A ray of light for feminist bioethics: the growing field of population health science is feminist science

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EDITOR’S NOTE:This contribution comes to us from new contributor Sean Valles, Associate Professor of Philosophy at Michigan State University. Valles studies the interplay of ethics and scientific evidence in population health, including race & migration issues and climate change issues.

“Help, bioethics friends. The bioethics blog I run is all badnews. Do we have ANY good news?” Alison Reiheld posted that question on socialmedia, leading to a conversation and now this blog post. So, to answer herquestion, I see the growth of the interdisciplinary field “population healthscience” as good news. This is the field I examine in my book, Philosophyof Population Health: Philosophy for a New Public Health Era (Routledge 2018). I was motivated to make sense of how and why scholars writingabout “population health” created a scientific framework that has “an explicitconcern with health equity” as a foundational tenet (Diez Roux, 2016, p. 619).

The field has a professional society, introductory volumes (Keyes & Galea, 2016) and textbooks (Nash et al., 2016), etc. It also overlaps in complex and disputed ways with contemporary public health science, such that it is hard to tell where “public health” ends and “population health” begins (Diez Roux, 2016). The best-known population health catchphrase is “culture of health,” popularized by the Robert Wood Johnson Foundation.

So why is the growth of this field good news? More reasons than Ican summarize here, but most of all because it is a field/approach/framework that approaches health as a phenomenonenmeshed in the diversity, messiness, and injustices of everyday social life.That orientation, and a commitment to ameliorating health injustices, has ledpopulation health to endorse positions long endorsed by feminist philosophers.

Even just the notion of aiming for a “culture of health” is awelcome change of pace for me as a feminist bioethicist. Gendered healthinequities often manifest clearly in the clinic—eating disorders, discountingof women’s accounts of their pain, pathologizing of bodies and behaviors thatdon’t conform to binary gender norms, etc.—but the roots of those inequitiesare in culture and everyday life.

As I review in Chapter 2, population health science is built from a gradual recognition—largely over the course of the second half of the 20th century—that health is fundamentally social in several senses.

1) The World Health Organization stated during its founding after World War Two that health is the presence of well-being in social context (I defend a modified version of this view in Chapter 3).

2) In the following decades, alarming data emerged showing that social structures (social determinants of health) have massive power over even things that can appear to be individual choices—I choose my diet in roughly the same limited sense that I choose which language I speak at home.

3) Effectively promoting health effectively requires a social ethics rooted in empowerment. As the 1986 WHO Ottawa Charter, which heavily influenced the field, puts it: “Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. Health is created by caring for oneself and others, by being able to take decisions and have control over one’s life circumstances, and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members.” (World Health Organization, 1986)

4) Health is methodologically social in the sense that we need to develop better participatory methods to responsibly elicit and synthesize health knowledge from patients, community activists, social scientists, physicians, nurses, etc.

Every one of these social understandings of health is a welcomedeparture from the elements of public health that many bioethicists—especiallyfeminist bioethicists—have long opposed: paternalism, cultural imperialism,inattention to social structures and power dynamics that serve to createinequitable privileges, and more. As reviewed in a new 2019 IJFABpaper by Julia Gibson,“So much outstanding [feminist] scholarship has been devoted to championing sociality(Jaggar 1983; Lindemann 2014), relationality (Anzaldua 1990; Plumwood 2002;Haraway 2008), and community (Weiss and Friedman 1995, Kimmerer 2013) in theface of liberal individualism—amongst other oppressive ideologies—run amok”(Gibson, 2019, p. 77).

The thing that makes me most sanguine about population healthscience, and a feature that makes it good news for feminist bioethics, is itscommitment to epistemic humility. The final chapter of my book surmises thatpopulation health science has tacitly but clearly embraced a commitment tothree related forms of humility:

1) A general epistemic humility

2) Intersectoral humility: government, non-profits, the healthcare industry, and other sectors each have roles to play in health promotion, but none deserves a hierarchical position above the others

3) Interdisciplinary humility: health has many facets and no single discipline sees all of the facets

In that section, I rely on Anita Ho’sexcellent IJFAB articleexplaining the relationship between epistemic humility and collaboration:“[epistemic humility] means a commitment to make realistic assessment of whatone knows and does not know, and to restrict one’s confidence and claims toknowledge only to what one actually knows about his/her specialized domain. Inparticular, it is a recognition that knowledge creation is an interdependentand collaborative activity” (Ho, 2011, p. 117).

Population health science is built on a sense of humble awe aboutthe vastness of health as a social phenomenon, an orientation that will help usconfront the socially complex challenges facing public health. We’ve inventedeffective biomedical tests and treatments for HIV disease, but haven’t figuredout how to make them safely accessible to all (see Chapter 6). We’ve found it’seasier to talk about the Dakota Access Pipeline as a source of toxic risks fromoil spills than it is to listen to Standing Rock Sioux accounts of how badlythe pipeline harms a community wherein the well-being of land, water, andhumans are philosophically tightly linked—where “water is life” (seeChapter 2).

The world is very very far from being a place of equitablethriving for all. Unchecked climate change looms over all good news, andpopulation health gains are uneven. Most countries in the world have risinglife expectancy, but that is coldcomfort to Americans who are inthe midst of a rare and frightening three-year-long (possibly four if the trendholds) downturn in life expectancy, a trendnot seen since the four-year period that included World War I and a global flu pandemic.

Even when the days are dark, I think it is worth celebrating whenone finds good allies to face them with.

References

Diez Roux, A. V. (2016). Onthe Distinction—or Lack of Distinction—Between Population Health and PublicHealth. American Journal of Public Health, 106(4), 619-620.

Gibson, J. D. (2019). Thevoices missing from the autonomy discourse (are also the most indispensable). InternationalJournal of Feminist Approaches to Bioethics, 12(1), 77-98.

Ho, A. (2011). Trustingexperts and epistemic humility in disability. International Journal ofFeminist Approaches to Bioethics, 4(2), 102-123.

Keyes, K. M., & Galea,S. (2016). Population Health Science. New York: Oxford University Press.

Nash, D. B., Fabius, R. J.,Skoufalos, A., Clarke, J. L., & Horowitz, M. R. (Eds.). (2016). PopulationHealth: Creating a Culture of Wellness (Second ed.). Burlington, MA: Jones& Bartlett Learning.

Valles, S. A. (2018).Philosophy of Population Health: Philosophy for a New Public Health Era.Abingdon, Oxon: Routledge.

World Health Organization.(1986). Ottawa Charter for Health Promotion. Retrieved from Ottawa, ON:https://www.who.int/healthpromotion/conferences/previous/ottawa/en/

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