Re: Dennis Raphael and 'Population Health'
In many countries a 'population health' approach as advocated by the CIAR
in Canada would be an advance. That is, a focus on the broader
'determinants of health' is more fruitful than a concentration solely on
the provision of health care services, narrowly defined. Yet, there are a
variety of approaches to the determinants, or the social determinants of
health. The problem is the rather, positivist, narrowly epidemiologically
oriented view sometimes taken.
I agree with Dennis Raphael (who happens to be in the same Department as
myself) that there is a new 'hegemony' in health care research in Canada.
This hegemony is centered around the dominance of a relatively few
epidemiologists, economists, planners and others centered around the CIAR.
All of these people believe they are doing 'science' write large. There is
little recognition that now there are different approaches to science in
general and the social sciences and health in particular. Postivist,
survey research approaches predominate - science to some, correlational
chaos to others. The notion of more meaning-oriented research, or of
research from a realist, or the now increasingly popular critical realist
position, is simply not recognized. Hence, the downgrading of qualitative,
historical or structural studies in favour of, yet another, exercise in
data manipulation.
I believe the increasing 'debates' over the relationship between income
inequality and health status is one example of 'two solitudes' attempting
to speak with one another.
No doubt survey research, or multivariate statistically oriented studies
are useful. The issue lies in the equating of such studies with a
monolithic view of science and the social determinants of health generally.
Along with this view also comes a downgrading of those who believe that
science includes analysis of the social, political and economic
underpinnings of good health.
While the successes of 'population health' should not be underestimated,
the danger lies in the way such approaches closely fit in with current
neo-liberal, or even 'third' or perhaps 'fourth' way politics and their
exclusionary effects regarding those who have different approaches to the
social sciences.
david coburn
public health sciences, university of toronto
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