Introduction
While analogous, there are many differences between the way in which community and individual health are practiced. In this short essay, I will outline some of these differences.
Definitions
The World Health Organisation in 1946 defined health as:
“A state of complete physical, mental and social well-being and not merely the absence of disease.”(World Health Organization, 1946)
This definition uses a biopsychosocial and inclusive model of health and can equally be applied to individuals as to communities, although the health of the individual is implied.
The NPHP in Australia defined public health in 1997 as:
“the organised response by society to protect and promote health and prevent illness, injury and disability.”(National Public Health Partnership, 1997)
This encapsulates the modern, multidisciplinary approach to public health.
Ethical Differences
In treating patients, healthcare practitioners generally use “principles” and deontological frameworks such as beneficence, non-malfeasance, equity and fairness. One strives to improve a person’s health without harming them, in a fair and just manner. In particular we advocate for an individual patient when engaging with other stakeholders rather than necessarily making a decision that takes other individuals into account- responsibility for community health is usually handed over to public health agencies and administrative bodies. However in community health, measures such as disability-adjusted life years (DALY) are used to allocate resources & design interventions in a utilitarian manner as the aim is the greatest good for the greatest number.
This distinction however is not altogether clear-cut. While traditionally, utilitarianism is cited as the underlying ethical principle in community health and a deontological framework the underlying ethical principle for individual treatment, there is evidence that a mixture of models is what is used in practice.(Fortes & Zoboli, 2002; Hedner & Hansson, 1988)
In addition, sometimes these two methods clash. Surgical intervention for an individual with many complex medical problems may in fact be very expensive and improve community outcomes only slightly in comparison with inexpensive population measures such as vaccination programs. A 2001 study of American publicly-insured elderly patients estimated that the 5% of the population of elderly people who were in their last year of life contributed roughly 30% of the medical expenditure, 6 times the expenditure when compared with their surviving counterparts (Hogan, Lunney, Gabel, & Lynn, 2001).
Measuring Health
Health status of an individual can be assessed in several ways. Health practitioners assess symptoms, signs and the results of diagnostic tests. Medical and psychosocial wellbeing can be evaluated qualitatively during a consultation as well as using various quantitative tools designed to, for example, evaluate risk of depression, functional score or pain scores. Further investigations can also be used to measure health via methods such as blood tests, radiology, pathology, exercise tolerance and other physical components.
In comparison, analysis and measurement of community health is less straightforward and is conducted on a larger scale. Health surveys are analogous to using qualitative and quantitative tools applied to many representative individuals rather than a single individual. Incidence and prevalence of disease conditions may be collected via disease & death registers, hospital & general practitioner databases (eg coding discharge summaries after inpatient stays), surveillance systems where data is compulsorily submitted to a central authority such as for notifiable illnesses. Demographic data, economic and educational data that are continuously measured also give information as to social determinants of health.(Baum, 2003; Canadian Public Health Association, 1986; Lin, Chaplin, Robinson, Fawkes, & Smith, 2007)
Health Interventions
Health interventions for individuals are generally more focussed on secondary and tertiary prevention, ie treatment of risk factors & disease states that already exist rather than prevention in healthy individuals. An example would be that of someone who presents to their healthcare practitioner with ischaemic chest pain. While risk factor reduction such as diabetic control, cessation of smoking and initiation of an exercise regimen may all be appropriate, the initial response will be targeted to treatment of the underlying cause of chest pain and its psychosocial effects. The “history of presenting complaint” is the focus of what we often do.
In contrast, much of community intervention is primary prevention. Legislation and regulation, health promotion and education, screening, vaccination, treatment of risk factors, environmental management, socioeconomic and education policy are some of the many ways in which public health interventions are practiced. There is a “bigger picture” approach that emphasises prevention and often requires a co-ordinated and multidisciplinary approach to the health of the system.(Baum, 2003; Canadian Public Health Association, 1986; Lin et al., 2007)
Conclusion
Public health is not just individual health on a bigger scale. While the healthcare of individuals is increasingly holistic, public health necessarily has a “bigger system” perspective involving not just healthcare workers and departments but also legal, economic and educational systems.
The focus is on prevention, surveillance and maintenance of wellbeing rather than on treatment of ill-health.
Bibliography
Baum, F. (2003). The new public health. Oxford University Press. Retrieved from http://www.cabdirect.org/abstracts/20043034459.html
Canadian Public Health Association, W. (1986). Ottawa charter for health promotion. Ottawa: Canada.
Fortes, P. a. C., & Zoboli, E. L. C. P. (2002). A study on the ethics of microallocation of scarce resources in health care. Journal of Medical Ethics, 28(4), 266–269. doi:10.1136/jme.28.4.266
Hedner, T., & Hansson, L. (1988). A Utilitarian or Deontological Approach Toward Primary Prevention of Cardiovascular Disease? Acta Medica Scandinavica, 224(4), 293–302. doi:10.1111/j.0954-6820.1988.tb19587.x
Hogan, C., Lunney, J., Gabel, J., & Lynn, J. (2001). Medicare Beneficiaries’ Costs Of Care In The Last Year Of Life. Health Affairs, 20(4), 188–195. doi:10.1377/hlthaff.20.4.188
Lin, V., Chaplin, S., Robinson, P. M., Fawkes, S. A., & Smith, J. (2007). Public health practice in Australia: the organised effort. Retrieved from http://arrow.latrobe.edu.au:8080/vital/access/manager/Repository/latrobe:24280
National Public Health Partnership. (1997). Memorandum of Understanding. National Public Health Partnership.
World Health Organization. (1946). www. who. int/bulletin/archives/80 (12) 981. pdf WHO definition of Health. In Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York (pp. 19–22).