Abstract
A focus on populations, and a corresponding population-level approach to intervention, is a foundation of public health and is one reason why public health matters today. Yet, there are indications that this foundation is being challenged. In some policy and practice domains, and alongside growing concern about the social determinants of health and health equity, there has been a shift from a population-level or universal approach to intervention, to a targeted approach focusing on those experiencing social or economic vulnerability. More than 30 years ago, Geoffrey Rose articulated strengths and limitations of population-level and high-risk approaches to prevention. In light of a strong analogy between “high risk” and “targeted” approaches, it seems timely, in a forum on why public health matters today, to revisit Rose’s points. Focusing on points of overlap between strengths and limitations of the two approaches as described in public health (population-level; high-risk) and social policy (universal; targeted), I illustrate strengths of a population-level approach from the point of view of health equity. Although different circumstances call for different intervention approaches, recent discourse about the weakening of public health suggests that there is value in discussing foundations of the field, such as the population-level approach, that we as a community may wish to defend.
Résumé
L’accent sur les populations, et donc sur les interventions populationnelles, constitue l’une des bases de la santé publique et l’une des raisons de son importance aujourd’hui. Des fissures semblent néanmoins se dessiner dans cette fondation. Dans certains domaines de politiques et de pratique, avec le souci croissant pour les déterminants sociaux de la santé et l’équité en santé, un changement s’opère : la démarche d’intervention populationnelle ou universelle cède la place à une démarche ciblée sur les personnes vulnérables sur le plan social ou économique. Il y a plus de 30 ans, Geoffrey Rose expliquait les forces et les limites des démarches de prévention populationnelles et de celles axées sur les segments à risque élevé. Vu l’étroite similitude entre les démarches « ciblées » et « axées sur les segments à risque élevé », il semble à propos, sur une tribune qui demande Pourquoi la santé publique aujourd’hui?, de revenir sur les arguments de Geoffrey Rose. En m’intéressant aux recoupements entre les forces et les limites de ces deux démarches, comme décrites par les acteurs de la santé publique (populationnelle; axée sur les segments à risque élevé) et des politiques sociales (universelle; ciblée), j’illustre les forces de la démarche populationnelle du point de vue de l’équité en santé. Bien que différentes situations appellent différentes mesures d’intervention, le discours ambiant sur l’affaiblissement de la santé publique donne à penser qu’il serait utile de discuter des fondements de notre domaine, comme la démarche populationnelle, qu’il serait bon de défendre collectivement.
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Notes
Definition from the 1988 Acheson Report on Public Health in England. Cited in Last (2001).
Public Health and Preventive Medicine; formerly Community Medicine (http://www.phpc-mspc.ca/en/students/what-is-phpm/).
In the Canadian context, this principle was demonstrated by Hertzman and colleagues in their work on children’s readiness for school across Vancouver neighbourhoods. They found that although the highest proportion of “vulnerable” children was found in the poorest neighbourhoods, “the largest number of children at risk [was] found more thinly spread across the middle class neighbourhoods that, taken as a whole, have a much larger number of young children than the poorest neighbourhoods” (Hertzman 2004, p. 8).
This shift is somewhat obscured by the use of the word “population” to mean quite different things, for example, everyone within a jurisdictional boundary (“geopolitical population”), or a subgroup defined by social or economic circumstances (e.g., “vulnerable population”).
Targeted universalism “defines goals for all, identifies obstacles faced by specific groups, and tailors strategies to address the barriers…” (NCCDH 2013). Proportionate universalism argues that “to reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage” (Marmot 2010). Interestingly, there is a subtly greater emphasis on universalism in the latter than in the former.
For example, https://www.ucalgary.ca/science/data-science/.
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Acknowledgements
I wish to acknowledge my colleague Dr. Melanie Rock for our interactions over many years, which have helped to shape these ideas and, perhaps more importantly, remind me that they represent one of many perspectives. I hope to have framed this commentary in such a way that it invites further discussion and debate around these issues, which I consider to be foundational to our field.
Funding
LM is supported by an Applied Public Health Chair funded by the Canadian Institutes of Health Research (Institute of Population & Public Health and Institute of Musculoskeletal Health & Arthritis), the Public Health Agency of Canada, and Alberta Innovates–Health Solutions.
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McLaren, L. In defense of a population-level approach to prevention: why public health matters today. Can J Public Health 110, 279–284 (2019). https://doi.org/10.17269/s41997-019-00198-0
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DOI: https://doi.org/10.17269/s41997-019-00198-0