Sarah Hawkes is a medical doctor with a degree in sociology and a PhD in epidemiology. She is Professor of Global Public Health at University College London where she leads a research theme analysing the use of evidence in policy processes, particularly in relation to gender and health, and sexual health. She is also Director of the newly established UCL Centre for Gender and Global Health.
The foundations of public health have various origins; I am going to confine myself to a starting point in the 17th century. In 1662 the haberdasher John Graunt became the founding father of modern demography and epidemiology when he published “Bills of Mortality” and exposed the inequalities of both life and death . Using church registry records, Graunt revealed that life expectancy for men and for those who live in cities was shorter than for women and rural populations, respectively. Men, he determined, “die by reason of their vices”. Women might be living longer than men, but Graunt also recognised that they were more likely to be sick from “Breedings, Abortions, Child-bearing, Sore-breasts, Whites, Obstructions, Fits of the Mother, and the like.” Meanwhile, Graunt’s comparisons of the city of London and rural Hampshire concluded that the “Fumes, Steams, and Stenches of London do so medicate, and impregnate the Air about it, that it becomes capable of little more” and contributed to the observed mortality rates in the city.
A similar picture could be said to exist in public health, epidemiology and demography today. Men live shorter lives than women in every country in the world. The life expectancy gap ranges between 1 year in the poorest countries (e.g. Mali) to over 10 years in the countries of the ex-Soviet empire – where much of the gap is determined by rates of exposure to alcohol. Meanwhile, anyone who has experienced the smog of Delhi or Beijing will testify to the impact on human health at individual and population levels.
Moving forward from Graunt, to the 19th Century, and attempts to improve population health were now seen to be interwoven with improving the social, economic and political conditions under which people live: Engels (1844) remarked that “The men wear out very early in consequence of the conditions under which they live and work” , and the recognized father of public health, Virchow, writing about how to prevent typhus in the 1840s noted that we should focus on “education, together with its daughters, freedom and welfare”.
By the 1970s, the physician Thomas McKeown was able to disrupt prevailing empiricist and reductionist concepts of public health even further by examining the idea that “human health depends on understanding the structure and function of the body and the disease processes that affect it….and consider [what this might mean for] health services, medical education and medical research”. McKeown examined in-depth the improvements in population health that had taken place over the course of 3 centuries. Most of the reductions in mortality rates (at young ages) in England and Wales and in Sweden were due to declines in infectious diseases. It would be reasonable to assume that this decline was strongly associated with improvements in medical care, but one reason that McKeown’s work was such a hit with medical sociologists in the 1970s and ‘80s was his empirically-derived conclusion that by far and away the greatest declines in rates of infectious diseases occurred before the advent of antibiotics or vaccines (with the exception of smallpox). Whether talking about tuberculosis, measles or polio – medical interventions to treat or prevent these infections arrived after the diseases had already significantly declined.
I mention these historical antecedents to give a public health context to my reading of John Tasioulas’ seminal work on Minimum Core Obligations and the concept of the Minimum Core of the Human Right to Health. Professor Tasioulas presents ideas that are powerful, inspirational, and importantly, can guide practical and pragmatic ways forward for those involved in setting priorities for resource (human, financial, logistical) allocation in health. In reviewing the legal (and some may argue, social justice) standards for deciding upon core obligations, Professor Tasioulas draws upon a rich legal and political scholarship. Academic public health is frequently less erudite, but, nonetheless, I propose that applying a more public health lens to Professor Tasioulas’ work allows for further practical refinement of these ideas, in two areas in particular.
Firstly, we need more recognition – from the worlds of law, politics, economics, social justice, and others – of the importance of keeping populations healthy alongside the current focus on ensuring treatment for people once they are sick. This is not, of course, to denigrate the role of the medical and allied professions in their roles as providers of health care to sick people. We are all going to need medical attention at some point in our lives (some sooner than others, some more frequently, and some for more complex medical conditions). But a discourse that focuses on treatment rather than prevention of illness/maintenance of good health, seems to me to be a unidimensional preoccupation for most societies. If we can apply concepts of core obligations for promoting healthy environments alongside realising the right to medical care, then we are likely to see improvements at levels of population health as well as improved health service coverage data.
Secondly, once we have agreed that keeping populations healthy is part of the minimum core, then we need to figure out how to do so. This is where the historical lessons are so important in showing how the health of populations improves or declines. Historically populations were largely at risk of infectious diseases and under-nutrition – and many of the prevailing human rights standards in health seem to reflect the epidemiology at the time of their writing (1940s and 1960s). In the 21st Century, more of us are going to die from the side-effects of over-consumption and over-exposure – processed food, alcohol, tobacco, environmental pollutants – than from any other set of risk factors. I propose that the time has come for us to recognise that we need a legal framework that recognises the determinants of health and illness have changed since international human rights law in relation to health was first formulated and codified. A set of minimum core legal responses that act to protect the health of the public by addressing 21st Century determinants – driven, frequently, by corporate behaviours and lack of effective governance on the part of state bodies – needs to be identified. Equally important as identification, we need solid mechanisms for holding states to account for protecting the health of populations alongside ensuring access to care when for those who are sick.
As a final note, I have a more personal reflection on Professor Tasioulas’ work. For too long public health has been stuck in a silo of its own making – unable to move into multi-sectoral action or conversation as we did not have the language to speak to other sectors and professions. The expansion of the study of population health beyond the counting of numbers to meaningful engagement with those disciplines that are able to show us potential ways forward – and the legal basis for doing so – is a very welcome development. Professor Tasioulas’ work exemplifies the kind of academic scholarship that is capable of challenging established ways of working, while also proposing ways forward that are pragmatic, actionable, and, most importantly, equitable. I am delighted that he has applied his expertise, ideas and proposals to the realm of public health – the health of populations can only benefit as a result.