Critical reflections on the politics of need: implications for public health
Introduction
In the waning years of the millennium, we are deluged with apocalyptic visions and scenarios. One of the more prevailing of these is the claim of “fiscal crisis” which, among other things, appears to be driving the near universal dismantling of the welfare state in most western industrialised nations. In the domain of health, the notion of “health care reform” has received much attention in this last decade of the 20th century, although what constitutes “reform” varies with the context. In the U.S., the unsuccessful health care reform agenda aimed at expanding universal health care insurance coverage beyond Medicare and Medicaid. In contrast, health care reform in Canada has generally meant the narrowing of the universality of health care insurance coverage by a number of provincial governments; this has involved such strategies as implementing various kinds of “user fees” and narrowing the comprehensiveness of coverage by “delisting” previously covered health care services such as mammography screening.
At the same time, public health has undergone a sea of change in the last two decades. This is a result primarily of the reframing of health promotion to incorporate into public health theory and practice concepts like “empowerment”, “community development” and “social determinants of health”. Underwritten, largely by documents like WHO discussion papers (WHO, 1986), The Ottawa Charter (Government of Canada, 1986) and in Canada The Epp Report (Health and Welfare Canada, 1986), this “new” public health places an emphasis on health inequalities and on the social, political and economic determinants of those inequalities in health. Many would argue that this is not so much a new public health as a return to the historical commitments of public health to social justice (Szreter, 1988; Minkler, 1989; Terris, 1994).
Most students of public health are familiar with the famous 1848 account by Rudolph Virchow of the desperate living conditions of the people of Upper Silesia, which he analysed as the real causes of their health problems (Tesh, 1990). The great sanitary movement in Britain at the end of the last century was largely driven by health activists, whose efforts at reform were directed at the appalling living and working conditions of the mass of urban poor (Szreter, 1988). As a result of this movement, important public health measures were instituted – “water and sewage were regulated, housing and factory codes were passes and child labor was prohibited” (Ellencweig and Yoshpe, 1984). And, attempts throughout the 20th century to align public health with a social justice agenda (see, for example, Nyswander, 1967; Beauchamp, 1976; Kickbusch, 1989; Minkler, 1989; Labonte, 1993; Terris, 1994) reveal the persistence of the moral thrust of public health.
However, largely missing in current discussions of the public health agenda is a consideration of what lies at the core of the concern with public health as social justice, namely the fundamental issue of human need. The purpose of the present paper is to critically examine the concept of human need, in the interests of articulating a renewed moral discourse for public health.
This paper begins with a brief discussion of some of the different ways in which need has been conceptualized historically. The second part of this paper discusses the politics of need and explores the possibilities for a language of need in the context of the modern welfare state, one cornerstone of which has been public health. The paper concludes by offering a reconceptualization of need consistent with the commitments of public health to social justice.
Section snippets
The question of human need
To invoke the notion of need is to invoke what may well be the most powerful rhetorical device in a social policy debate. To argue that “X needs Y” is to imply the normative corollary that “X should have Y”. The concept of need, thus, carries with it an aura of moral suasion. Indeed, many of the classical philosophers – Plato, Aristotle, the Stoics and the Epicureans – “argued that a man's character and the moral condition of the culture from which he sprang could be judged by those values
The dilemma of the modern welfare state
At the heart of the modern welfare state is what Deborah Stone has called a “distributive dilemma” (Stone, 1984, p. 15). The primary distributive system in market societies – which characterises most developed nations, capitalist as well as socialist – is work-based: labour is a commodity and people work in order to acquire what they need. However, labour markets never function perfectly; nor can the work-based system meet the needs of people who cannot work or who cannot work enough. This
A renewed language of need for public health
It has been argued that public health is fundamentally about community and about the shared values of life, health and security (Ignatieff, 1984, p. 17). Dan Beauchamp argues further that “the emphasis in public health on common measures to protect the health and safety of the community makes public health measures “collective goods”” (Beauchamp, 1983, p. 78). It is in this sense that the language of public health is bound up with a language of need. This paper ends by exploring the possibility
Conclusion
This paper has engaged in a critical examination of the politics of need in the context of the modern welfare state in general and in relation to public health in particular. It also has explored the possibility of a language of need appropriate to the aims of public health and offers “a moral economy of interdependence” as a possible language.
Others have invoked the principle of interdependence in relation to public health. In arguing for an ecological base for public health, Kickbusch (
Acknowledgements
The author gratefully acknowledges the insightful and very helpful comments of Meredith Minkler and of anonymous reviewers on earlier versions of this paper.
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