Constructive Conversations About Health

Pt. 2, Perspectives on Policy and Practice

Marshall Marinker, Fritjof Capra

• Publisher: CRC Press
• Year: 2018
• eBook ISBN:
  9781315347578
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Current health policy is required to respond to a constantly changing social and political environment characterised, particularly in Europe, by ageing populations, increased migration, and growing inequalities in health and services. With health systems under increasing strain there is a sense that we need to seek new means of determining health policy. Much political debate focuses on managerial issues such as the levels of health funding and the setting and missing of targets. Meanwhile our moral imperatives, our values and principles, go relatively unexamined. What are these values? Can we agree their validity and salience? How do we manage the paradox of competing goods? Can we find new ways of talking about, and resolving, our conflicting values and competing priorities in order to create sound, appropriate, and just health policies for the 21st Century? Written by leading health policy makers and academics from many countries, "Constructive Conversations about Health" examines in depth the underlying values and principles of health policy, and posits a more enlightened public and political discourse. The book will be invaluable for those involved in health policy making and governance, politicians, healthcare managers, researchers, ethicists, health and social affairs media, health rights and patient participation groups. 'The literature on health policy is vast. On offer are models of health services, economic theory, management theory, disquisitions on ethical principles, social analyses, literally thousands of publications. In a globalised and electronically networked world, this literature has already generated its own particular language, a policy jargon replete with terms that look deceptively familiar, terms that will be much in evidence in what now follows, terms whose meanings require our closest attention.' - Marshall Marinker.

Chapter 1

Health policy and the constructive conversationalist

Marshall Marinker

In Lewis Carroll’s classic children’s story Through the Looking Glass, Alice encounters Humpty Dumpty.¹

‘When I use a word,’ Humpty Dumpty said in rather a scornful tone, ‘it means just what I choose it to mean - neither more nor less.’

‘The question is,’ said Alice, ‘whether you can make words mean so many different things.’

‘The question is/said Humpty Dumpty, ‘which is to be master -that’s all.’

Humpty Dumpty issues a sharp challenge to those who advocate constructive conversation about health, with which this book is concerned. The literature on health policy is vast. On offer are models of health services, economic theory, management theory, disquisitions on ethical principles, social analyses, literally thousands of publications. In a globalised and electronically networked world, this literature has already generated its own particular language, a policy jargon replete with terms that look deceptively familiar, terms which will be much in evidence in what now follows, terms whose meanings require our closest attention.

Although I acknowledge the force of Humpty Dumpty’s relativism, my aim will be to limit some of the damage caused by a systemic ambiguity in the way we talk about health. When we choose a word it cannot mean just what we choose it to mean, although it will almost always mean both more and less. Humpty Dumpty’s assertion is the dilemma that lies at the heart of constructive conversation about health.²

In 1847 Rudolph Virchow, who famously averred that medicine was a social science, was asked to investigate the causes and containment of a typhus epidemic among immigrant Polish workers in Silesia. He recommended ameliorating the hardships and injustices experienced by the workers, improving their education, increasing their income, involving them in local politics, and permitting them to use Polish for official purposes.³

Some 40 years later Robert Koch was to demonstrate the bacterial causes of the infectious diseases. Yet more than a century after Koch, and a century and a half after Virchow, Victor Rodwin⁴ describes the cities of the West, citing New York, London, Paris and Tokyo, as socially infected breeding grounds for both disease and urban terrorism, and implies an overlapping of causes. He links a failure to deal adequately with fresh epidemics of infectious diseases, including AIDS and TB, with problems of water and air pollution, homelessness, poverty, the exclusion of ethnic minority groups, and terrorism.

What is the link, in Rodwin’s analysis, between TB and AIDS, which can be described in terms of a biological model, and urban terrorism which cannot? What model of disease could possibly have connected the severity of the typhus outbreak to the denial of use of a mother tongue? How are we to understand the full meaning of the public health?

Marc Danzón (Chapter 2) observes that ‘health seems to be universally recognised as the hard currency of modern times’. The word has been so often defined, by philosophers, politicians, poets. What does health mean to the individual, to the citizens in whose name all health policy is made?

The following quotation is ascribed to the novelist Katherine Mansfield, written in a letter when, as a young woman, she was already dying of tuberculosis. The words, or some version of them, appear in a number of contexts, such that perhaps the feelings expressed were thematic throughout her writing and life. ‘By health I mean the power to live a full, adult, living, breathing life in close contact with what I love... the earth and the wonders thereof - the sea - the sun... I want to be all that I am capable of becoming.’ I italicise those seven words because they resonate with the capabilities approach of Amartya Sen and others.⁵ In Bismarck’s terms, health was a means to a public end - the productive capacity of Prussia’s workforce and the fighting capacity of its soldiery. Referring to Sen and others, Jennifer Prah Ruger (Chapter 4) observes that ‘... the degree to which individuals have the capability actively to participate in their work, social and political life, to be well-educated... are ends in themselves’.

In the early 1960s I was a general practitioner. One of my patients was a child (I will call her Helena) born with multiple congenital abnormalities - microcephaly (small head size with incomplete development of the cerebral hemispheres), a deeply cleft soft palate with micrognathia (failure of the lower jaw to develop), transverse limb deficiencies (the arms and legs were stumps with vestigial hand-and foot-like structures). She was doubly incontinent, communicated by piercing screams, moved by scuttling along the floor, and suffered occasional epileptic seizures. This was the most extreme example of congenital damage in a surviving child that I had ever seen. With no hesitation, the young parents, supported by their own parents and neighbouring siblings, declared that they would look after the child at home.

One morning, when Helena was five years old, I was called to see her. This in itself was unusual; the parents rarely asked for a home visit and were stoically self-reliant. A brief examination revealed some small spots, like grains of salt, on the palate: she was developing measles and I explained that the rash would appear the following day. As I left the house her mother turned to me and said, ‘I hesitated to bother you, but yesterday I just knew she was not well.’

Down the years those words have continued to disturb and shock. Helena ‘was not well’ that day. What do we mean by ‘well’? What do we mean by ‘health’? How are we to communicate across the yawning gap of words? In this opening chapter I will present the Madrid Framework, an array of the issues in health policy and governance - their scope, processes, aims, principles and the values that underpin them. I will be concerned both with the elements of health policy, and since all policy begins in discourse, I shall say something about words and how we use them.

The Madrid Framework

The language of health targeting was given international currency by the World Health Organization,⁶ and has since dominated the literature and practice of health policy. Targets, in the new lexicon, were to be specific, quantifiable and measurable objectives designed to improve the health of individuals and families, communities, and regional and national populations.

Thenceforward ‘targeting’ rapidly came to usurp and incorporate ‘policy making’ and ‘implementation’, and to permeate the health policy discourse. Yet in the course of the ensuing years a number of analysts have voiced dissatisfaction with the dominance of targeting as a metaphor for policy - for example, Ilona Kickbusch, describing the epidemiological-rationalist approach characteristic of the late twentieth century, wrote: ‘The wish for governability and order overshadowed the drive to establish a new territory and make history.’⁷

Increasingly it became evident that ‘targeting’ might prove too restrictive a means for our full purpose. Policy in pursuit of health is a socio-political exercise, and targeting is a purely technical conceit. Also, health policy begins with moral purpose, not data. And it is driven by our values. We required a more elaborate linguistic code adequately to express and explore the values embedded in evidence, policy, politics and the historical contingencies of particular societies.

In May 2003 an international workshop of health policy experts was held in Madrid, with the intention of considering the values that underpin policy making.⁸ In my chairman’s briefing for that meeting I wrote: ‘The task that we have set for ourselves is to construct some sort of exploratory/evaluative instrument that can be applied to examples of health targeting... ‘⁹ Armed with the thoughts of the participants in the Madrid conference, I attempted to outline such an instrument, and in May 2003 produced a first draft of the Framework. In the years since that meeting, and in the light of subsequent health policy workshops in Wales, Hungary, Spain and Scotland, the Framework has undergone a great deal of useful modification of detailed content, but its original structure and function have so far not been seriously challenged by those invited to experiment with its use, and remain intact.

The Madrid Framework¹⁰ is imagined as a multi-dimensional space. Each dimension represents a salient force (equity, choice, democracy and so on) that acts on the creation and implementation of policy. I was seeking to describe a force field in which each group of concerns would pull in its own direction, so that policy and governance must perpetually adjust in order to find an equilibrium. This spatial imagery seemed appropriate because I wanted the Framework to represent a theoretical universe of health policy discourse.¹¹ However strained the metaphor, and it is strained, the dynamic imagery embraced the key notions of uncertainty and change, and was intended sharply to contrast with, and critique, the static imagery and rigid language of the dominantly fashionable ‘targets’, ‘guidelines’ and ‘protocols’.

Initially the idea of a ‘framework’ came in for some criticism: was this not too prescriptive, rigid, concrete, constraining, a structure for our purpose? Why not present the issues, the so-called ‘dimensions’, as a checklist, an inventory, a lexicon? My contention was that ‘framework’ helps us to visualise not only the inventory of issues to be considered, but their relationships. When we speak of health, equity, choice and the rest, we employ ‘lexical reasoning’. This allows us to explore their meanings in some fine detail. But lexical reason is less strong in helping us to see how these different, and often contradictory, elements relate to one another.

It is ‘cartographic reason’¹² the ability to map, that allows us to see these spatial relationships, and to play with them. Maps trace the landscapes in which we live; they allow us, they compel us, to envisage location, destination, departure, arrival, and exploration. In his essay on the possibilities of inter-sectoral and inter-agency governance, Morton Warner (Chapter 10) describes the spatial relationships of the players, and offers us a diagram (page 123) that is actually a conceptual map. The Madrid Framework invites a coincidence of lexical and cartographic reason.

I began with an exhaustive list of the issues that had been raised at the Madrid conference, and in the wider literature on health policy. These I bundled into baskets of coherent value-laden qualities and concerns that seemed to belong together. They were composed to achieve maximum separation between the groups of related concepts, while acknowledging an irreducible degree of overlap. The brief descriptions of the 11 dimensions that follow, already the fruit of constructive conversations with very many stakeholders, are only indicative, and in no way comprehensive or definitive.¹³

1. Health and wellbeing: The protection and improvement of health is the raison d’etre of all health policy, the ultimate goal of which is to enhance the capabilities of the citizen to live a full life. The WHO definition of health embraces physical, social, mental and spiritual wellbeing. Health policies are directed to determinants of health, risk factors for diseases, access to, and quality of, health services.
2. Equity and fairness: Inequalities in health, in the probabilities of disease, and in the quality of, and access to, services, are found within and between all societies. These are largely determined by social factors, income, age, ethnicity, education, housing and so on, such that the pursuit of health and social justice become inextricably entwined. Fairness relates also to such difficult concepts as merit and potential benefit.
3. Choice: What is deemed best for the population will only randomly be best for its sub-groups, or for the individual. Since personal choice is linked to the right to health, trade-offs have to be negotiated between the collective interest and the interests of individuals and particular groups. Choice and equity constitute one of the fundamental political fault lines in the landscape of health policy.
4. Democracy: In order to engender confidence in health policies, all stakeholders, and especially citizens and patients, need to be actively engaged. Access to health information and health literacy are crucial to such engagement. Health policies succeed in relation to the sense of solidarity and shared values that they foster.
5. Stewardship: Health is a vital public resource requiring investment by government. Traditionally governments were deemed to have three key duties: ‘the defence of the realm’, ‘law and order’, and ‘the stability of the currency’. In the twenty-first century, a fourth duty, ‘to protect and enhance health’, emerges as of at least similar importance.
6. Evidence: Successful policies require good data comparable over time and locations. All data are socially constructed. It is therefore important to consider not only the statistical but also the ethical and political values embedded in evidence.
7. Efficiency: Government has a dual accountability: to protect and improve health; to ensure the optimal use of the public resources entrusted to it. Allocative efficiency is concerned both with the effectiveness of interventions and the priority accorded them. Operational efficiency is concerned with the opt...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• About the Editor
• About the Contributor
• Acknowledgements
• 1 Health Policy and The Constructive Conversationalist
• 2 The Value of Values
• 3 Health and Wellbeing
• 4 Equity and Justice
• 5 Choice
• 6 Democracy
• 7 Stewardship
• 8 Evidence
• 9 Efficiency
• 10 Synergy
• 11 Sustainability
• 12 Interdependence
• 13 Creativity
• 14 Ethical Considerations in Health Systems
• 15 Justice and the Allocation of Healthcare
• 16 Health Values and the Politician
• 17 Managing Paradox
• 18 The Future
• Index