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Critical Perspectives in Public HealthReview - Critical Perspectives in Public Health
by Judith Green and Ronald Labonte (Editors)
Routledge, 2008
Review by Tony O'Brien, RN, MPhil
Mar 18th 2008 (Volume 12, Issue 12)

This collection of readings takes its name from the journal Critical Public Health in which many of the chapters were originally published as individual papers, between 1998 and 2005. The book contains sixteen chapters in four sections, with an integrative introduction to each section. This is a wide ranging collection, covering inequalities, research, colonization/globalization, and the environment. Authors are about evenly spread across both sides of the Atlantic and appear to be mainly social science or medical academics from the specialty of public health. Critical Perspectives in Public Health is a useful reader in providing an overview of methodology and theory, as well as case studies of particular issues.

Co-editors Green and Labonte begin with a preface on public health that sets the tone for the book.  The preface ends with a quote from early Prussian public health advocate Vichrow, who is reported to have declared that "All disease has two causes, one pathological and the other political." If Vichrow didn't say this, it matters little. It is a succinct summary of the dichotomy addressed by public health, that the causes of disease are at once social and biological. Throughout the rest of the book the implications of this message are clear; that society must attend to social factors contributing to health (often called social determinants) as well as to their effects on individuals through appropriate care and treatment. This is also of course, where things become contentious. What is the proper balance between treating affected individuals and relieving the social conditions that cause disease? The issue becomes more complicated when it is realized that attempts to treat individuals may make things worse at a population level, and that macro level interventions such as economic reform and globalization, while they may provide real opportunities for improved health may also prove harmful.

Vichrow is again the subject of Green and Labonte's introduction, where the origins of the journal Critical Public Health are traced to an earlier journal Radical Community Medicine. A series of cover images from this journal are reproduced, the social realist artwork making a statement as bold as the themes covered: "The Inner City"; Unemployment", "Housing and Health" and so forth. There must have been some reason for giving up this wonderful iconography in favor of the rather bland red cover of the present journal; perhaps it didn't look serious enough on the library shelves of the academy. The Introduction sets out the twofold agenda of critical public health: critical analysis and engaged action. A critical stance to the new public health philosophy of 'self care' or 'self management' is outlined, as well as the use of concepts like 'social capital' and their capacity to absolve the center from responsibility for health.

The section on social inequalities makes for sobering reading, showing how across the world social status contributes to health status. The poor of the developed world share with the poor of the 'third world' reduced access to health care, exposure to noxious environments and, as Katrina illustrated (not covered in this book), the lasting effects of social policies that assign them to more risky housing, with a less generous official response to disaster. The section on research is a welcome corrective to over-reliance on epidemiological approaches to pubic health which, for all their value in charting systematic inequalities, are often aloof from their subject communities. The case study of South Wales, with its engaging and idiomatic participant quotes show that public health needs to relate to lived realities that may be many times removed from the carefully contrived world of epidemiology. You don't 'control for error' in the Gurnos of Merthyr Tydfil, you roll with it. Critical public health, however, is aware that epidemiology has a role to play, as Polanyi and co-authors comment in their chapter on participatory research: 'Positivist, quantitative research has the potential to be used as a tool for emancipation and empowerment of marginalized groups' although they later caution that 'conventional scientific standards also marginalize values, desires and emotions as biasing or distorting knowledge.'    

The sections on globalization and technology look outwards at the contradictions and possibilities of new developments. There is a plea for respect for indigenous knowledge, and a critique of western responses to 'genital mutilation'. The latter is a challenging contribution that questions western attitudes to genital surgery in some immigrant communities while regarding western women's decisions to have unnecessary breast, genital and other plastic surgery (and you could perhaps add elective caesarian sections) as a matter of individual choice. There is a thoughtful piece on antibiotic resistance (and a mild rebuke to Illich) and a rater complex theoretical chapter on space.      

Altogether the pickings from this collection are rich. For ideological as well as methodological reasons not everyone will agree with the analysis and emancipatory agenda of critical public health. But as long as health inequalities continue 'Vichrow's dictum', if it can be called such, will provide policy makers, researchers and practitioners with a case to answer. Followers of the public health literature may not find much that is new in this book, but it does bring a diverse range of topics together in a single volume. Public health practitioners may find the diversity a limitation; they might also benefit from seeing how the concept of public health plays out in different contexts. This will be an especially helpful book for teachers and students, as well as those with a non-specialist interest in public health.

© 2008 Tony O'Brien

Tony O'Brien, RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland, a.obrien@auckland.ac.nz

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