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Aletta Jacobs School of Public Health
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Klasien Horstman: Where are the publics of public health? Reframing problems of 'reach'

Datum:19 maart 2019
Klasien Horstman
Klasien Horstman

On 5 April our 5th edition of the Aletta Research Meet-up will take place! Klasien Horstman will hold a keynote about making public health ‘public’ again. According to Horstman it is required to reflect on its current paradigm and to develop new paradigms that imagine and perform new relationships between public health and the communities it aims to work for.

Klasien Horstman
Klasien Horstman was trained as a philosophical and historical sociologist at the University of Groningen, the Netherlands. Between 2001 and 2009 she was Socrates Professor in Philosophy and Ethics of Bioengineering at Eindhoven University of Technology and since 2009 she has been professor of Philosophy of Public Health at Maastricht University. She studies the dynamics of science, politics and culture in public health practices: from (workplace) health promotion to healthy neighborhoods, vaccination and AMR prevention.

Philosophy needed in Public Health
Klasien Horstman is a professor of Philosophy of Public Health, but what does this entail? Horstman explains: “My chair is dedicated to philosophical and sociological reflection on the meaning of public health. That meaning is not given or self-evident but continuously contested. I am interested in how public health discourses have developed and how do these discourses construct specific practices, relationships, responsibilities, inclusion and exclusion. I think that to understand public health practices we need to understand how public health practices developed and develop on the interfaces of science, politics and society and how they embody specific moralities. To enable that, my chair combines sociological and anthropological research and philosophical reflection.”

Philosophy need in Public Health
According to Horstman there are under streams that go in a different direction, but the institutional and professional field of public health understands itself primarily as a branch of medicine and not as a societal practice. “However,” Horstman explains knowing these are bold statements, “the positioning of public health in the context of medicine created an inferiority complex, as the medical disciplines appear to have much more ‘quick fixes’ available than public health: in this context public health struggles to show relevance.  To solve this problem, public health has chosen to identify with medicine even more, to adopt the evidence culture of medicine and to become more technocratic. This process implies that public health lost touch with social health practices. I think philosophy – social philosophy, philosophy of science – is needed to address the question whether public health is on the right track. Public health misses the sociological and philosophical imagination to contribute to problems like widening health gaps and increasing inequalities. Public health urgently needs input of the humanities, the arts and social sciences.”

Meaning of Public Health
Horstman explains she does not like definitions as they often become (medical) professional of institutional, and then the disconnection to everyday social practices is already build in in the definition: “I prefer to speak about public health practices, as practices refers to people (all kinds of people, not just experts or policy makers) who do things; it refers to formal and informal practices, to frontstage presentations and back office stories. I can think of all kinds of human practices as public health practices, as they articulate how people care for health of humans, animals and environments. For example, snack bars, walking the dog, etc.”

Public Health policy-making
According to Horstman we could involve people in public health policy-making by making them owner of public health. Horstman explains: “It all starts by taking people seriously, to acknowledge their knowledge, experiences, perspectives, habits, their definitions of problems and of solutions – to respect ‘otherness’.  People care for what they consider important, not for what others prescribe them. The institutional field of public health should be interested in what people care for.” And why is this important? “This is what ‘public’ is about in a democratic context: it is about engaging ‘others’, not making 'them' to live their lives like 'us', about dealing with differences, not about standardizing human beings. Public refers to the democratic character of health.”

But does ‘the public’ want to be involved in this? Horstman states they do: “They want to if the issues addressed are issues, they care for. Discussions about vaccination show that people want to be engaged and heard: for a long time public health forgot about her publics. While society and even health care democratized, think of the rise of patient movements,  public health tends ‘to look like a state’. So, it is no surprise that now she is shocked by controversies about for instance vaccination, but I think these discussions may be a blessing, a wakeup call for public health.”

Personal responsibility vs public responsibility
Do you have an opinion on where personal responsibility for health stops, and public responsibility starts? “I would not frame it like that. It is always and/and, but what that entails in concrete cases is more difficult to explain. I take institutional responsibility very seriously and I think many people are skeptical about social and health institutions, as these institutions do not work for them as they expect. I also take individual responsibility very seriously, but I recognize that this may mean very different things. I am quite critical about a public health discourse that is not able to put its own norms about individual responsibility for health in perspective. Philosophy is very helpful here: Greek philosophers make you realize that we may try our best, but that we are not in control, and that illusions of control often create suffering. Public health is about trying out and learning, and not about perfect health. Perfectionism is killing.”      

Popularity of positive health
The concept of ‘positive health’ by Machteld Huber is becoming quite popular. According to Horstman it illustrates that many professionals long for less standardized, less technical and less medicalized notions of health and disease, and prefer ways of working that enables them to get in touch with patients as persons. Horstman sees the popularity of positive health as a cry for humanism in a technological, economy driven – time = money -  health care system: “But I also have my doubts with the concept: it is quite individualistic as it departs from a clinical encounter, the expectations of self-management tend to be too high, and it may disregard suffering. I do not like labels like positive to deal with phenomena that people struggle with, are suffering from, are sad about etc. Labels like ‘positive’ are too Big and too much a label – it may be my northern background or my critical analysis of Marxism during my study – but I am skeptical. Positive health may develop as another professional domain: in that case the language becomes really weird – how to express disappointing experiences with positive health? All new notions run the risk of becoming new standards and new ideals become sterile if they do not actually become practical.  For me, it is good to stick to the notion health, but I find it important to consider health as a contested concept, and to have an open eye for what it means in diverse practices.”