Making Sense of Public Health.
‘Public health’? ‘Public’ ‘health’? A mysterious third thing?
‘Public health’ is notoriously difficult to define. Like pornography, or so goes the cliché, everyone has a sense of what it means, can recognise it when they see it, but ultimately struggles to provide a definition that encompasses its many nodes, facets, and activities. As such, to limit the amount of conceptual flailing (public healthists are practice-minded people, after all), attempts to define ‘public health’ often depart from the C.E.A. Winslow’s—an early-20th century bacteriologist and sanitary pioneer—over-famous dictum:1
“Public health is the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organised community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organisation of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.”2
Then, if the attempt’s authors are British or focused on Britain, they might also cite the definition in Donald Acheson’s, the country’s Chief Medical Officer at the height of the AIDS crisis, report on Public Health in England:
“...public health [is] the science and art of preventing disease, prolonging life and promoting health and wellbeing, through the organised efforts of society.”3
Finally, they might even include the definition proposed by Derek Wanless, a businessman commissioned by the Treasury to review England’s public health capacity, in 2004:
“The science and art of preventing disease, prolonging life, and promoting health through the organised efforts and informed choices of society, organisations, public and private, communities and individuals.”4
Or Richard Horton’s, The Lancet journal’s editor-in-chief, one from 2011:
“Public health is the science of social justice, overcoming the forces that undermine the future security of families, communities, and peoples.”5
Whichever of these statements, or combination thereof, attempts to define ‘public health’ cite, it is never clear to me what to make of them. Are we to take them at face-value as applicable to contemporary public health? Are we to take them as identifying some essential property that is common to both the public health of the 1920s when Winslow wrote and of today? If so, how are we to deal with the differences and variations between them? While there are some through-lines (‘science’, ‘preventing disease, prolonging life, and promoting health’, and ‘organised efforts’), there are also clear differences (Acheson inserts ‘wellbeing’, Wanless emphasises choice, and Horton centres ‘social justice’) that reflect their differing contexts of articulation.6 How then are we to choose between them today? And what does ‘health’ (or indeed ‘life’ and ‘social justice’) mean anyway?
In his own attempt to define ‘public health’, John Coggon effectively offers two ways of making use of these older definitions of ‘public health’, each of which reflects a different approach to defining ‘public health’.7 The first is to do what I just proposed and to treat them as attempts to provide authoritative definitions of ‘public health’ by identifying its essential characteristics. The second, however, is to historicise them and to treat each as a particular practitioner’s statement, made in a particular place, at a particular time, for a particular purpose. This effectively entails dropping the assumption that there exists a ‘public health’ essence to be identified (without thereby asserting its inexistence) and instead treating ‘public health’ as a widely-used term, whose history reveals a matrix of ever-evolving meanings, practices, institutions, etc. Here, I will outline both approaches to defining ‘public health’, before (briefly) defending the latter and drawing out some of its implications for the empirical study of public health.
From essentialism to non-(but not quite anti-)essentialism.
In a report written for the Faculty of Public Health (‘What is Public Health?’), John Coggon offers two contrasting approaches to defining ‘public health’. The first is to hunt for a final, authoritative description of what ‘public health’ is that somehow latches onto its essential characteristic(s). Accordingly, I will call this approach essentialism.
There are probably many ways for an essentialist about ‘public health’ to proceed but Coggon focuses on conceptual analysis, a method most typically favoured by some philosophers.8 Too crudely, this amounts to taking one of our concepts (in this case ‘public health’, but it has been extensively applied to ideas like ‘freedom’, ‘justice’, ‘knowledge’, etc.) and trying to work out what it means by spelling out the intuitions that underlie our use of it. The spelling out can be done through introspection, debate, thought experiments, or whatever but the key point is this: for a conceptual analyst, identifying a term’s meaning entails identifying the cases to which we would apply the term and then formulating a description that duly encompasses them all (it can be as vulgar as formulating a conjunction of the form ‘X is [case 1] and [case 2] and [case 3]... and [case n]’, but this strategy’s utility and feasibility have obvious practical limits).
So on these terms, the definitions given above should be read—and evaluated—as exercises in conceptual analysis, and it is worth briefly noting how badly they fare. Take Horton’s definition first. In ordinary parlance, ‘social justice’ can refer to anything from historic efforts to achieve universal suffrage or secure workers’ rights to holiday time and pensions to inanities like ‘decolonising’ the curriculum. While some of these might have benefits that we might describe as contributing to public health, it is not clear to me that any of these qualify as ‘public health’ proper. As such, Horton’s definition fails to spell out our intuitions and can be dismissed. Turning to the other three, they all suffer from a common problem: centring on ‘health’ (and Acheson adds ‘wellbeing’), a term that Coggon notes desperately needs a conceptual treatment of its own.9 Absent that treatment, it is unclear what cases Winslow, Acheson, and Wanless’ definitions cover, and so it is unclear how informative they actually are.
To reiterate, conceptual analysis is probably not the only method available to essentialists, but it is the one that Coggon dwells on and that has two advantages: (1) it illustrates what an essentialist might do in seeking an authoritative definition of ‘public health’ and (2) it raises questions about the utility of an essentialist appealing to seemingly authority-laden definitions like Winslow, Acheson, Wanless, and Horton’s.
Besides essentialism, Coggon also considers an approach to defining ‘public health’ that I will call non-essentialism. Non-essentialism adopts a different analytical starting point to essentialism; dispensing with the (as we will see below, unjustifiable) assumption that there is an authoritative definition to be given of ‘public health’, non-essentialists start from the (much less problematic) observation that ‘public health’ is a term and concept used by swathes of real people, out there in the real world.10 As such, our attempts to identify its definitions should start by systematically mapping out what ‘public health’ means in the real world, what uses it is put to, and how these have evolved over time. To get an idea of what this might look like, consider the list of possible meanings that Coggon provides:11
‘Public health’ as a set of government functions: Here, ‘public health’ is an aspect of what modern government is and does. It can refer to any number of government institutions and policies, including, for example, the UK Health Security Agency, the Department of Health and Social Care, and Keir Starmer’s Fit for the Future: 10 Year Health Plan for England.
‘Public health’ as a social infrastructure: Here, ‘public health’ reaches beyond government and refers to an aspect of what civil society is and does. It can include institutions like NGOs, lobby groups, universities, and think tanks, as well as functions performed by restaurants, churches, schools, and individual citizens themselves. Central governments often appeal to ‘public health’ as social infrastructure in their own policy.
‘Public health’ as an academic discipline and profession: Here, ‘public health’ refers to a type of education, expertise, formal qualification, and/or career path that a person might have. It refers both to a particular field of study (complete with its own bank of assumptions, concepts, and preferred modes of reasoning) and a field of employment, most typically in one of the government and civil society institutions listed above.
‘Public health’ as a blind benefit/harm: Here, ‘public health’ is used as shorthand for the effects of an intervention that can (ostensibly) be observed at the population-level, but not the individual level. A good example of this is a reduction in alcohol consumption.12 If a government’s poster campaign or sumptuary tax successfully drives down the average number of units drunk per week, we might observe a drop in cases of liver cirrhosis in the general population. We would not, however, be able to say of any particular individual that he benefitted from the intervention or that he would have developed cirrhosis had the government not acted. ‘Public health’ as blind benefit/harm can effectively be further divided into two sub-meanings:
‘Public health’ as the observation of population-level phenomena: Here, ‘public health’ is shorn of any value-judgements and refers only to observations of population-level effects, like disease prevalence or number of vaccines given per capita. On these terms, to do ‘public health’ is to make these observations without evaluating them or commenting on whether they are good or bad.
‘Public health’ as a statement of solidarity: Here, ‘public health’ expresses the value-judgement underlying much ‘public health’ as benefit/harm-talk: the basically communitarian or solidaristic idea that ‘health’ is a population-level, rather than merely individual, concern. ‘Public health’ in this sense makes an appearance when you are encouraged—or coerced—to get vaccinated to contribute to herd immunity and thereby promote public health.
‘Public health’ as a political rationale: Here, ‘public health’ is the justification given for a particular policy or intervention. To say that an intervention is ‘for public health’ in this sense is to say two things: first, that the domain of intervention is worthy of the intervener’s attention and second, that ‘health’ is amongst the intervener’s guiding values. Crucially, this is not exactly the same as ‘public health’ as blind benefit/harm because it is not necessarily couched in population-level terms. There are, for example, situations in which we might say that ‘public health’ justifies making available a drug that has shown positive effects for individual users, but not in placebo-controlled (or other population-level) trials.13
A few things to note here. First, note that these uses are non-exclusive and often overlap in practice. A politician who means the desirable population-level benefits of getting vaccinated when he cites ‘public health’ as his justification for implementing something like vaccine passports is simultaneously using ‘public health’ as blind benefit/harm, a statement of solidarity, and a political rationale. Second, note that this list is non-comprehensive. The purpose here is not to exhaustively list all of ‘public health’s’ possible uses and meanings (not least because language evolves and new uses/meanings emerge all of the time), but merely to demonstrate its polysemy and polyfunctionality. And, most crucially for the anti-essentialist, neither is it to adjudicate over which meaning is most definitive or final. Having dropped the assumption that such a definition exists, the non-essentialist is free to approach ‘public health’ with an open mind, to study how the term is actually used, to map out the concepts, practices, and institutions that these uses presuppose and perpetuate, and to examine how all of them have evolved over time. Some authoritative definition(s) might emerge over these investigations’ course, but it is neither expected nor aimed at from the outset.14
Before spelling out some of non-essentialism’s implications for the meaning of ‘public health’, it is worth briefly considering how it affects our reading of the historic definitions cited above, using Horton’s as an example once more. For non-essentialists, Horton’s claim that ‘public health’ is ‘the science of social justice’ should be understood not as an attempt to authoritatively capture the essence of what public health is, but as a particular actor’s statement, made in a particular place, at a particular time: that actor being Dr Richard Horton, the editor-in-chief of the influential Lancet journal, known for his commitments to broadly progressive-coded causes; that place being an opinion column in The Lancet, expressing dismay about the English public health establishment’s lack of direction and influence; and the time being 2011, during the centre-right Cameron-Clegg coalition government.15 Consequently, Horton’s frankly activist definition of ‘public health’ (effectively combining public health as an academic discipline and profession and as blind benefit/harm) could be read as a politically engaged, public-facing medic’s attempt to galvanise his fellow professionals to stand against a government whose policies, and general political orientation, he opposes.16 His particular use of the term was made possible by a suite of pre-existing concepts (e.g., ‘social justice’), practices (e.g., opinion column writing, a commitment to progressive activism17), and institutions (medical journals, the governmental and non-governmental leadership positions to whom Horton is addressed) and sought to stir up some sort of political momentum and promote an ultimately technocratic approach to public health policy.
In this way, and unlike the conceptual analyst, the non-essentialist cannot simply dismiss Horton’s statement as wrongheaded, misguided, or uninformative; it tells us something important about what ‘public health’ means and how it functions out there in the real world.
So, what does ‘public health’ mean?
As noted, non-essentialists leave the question of ‘public health’s’ essence open, and we should, in principle, continue to do that here; it may be that beneath Coggon’s seven meanings of public health, there lies an as-yet undetected shared property to ground an authoritative definition of ‘public health’. I cannot see it however, and to me Coggon’s empirical work instead reveals a sort of matrix—what Nikolas Rose might call a ‘complex’18—of overlapping institutions, professional and personal activities, and subject-positions, within and between which concepts, facts, and explanatory and moral rubrics are formed, reformed, and can travel.19 None of these meanings is reducible to any other and their interrelations are too complex to exhaustively map out or schematise here (for one thing, the matrix is now world-wide; for another, it is, again, ever-evolving).
Consequently, what ‘public health’ means depends on the question being answered. If it is Coggon’s very general one (i.e., “what is ‘public health’?”), then the answer is that ‘public health’ is not one thing but that it can, with the proper caveats, be used as shorthand for a fuzzy, protean entity: the moral-conceptual-professional-institutional matrix revealed by his seven-faced taxonomy. Researchers aren’t usually interested in such general terms, however, and their questions and explanations focus instead on a sliver of the overall matrix (e.g., “how did public health’s concept of ‘population-level phenomena’ emerge and spread?”, “what shapes the government’s public health policies?’, “Is obesity/misinformation/climate change a public health issue?”). In these cases, it is incumbent on researchers to specify what particular configuration of ideas, practices, persons, and institutions they mean by ‘public health’.20 The appropriate level of detail will vary (book-length expositions allowing for more granularity than five-page articles), but in no case should researchers lamely resort to context-insensitive, cod-authoritative Winslow/Acheson/Wanless/Horton-style definitions.
Before ending, I should address a possible (and likely) objection to non-essentialism about public health: namely, that it implies that ‘public health’ ultimately means everything and nothing. If ‘public health’ can be used to mean whatever a researcher says it does, the objection goes, then it might as well mean nothing at all and is of no descriptive or explanatory value. The problem with this argument is that it ignores non-essentialism’s reliance on empirical work like Coggon’s taxonomy. In paying close attention to how ‘public health’ is used in the world, work like Coggon’s sets bounds on what researchers can take the term to mean (assuming, of course, that their aim is to learn about the real world). It is, for example, pretty clear that schizophrenia prevalence and cannabis dispensaries can appropriately feature in a definition of ‘public health’, whereas English Heritage (the quango) or supermassive black holes cannot.21 These bounds aren’t sharp and there will be edge-cases (the military-industrial complex, for example!), but they are firm enough to head off a meaning-destroying free-for-all. Non-essentialism does not imply Humpty-dumptyism, but a context-sensitive, worldly pluralism.
(Thank you to Mike Casey for his generous and helpful comments on my first draft! 👍)
I myself have done this! See Lacour, M (2024) Following The Science: An Essay on the Role of Scientific Advice in the UK Government’s Decision to Impose a Lockdown in March 2020 Available at SSRN: https://ssrn.com/abstract=5207323 or http://dx.doi.org/10.2139/ssrn.5207323
Winslow C. E. (1920) THE UNTILLED FIELDS OF PUBLIC HEALTH. Science (New York, N.Y.), 51(1306), 23–33. https://doi.org/10.1126/science.51.1306.23, p.30
Acheson, E. D. (1988) Public Health in England : The Report of the Committee of Inquiry into the Future Development of the Public Health Function. HMSO, p.1
Wanless, D. (2004) Securing Good Health for the Whole Population, published by HM Treasury on behalf of the Controller of Her Majesty’s Stationery Office, p.3
Horton, R. (2011) ‘Offline: Where is public health leadership in England?’ The Lancet, Volume 378:9796, 1060
Berridge, V. (2016). Public health: a very short introduction. First edition. Oxford University Press, pp.1-5
Coggon, J. (2023). What Is Public Health? Faculty of Public Health. https://www.fph.org.uk/media/3931/what-is-public-health-final.pdf
Coggon (2023), pp.11-16 and Jackson, F. (2003) ‘The Role of Conceptual Analysis’, From Metaphysics to Ethics: A Defence of Conceptual Analysis, Oxford, 2000; online edn, Oxford Academic.
Coggon (2023), p.12
Coggon (2023), p.16
Coggon (2023), pp.16-17
Coggon, J. (2012) What Makes Health Public?: A Critical Evaluation of Moral, Legal, and Political Claims in Public Health. Cambridge Bioethics and Law. Cambridge University Press, pp.66-67 https://doi.org/10.1017/CBO9781139061032.
For instance, in the early months of 2020, there was arguably a ‘public health’ case to be made for allowing doctors to freely prescribe hydroxychloroquine to COVID-19 patients, despite a continuing lack of evidence for its population-level efficacy. See Doidge, N. (2020) ‘Hydroxychloroquine: A morality tale: A startling investigation into how a cheap, well-known drug became a political football in the midst of a pandemic’, Tablet Magazine, 14 August. Available at: https://www.tabletmag.com/sections/science/articles/hydroxychloroquine-morality-tale
Hence non-essentialism rather than anti-essentialism. In bracketing the assumption that ‘public health’ has an essence, non-essentialists do not for that matter assert that it has no essence. At most, they leave the question of essence open and awaiting an answer that may or may not emerge with time.
Anthony, A. (2020) ‘The Lancet’s Editor: “The UK Response to Coronavirus Is the Greatest Science Policy Failure for a Generation”’. Politics. The Guardian, https://www.theguardian.com/politics/2020/jun/14/the-lancets-editor-the-uk-response-to-coronavirus-is-the-greatest-science-policy-failure-for-a-generation and Carl, N. (2023) ‘Richard Horton Is Destroying The Lancet with Politics’. UnHerd https://unherd.com/newsroom/richard-horton-is-destroying-the-lancets-with-politics/.
Horton, R. (2017) ‘Offline: Not One Day More’. The Lancet 390, no. 10090: 110. https://doi.org/10.1016/S0140-6736(17)31798-1.
This is not to pick on Horton. Public healthists have a long history of left-wing, progressive, or what you might even call ‘Fabian’ activism. See Keating, C. (2014) Smoking Kills: The Revolutionary Life of Richard Doll. Signal Books Ltd and Snowdon, C. (2025) Anti-Capitalism and Public Health https://iea.org.uk/publications/anti-capitalism-and-public-health/ for examples.
For example, Rose, N. S. (1985). The Psychological Complex: Psychology, politics and society in England, 1869-1939. London: Routledge & Kegan Paul.
Morgan, M. S. (2012). Travelling facts. In P. Howlett & M. S. Morgan (Eds.), How well do facts travel? (pp. 3–40). Cambridge University Press.
This will invariably require a measure of what Gabriel Tarde would have called ‘micro-sociology’, which is to say closely attending to the the particular combination of concepts, minute social, scientific, and interpersonal practices, and inter/intra-institutional relations that underlies and/or corresponds to the researcher’s use of ‘public health’. See Deleuze, G. (1986). Foucault. Paris : Les Éditions de Minuit, p.44 and p.81
At least, currently! The world might shift in such a way that supermassive black holes’ inclusion becomes feasible (in which case, we might have bigger problems than the meaning of ‘public health’...).
What is public health for the tribesmen in the Amazon forest? Or rather how do some tribesmen keep healthy? What would they tell us?