The choice between advocacy for long-run structural change versus implementing immediately remediable action that may fail to address underlying health determinants has been described as a choice between public health nihilism versus public health pragmatism.[i]
Pragmatists emphasize immediate solutions to pressing public health problems such as education and behavioral modification strategies. Nihilists argue that these constitute band-aid solutions that fail to address the deeper, social and structural issues that give rise to health inequities such as economic and social inequalities in society.
Without addressing these “fundamental causes” of health inequities, nihilists argue that health inequities have an uncanny way of reasserting themselves.
For instance, whereas smoking used to be a pastime enjoyed primarily by the wealthy, over time, as greater information has emerged about the health risks associated with smoking, this practice and all of its insalubrious consequences, have increasingly accrued to the disadvantaged.
Another framework for thinking about this question is to consider modifiable and non-modifiable risk factors for diseases. Pragmatists aim to alter modifiable risk factors such as diet and exercise but view social issues such as the distribution of income in society or structural racism as “non-modifiable.”
Nihilists view this pragmatic approach as furthering the status quo.
To blend these two approaches, which are so often in tension, I propose a politically conscious Freirian approach to addressing health inequities. Paulo Freire is recognized as one of the most influential thinkers about education in the twentieth century. A Freirian approach would focus on raising consciousness among individuals about health disparities in their communities, the role of subsidies in incentivizing unhealthy eating habits, the political economy of the food industry and the built environment influencing our diet and exercise routines. This methodology would encourage grass roots political action to tackle the environmental and structural determinants of health within communities.
This approach would blend the short term benefits of educating individuals about the health risks in the social environment allowing them to make individual changes in their lives and habits while linking this individualistic approach to the larger structural barriers in society that produce health inequities.
[i] See Bayer, R. “Does Anything Work? Public Health and Nihilist Thesis,” Paper presented at the 124th Annual Meeting of the American Public Health Association, New York City, November 1996; Amy L Fairchild; Gerald M Oppenheimer. Public health nihilism vs pragmatism: History, politics, and the control of tuberculosis, American Journal of Public Health; Jul 1998; 88, 7: 1105.
Image credit by North Charleston under creative common license.
Ashley Fox is an Assistant Professor at the Mount Sinai School of Medicine, Department of Health Evidence and Policy.
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