Robin Bunton

The New Genetics and the Public's Health

I welcomed the opportunity to review this book, which claims to be unique in its approach to the issue of genetics and its impact on the public health. Rather than focusing on medical genetics, preventative medicine or bioethics, the book takes a sociocultural approach. The authors set out to address the implications of the new genetics for public health practice and development by tackling five themes: risk and decision-making; the nature/culture dichotomy; anticipated new gene therapies; the role of the media in framing the debate; and the logic of the market. They attempt to examine the ways in which conceptions of health, disease and normality have been reshaped by politico-economic and global issues. These issues are examined by looking at the cultural context in which public health genetics is placed. This is then related to the impact this has upon the individual or ‘self’. Although there is an attempt to link the chapters, in reality they can be considered as a series of independent essays. Petersen, who has written the lion’s share of the book, introduces the ‘new genetics’ by saying it is a contested term that is widely used but poorly defined. He presents a range of definitions for the new genetics that he finds unacceptable. His main concern is that authors outline specific aims or outcomes of the genetic technologies rather than presenting a definition. Petersen offers his own interpretation, arguing that there is very little to distinguish the ‘new genetics’ from the ‘old eugenics’ because, in the most general terms, both are concerned with ‘human betterment’. Eugenics, he argues, was supported by the state’s desire to improve the population, whereas the ‘new genetics’ is, as both a term and a concept, possible because we live in a society that encourages neo-liberalism, i.e. a society managed through the political and cultural contract between government, people (the electorate) and their subsequent actions. For example, in developed countries the government acknowledges that it is much easier to achieve predetermined goals if people believe that they are autonomous and have ‘freedom of choice’. So utilizing one of the key aspects of neo-liberalism, ‘active citizenship’, people are encouraged to manage their own affairs through adopting risk minimizing strategies, such as screening. Based upon neoliberal principles, advances in genetic technologies have encouraged society to frame the individual as an ‘active seeker’ of information through the use of terms such as ‘freedom of choice’ and ‘autonomy’. Emphasis is placed on the importance of achieving genetic literacy so that the individual can minimize their ‘risk’ of developing disease. This, Petersen argues, has informed discussions about the new genetics and its benefits, diverting attention away from the global and social issues that affect health, and placing the responsibility of ill health with the individual and family members. Foucault’s work on bio-power is used to interpret the impact of the new genetics upon the public’s health. Bio-power, in its simplest form, is about the level of control that it is possible to achieve over life processes. The Human Genome Project (HGP) symbolizes the discourse and practices of bio-power because by revealing what happens at molecular level in the body, it then becomes possible to control conception, birth, morbidity and mortality. Petersen has selected to offer a rather optimistic perspective on the possible benefits of the HGP. There are numerous authors who are cautious about suggesting that knowledge of the genome can be of direct therapeutic value to the general population. However, Petersen documents his concern that

The ‘stages of change’ model in health promotion: Science and Ideology

The transtheoretical or ‘stages of change’ model has greatly influenced health promotion practice in the USA, Australia and the UK since the late 1980s. Application of the model has shaped service planning, provision and implementation. ‘Stages of change’ also has impacted on training agendas at local, regional and national levels. Associated areas of motivational interviewing and brief intervention have led health promotion initiatives in areas such as smoking cessation and alcohol-reduction policies. A number of critiques have recently challenged the ‘stages of change’ model and health promotion orthodoxy. This review examines these critiques, with a focus on the ‘scientific’ status of ‘stages of change’. The review also examines a data-based approach to stages of change, model adequacy, the social and ideological context of change theories in health promotion contexts, levels of explanation and prediction in the ‘stages of change’ framework. Some reasons are offered for the apparent popularity of the model amongst health promotion workers. Recommendations are made about alternative conceptual frameworks.

Time's up. descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey.

Most Western health systems remain single illness orientated despite the growing prevalence of multi-morbidity. Identifying how much time people with multiple chronic conditions spend managing their health will help policy makers and health service providers make decisions about areas of patient need for support. This article presents findings from an Australian study concerning the time spent on health related activity by older adults (aged 50 years and over), most of whom had multiple chronic conditions. A recall questionnaire was developed, piloted, and adjusted. Sampling was undertaken through three bodies; the Lung Foundation Australia (COPD sub-sample), National Diabetes Services Scheme (Diabetes sub-sample) and National Seniors Australia (Seniors sub-sample). Questionnaires were mailed out during 2011 to 10,600 older adults living in Australia. 2540 survey responses were received and analysed. Descriptive analyses were completed to obtain median values for the hours spent on each activity per month. The mean number of chronic conditions was 3.7 in the COPD sub-sample, 3.4 in the Diabetes sub-sample and 2.0 in the NSA sub-sample. The study identified a clear trend of increased time use associated with increased number of chronic conditions. Median monthly time use was 5–16 hours per month overall for our three sub-samples. For respondents in the top decile with five or more chronic conditions the median time use was equivalent to two to three hours per day, and if exercise is included in the calculations, respondents spent from between five and eight hours per day: an amount similar to full-time work. Multi-morbidity imposes considerable time burdens on patients. Ageing is associated with increasing rates of multi-morbidity. Many older adults are facing high demands on their time to manage their health in the face of decreasing energy and mobility. Their time use must be considered in health service delivery and health system reform.

War and public health

Public health specialists and activists frequently struggle to maintain a broad perspective in achieving their mission, to think globally even if they act locally, as the saying goes. Yet, the fields of international policy often appear to be beyond the remit of public health action, especially when it means involvement in establishing international human rights, or challenging international trade, or even wars. Critical Public Health has addressed such changing global processes as the HIV/AIDS pandemic, the increasing rates of refugees and migrants, and the issue of access to medicines in the developing world but rarely the public health topics of war directly. War has been a relative latecomer to an expanding public health horizon, although we can no longer ignore its relevance to public health. The roots of its neglect as a public health issue arise from the fact that at the beginning of the twentieth century only 14% of the victims of violent conflicts were civilians (Garfield & Neugut, 1997). International attempts to address the health consequences of war thus focused on the military. Military medicine was commonly equated with treating the wounded and often ignored the far greater contribution of disease to the mortality and morbidity of soldiers. The 1864 Geneva Convention in its establishment of neutrality on the battlefield and ocean thus merely enabled the easier evacuation of the wounded and sick and other international organizational judicial developments did not aim to protect or consider the general population. It was not until the Nuremberg and Tokyo tribunals addressed the atrocities of the Second World War that the fourth Geneva Convention of 1949 recognized and defined protection of civilians, following the principles of the Universal Declaration of Human Rights, which appeared a year earlier. Significantly, around the same time, the newly established World Health Organization reproduced a ‘war-blindness’ by excluding war damage from medical and public health responsibility. The nuclear threat initiated some of the first concerns about war as a public health issue with the establishment of International Physicians for the Prevention of Nuclear War (IPPNW). Actual conflicts and their effects on civilians in Africa and Asia led also to the establishment of Médicins sans Frontières and Médecins du Monde, which developed as global movements. In this issue, Mike Rowson from Medact in the UK comments on the health crisis in Iraq. Medact was formed by a merger of two older organizations in 1992. The first, the Medical Association for the Prevention of War, was founded by Sir Richard Doll, Horace Joules, Lionel Penrose and others in 1951 during the Korean War as a medical lobby for peace. The second, the Medical Campaign Against Nuclear Weapons, was founded in 1980 and was instrumental in undermining the idea that nuclear war was ‘survivable’. NGOs, in fact, continue to lead the way in highlighting the centrality of war to public health, witness the recently published reader War or Health (Taipale et al., 2002), which was commissioned by the Physicians for Social Responsibility in Finland. This text makes links with a longer tradition of medical opposition to and involvement in

Visions of the public and private in public health genomics: the case of a nascent Australian biobank

Bio-banks have been heralded as a new frontier of bio-molecular research potentially transforming public health by providing improved techniques for predicting illnesses, as well as potentially allowing more targeted health interventions. The teams of health professionals and others that build these technical and informational resources routinely consider ethical, legal and social issues and thereby co-produce the boundaries of a number of cultural and social categories such as the public and private. Drawing upon a study of stakeholders in one genetic biobank, this paper focuses on visions for its future. Participants envisage the creation of bio-value that had both commercial benefit as well as global scientific and public health value. The bio-bank was seen as a public/private hybrid which will have simultaneous local and global impact. Whilst the potential for undue private influence was recognised, stakeholders were confident that an appropriate public/private balance could be managed.

Tribute to Gavin Mooney and Del Weston

No journal could have been more appropriate for Gavin to serve on the Advisory Board than Critical Public Health (CPH). The aims of CPH state that it “is committed to exploring and debating issues of equity and social justice”. Equity and social justice describe the very essence of Gavin; it is unlikely that anyone else has written as prolifically on the issue of health equity or fought as tirelessly in his everyday actions for social justice. The other aspect of CPH’s aim that was so perfectly suited to Gavin is the commitment to “debating issues”. He constantly strove to stimulate debate and frequently published as part of a series with other authors, expressly to present a range of perspectives and to prompt debate and critical thinking in pursuit of identifying appropriate ways of addressing the challenges facing the society. As Gavin himself said, “[t]here is a need not only for greater tolerance of other voices but also for a burgeoning of encouragement of debate” (Mooney 2002). But why did Gavin believe so passionately in the importance of debate? In his own words: