue of responsibility of the individual or the polity. In other words are prevention and promotion private or societal and political issues?

Prevention and Promotion a Private or Social Issue?

It can be easily agreed that the individual plays a key role in the preservation or maintenance of his or her own health, and that he or she cannot be forced to avoid activities or take action(s) his or her well-being. As classically set by John Stuart Mill in his “On Liberty” [7] “the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm others. His own good, either physical or moral, is not a sufficient warrant”. It could therefore be claimed that society and polity have little to nothing to do with prevention and promotion. However (!) two questions arise from this approach. The first relates to the either direct or indirect repercussions of the actions of the individual for others, and the second to the framework and environment within which the individual can take his or her decisions, alongside the environment within he or she lives, as it can affect not only decisions as just said, but health itself too.

A reply to the first question has been given by Mill himself in the continuation of his “On Liberty” with regard mainly to parental responsibility over their children’s education, but also with a broad reference to ‘not harming others’ too. Though Mill does not refer to it, in this paper’s view the idea of compulsory vaccination and adherence with safety rules (spearhead technology either in vaccines or in automobiles, machinery, equipment etc. is a key player in this) are good examples of the legitimacy of societal and/or polity intervention. We wish to argue that the former does not only immunize the individual, but renders him/her-self less dangerous for others as a carrier of disease. Additionally, in the case of automobiles we could use the example of a reckless drunken driver in a busy road. An indirect reply could be based upon an argument of cost of the individual’s illness or incapacity for dependents and for the wider society too, a practice referred to by Freeman [15] with relevance to statutory screening in various states and its role to prevention.

However, there are two more issues to be examined in relation to prevention and promotion as individual-(istic) or social and political problems. The first relates to the information, knowledge etc. the individual may have as to take a decision regarding actions; and the second on the effects living conditions (that may lie beyond the control of the individual) have on his or her health.

Addressing briefly the first question we observe the importance of health education (that by itself requires some general education too) alongside the absence of temptations. Good examples on these are given, regarding both ban of tobacco advertising in Europe and HIV/AIDS education as examples [14]. We should however note that any recipient of the message has to be receptive too, and that this said ability of reception may be socially determined.

The second question in this approach deserves little more thought.

We will commence by reminding what has been long known, that health status is the outcome of many factors (many of them social) and not just individual actions on prevention and promotion. This has been exemplified early enough (for our times!) in the so-called ‘Black Report’ of 1980 [16], a line followed later on by other commentators notably in Gordon et al. [17] discussing among other issues poverty, social environment, education, nutrition as factors of health vis-à-vis as factors of health. Sally McIntyre in her chapter [18] makes a response in overstating prevention and promotion as matters of individual behavior, stating that according to an array of authors “where you live matters for health, although probably not as much as who you are”. She claims that important factors are employment, education, transport, housing, recreation facilities, pollution, and most having to do with wider social inequalities. The wider inequalities argument is further analyzed and indeed emphasized in the ‘widening gap’ of Mary et al. [19] where inequalities in health are examined further ones such as in education, income, home-ownership, degrees, car ownership etc. in the context of constituencies and the North/South divide. It becomes evident that prevention and promotion are not the sole determinants of health, whilst they may (as we will see later) be socially dependent too. Though choices may remain with the individual, as Jane [20] remarks there is a time lag between ‘healthy’ (and perhaps currently ‘fashionable’ too) behavior, which however requires time and (occasionally) monetary resources, and its effect later in life, especially with reference to chronic diseases. The question now becomes whether all individuals have the same time and monetary resources, and opportunities and facilities both to be informed over the value of ‘healthy’ behavior and to pursue it. The argument regarding facilities and opportunities is further examined in the same volume, in the Chapter by Tamara et al. [21] approaching obesity versus built environment. In an analysis of Pittsburgh population groups issues of income are examined along healthy diets, food purchasing venues and cost of healthy food, amenities for physical activity, socio-economic status degree of urbanization as factors influencing behavior and health, raising issues not just of healthcare services but of urban planning too. Therefore health prevention and promotion may in parts remain out of the realm of a narrow understanding of healthcare services and their planning. At a first grasp level they may seem matters of individual behavior, but once we consider the social environment they might not be only that but societal and political issues too. Or as the volume editor Salvatore [22] sets it in his introduction (p1) over the past decades there has been an “emergence of a ‘new’ new public health focused on how social, economic and political factors affect the level and distribution of individual health³. […] environmental factors (broadly construed) are now more important for understanding differences in the health of individuals than ever before. […] [These] factors [are] related to the social structures in which people are embedded”.

Therefore, when addressing the issue of health prevention and promotion we should at first notice that it relates not only to individual behavior (vaccinations should be provided, screening, mammograms etc. should be available, clean water and safe swage are imperatives), but on actions by the polity too. Additionally, health depends upon more factors than prevention and promotion (and indeed intervention), such as the environment, working conditions etc. Individual behavior is an important parameter, but should not be overstated and should also be seen in a social and political context.

Brief Concluding Remarks

Health is a goal by itself and it is related to strong political arguments of ‘well-being’, welfare, utility, dignity, freedom, happiness, general will and common good, attainment of aspirations etc. as set by many political and social theorists. Prevention and promotion are key however not sole determinants of health, as other factors play their part alongside, whilst the latter (promotion) can be seen as a goal by itself too.

Also prevention and promotion take place within certain social and political environments even when examined in a narrow sense as matters of individual responsibility and behavior. Therefore prevention and promotion become social and political issues and should be seen as such, in order to give the best results possible.

Healthcare systems performance can be enhanced in these two aspects of the healthcare provision spectrum, with the use of technology (medical or other), medical science and management techniques etc. always keeping in mind moral-political and ethical goals and the restrictions posed by a social and political environment.

Therefore, new pathways of collaboration between medical science, the discipline of healthcare management, sciences in all scope of technology, and political science alongside other social sciences should be sought.

¹Such an approach is out of focus of the paper. Short references to political/ideological issues will be made later on.

²That in its turn is education and training of the wider population both broad and in the subject.

³In the article’s view this trend may be much older, either since the ‘Black Report’ or even since the various Reports on health during the years of the industrial revolution and early urbanization.

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